To provide an updated overview of the Sustainability and Transformation Programme (STP), One Herefordshire and the integration agenda for health and social care.

The chairperson invited Jo-anne Alner, managing director of NHS Herefordshire Clinical Commissioning Group (CCG), to provide the briefing.  Ms Alner delivered the presentation ‘Integrated Care Systems and One Herefordshire’ and the principal points are summarised below.

Integrated Care Systems (ICSs)

1.         ICSs represented an evolution of the Sustainability and Transformation Partnership (STP) model, where health and social care partners worked collaboratively across a geographic footprint, so that ‘… commissioners will make shared decisions with providers on how to use resources, design services and improve population health’ (NHS Long Term Plan, paragraph 1.51).

2.         This was not required in legislation currently but was government policy and seen as the direction of travel.   The aim for Herefordshire and Worcestershire was to become a true ICS from April 2021.

3.         Streamlined commissioning arrangements would typically involve a single CCG for each ICS / STP area and these would become leaner, more strategic organisations.  It was reported that a formal letter had been received that morning confirming the merger of the four CCGs across Herefordshire and Worcestershire into one CCG from April 2020.  This would provide costs savings of £2m to be redirected to frontline staffing and healthcare at a national level. 

4.         There would be emphasis on supporting providers to partner with local government and other organisations on population health, inequalities and service redesign.

5.         There would be changes to funding flows and contract forms, with the aim of moving to a system control total.

Herefordshire and Worcestershire STP Vision

6.         The joint vision would remain ‘Local people will live well in a supportive community with joined up care underpinned by specialist expertise and delivered in the best place by the most appropriate people’.

7.         An outline was provided of the building blocks to enable the transformation, through an integrated approach, from ‘A system too reliant on emergency access and beds where people believe that hospital is the best place to be when you are unwell’ to ‘A system that is built around care close to home, where hospital beds are only used where somebody cannot be cared for safely in their own environment’.

The tiers in an ICS

8.         The system-wide (Herefordshire and Worcestershire), place (Herefordshire), and neighbourhood (Primary Care Network) tiers were outlined.  Within Herefordshire, there would be five Primary Care Networks (PCNs), each led by a clinical director.

One Herefordshire

9.         One Herefordshire was the place based integration plan, involving partners working together locally.  The principles of functional integration included integrating at the point of delivery, looking for shared efficiencies, and not shifting risk.

10.      A five year plan was being developed, aligned to the NHS Long Term Plan.

Integrated care in Herefordshire

11.      It was expected that integration would remove workforce and leadership boundaries, address financial sustainability, and deliver quality improvement.

2019/20 delivery and assurance

12.      The delivery and assurance structure of One Herefordshire was outlined, from the health and care executive alliance down to programme groups (with executive leads) focused on medicines optimisation, integrated community alliance, planned care, urgent care, other areas including specialist services, and Talk Community.

Talk Community

13.      The head of partnerships and integration explained that the Talk Community agenda was a priority area for the council, involving: working with communities to help them to be resilient and support individuals; utilising innovation and partnerships to maximise independence and wellbeing; developing place, space and economy to ensure that communities were vibrant and sustainable; and promoting prevention and helping people to lead healthy lifestyles. 

14.      The six Talk Community key programmes were outlined: hubs (with 20 to be established by the end of 2019/20, with the intention to expand to up to 50 hubs); commissioning approach; business; safety and cohesion; public health; and operational developments.

15.      The director of public health said that the NHS Long Term Plan recognised the role of ‘anchor organisations’ that can have an impact on health and wellbeing.   It was reported that around 32k people worked in health and social care across Herefordshire and Worcestershire, many routine manual workers, and supporting them could help to improve the health and wellbeing of the population in general.  In terms of place and space, making environments such as hospitals good places to work in and visit would provide opportunities to promote healthy choices.

Integrated primary and community services

16.      Ms Alner explained that integrated primary and community services was a core focus of the NHS Long Term Plan.  Guidance was to be issued by government in the next few months which would outline what was expected at a neighbourhood level, including access to, and the responsiveness of, community services.  The purpose of service redesign would be to support more domiciliary / home based care based on the principle ‘own bed is best’ and ensure that acute services operated as effectively and efficiently as possible.

Integrated care alliance board work plan

17.      An overview was provided of the projects being undertaken by the board, including: PCN development and supporting clinical directors to become leaders in their localities; integrating teams to minimise hospital admissions and improve the speed of discharge; addressing the needs of high intensity users of acute and GP services; integrating services and providing 24 hour care; and using business intelligence to anticipate demand and improve health outcomes.  It was noted that integration projects not only involved cultural change on the frontline but also at an executive level.

Accident and emergency board

18.      It was reported that this board was a statutory requirement and looked at the functioning and capability of accident and emergency and urgent care pathways.  An overview was provided of the projects being undertaken, including: ambulance response and conveyances; reviewing the Directory of Service in order to support the ambulance service and NHS 111 to direct patients to the most appropriate service; the frailty front door initiative which was a successful new model of delivery to treat frail patients in accident and emergency and would become a seven day service shortly; the delivery of other seven day services at the hospital; Delayed Transfers of Care (DToC) reduction; and joined up advance care planning to support people’s preferences and priorities for their care when reaching their end of life period.

Better Care Fund (BCF)

19.      The head of partnerships and integration reported that the BCF was a national programme across both local government and the NHS to join-up health and care services.  There were a number of pool budgets to deliver and support services; amounting to over £50m in Herefordshire.  There were national metrics for the BCF relating to non-elective admissions, admissions to residential and care home, effectiveness of reablement, and DToC.  The BCF and integration plan 2019-20 had been submitted and, in particular, this sought to continue to integrate functions and align health and care capacity to support people out of hospital and into their homes.

Achievements to date

20.      Ms Alner outlined the following achievements over the last eighteen months: DToC system improvement; increased number of people supported at home rather than in community hospital; implementation of a discharge to assess facility; front door frailty team supported improvement of flow at the front door; integrated discharge function; and development of Talk Community hubs.

21.      In concluding the presentation, Ms Alner said that providers had competed with each other in the past but current policy direction was about collaboration, with budgets and decision-making to be delegated to the appropriate tier.

The director of public health said that, in order to stem future demand into the NHS, it was important to recognise the wider factors which affect people’s health and to build community resilience.  She commented on: the value of workforce development and ‘making every contact count’; the opportunity for Talk Community to connect people, helping to address loneliness and keep older people active; the potential for PCNs to help people with long term breathing problems to control their breathing better; the need to consider estates collectively; and the importance of digital inclusion.  The director of public health reported that there would need to be a stronger focus on health inequalities, with dashboards and locality profiles developed for each PCN.

The chairperson said that, in view of the significance of the transformational cultural shift required, there could be a number of areas which the scrutiny committee might wish to look at more closely in the future.  Ms Alner provided responses to a number of questions from the chairperson, including:

i.           The One Herefordshire Health and Care Executive Alliance could only make recommendations at present, requiring the partner bodies to make separate decisions through their existing governance processes.   The executive alliance provided the forum for senior executives to discuss the structural, operational and cultural changes required.  It was anticipated that it would become more formal as and when future legislation allowed.

ii.         The role and work programme of the health and wellbeing board was being reviewed currently.  The head of partnerships and integration added that the relationship of the board and the executive alliance could be explored in order to minimise duplication and ensure appropriate accountability.

iii.        The projects identified in the Integrated Care Alliance Board work plan were in progress, with some involving timescales over two years.

iv.        With reference to anchor organisations, the chairperson commented on the value of mental health first aid provision, for both public sector and other employers in the county. 

v.         The chairperson welcomed the stated principle of not shifting risk but noted that this would need to be monitored to ensure that needs were addressed and not just moved around the system.

vi.        PCNs would be responsible for new roles in coming years, with funding aligned.  For example, each PCN was in the process of recruiting a social prescriber.  The importance of linking this role locally with Talk Community was noted.

vii.       With reference made to the statement in the NHS Long Term Plan Implementation Framework (page 14, paragraph 3.4) that: ‘We expect systems to set out how they see the provider and commissioner landscape developing, for example to overcome challenges faced by providers in rural or remote locations…’, it was reported that the draft plan submitted to NHS England / Improvement identified the particular geographic and demographic challenges in Herefordshire and in Worcestershire.

Ms Alner also provided responses to a number of questions from the vice-chairperson, including:

·                One Herefordshire and its associated work programmes provided opportunities for collaboration currently but each partner organisation was still accountable for its own budget.

·                The Herefordshire and Worcestershire system-wide tier would determine the funding for each county / place tier.  Local authority funding would not be affected.

·                With reference made to the example of the waiting time for occupational therapy, as identified in the 2019 Healthwatch engagement report, the committee was advised that integration would provide opportunities to remove boundaries, minimise duplication, and pool resources to meet the requirements of the population.

In terms of making the best use of the ‘Herefordshire pound’, the director of public health commented that the partners – as anchor organisations – had a part to play in terms of the local supply chain, putting social value into contracts, and using technology to generate efficiencies.  The example of outpatient appointments was outlined which could be dealt with digitally or through other models of working, thereby securing savings for the NHS and reducing travel and parking costs for outpatients.

Comments and questions were invited from committee members and other attendees, the principal points included:

a.         A committee member welcomed the briefing but expressed concern about the extent of the integration in such a short space of time.  Herefordshire was described as ‘punching above its weight’ in some services and it was considered that this position needed to be protected.

Ms Alner emphasised that there was a duty to look after the populations of both Herefordshire and Worcestershire, there were already patient flows between the two counties, and CCG presence would remain in Hereford.

b.         A committee member commented on the need for urgent support for people contemplating suicide, particularly people presenting to accident and emergency.

c.         Mr Stead said that Healthwatch Herefordshire supported integration and the direction of travel generally, especially supporting people at home as far as possible.  It was noted that the engagement report had been well received and had been adopted by the STP.  He added that it was important for local people to also have a voice in the development and operation of the PCNs.  The chairperson commented that the input of Healthwatch Herefordshire was vital and highly valued.

d.         In response to questions from a committee member, Ms Alner explained the funding arrangements for Herefordshire and Worcestershire in more detail and commented on the need for the CCG and providers to achieve financial balance. 

The head of partnerships and integration added that council funding streams would remain the same, with some overlap in terms of the BCF, and the council would work in collaboration with partners to commission services using the integrated approach, wrapped around the service user.  She added that this would be done as organically as possible, informed by need; the example of integrated discharge was given, where an underperforming function had been examined in order to reduce duplication and improve systems and pathways. 

Ms Brooks commented that work to date on the BCF and the agreed new plan demonstrated that the NHS and the council could work together effectively and confirmed that there was proper governance and monitoring for the expenditure.

e.         In response to questions from a committee member, Ms Alner explained the role of Taurus Healthcare in supporting GP practices in Herefordshire and the circumstances of the merger of the Market Street and St Katherine’s GP practices in Ledbury.

f.          In response to questions from a committee member: Ms Brooks said that the merger of a number of city GP practices to form the Hereford Medical Group predated the PCN model and provided opportunities to rationalise estate, offer different services, and share expertise; Ms Alner said that patients would perceive fewer boundaries through the minimisation of the number of different people visiting, the maintenance of a single digital record so that patients did not need to retell their story, and a reduction in onward referrals; Ms Alner noted the need to ensure that there was a clinically skilled workforce to deliver services in the community and said that integration would enable resources and capacity to be used more effectively; and the head of partnerships and integration confirmed that the Talk Community hubs would provide a range of offerings, informed by local need and co-produced with the community.

g.         The vice-chairperson commented on the potential for health hubs to bring people together, perhaps through cafes or lunch clubs, to help address loneliness. 

h.         The vice-chairperson, drawing attention to the year 1 and year 2 priorities identified in the covering report, questioned how the system would assure itself that it had achieved positive change.  Ms Alner advised that there were a number of health outcomes, such as healthy life expectancy, and performance outcomes, such as timely referrals, which the system would be accountable for.  The director of public health added that action on prevention and health inequalities was also important.  In response to a further question, Ms Alner outlined how each tier of the ICS would be responsible for different elements of the outcome measures.

Ms Brooks noted that the committee’s work programme anticipated an item on ‘Clinical Commissioning Group benchmarking and performance / delivery data’ for its May 2020 meeting and suggested that the outcome measures could be included in that presentation.  This was welcomed by the chairperson, along with a request for more granularity around the priorities.

i.           In response to a question from the chairperson, Ms Alner explained that the budget for the Herefordshire and Worcestershire footprint would be based on total population and funding at a neighbourhood level would be calculated on the basis of various factors.

j.           In response to questions from the cabinet member for health and wellbeing, Ms Brooks: reiterated that the merger into one CCG in Herefordshire and Worcestershire from April 2020 had been approved and costs savings would be achieved; confirmed that significant new funding had been announced recently for Herefordshire and Worcestershire for community mental health, as one of twelve trailblazer sites in England, and outlined how the PCNs would be involved in developing and delivering the new model; considered the running of the NHS 111 helpline service in the region by the West Midlands Ambulance Service to be a positive development, as it would provide a better patient experience and ensure that they reached the right place as quickly as possible; and explained that, in relation to the recently announced temporary winter closures of the Leominster and Ross-on-Wye Minor Injury Units (MIUs), staff running the MIUs were skilled and experienced emergency nurses and would be redeployed to support urgent care at Hereford County Hospital, and Wye Valley NHS Trust had undertaken a dialogue with the affected staff.

k.         In response to questions from the vice-chairperson, Ms Alner said that the application for the CCG merger had been supported in Worcestershire, the potential for joint scrutiny activity between Herefordshire and Worcestershire was a matter for the local authorities concerned, and competing demands would need to be managed but it was emphasised that the CCG was responsible for every single member of the population.

l.           A committee member sought assurance about ongoing local engagement.  Ms Alner commented on the work undertaken on communication and engagement with the council, GPs, and the public.  Mr Stead said that Healthwatch Herefordshire was involved in many of the programme groups and reiterated the need for local engagement in the development of the PCNs.

The chair invited the committee to consider potential recommendations, suggestions included:

§    Formalising the request for further details of the One Herefordshire priorities and outcome measures as part of the future agenda item on ‘Clinical Commissioning Group benchmarking and performance / delivery data’.

§    Exploring the potential to work in partnership with communities as part of the future agenda item on ‘Talk Community hubs’.

A committee member commented that parish councils were not always aware of the opportunities available to them and urged officers to share information with ward councillors to ensure that messages were communicated as widely as possible and communities were engaged fully.

§    Consideration of the legislation that would eventually come forward in relation to ICSs.  The democratic services manager and statutory scrutiny officer commented that this was likely to reflect the direction of travel outlined in this briefing and the legislation may involve more detail than the committee might require.

Resolved: That

(a)       the Clinical Commissioning Group be invited to include details of the One Herefordshire priorities and outcome measures as part of the agenda item on ‘Clinical Commissioning Group benchmarking and performance / delivery data’ due to be received at the May 2020 committee meeting; and

(b)       the potential to work in partnership and improve engagement with communities be explored as part of the agenda item on ‘Talk Community hubs’ due to be received at the March 2020 committee meeting.