Agenda item

The Select Committee will receive a presentation on this item from Jane Shayler and Dr Ian Orpen.

The Director for Integrated Health & Care Commissioning gave a presentation to the Select Committee. A copy of the presentation can be found on their Minute Book and as an online appendix to these minutes, a summary is set out below.

National and local context

•  Future arrangements for commissioning and delivery of services are changing

•  Recognition of  benefits of working more closely with the Council to join up services locally

•  Desire to secure ongoing clinical leadership and develop place-based approaches

Key terminology

•  Neighbourhoods (30k-50k) – Groups of GP practices coming together e.g. primary care at scale, Primary Care Home models 

•  Place (250k-500k) – In line with Council boundaries - integration of primary, secondary and social care

•  Systems (1million +) – Like Strategic Health Authorities - self-regulating with 7-8 regions nationally each covering populations of  5-10m

The plan for B&NES

From 1 April 2019:

•  One team made up of CCG and People & Communities directorate

•  One management structure

•  One integrated commissioning and delivery function for health, social care, children & young people’s services and education transformation

What does this mean?

•  Pool or align all commissioning budgets

•  Create a new governance structure

•  Co-location of staff (over time) 

Case study: Joint Agency Panel

•  Funding packages for individuals with a high level of needs

•  Combined resources allocated to meet individual requirements

Our organisations in numbers

•  Council: 700 employees work in People & Communities / £85m budget (75% of overall Council budget)

•  CCG: 75 employees / £261m budget

Three groups

•  Group A – Integration (inc. commissioning, quality and safeguarding) – Formal consultation on new structure for some departments in September whilst options are still being considered on others.

•  Group B – Centralisation – Mapping exercises underway, timescales vary.

•  Group C – Delivery – Savings plans and change processes already underway (independent of integration programme).

Engagement activities

•  Online survey / Lunchtime drop-in events

•  Team meetings / Interviews with senior managers

Key themes – positives

•  Emphasis on staff training & development

•  Joining up IT systems

•  Key values: open, honest, supportive, positive, curious, inclusive, understanding each other

Key themes – challenges

•  Too high-level, more detail required

•  Capacity to deliver multiple change programmes

•  Some groups fearful of being overlooked:  Children and young people’s services /  Social workers /  Clinicians

Governance arrangements

•  Dual decision making process, both with a formal vote.

•  Meeting in shadow form currently, public meetings from end of 2018 / early 2019

•  Observer status intended to be similar to the arrangements for the Health & Wellbeing Board

Fitting the pieces together

•  Transfer of some commissioning functions to Virgin Care

•  The Council’s ‘Changing Together’ Programme

•  Council & CCG Integration Programme

•  Commissioning at scale across B&NES, Swindon and Wiltshire (STP)

Councillor Lin Patterson asked if any loss of staff was planned as part of this process.

The Director for Integrated Health & Care Commissioning replied that none was anticipated. She added that she recognised that there may be anxiety among staff, but that engagement and communication was taking place with them on a regular basis.

Councillor Patterson asked how often the Select Committee could be updated on the process.

Councillor Pritchard replied that they could have updates as often as they deem appropriate.

The Director for Integrated Health & Care Commissioning added that an update could come in the regular form through their standing items from the CCG and the Cabinet Member and a formal report could be scheduled for November 2018/ January 2019.

Councillor Tim Ball commented that he felt that the work of Social Workers and Clinicians must be kept separate to prevent any lack of clarity of statutory responsibilities and that good governance must be in place to ensure that the Council continues to meet its statutory responsibilities. He suggested that Dr Orpen and the Director for Integrated Health & Care Commissioning brief all political groups on this process.

Councillor Pritchard agreed with this proposal and said that arrangements would be made for some cross party Councillor briefings to be held.

The Director for Integrated Health & Care Commissioning added that in respect of ensuring that the respective statutory requirements of both the Council and CCG continue to be met in respect of safeguarding and quality, both the Council’s Director of Safeguarding and Quality, Lesley Hutchinson and the CCG’s Director of Nursing and Quality, Lisa Harvey both have an important role.  She confirmed that both the Council and CCG are carefully considering the governance arrangements that must be in place, including those that ensure that both organisations’ statutory responsibilities are clear and continue to be met.

Councillor Ball asked who staff will report to following integration.

The Director for Integrated Health & Care Commissioning replied using her own example that in terms of people in integrated or joint roles she has signed a Section 113 agreement that allows her to perform a dual role for both the Council and the CCG. She added that she is accountable to both organisations through the Council’s Corporate Director, People and Communities, Mike Bowden and Tracey Cox, the CCG’s Chief Officer. She stated that any statutory responsibilities cannot be transferred to the partner organisation.

In response to questions about single assessment, she said that a Trusted Assessor Model is being introduced to ensure timely discharge to care home placements. She explained that this is where one person / team undertakes an assessment on behalf of a number of organisations/disciplines, using agreed criteria and protocols.  This approach has been implemented in a number of other areas and is proving successful in reducing the timescales and removing “blocks” that can delay discharge from hospital.

Councillor Geoff Ward asked if integration between the Council and CCG would be a final position for the local commissioning and delivery of Health & Social Care.

The Director for Integrated Health & Care Commissioning replied that this work builds on the success following ‘Your Care, Your Way’ and has been the direction of travel for a long time. She added that it may be appropriate to undertake some commissioning, for example of specialist cancer services across a wider footprint, such as B&NES/Swindon/Wiltshire Sustainability and Transformation Partnership but prevention, early intervention and early help would continue to be primarily commissioned and delivered at a Bath and North East Somerset level, including through integration.

Councillor Ward asked in the context of keeping the public healthy with regard to obesity, drugs, alcohol and age, is there a conflict between surgical procedures and advice / change of lifestyle.

The Director for Integrated Health & Care Commissioning replied that she felt a change is occurring and that clinicians were moving away from recommending surgical intervention and thinking, instead, about how people are supported and enabled to improve their health, through, for example, lifestyle changes.

Councillor Patterson asked if there is parity between the physical and mental health needs of residents.

The Director for Integrated Health & Care Commissioning replied that the work of the Mental Health Pathway Review, which sits under the umbrella of Your Care, Your Way is considering how to further integrate and join up physical and mental health services and, also to promote positive mental health and wellbeing.  This includes ways of addressing loneliness and isolation, maintaining and accessing employment and skills development and facilitating partnership work between the wide range of organisations providing mental health and wellbeing services in B&NES.  In terms of integrating mental health services with physical health services, the Mental Health Pathway Review is also looking at how, for example, there is close working between Primary Care working on a local level, in communities with Avon and Wiltshire Mental Health Partnership NHS Trust (AWP), which works.  AWP currently work across multiple CCGs and six local authorities, including B&NES.

She said that AWP and Virgin Care are seeking seamless pathways for required services and that Oxford Health, who provide services through CAMHS are working towards further joint working with AWP, Virgin Care and Primary Care.

Councillor Patterson commented that she would like to request that consideration be given to funding a local Post Traumatic Stress Disorder (PTSD) support group.

The Director for Integrated Health & Care Commissioning replied that she could not comment directly on the proposal, but acknowledged there may continue to be some gaps in the provision and it is important to consider how these specific needs, including of those people with PTSD can be met.  However, it is the case that resource constraints remain in place.

Councillor Lizzie Gladwyn said that she welcomed the idea of patients only having to share information once, but had similar reservations to those raised by Councillor Ball in terms of the roles of Social Workers and Nurses and ensuring that these are clear and recognised as different and of equal value.

The Director for Integrated Health & Care Commissioning replied that the context of the scenario would be taken into account, but the approach in most cases would be for a single assessment. She reminded the Select Committee of the ‘Three Conversations’ model that seeks to avoid any formal assessment.

She said that the challenges around this new approach are recognised and that the Council will need to ensure that eligibility assessments for statutory care continue to be undertaken by an appropriately qualified individual and that the Council ensures that its statutory responsibilities are met.

The Chair thanked the Director for Integrated Health & Care Commissioning for her presentation on behalf of the Select Committee.