Agenda item

The Committee is asked to consider a letter from Dr David Wingfield, Chairman of the Hammersmith & Fulham General Practice Federation (Appendix 1); and subsequent response from Clare Parker, Chief Officer, Hammersmith and Fulham Clinical Commissioning Group (Appendix 2). 

Dr David Wingfield briefly outlined concerns set out in a letter from the GP Federation to the CCG, and their subsequent response (included as Appendices 1 and 2, respectively).  The GP Federation had worked closely with the CCG.  Dr Wingfield explained that in addition to leading three practices in the Borough, he had also been a resident for 25 years.  The practices were an intricate business, with a cash limited budget funding nursing and GP services which could not be over-extended.  Local funding had historically been low and a “catch up” programme of investment was in place to address this. Dr Wingfield queried with the CCG the slow pace of delivering investment.  The GP Federation had worked with the CCG to develop the Primary Care Strategy (published September 2017) but felt that there had been lost opportunities. 

Janet Cree referenced the CCG letter of response from Clare Parker, Accountable Officer, NWL CCG, and affirmed that the CCG continued to work closely with the GP Federation.  This had been a challenging year and the first year in which the CCG had received primary care delegated funding. They had worked hard to discharge their responsibilities as efficiently as possible.  Considerable progress made and approximately £1.134 million had been spent. Collectively, she felt that good progress had been made.  £600,000 was committed to ensure sustainable primary care, as set out in the Primary Care Strategy, and continued to be a priority.  It was a challenge to ensure that accountability remained and that money was being invested for the benefit of the intended recipients.

Councillor Carlebach sought clarification about the distinction between the role of the CCG and that of GPs, with the CCG as commissioners.  Janet Cree explained that the CCG comprised of member GP practices, with a governing body having oversight of commissioning.  GPs were also providers, delivering primary care services to patients and the GP Federation covered the provider aspect, with the CCG having delegated powers to delivery primary care. 

Councillor David Morton sought clarification regarding the headroom fund 2017/18 and whether it need to be spent this financial year and what the financial risks were if it could not be carried over. Janet Cree responded that there was a plan to spend the money within the financial year. 

In response to a question from Bryan Naylor, it was explained that £1.34 million of the budget had been allocated. While he appreciated the complexities, Bryan Naylor observed that nine months into the financial year, very little of the money had been received. Janet Cree explained that the CCG were currently awaiting invoices from GP practices.  £605,000 had been allocated but the CCG awaited the receipt of invoices, before funds could be released.  To date, £190,000 had been paid, the precise detail of which she did not have but could be provided.  Janet Cree disagreed that funding had not been allocated or spent, and clarified that the areas highlighted in Dr Wingfield’s letter had been agreed as the focus of the investment. 

Acknowledging Dr Wingfield’s comment that home care and complex care were not separate from the proposals, Bryan Naylor sought further clarification as to why the funding had been delayed for 9 months. Vanessa Andreae explained that headroom money must be seen in context with primary care strategy and that the CCG had been waiting for this to be allocated and flow.  She continued, recognising the frustration this caused, but stated that it took time to get practices to work together.  The CCG could not impose practices on GPs, they must work together.

Jim Grealy welcomed the discussion initiated by the GP Federation and Dr Wingfield on the provision of primary healthcare to residents in the borough.  He appreciated that there was a flow of money but pointed out that key decisions were not being made in the Borough, but elsewhere.  Citing the example of Ealing, which had rolled out funding and with the on-going winter crisis, he did not feel confident.  He suggested that the GP Federation draw up a list of what they wanted to achieve in the Borough. 

Dr Tim Spicer, Chair, H&F CCG, conveyed how the CCG had worked hard with the GP network to deliver a joint primary care strategy.  They had achieved something that very few other CCGs had done, developing a strong and mature network. Vanessa Andreae added that primary care commissioning would remaining localised, with any conflicts managed through a local conflict resolution committee.

Jim Grealy reiterated his earlier view and observed that he found it impossible to explain to members of the public why money had been allocated so late in the year.  The winter crisis was an anticipated annual occurrence that could have been planned for utilising this funding.

Victoria Brignell concurred with this prevailing concern and asked, with two months to the end of the financial year, how easy would it be to spend in the intervening period.  She asked how funding would be invested in staff and how this recruitment would be managed.  Janet Cree confirmed that money was being invested in both primary care and in staff, with £600,000 committed in 2017/18, which would continue into 2018/19.

Dr Wingfield emphasised that the formation of GP networks was a model that had gradually been built up in the last 7 years.  The pace of development this year had increased notably. However, the pace of collaboration and of investment had not aligned.  Responding to an earlier reference to staffing, he explained that to recruit short-term staff to release other staff for long term projects was not an ideal approach, advocating a preference for permanent staff.

Councillor Coleman considered the allocation of £1.35 million, noting that approval was being sought for approximately £588,000 and sought clarification as to whether the budget for 2017/18 would be rolled forward into 2018/19.  Vanessa Andreae confirmed that there was a shortfall of £170, 000 for the current financial year, but reported that there would be further allocations at a future committee meeting.  The pace of work had been rapid but everything would be put in pace in place by October 2018.  Councillor Coleman asked how long it would be before the £1.3 million would be spent.  Janet Cree reiterated that the allocated funding was public money, requiring appropriate governance and approval mechanisms.  There was an expectation that invoices would be provided by GPs in the coming months.

Dr Wingfield, in response to a follow up query from Cllr Coleman, contended that it was difficult to estimate the possible time it required to “spend” the allocation.  This was late in the day, given the combined concerns of recruitment, delivering care, and measured outcomes. Dr Wingfield added that he thought it unlikely that the money could be spent and that they would be doing well to have spent half of this by March 2018, with the added caveat that some of the work needed was to lay foundations for new ways of working.  Some of this work would not see outcomes by March and part of the discussion with the CCG was to identify what those outcomes were.

In response, Janet Cree explained that there was an assessment process to evaluate bids, which was partly the reason expenditure had been part of the budget setting process, accepting that some submitted bids were not achievable.  Recognising the inherent challenges, she felt confident that the £1.35 million could be spent.  A primary care commissioning committee was due to meet on 13^th February, and she acknowledged that there remained some governance procedures to conclude.

Discussing the possibility of a further meeting to review if the money had been spent, Councillor Morton suggested that it would have been helpful to have had this considered by the Health and Wellbeing Board (HWB).  Councillor Coleman confirmed that this issue had arisen after the last meeting of the Board (November 2017).  Janet Cree provided further context and clarified that the issue was about delivery of the primary care strategy and that the subject had been fully discussed at HWB.  In a wider context, this was also a North-West London governance issue.  Decision making about primary care was local but there was a broader, budgetary process to consider.  Primary care was not sufficiently robust to meet Sustainability and Transformation Plan (STP) needs and required further modelling and a wider strategic discussion.

Merrill Hammer (Save Our Hospitals campaign) asked what the alternative would be if the entire spend was not utilised and whether the CCG would have to account for monies not spent.  Janet Cree explained that overall, they were currently forecasting to be on budget, with support from other CCGs and that they were not in an underspend position.

Councillor Vaughan speculated that some invoices for work already commissioned up to £1.35 million had been issued and expected that this would meet targets out of the headroom fund. Janet Cree explained that they were working on the implementation of the CCG programme of investment in general practice, meeting regularly with GPs.  The actual mechanism was working and the question of headroom would occur next year, with the process commencing earlier. 

Councillor Coleman asked whether funding could be invested in the Community Independence Service (CIS).  Janet Cree replied that the CCG was already investing in primary care and although she could not commit primary care money to the CIS, the CCG would be happy to work with the Council on this.  Lisa Redfern, Director ASC added that they were already working with the CCG on homecare, providing services for the vulnerable and elderly. ASC was well placed to assist and she confirmed that they would be happy to continue to work with the CCG.

Kim Dero, Chief Executive, LBHF, sought clarification about the submission of invoices and asked whether activity had already commenced and if there was an expectation that GPs will be delivering this in the next 6 weeks or if it would continue into the coming financial year. Janet Cree confirmed that it would be a combination of the two. Responding to a follow up question regarding the percentage of the funding pot that had been allocated and how much was going to be spent, Janet Cree confirmed that these figures could be provided.  Vanessa Andreae added that some of this was about setting up processes for next year, so work was in train for 2018/19, and, about practices organising themselves to deliver in the next financial year. 

In summarising the key points of the discussion, Councillor Vaughan observed that there were inherent difficulties in allocating funds, noting that both the CCG and the GP Federation had worked diligently to resolve this, recognising the additional concerns and pressures about the process and time taken to reach this point.  It was agreed that this would be brought back for further discussion at a future meeting. 

RESOLVED

That the report be noted and the issue be reviewed at a future meeting.