Agenda item

The purpose of the report is for the Board to consider implications that there will be a change to the structure of CCGs with one CCG developed to correspond to each of the proposed integrated care system areas. 

Mark Easton provided an overview of the Case for Change from the North West London Collaboration of CCGs (NWL Collaborative).  Commenting on the title he explained that this should be re-titled as it was not a “draft” document.  As the consultation continued, further information would be incorporated as an update.  The deadline of 24 July as the closing date for comments offered a mistaken impression.  Comments on the Case for Change would be accepted up to 24 August, in advance of the CCG governing body meetings planned for September.

The Case for Change reflected London wide and national reform. NHS England required that CCGs indicated their views as to the proposals for CCG reform by the end of September, to feed into changes that will be implemented in April 2020.  CCG governing bodies will consider whether they wish to merge by April 2020.  If they agreed to merge, then GPs will need to vote to determine whether they too agreed to the proposal.  NHS England will then go through an assurance process. It was explained that the NWL Collaborative was now being supported by the newly established NHS London (following a merger of regional offices).  

The proposals for reform were rooted within NHS Long-Term plan (published January 2019), and referenced a significant reduction of CCGs to align with integrated care partnerships (ICPs) over the next two years. It was clear that to not accept reformation was not an option and that there was an expectation that there will be one CCG per STP (sustainability and transformation partnership, now known as integrated care systems (ICSs) area.  There were five ISC areas in London and other than North West London, all of them had declared their views and agreed to accept reformation.  North West London would be the last area to formally declare their position.   

Mark Easton was of the view that the Case for Change would facilitate a better way of understanding how the care and health system will operate in future. Long term, the strategic aim was to promote the evolution of ICSs.  At place or borough local level, this would encompass the development of links within the framework of a local PCN. Work continued to develop innovative approaches to joint commissioning and integrated provision at place based, borough level and this would form the basis of ISCs. There would be a greater emphasis on collaborative work between providers, heading towards integrated partnerships. Preceding this, there would be an intermediate stage which would encourage the development of local partnerships with the local CCGs. A scheme of delegation would be established to allow the new structure to exercise decision making powers, possibly with joint appointments and shared budgets.  This was something that would need to be shaped and developed locally and would be influenced by the quality of existing, local relationships.

Mark Easton explained the differences between what would be commissioned at North West London level and locally.  Specialist services would continue to be commissioned at North West London level and community-based services, locally.

Councillor Coleman sought clarification about the timeframe for agreeing the proposals by September.  He pointed out that the merger guidance produced by NHS England (Procedures for clinical commissioning groups to apply for constitution change, merger or dissolution, published April 2019) advised that the deadline was 31 October 2019 and that there was an option to implement change at the later date of April 2021.  The CCGs were required by NHS England to indicate whether they wished to change by either 2020 or theoretically, elect to merge in 2021.  Mark Easton responded that NHS England sought a response by April 2020, however the legal point was correct, it was technically possible for the CCGs to not respond.

Councillor Coleman enquired about what would be included in the next update.  Mark Easton confirmed that the update would include more detail about the operating model that would exist at North West London and local levels, it would set out how the CCGs would undertake strong engagement, scrutiny, and describe financial structures.  It would also refer to work on-going at London level.

Keith Mallinson felt that reform proposals lacked a mechanism to facilitate democratic, local accountability.  He asked about Healthwatch representation on the combined CCG and what the role of Healthwatch would be, given their statutory powers, and how this would work with regards to governance at a North West London level.  Mark Easton responded that there was no blueprint to explain what the democratic framework would look like.  Engagement on the Case for Change will help formulate ideas, but the final structures would need to be decided. Healthwatch representation, to illustrate, could be determined locally. Public engagement and scrutiny were also being developed and co-produced, to ensure that the patient voice was included.  Vanessa Andreae referred to page 14 of the report and confirmed that in terms of governance, the ICP board will be democratic, accountable and offer a voice for all providers.  The ICP board will also exercise statutory functions, which residents would not want to be involved in.  Representation could include Healthwatch and councils. There would be an emphasis on shifting care to fit patients, but local infrastructures would be established as part of the transition process.

Councillor Coleman asked how a new sub-committee would align with existing structures. Mark Easton explained that the CCGs would delegate authority to the new structure under a scheme of delegation. The intention was to ensure a consistent framework for place-based provision, commissioning services based on best value care and quality of care, that was locally sourced.  Exploring this further, Councillor Coleman asked what the sub-committee would do that would be different from the current delivery model, and what this could look like. In response, Mark Easton stated that the new structure would be the opposite of the current structure, with a single statutory body, operating under a scheme of delegation, commissioning local services. The existing decision-making process would continue but there would be more joined up working within the strategic framework of a single CCG.  The new structure would also seek to put in place certain care quality standards in terms of driving up value.  It was pointed out that much of this work had been on-going for some time and that this current phase was a continuation of a direction of travel that had been followed over the preceding18 months. 

Councillor Coleman enquired about the financial cost of implementing and supporting the sub-committee and to what extent this had been considered. It was understood that there were plans to reduce the management cost envelope for 2021 but these costs had already been significantly reduced.  Cost reductions would not be achieved through a reduction in management in what was one of the most efficient services in the world.

Highlighting concerns about the impact on residents, Councillor Richardson sought further information about the governance arrangements. It was noted that the detail of the next iteration of the document will describe government structures at a local level and set out what could be commissioned at local level.  This will be a more detailed than the Case for Change.  However, it was important to frame the involvement of residents within a statutory framework otherwise this would be lost.  Mark Easton replied that engagement and involvement with patient groups would be embedded within the new structures, but that public engagement could not happen without the involvement of staff.   It was clarified that work on the patient’s citizens panel was being led by Rory Hegarty, Communications Director, H&F CCG. The number on the panel had been reduced from 4000 to 3000 and would be democratically representative, reflecting the local demographic. There had been some delay on the work, as he was currently working on a report covering issue of public engagement on the Case of Change which would shortly be considered by the CCG.

Councillor Quigley referred to a letter from Mark Easton to Councillor Coleman dated 19 June 2019 and his personal view that it was better to progress change swiftly rather than risk uncertainty for CCG staff.  Councillor Quigley questioned why there was a need to move so quickly with the reform when there was an option to delay until 2021, particularly given that he stated in the same letter the need to move at a considered pace.  Mark Easton confirmed that he had expressed his personal view that delaying reform could result in the loss of valuable staff. The key concern was about whether the CCGs were ready to move forward and if the reforms deliverable.  If it was possible to demonstrate that change could be delivered more quickly and safely, then it should be.  A decision was required by the end of September and this was a major change to determine within two months.  This decision had already been taken in other parts of London but had progressed any further along in terms of development. 

Referring to the letter again, Councillor Quigley pointed out that Mark Easton had stated also that he did not make decisions until he was ready to make them and queried again why the decision was being progressed so quickly. It was explained that the North West London area was the last of the five London areas to be taking the decision.  Councillor Coleman responded that the CCG should not be influenced by the pace of decision making of the other London areas and highlighted the Council’s own approach in being an outlier in not charging for home care.  Mark Easton explained that the NHS was a statutory service and that it was not unreasonable to consider the evidence for change in September and then reach a decision.  Councillor Coleman suggested that it should be possible to progress with greater caution, reinforcing agreement incrementally however, Mark Easton was of the view that it was reasonable to align with other parts of London, particularly if this meant retaining staff. Vanessa Andreae observed that staff had been affected by the proposed changes and uncertainty. The NHS had signalled change and it would better to navigate the reforms whilst retaining good staff.  Further, Mark Easton and his team had been extremely sensitive in their dealings with the CCG and its governing body. 

Olivia Clymer commented that Healthwatch would be articulating its concerns regarding the progress of the reform and highlighted that there were particular issues around assurance and quality, and what this would look like at a local level.  Healthwatch welcomed details about the proposals for a new sub-committee but given that the statutory framework remained in place, the absence of a legislative driver needed to be addressed, together with the logistics. The Case for Change was not being driven by a white paper or policy document and Mark Easton offered assurance that the role of Healthwatch would not be revised and that they would be represented on the sub-committee.  Olivia Clymer observed that the pace of change was a challenge, particularly in respect of the timely receipt of documents.  It was clarified that while this did not prevent Healthwatch from engaging, it was a challenge to provide appropriate and timely commentary.   It was noted that this was addressed, in part, with the now bi-monthly meetings of the CCG and the Chair of Healthwatch, Christine Vigers had been in dialogue with the CCG about this concern. Olivia Clymer suggested that if papers were issued earlier, this would allow more time for Healthwatch to comment. 

Merrill Hammer, Hammersmith and Fulham Save Our NHS (HAFSON) observed that the proposals had been regarded as a management decision that would not impact on residents, a view that she disagreed with.  The recent Joint Health Overview and Scrutiny (JHOSC, 21 June 2019) had made the point that members were being invited to comment on partially formed proposals.  She continued that as a member of the public, there was little opportunity to comment on the proposals which had been drip fed or to ask questions about them, replicating the uncertainty and lack of engagement that had existed with Shaping a Healthier Future (SaHF). 

Addressing this comment, Mark Easton responded that SaHF was about a service reconfiguration strategy that involved change over a ten-year period and changes to local hospitals.  This was not a proposal for service change, it was about how the NHS better integrated itself with partner providers and moved away from commercial partnerships. The NHS genuinely listened to comments from Healthwatch and local government colleagues.  Accepting the point about the fragmented release of information, he explained that the intention had been to put forward ideas that were emergent and could be shaped by the views being put forward. It was acknowledged that this approach made appear as though the CCG would come to each meeting with something new, but the aim of this was to gather information and views to shape proposals.

Lisa Redfern referred to a recent workshop held with senior staff and which Mark Easton had viewed as being ‘useful’. It was stated that in her view, the workshop had not provided further clarity and little detail about the Case for change.  She enquired why it was not possible to move forwards with reform without changes to the management structure.  Mark Easton observed that the workshop had been an opportunity to co-design proposals with local government colleagues as to what would be appropriate at the North West London Level. 

Mark Easton was asked by Councillor Coleman to highlight what the CCG was going to differently, following the workshop.  He explained that the CCG valued opportunities to undertake public engagement and that the workshop had facilitated preliminary consensus, dialogue and engagement as to what could be agreed at the North West London level and locally.  He reiterated that this was an opportunity to hear other views and use these to shape proposals. Decisions were currently delegated up and this will reverse the decision-making model.  One of the key decision-making elements of the NWL Collaborative was that if one CCG disagreed, then alternative options would have to be considered.

Councillor Coleman sought reassurance about how patients will be consulted. There had been no information about this in the paper to indicate how this would happen, other than the Citizens Panel.  Councillor Coleman compared this to a large focus group and asked about the format and decision-making structure.  Mark Easton felt unable to provide full details about this as Rory Hegarty, who was leading on this work, was better placed to provide the details of how this would be established. He confirmed that Citizens Panel would represent the local demographic and allow the NWL Collaborative to test out views.  The Citizens Panel would not be a decision-making body and would have no statutory powers to take decisions. 

Councillor Coleman referred to NHS guidance on engagement and consultation on changes to specialist services, where there were different commissioning arrangements proposed or, for example, when a service relocated from one borough to another. It was confirmed that the NWL Collaborative would continue to commission acute and mental health services and that, by this example, there was such a service change, then this would be reviewed by a joint health overview and scrutiny committee, which could be formed by agreement between the boroughs involved.

Sue Spiller commented on level of engagement with third sector, voluntary providers by ICPs, which had been difficult.  Mark Easton agreed with the view that this should be less clinically led, rather than financially driven.  He continued, that if the CCGs were to decide that they were not ready to make this change, then they will not decide on the issue.  It was noted that there would not be a fully developed ICP in place by April 2020 or 2021, which were currently being formulated.  Based on good examples of new structures that had been already established in areas such as the West Country and Somerset, Mark Easton observed that the success of the changes depended on the nature of the local relationships.  Those with well-developed local links will move forwards fastest.  Janet Cree concurred and said that it was essential to build links into the ICP, so that they could make the most of opportunities such as social prescribing.

Jim Grealy drew comparisons with the reformation of the Inner London Education Authority.  He commented that he had attended three of Mark Easton’s presentations discussing the changes, but greater clarity was still required. Working together was a matter of trust.  Jim Grealy continued that 2.5 million people were being asked to consider a set of complex ideas.  He suggested that it would be better to take the ideas and structure them in September, then advise NHS England of their intentions to plan for 2021 following full consultation. It was better, in his view, to not move quickly and work to get it right for 2021, taking along staff as it progressed.  He cautioned that the alternative would be to engender further resentment with colleagues in local government and the voluntary sector who had not been adequately consulted.  Mark Easton reiterated his earlier view but acknowledged that this was a fair point.  He added that it might also be possible that the CCGs in September concluded that they were not ready. He agreed with the concept of taking people with them but there was also a concern that not moving quickly would mean the loss of able staff as they applied for alternative employment.  The NWL Collaborative hoped to promote something that was federated and decentralised with local decision-making.

Councillor Coleman commented that he struggled to understand the proposed structure and how this was substantially different from the existing structure.  If the aim was not to save costs, he asked what the point was of having a new sub-committee. This was not set out clearly in the business case which lacked detail. Mark Easton replied that the reforms should be considered in the context of what difference these would make to patients. He genuinely believed that patients suffered from multiple hand offs, and that they would benefit from integrated care and seamless transitions, for example, better information systems, using common databases, leading to seamless arrangements for patient discharge.  He was committed to promoting this way of working both strategically and locally.

Lisa Redfern concurred with the idea of having integrated patient pathways but explained that there was little to prevent the formation of integrated care systems now. This was about shifting culture, which was easier to achieve in terms of small-scale structures. She queried the point regarding enhancing the provision of support for patient hand offs and it was clarified that this was about the acceleration of partnerships for ICS.  There were currently eight different systems for discharging patients, with differences varying from borough to borough. Integrated working made it easier to have conversations about delayed discharges. 

Councillor Coleman questioned the need for a merger of the CCGs, given that it was possible to develop a mechanism to ensure that standards were consistent. Mark Easton explained that different services were organised respectively at either North West London or local level and that it was about what level of organisation was appropriate at policy level. Lisa Redfern pointed out that organising a joint approach encompassing three to five local authorities and CCGs, was an effective structure which was already working towards merged services and cited the example of the Community Independence Services (CIS), which had been awarded excellent.  The premise of the CCG argument was that a merger would be of benefit, but in her view, what would be the purpose of having a large CCG, when there was already ongoing work to improve integration or collaboration.

Councillor Culhane enquired about working with stakeholders.  Following the earlier education themed analogy, he cited the example of academies and local government advisory boards and reorganisations which had resulted in the loss of well-regarded head teachers.  Councillor Culhane cautioned against an approach that might have a similar impact and asked what would be in the next update and if this would set out the detail of how the NWL Collaborative would work with the ICP.  Mark Easton responded that what they were doing was in the opposite direction of educational reform, rejecting the market and making stronger, strategic plans with the intention to redirect spending back into the NHS.  The next document would set out the role of the sub-committee, the interface with the CCGs and the structure of local delegation. 

The next publication was expected in July and the decision as to whether these would be held in public was not ruled out by Mark Easton although it was noted that this not a matter for him to determine.  Meetings would continue to rotate between different London boroughs which will help foster engagement with local authorities.  Each would be supported by a local team and led by a lead clinician.  How firm this plan was would be determined in the next publication.

Councillor Coleman summarised the discussion by describing the possible challenges of taking a decision in September and the concerns about moving at pace with insufficient detail and whether this had given any encouragement to pause the process.  Mark Easton referred to his letter of 19June and paragraph that had earlier been read out by Councillor Quigley.  A further query from Councillor Coleman established that the CCG had received legal guidance from colleagues who had consulted lawyers and that the legal framework had been discussed.  While Mark Easton acknowledged Councillor Coleman’s point about this being, in part, the opposite of localism, mergers had already taken place across the country.  It was confirmed, however, that legal advice had not directly been sought and that the NWL Collaborative was not aware if other CCGs had sought legal advice.

Councillor Quigley reiterated her concerns about the impact of the reform on residents in the Borough, regardless of whether the changes were implemented in 2020 or 2021, this would have a significant impact on residents. She asked if residents will have to travel to access services in future.  Mark Easton confirmed that there was nothing within the proposals that indicated that residents would have to travel to access services.  Councillor Coleman asked if this could be guaranteed and Mark Easton confirmed that yes, this was guaranteed.

Councillor Coleman referred to an earlier comment from Mark Easton regarding the fact that initially, budgets might be separate but may later be merged.  Mark Easton confirmed his opinion that the process that they were engaged in was work in progress and that it would test out agreement on services.  In his opinion, it was unrealistic to move services unnecessarily.  In terms of what could be guaranteed, Mark Easton explained that the reaction to the changes will form the basis of the Case for Change, but it was notable that there had existed a history of CCGs lending funds to support other CCGs.

It was understood that a provisional timeline had been mapped out and that Mark Easton would be on annual leave from 13 August, returning on 10 September, the day after the next meeting of the Board. Councillor Coleman asked if there was time to have a second round of discussions.  The Board was keen to work with health colleagues, but it was important that this intent was reciprocated.  Councillor Coleman commented that the compressed timeframe, which did not involve patients, was not helpful in terms of progress.  He acknowledged that it was helpful that the NWL Collaborative was willing to countenance other ideas, there was not sufficient time to have proper engagement.  Councillor Coleman was not convinced that there was sufficient detail to support the concept of a merger, although it was helpful to have ideas to shape the process.

Councillor Coleman asked how confident Mark Easton was that the concerns raised during the discussion might delay the process.  Mark Easton repeated his earlier comment that a decision would have to be reached in September as to whether the merger might take place, and, whether this would occur in 2020 or 2021.  It was pointed out that there was nothing to force compliance, however, Mark Easton repeated that there was an expectation from NHS England that the NWL Collaborative will advise them of their decision in September.

In terms of the NHS policy guidance on the merger, Councillor Coleman pointed out that if the CCGs decided to not merge, any application received after 31 October will revert to a single organisation and would therefore have longer to develop plans to merge. It was also pointed out this was another reason to allow more time.  In addition, there was also no specific directive to have a CCG that was co-terminus with an ICS, so North West London could have two ISCs and two CCGs, in theory.  It was conceivable that there could be several different borough-based configurations of CCGs, but the paper made no reference to the potential number of CCGs that might be possible.  Mark Easton accepted this point but typically, there would be one CCG per area and a strong case would need to be made in order for an atypical configuration to be agreed.  He outlined two possible scenarios:

1.    Some boroughs may conclude that there was a strong argument for having a bi-borough arrangement; or

2.    In terms of CCG merger configurations, it was possible that, example, there could be a 6/2 split of CCGs, and that two CCGs could later decide to join the other six.

The above scenarios where possible outcomes in theory, but Mark Easton felt that this would unpick all the work that had taken place around the NWL Collaborative and there could be little appetite for this. Comments on the merger could be submitted up to 24 August. 

Councillor Coleman thanked Mark Easton for his attendance but remained unconvinced by the Case for Change. Councillor Coleman also highlighted the fact that the timeframe might not be sufficient given that papers would need to be circulated a week in advance to the CCGs.  It was accepted that substantive comments would have to be provided well in advance.

RESOLVED

That the report be noted.