Meeting documents

Health Scrutiny Sub-Committee (DCC)
Thursday 16 March 2006


            Meeting: Health Scrutiny Sub-Committee (County Hall, Durham - Committee Room 1a - 16/03/2006 01:00:00 PM)

                  Item: A2 Consultation:Proposals for Primary Care Trusts, New Strategic Health Authority and New Ambulance Trust (a) Report of Strategic Health Authority (b) Report of Head of Overview and Scrutiny


         



Ensuring a Patient-led NHS Consultation update
as at 1 March 2006
1. Introduction

This paper provides an update on the consultation process in terms of the number of meetings held to date and the common themes and issues that are being raised in meetings and responses received to date. Many of the concerns relate to the arrangements for providing a local focus within larger PCTs, if this is the decision of the Secretary of State, and there have been many requests for more information on how this would work. Whilst it is recognised that if larger PCTs are set up, the decisions about management arrangements and approaches would rest with the new chief executives, the SHA is giving thought to what expectations there would be of the new PCTs. This paper therefore sets out the current thinking on these expectations in relation to local focus and provides some brief illustrations of what this could mean in practice. This work will continue to evolve and change over the coming weeks and it is very important to receive these ideas in this context.
2. Consultation meetings
Meetings CDTV Total across NE
Meetings arranged to date CDTV: 40 Total: 78
Public meetings CDTV: 16 Total: 24
Others CDTV: 24 Total: 54
Meetings attended to date CDTV: 28 Total: 54
Meetings remaining CDTV: 12 Total: 24


Six additional public meetings have been held/arranged in County Durham and Tees Valley in response to requests from local councils or PCTs - Stanley, Barnard Castle, Loftus, Redcar and two public meetings held on Teesside that focused on the proposed changes to the ambulance trusts.


‘Other’ meetings include meetings with OSCs, voluntary and community sector, trust board meetings, local authority meetings, Local Medical Committees.

All the meetings have covered all three elements of the consultation. However, the proposals for the future configuration of PCTs have generated the majority of comments and questions in all the meetings. This report therefore concentrates on this part of the consultation.
3. Common themes in relation to PCTs identified as at 1 March 2006 from responses received to date, public meetings and other local meetings

Whilst a wide variety of views and comments have emerged during the consultation so far, there are some areas that have recurred consistently.

People are concerned about how larger PCTs would address the following:

  • Partnership working with local authorities and other local stakeholders, particularly in relation to
  • improving the health of the population
  • implementing the White Paper ‘Our health, our care, our say: a new direction for community services’
  • meeting the needs of a number of client groups through joint commissioning
  • meeting the needs of a number of client groups through integrated service delivery
  • making the best uses of available resources, eg through shared capital developments
  • Using Local Area Agreements (already in place in some areas) as a vehicle for the agreement and delivery of these objectives.
  • Clinical engagement with primary care to enable the effective implementation of Practice Based Commissioning
  • Patient, carer and public involvement
  • Working with the community and voluntary sector.
People are also keen to know how the management savings would be made and how they would be invested in patient care. Concern has also been expressed about how resources allocated to existing PCTs to meet the needs of specific populations, could be protected in the future.

4. Responding to issues raised to date in the consultation

The Department of Health, supported by all PCTs across the North East, has identified the need to reap the benefits of strengthened and improved commissioning. There is an equally strong need to identify a way for larger PCTs to have arrangements in place that would enable the continued development of the good work and effective relationships currently in place at local authority level that are resulting in tangible benefits for local people and organisations.

If the decision by the Secretary of State for Health at the end of the consultation is to establish four PCTs for the North East, the decisions about the organisational structure of those PCTs will be made by the new chief executives of the PCTs and it is not appropriate to pre-empt these decisions. However, given the concerns coming through the consultation process to date, work is ongoing to identify principles and outcomes from a local focus within larger PCTs that the SHA, as the organisation responsible for the strategic overview of the NHS in the North East, would expect to be delivered through locally agreed arrangements, if larger PCTs are established.

Given the different circumstances and needs within the four areas that would be covered by the larger PCTs, including the needs of rural communities, it is unlikely that the same arrangements would be appropriate for all four areas. However, there are some key principles that would be applied to all the PCTs to underpin their work with local partners.
1. All the PCTs would have to deliver locality working as well as the other requirements of a PCT fit for purpose to deliver a patient-led NHS. The PCT would have to do this within the management cost ceiling identified for that organisation after the required management savings have been made.
2. The detailed arrangements would have to be designed and established in consultation with, and have the support of, the relevant stakeholders.
3. Governance arrangements would have to be agreed that achieve the right balance between the needs of localities and the overall objectives of the PCT. For example, meeting the needs of localities cannot be allowed to move the PCT as a whole, off course from delivering financial balance. There would therefore have to be an explicit agreement on the ‘give / get’ relationship between the localities and the PCT as a whole - ie the locality structure has to contribute effectively to the PCT’s achievement of its core responsibilities and corporate governance and the PCT as a whole has to give a commi Governance arrangements would have to be agreed that achieve the right balance between the needs of localities and the overall objectives of the PCT. For example, meeting the needs of localities cannot be allowed to move the PCT as a whole, off course from delivering financial balance. There would therefore have to be an explicit agreement on the ‘give / get’ relationship between the localities and the PCT as a whole - ie the locality structure has to contribute effectively to the PCT’s achievement of its core responsibilities and corporate governance and the PCT as a whole has to give a commitment to providing sufficient support to localities to deliver the areas identified above.
4. The effectiveness of the agreed structure would be subject to regular review to ensure it continues to be fit for purpose and consistent with the overall strategic direction for the NHS in the North East.
5. Maintaining a local focus and building partnerships for the future

It is very important to be clear that the ideas set out below are illustrative in order to provide a sense of what a local focus might mean in a larger PCT. The decisions about what arrangements would be established would be taken by new chief executives in conjunction with local partner agencies.

Arrangements to ensure an effective local focus would need to deliver, as a minimum, board level connections with local authority areas to provide a direct connection between the decision making of the PCT and the local authority areas, with the overall goal being health improvement.

In relation to clinical engagement, a similar arrangement could be designed between the professional executive committee (PEC) and the practice based commissioning groups. At local level, there would be a need to establish a relationship between the PBC groups and local arrangements for working with other key stakeholders and local communities.

There would be different ways of providing support to deliver effective locality working and this may depend on the resources in terms of management costs available to the organisation.

The extent of partnership working within PCT areas would be spread along a continuum, depending on a number of variables including the maturity of relationships and congruence of agendas and priorities. This continuum could extend from cooperation between agencies on some areas of work right through to co-ownership and the integration of some PCT functions and responsibilities with those of the local authority. At this level the approach could include integrated commissioning arrangements, including joint needs assessment and joint planning, an integrated quality assurance process and performance management function and also joint workforce plans in some areas of service provision.

6. Working with local authorities

In order to continue to progress the areas of partnership working with local authorities set out in section 3 above, the PCT would need to ensure that it could continue to identify resources available to meet the health needs and improve the health of specific populations. They would need to be able to do this in terms of resources available for commissioning and providing services that need to be locality focused and there would be a need to identify management resources to support this locality working.

In relation to health improvement, there is no requirement for a one size fits all approach to public health delivery in localities and each PCT will take a view as to how this will be best achieved. It is anticipated that each PCT will have a Director of Public Health accountable for public health delivery but also a named public health specialist for each Local Authority area to lead the provision of public health services in collaboration with partner agencies.
This will allow public health specialist input into commissioning of services and also allow public health provision to be locally sensitive, building on existing partnership arrangements. Tackling health inequalities remains a national priority and will be addressed both locally, and regionally through more integrated work between SHAs and regional public health groups.

7. Engagement with primary care clinicians

This element of partnership working is crucial for the development of practice based commissioning (PBC) which will be central to successful commissioning in the future. This is particularly important for the implementation of the White Paper on community based services and to provide important links within local areas with local communities. If provided with the right support and effective links to broader strategic development within PCTs, for example joint working with local authorities and patient, carer and public involvement, it has the potential to be the key mechanism to deliver the four key goals of the White Paper
  • Early intervention
  • More choice
  • Tackling inequalities and improving access to community services
  • More support for people with long term needs.
PBC therefore has to be central to the PCTs’ commissioning strategies and structures and the right balance of local and central support will be necessary to achieve this. This would require a structure to support the continued development of clinical engagement and the implementation of PBC that would deliver a balanced investment and development programme to meet the PCT wide Local Delivery Plan (which includes national targets) and PBC group commissioning intentions.

8. Patient, Carer and Public Involvement

It is clear from the responses in meetings held so far as part of the consultation that the relationship between the existing PCTs and the various routes for patient, carer and public involvement, including the patient and public involvement forums, are valued by the PCTs and groups alike. Messages about the importance of having a voice at a very local level and being able to connect with the senior management of the PCT are coming through clearly. There is a national review of patient and public involvement under way and future arrangements will need to respond to the outcome of this review. However it is clear that within the new national framework, larger PCTs would need to design structures that enable effective two way communication between local communities and the most senior levels of the PCT. It is this level of access and influence that is greatly appreciated now and new PCTs would have to give a commitment to find ways of continuing to achieve this and ensuring there is effective involvement at every level of commissioning and delivery. The NHS is very aware that local authorities have been working on effective local engagement for many years and there would be obvious advantages to connectin g patient, carer and public involvement with the community engagement arrangements established by local authorities to support the development and implementation of community strategies and LAAs.

9. Working with the community and voluntary sector

There are two aspects of working with the community and voluntary sector that would need to be recognised within the ways of working of larger PCTs - as providers of services and as sources of advocacy and support for specific client groups. It is vital therefore that as the larger PCTs establish their mechanisms for ensuring the development of PBC within their overarching commissioning framework and influential patient, carer and public involvement, they incorporate effective working relationships with the community and voluntary sector. This would include the involvement of the sector in strategic planning, commissioning, system redesign and provision of services. Again, this is an area where the NHS has much to learn from our local authority colleagues.

10. Conclusion

As stated in the introduction, the ideas set out in this paper are a starting point for discussion and will evolve and develop over coming weeks as discussion and debate take place. The SHA is working on this in response to requests at consultation meetings for more information on how partnership working would be addressed. This is particularly important in County Durham since both options for PCT configuration involve the merger of at least the existing five PCTs in County Durham. In North of Tyne, a commissioning consortium has been in place for two years and the learning from that experience, particularly in relation to commissioning and the commissioning of pathways of care across primary and secondary care, needs to be included here. Some NHS organisations, notably the mental health trusts, have been working across a number of local authorities for a number of years and we need to learn from them about what works well.

The continued debate on these issues will contribute to firming up the SHA’s expectations of PCTs and the final decisions on such arrangements that will be taken by the chief executives of PCTs, whatever their configuration. It should also be noted that these arrangements, in addition to the other responsibilities of PCTs in the future, will be subject to a fitness for purpose review that will be carried out by the SHA as part of a national review.



Rosemary Granger
Executive Director
2 March 2006







Health Scrutiny Sub-Committee

16th March 2006

Consultation: Proposals for Primary Care Trusts, new Strategic Health Authority and
new Ambulance Trust.

Report of Head of Overview and Scrutiny

Purpose of Report

1. To suggest comments from the Health Scrutiny Sub-Committee in response to a consultation exercise proposing changes to the administrative structure of the National Health Service in the North East.

Background

2. A consultation exercise started on 14th December 2005 and will be ongoing until 22nd March 2006 setting out proposals to change the structure of the National Health Service in the North East of England. The consultation documentation indicates that these proposals do not focus on patient services but on administrative arrangements. As such, the role of Heath Scrutiny is not a statutory one but the Committee is part of the consultation process which needs to take place before final decisions are made ultimately by the Secretary of State for Health.

3. Copies of the formal consultation documents were considered initially by the Sub-Committee on the 9 th January 2006. This report sets out the broad proposals.

Primary Care Trusts in County Durham

4. There are two options affecting County Durham -

First Option

  • Second Option

  • Create a new County Durham Primary Care Trust aligned to the boundary of Durham County which would mean merging the five current Primary Care Trusts in County Durham. A separate PCT would be established covering Darlington.

    5. The bigger picture affecting the whole of the North East region is that it is proposed that the 16 current Primary Care Trusts will either be reduced to 4 covering the North of Tyne and Northumberland, South of Tyne and Sunderland, County Durham and Darlington and Teesside or reduced to 12 Primary Care Trusts, one for County Durham and one for Northumberland and 5 for Tyne and Wear and 5 for Teesside.

    6. The consultation document makes the point that a key issue for a County Durham-wide PCT will be “to ensure that locality structures are developed that enable resources and activity that are locality-specific, based largely on District Council boundaries, to remain so”.

    7. The main stated reasons for the proposed changes to PCTs, which plan and purchase health services to meet the needs of local people, are to -

  • Ensure PCTs are large enough to make the best use of their budgets but are still able to work closely with local GPs.
  • Improve the range and quality of local health care so patients get more choice and have better access to high-quality services.
  • Develop ways of improving health and encouraging healthy living.
  • Make big reductions in expenditure on management and administration - across the North East savings of £14m need to be made to be reinvested in local services.

    Strategic Health Authority Arrangements

    8. There is a proposal to merge the two existing strategic Health Authorities which currently cover County Durham and Tees Valley and Northumberland and Tyne and Wear to form one Strategic Health Authority for the North East of England.

    9. The main stated reason for this proposed merger is to -

  • Create a brand new organisation fit for future purpose with the same boundaries as other regional organisations, such as the Government Office for the North East.
  • To meet the changing role of Strategic Health Authorities in the light of increasing numbers of NHS Foundation Trusts, the likelihood of fewer PCTs and the drive to release more NHS money into patient care and treatment.

    Configuration of Ambulance Trusts

    10. There is also a proposal to extend the southern boundary of the North East Ambulance Service to include Teesside. The current boundary of the North East Ambulance Service covers Northumberland, Tyne and Wear, County Durham and Darlington. The proposal would involve adding part of the current Tees, East and North Yorkshire Ambulance Trust - covering Hartlepool, Middlesbrough, Redcar and Cleveland and Stockton-on-Tees.

    11. The stated main aim is to introduce improvements by having larger and fewer Ambulance Trusts with the infrastructure, capacity and capability to deliver and sustain the patient centred changes for the NHS.

    Issues for the Scrutiny Sub-Committee

    12. One role of the Sub-Committee is to seek to ensure that patients and the public have had a full opportunity to influence the outcome of the consultation. It will be appreciated, however, that as the focus of the proposals are on structural changes rather than direct patient care, it is not easy for patients to assess the benefits or possible disadvantages. A representative from the Strategic Health Authority will be in attendance at the Committee to provide an update about views provided so far. A report is included on the agenda for today’s meeting.

    13. The main areas of concern relate to the proposed reconfiguration of the Primary Care Trusts. It is suggested that the following issues should be raised by the Health Scrutiny Sub-Committee in their response to the consultation process.

  • Local authorities have invested significant time in joining up services with the current Primary Care Trusts. Firm assurances are required to ensure that if the proposed new Primary Care Trust covering County Durham is established this will not affect the progress which has been made in the delivery of local services.
  • The local delivery of commissioning services should be maintained and developed if one PCT is formed.
  • One of the stated aims of the proposals is to make significant savings to be redirected into direct patient care. Any savings derived from reorganisation in County Durham should be redirected transparently into front-line services for the population of County Durham.
  • The particular health needs of those areas of deprivation in County Durham should be a priority in any new structure and there should be a commitment that the additional funding provided for the Easington PCT area should be applied to meet the needs of the Easington population.
  • There should be an assurance that the quality of front-line services provided by the proposed PCT will be preserved, particularly in the light of the major changes to children’s and adult services in local government which is happening at the same time.
  • There needs to be an assurance that any commitments from existing PCTs (and the Strategic Health Authority and the Ambulance Trust) will be fulfilled by any successor organisations.
  • The implications for the public and patient involvement agenda and, in particular, Patient Forums and PALS should be clarified at an early stage and the progress made to date by these bodies should be maintained.

  • Recommendation

    14. You are asked to draw attention to the issues in paragraph 13 above as the Health Scrutiny Sub-Committee’s response to this consultation exercise. It is suggested that no specific comments are made in relation to the proposed reconfiguration of the Strategic Health Authorities and the Ambulance Trusts.


Contact: Ian Mackenzie Tel: 0191 383 3673







One new Primary Care Trust for County Durham and Darlington. This would mean merging the six Primary Care Trusts serving Durham and Chester-le-Street, Sedgefield, Easington, Durham Dales, Derwentside and Darlington.

Attachments


 Item 2b pdf.pdf;
 Item 2 apdf.pdf