The Chairman of the Committee has received a request from Tony Parkinson, Chief Executive, Middlesbrough Borough Council, to address the Committee regarding a number of issues raised at a recent meeting of the Middlesbrough Borough Council’s Health Scrutiny Panel in respect of concerns around the extent of local authority involvement and engagement in the development of the Durham, Darlington and Teesside, Hambleton, Richmondshire and Whitby STP.
The issues raised at the aforementioned meeting include:-
· The Chief Executive Lead on the STP had written to the NHS STP Lead stating that from a local authority perspective there were issues with the way the STP was operating;
· There was a risk that the STP process could jeopardise the integration work currently taking place in South Tees and propose a completely different model;
· The Council and South Tees CCG were relatively small organisations trying to have an influence but the agenda felt very much dominated by the acute sector;
· NHS England had outlined ambitions for STP’s to evolve into ‘accountable care systems’ (ACS) - the DDTHRW STP could be incorporated in a North East and Cumbria ACS and the influence of individual Councils and CCG would decrease further as the footprint widened;
· The STP Lead’s perspective on the role of the local authority in the DDTHRW Sustainable Transformation Partnership (STP) would be beneficial;
In agreeing to the request, the Chairman has invited the Chief Executive, or their appointed representative, from each of the local authorities within the STP footprint to attend the meeting also.
Minutes:
The Chairman introduced Tony Parkinson, Chief Executive, Middlesbrough Borough Council, to address the Committee regarding a number of issues in respect of concerns raised around the extent of local authority involvement and engagement in the development of the Durham, Darlington and Teesside, Hambleton, Richmondshire and Whitby STP. Tony Parkinson stated that prior to discussing some of the real challenges with the STP it was important to make the point that all of the constituent local authorities appreciated the scale of the challenge facing both health and social care and the need for change. At a South Tees level there was some really good innovation work taking place. For example on admission avoidance, however, there was a real concern about how that work at a locality level fitted with the much larger STP and the impact potential reconfigurations of services could have on local delivery.
It was emphasised that there was a real need for the STP to reflect the whole health and social care system, as well as take into account public health, the local prevention agenda, challenges around cuts in grant funding and issues faced by the adult social care provider market, as well as specifics around the pace of change. At present there had been limited political and community involvement in the STP and there was a general lack of understanding around where the STP sat in the governance architecture. It was felt that insufficient consideration had been given to local authority involvement in the STP despite a reliance on the social care system for successful delivery. At present local authorities had no detailed understanding of possible acute service reconfigurations even though they could be real advocates for the STP.
Miriam Davison, Director of Public Health, Darlington Borough Council stated that she echoed the comments regarding the lack of public involvement in the STP, although welcomed the NHS’s increased involvement in the prevention agenda. The point was made that further clarity was needed with regard to care closer to home and where opportunities for local integrated services existed these needed to be developed.
Jane Robinson, Corporate Director for Adults and Health Services, Durham County Council welcomed the care closer to home aspect of the STP proposals but stressed that locality work in respect of Health and Social Care Integration would be at different stages across the STP footprint.
Paul Edmundson-Jones, Director of Public Health, Hartlepool Borough Council advised that he shared the views expressed by others and recognised that a lot of integration work was taking place across the North East. From Hartlepool’s point of view the question was around whether this work would be undertaken at scale and systematically. Tony Parkinson reiterated that the concern for local authorities was how all of the integration work was taken forward as part of the STP process and how each local authority could be true to its local populations, while still working collectively with partners.
Councillor Clark advised that North Yorkshire was made up of 7 district councils, 5 CCGs and was covered by 3 STPs. As a concept he preferred ‘place based delivery’ but questioned whether there was first a need to change some fundamental concepts. For example, was it possible for the NHS internal market to fit within an STP structure given that the two were fundamentally different? He expressed the view that the NHS does not understand that elected members are democratically accountable to the people they serve and that there needed to be a step change in the NHS’s approach to the STP agenda. In terms of the Accountable Care System (ACS) North Yorkshire was included in Yorkshire and Humber. It was stated that all of these proposals needed to be very carefully assessed and the impact on smaller hospitals understood. It was again emphasised that there was insufficient democratic accountability and the principle of the STP was wrong, as it should be focussed on ‘place based delivery’.
Patrick Rice, Director of Public Health, Redcar and Cleveland Council stated that his Council was not supportive of the STP in its current form and although the rhetoric stated that the plans had been developed in partnership in reality that was not the case. The STP focussed on the general upscaling of acute specialist healthcare and providers entering into agreements with the CCG and there were also concerns around the potential impact upon local authority Improved Better Care Funding and investment plans as a result of STP proposals.
Councillor Grainge stated that from Stockton’s perspective clarity was sought around what was happening with the STP locally and where it tied in with the Health and Well Being Boards.
Councillor Dryden raised a query in terms of a Chief Executive’s perspective on how STP lead officers were communicating with local authorities and how local authorities were inputting into the process. Tony Parkinson advised that from his perspective there were much further developed proposals in other STP areas and information regarding proposals contained in DDTHRW STP often came through other routes. For example, Middlesbrough had provided some pre-planning advice in respect of proposals for the future development of James Cook University Hospital (JCUH). However, these proposals had not been raised with either him or the Director of Adult Social Care and Health Integration, which had led to some mistrust.
Tony Parkinson stated that in terms of the work involved in the STP he did not underestimate the scale of the task. Given that fact it was simply not possible to have a single Chief Executive leading on behalf of all of the local authorities. Each local authority needed to provide an input and he had no authority to speak on any other authority’s behalf. The real question was around how much influence local authorities could have on the STP?
Reference was made to the Local Government Association conference in June at which Simon Stevens, Chief Executive of NHS England acknowledged that one of the problems was that there was no statutory framework for STPs or ACS’s. The view was expressed that even though it had been stated that 80 per cent of the changes covered by STP’s could be undertaken within existing legislation it was no way to operate a national health and social care system.
The Chairman invited Alan Foster, Lead Officer for the DDTHRW STP, to respond to the views expressed by Members and Senior Officers from across the STP footprint. Alan Foster stated that since taking up his role many people had asked him why he wanted to do the job and he advised that his passion was the same as everyone else’s in attendance, in that he wanted to make the system better and more sustainable although he recognised in order to achieve that everyone needed to work together. It was acknowledged that there were difficulties in terms of finances, demand and demographics and that through the STP efforts were being made to try and design a better system for the future.
Alan Foster expressed the view that health care improvements should be place based and that competitive tendering had not been the right way forward, as it had created organisations that were not sustainable or viable. It was all about trying to work with people in the system and no new legislation was expected anytime soon. Everyone therefore had to work within the existing legal framework. Patients were always at the heart of developments and some fantastic pieces of work had been undertaken through the Health and Wellbeing Boards across the region. Alan Foster explained that he had been asked to bring the three STPs together and there was a need to look at what could be done better. Lobbying was taking place at a national level in an effort to maximise resources and support, although it was acknowledged that the STP was a toxic brand.
Reference was made to the work that had been undertaken under the Better Health Programme (BHP) and it was acknowledged that progress had been made as a result of the BHP. However, that work had reached the point where workforce, financial and other challenges required further work. The STP public consultation had been planned for 2018, although it was advised that this was no longer expected to go forward next year. Alan Foster acknowledged that more resources did need to be invested into the whole system and he had written letters and co-signed letters to request additional NHS resources, which could be used more widely. The view was expressed that regardless of the future structure partners needed to work collectively to shape the future of that system or otherwise it would be shaped for us.
Alan Foster stated that in his view the NHS could not stay as it was, as in its current form it was broken. The system was fragmented, however, this did not mean he would be closing local hospitals. It was emphasised that locally we needed to find the resources and the STP was still in a bidding war for funding to undertake various pilots. It would be important to get the governance structure right and further clarity was needed in terms of merging the 3 STPs into 1. Partnership working across the whole system was key and reference was made to the Health and Social Care Partnership in Manchester, which was in receipt of a £450m transformation fund. The Cumbria and North East and Cumbria STP needed to make the case that we work together and at scale to ensure people received equitable services. However, it was also acknowledged that we would struggle to keep all of the hospitals, as they were now, in the future.
In terms of the Care Home market the view was expressed that one of the challenges was that every local authority had different policies, fee structures and contract management arrangements, which could be better co-ordinated. Similarly the commissioning of health services were spread across 12 CCG’s, with wasted transaction and staff costs. A better way of operating as a whole scale system needed to be developed. Alan Foster stated that he was in agreement with the majority of comments made by Members but that he would not be the person making these decisions. Any proposals would be consulted upon before the CCG’s made a decision. If no action was taken then some current services would no longer be able to continue.
The Chairman stated that he had been under the impression that the purpose of the Joint Committee was to consider the STP and chart a way forward. Yet despite a lot of good work taking place across the region at a local level there was no clarity in terms of the STP, with regard to what is in place, where people will be able to access different services and whether there would be any capacity once people arrived. The view was expressed that the information provided to date had been unnerving for people and that clarity was needed to provide everyone with peace of mind about future service provision.
Councillor Martin-Wells expressed the view that the Committee had looked at the STP over the two last years, as well as the BHP before that, and to hear there would be no consultation on the STP proposals in 2018 only created further uncertainty. Such uncertainty impacted on NHS staff directly forcing them to consider other employment opportunities and potentially resulting in unsafe services. It was also not possible for the Joint OSC to scrutinise the STP when no additional or detailed information was being provided.
Councillor Newall asked what reassurances could be provided to residents in Darlington if in reality there were no imminent plans to close Darlington Memorial Hospital. The point was made by Members that Darlington residents had a very active NHS Save our Hospital campaign up and running and people deserved to know what was happening. In response Alan Foster stated that not going out to consultation in 2018 did not take away the very real issues. The longer that no action was taken the higher the likelihood of changes in service provision developing piecemeal rather than via a planned and co-ordinated approach. In order to maintain and improve standards, and in absence of a plan, people would have to travel in order to access some of the more specialist services.
Councillor Tostevin stated that it was distressing to hear the phrase ‘in the absence of a plan’ given that Members of the Committee had wanted to be engaged in the STP for the last 2 years. However, without being given any detailed information it was not possible to scrutinise the proposals. In the meantime the CCG’s were pushing forward with their agendas, there were problems with GP recruitment and services were being consolidated. The point was made that it effectively felt as though at present everything was being done under the radar.
The point was made that a communications plan needed to be developed, as although the CCG Boards met on a monthly basis they were not accountable in the same way as elected Members. The STP team needed to feed that detailed information through the Joint OSC even though some of the information may not be what people want to hear i.e. there was no imminent threat of closure to Darlington Memorial Hospital but equally the possibility could not be ruled out. It was recognised that although a lot of good work was taking place at the local level there needed to be a sufficient worked up plan on the hospital side of the issue. In trying to retain Darlington, North Tees and JCUH this did not solve the problem and there did need to be an acute service provision solution.
Reference was made to the development of care services and the ability to deliver services traditionally undertaken in a hospital setting out in the community. It was emphasised that people would only need to travel when they needed access to specialist services. Cancer care, for example, would in the future be provided at the Friarage and it was about ensuring that services were delivered in the right place and that they were also sustainable for the future. There were some services that could be delivered locally and others that would be delivered further away but these changes would help ensure that people were able to fully recover. In addition, more work could be undertaken to prevent people from being admitted to hospital in the first place. For example, during the last year of an individual’s life on average they were admitted to hospital four times. Supporting them to have the best quality of life during that year was equally important.
Councillor Blackie stated that the issue with the CCGs was that the Governors were GPs and were not elected by members of the public. Janet Probert, Chief Officer at Hambleton, Richmondshire and Whitby Clinical Commissioning Group (CCG) expressed the view that in her opinion she did not believe any of our local hospitals were at risk. It was stated that in the future our local hospitals would look different but they would all be there. Specialist units would provide the necessary expertise and this needed to be articulated to members of the public. From the CCGs perspective Board Members were very much of the view that they were accountable and planning for the next 15 years of health care delivery was a real challenge.
Tony Parkinson raised that query as to whether we were any further forward following discussion, as although reference had been made to whole system change we currently did not have the whole system working together. The financial pressure of £281 million, as outlined in the STP was easily in excess of £300 million when accounting for all of the other pressures. South Tees CCG was an organisation made up of 25 people and it was not sustainable, it was overspending on its budget and having to move money from the Better Care Fund. It was emphasised that the whole system needed to be incorporated in the STP. There also needed to be a governance structure that everyone was signed up to and the STP needed to be shaped collectively. It could not be about cost shifting and the Directors of Adult Social Care across all local authorities needed to be involved.
It was accepted that there had effectively been a pause in the STP process, as there was no benefit of putting something in place until there was much greater clarity around many of the issues raised. The Committee requested that a further update be provided to a future meeting.
Resolved that the information discussed and the comments made, be noted and further details be provided at the next meeting.