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Agenda item

An Integrated Care System for the North East and Cumbria

(i)           Developing Integrated Health and Care Partnerships


Presentation by Alan Foster, STP/ICS lead


(ii)          Clinical Strategy Development – South Integrated Care Partnership


Joint presentation by the Chief Executives of County Durham and Darlington NHS Foundation Trust, North Tees and Hartlepool NHS Foundation Trust and South Tees Hospitals NHS Foundation Trust.


(i)      Developing Integrated Heath and Care Partnerships


Alan Foster, STP/Integrated Care System Lead gave a presentation regarding the development of an Integrated Care System (ICS) and associated Integrated Care Partnerships (ICP) across North Cumbria and the North East Region.


The Committee were advised that the North East and North Cumbria had declared their position as an aspirant Integrated Care System under a programme developed by NHS England and NHS Improvement. The North Cumbria and North East region currently consisted of 3 STP footprints which, under the ICS Programme, would develop a shared ambition to the best in England and Europe for health and care outcomes.

Mr Foster stated that the Cumbria and North East was a relatively high performing area for health and care albeit with some performance and finance challenges. It has a long established geography with a positive history of joint working across a highly interdependent system of clinical services where patient flows remain mostly within this area. Members have been advised in previous reports of service sustainability and configuration issues which have remained unresolved and fragmentation following the Health and Social Care Act 2012 that has made system wide decision making difficult.

The Committee noted that faster progress on improving health outcomes for the population was needed with more empowered patients supported by fully integrated health and social care. The system also needed to deliver a sustainable, equitable and affordable core offer of acute services as well as a strengthened collective decision making process for “at scale” improvement initiatives.

The presentation reaffirmed a unanimous commitment from NHS bodies to become an Integrated Care system with robust governance arrangements. The ICS would develop a vision and strategy supported by a suite of enabling workstreams. The ICS would create 4 Integrated Care Partnerships based upon existing population density/patient flows and hospital sites whilst preserving place based clinical leadership. These ICPs would be empowered to deliver sustainable acute services through managed clinical networks across multiple sites.

Mr Foster stressed that an ICS was not a statutory organisation in itself but rather an agreed partnership of individual organisations working to improve health and care based upon:-

        Developing a shared vision and high-level plan across NHS organisations;

        Reaching a formal agreement with NHSE/I to implement faster improvements in population health outcomes;

        Taking devolved responsibility for key NHS resources, and

        Collaborating across boundaries, e.g. clinical staff from different organisations working in networks ‘horizontally’ across hospitals but also integrating ‘vertically’ with GP and community services.


Integrated Care Partnerships were alliances of NHS Providers that work together with local commissioners to deliver care by agreeing to collaborate rather than compete. In this context providers could include hospitals, community services, mental health services and GPs as well as social care, independent and third sector providers.


Mr Foster also referenced plans by NHS England and NHS Improvement to develop seven joint regional teams led by directors tasked with developing more integrated local leadership. One of these teams would cover the North East and Yorkshire footprint. He stated that the ICS wanted to take more control over the resources it received and also take local decisions around staff recruitment, training and retention.


Members then considered the emerging outline of ICP geography with 4 ICPs being set up based around population density, patient flows and existing hospital sites. These would be for North Cumbria; North; Central and South.


In setting out the ICS approach to planning, Mr Foster indicated that a five year revenue budget settlement was anticipated for the NHS covering 2019-20 to 2023-24 which should provide a degree of certainty in developing the NHS Long Term plan. The new NHS approach to planning would include a review of standards, new financial architecture and more effective workforce and physical capacity planning. It will then be for the ICS to develop their own strategic plan which will deliver the NHS Long Term Plan and set out how the local NHS system will be run using available resources. In preparation for this all organisations (commissioners and providers) will be required to aggregate their plans into a single operating plan. This whole system plan for North Cumbria and the North East would in turn be signed off by all organisations by summer 2019.


Councillor Blackie stressed the dependency of rural communities in the area he represented upon those acute services provided at Darlington Memorial Hospital, James Cook Hospital, Middlesbrough and the Friarage Hospital, Northallerton. In acknowledging the development of the ISC and ICPs he stated that assurances were needed that acute services will be provided across the whole region equitably.


Councillor Moorhouse, whilst acknowledging and agreeing the development of ICPs based around existing population density, highlighted the different population demographics across the North Cumbria and North East SC footprint and the importance of health and social care providers and commissioners developing services that meet specific needs of local communities. She gave the area of Hambleton, Richmondshire and Whitby as an example of a locality where there was a greater elderly population with highly complex health needs which would require a different approach to some more urbanised areas of the region. She stated that for such people it was more likely that care was provided in a more community based service model rather than at acute hospital centres.


Mr Foster referenced the excellent work being undertaken across the Hambleton, Richmondshire and Whitby CCG locality in respect of “frail elderly” and this being an example of the desire to provide care more locally. He advised the Committee that demand placed upon the health and social care system by frail elderly and the increase in such work was at the forefront of a specific workstream.


Councillor Bell referenced the proposal for a North East and Yorkshire regional development team and what that may mean for the 3 site acute centre model previously discussed by the Committee. He asked whether an emerging ICS would include North Yorkshire colleagues who sit on the STP Joint OSC at present. In response, Mr Foster indicated that Yorkshire was potentially to be covered by 3 ICS which added to the complexity of partnership working and the development of relationships across multiple provider and commissioning organisations. He stressed however that no “iron curtain” would descend upon patients seeking treatment within the region and that above all else patients would be put first. Councillor Bell welcomed that reassurance.


Cllr Robinson suggested that with the development of ICS and ICP structures there appeared to be a move back to the 1970’s structures within the NHS of Regional and Area health authorities. He asked whether County Durham was definitely to be included in the Central ICP?


Mr Foster indicated that this was still being discussed and that a letter had been sent by the Leader and Chief Executive of Durham County Council seeking clarification on this issue.


Mr Foster stressed that the development of ICPs would not necessarily determine where patients would go for acute services but was rather about developing the opportunity for joint working amongst the NHS across organisational boundaries.


In response to a question from Councillor Loynes, Mr Foster stressed that the ICP boundaries on the map within the presentation were merely indicative of population density and all areas of the region would be covered by an ICP.

Councillor Tostevin expressed some doubt about the ability to develop and manage sustainable relationships under the ICS/ICP system as she felt this was much easier to achieve within a single organisational structure.  Mr Foster acknowledged that the agenda for change was considerable and that to deliver the changes necessary, partnerships needed to work. He stressed that whilst there was no suggestion that Local Government structures would change under the ICP development programme it was evident that relationships across the NHS were developing and delivering increased collaborative arrangements which was a particular strength within the region. Councillor Tostevin responded that she was also worried about the reality of the timeframes potentially being discussed for the establishment of ICS/ICPs given the huge amount of work currently being undertaken across the NHS and Local Government in terms of health and social care integration.


(ii)     Clinical Strategy Development – South Integrated Care      Partnership


Siobhan McArdle, Chief Executive, South Tees Hospitals NHS Foundation Trust gave a presentation regarding clinical strategy development and the work proposed under the South Integrated Care Partnership (ICP). Ms McArdle explained that a vision and scope had been developed for the South ICP. The vision was to “work collaboratively to maintain local access with a focus on delivering out of hospital care and ensuring the sustainability of safe clinical services to meet the needs of the population.”  The scope of the programme was “to develop a clinical strategy for the South Integrated Care Partnership with the aim of achieving and sustaining high quality hospital care across the area.” The scope of this work included the following acute provider organisations:


        County Durham and Darlington NHS FT

        North Tees and Hartlepool NHS FT

        South Tees Hospitals NHS FT


The Programme would cover acute health services commissioned and provided for the people of Darlington, Tees, Durham, Dales and Easington, Hambleton, Richmondshire and Whitby. University Hospital North Durham will continue to provide the existing range of services.


Ms.McArdle reported that the clinical strategy for the South ICP would focus on how the following services would be delivered:-


        Urgent & Emergency Care

        Paediatric, Maternity (Gynaecology modelling interdependencies)

        Elective care:




        Frailty services

        Stroke services


It was intended that the clinical strategy would be brought back to the Committee in January 2019 for consideration.


Members were informed that the programme work builds on that undertaken as part of the Better Health Programme which had been reviewed to ensure a clear audit trail and evidence of previous stakeholder engagement. The starting point for the ICP was a working list of ideas that will be appraised against ‘must have’ criteria for viability.


Thereafter modelling workshops would take place to build up and discuss scenarios. Ms. McArdle stressed that clinical standards were a key driver to improving quality and patient outcomes and indicated that viable ideas would be subject to robust financial and activity modelling (value impact assessment) and further evaluation through stakeholder engagement. As part of this work, individual service clinical case for change will develop the draft case for change with credible scenarios being identified for formal consultation.


As part of this process, the Committee were informed that the following operating principles had been put forward by the programme leads:-

        The needs of people will have priority over organisational interests;

        We will work in clinical networks across hospital sites - sharing scarce resources to maintain local services;

        We will work collaboratively, urgently and with pace on system reform and transformation;

        Costs will only be reduced by improving co-ordinated care;

        Waste will be reduced, duplication avoided and activities stopped which have limited value or where benefit to our population is disproportionate to cost.


As previously reported, Ms. McArdle confirmed that clinicians were currently developing the clinical strategy. In doing so she stated that the programme would preserve each hospital into the future by using them differently and in a more joined up way to benefit all patients. It was suggested that some changes and improvements may be necessary to services currently provided from different hospital sites. All three NHS Trusts wanted to introduce new ways of working so that clinicians can work easily across multiple organisations and clinical sites. They were also committed to expanding the use of new roles and care models that would assist in managing demand and drive an improvement in health outcomes.


The presentation concluded with a proposed timeline which included the proposed clinical review of the Value Impact Assessments developed for the services in question during December 2018. At the same time a strategic Oversight Group would meet to review the draft clinical strategy.


Following any comments made as part of that process the Group would meet again in January to approve the final draft clinical strategy.


Thereafter the various scenarios developed and the proposed pre-engagement activity and emerging plans for formal consultation and engagement would need to be brought back to the DDTHRW STP Joint OSC for consideration and comment. Ms. McArdle suggested that this could be done towards the end of January 2019. The proposed timeline concluded with plans for a formal launch of service reconfiguration with staff, external stakeholder and public engagement scheduled for March 2019.


Members were advised that there were 6 key phases proposed in the programme timetable namely:-

Phase 1 – Clinical Strategy Development

Phase 2 – Pre-consultation engagement and develop business case

Phase 3 – Public Consultation

Phase 4 – Period of reflection

Phase 5 – Decision making process

Phase 6 – Final Business Case


Ms. McArdle concluded by emphasising that the programme was currently at Phase 1.


The Chairman then invited questions from members of the Committee.


Councillor Bell referred to previous discussions that had taken place in the development of a 3 acute hospital site model as part of the Better Health Programme and asked whether there had been “in principle” agreement to retain that model and were clinicians sited on and have an for a collaborative working model across multiple hospital sites?


Deepak Dwarakanath, Medical Director, North Tees and Hartlepool NHS Foundation Trust reported that clinicians across the South ICP were pushing for change to improve the quality of care available and delivered to patients. They also recognised that current workforce pressures being experienced across the clinical areas being reviewed would not allow for these services to be delivered across all sites. He referenced current problems being experienced in respect of gaps in workforce rotas, increased shifts for current staff and the reliance on locum clinicians.


Councillor Blackie placed on record his thanks to the NHS organisations across the area who had delivered life-saving treatment to himself and expressed the fervent wish that the NHS Services in the area were not stretched to the point that they “fell down”. In discussing possible future service models, Mr Dwrarkanath suggested that most services would remain available in the three major sites (Darlington Memorial Hospital; University Hospital of North Tees and James Cook Hospital) and that ambulatory services/care was a key element in facilitating this. He also stressed that any changes advocated by clinicians would aim to future proof services across the region and that this would include enhanced IT provision.


Councillor Blackie asked whether 24/7 Accident and Emergency and Maternity and Paediatrics services would be available from the three sites as there have been many concerns expressed about potential changes in acute services along with the development of specialist centres and the importance of having appropriate and effective patient transport systems that facilitate access to these services. Ms McArdle reiterated the comments of Mr Dwrarkanath and the input of clinicians and stressed that work was ongoing across the North Yorkshire and South Tees NHS FT area in this respect.


Councillor Hall welcomed the reference to working at pace and stressed the importance of North Tees and Hartlepool NHS FT and South Tees NHS FT working collaboratively to improve services. She stated that it had been this lack of pace which had frustrated members of this committee particularly in terms of the absence of information about what services are planned for future delivery. In responding, Ms McArdle agreed with and noted the concerns around the pace of change, emphasising the importance of NHS Partners keeping local authorities engaged at the same pace.


Regarding transportation links and accessibility to services, Councillor Moorhouse referenced the Esk Valley Railway line which whilst being underused and poorly maintained was a potential asset that could be utilised to improve accessibility to services from North Yorkshire.


The Chair referred to the proposed Value Impact assessments that are being drafted in respect of Urgent & Emergency Care; Maternity Paediatrics; Stroke, Frailty, Breast, Spinal and Urology services and urged care in how the delivery and publication of these was to be managed to avoid adverse public reaction and also the risk of premature referrals to the Secretary of State for Health and Social Care.

Mr Dwrarkanath stated that the region’s two main trauma centres would remain at Newcastle and Middlesbrough and that it was anticipated that no other A&E facilities would close. He also suggested that there would be no probable change with Maternity/Paediatrics services. He did recognise that the medical leaders/professionals had been poor at promoting and managing maternity services.


Councillor Bailey emphasised the importance and need for robust public consultations for any potential service changes and continued local authority involvement and engagement in that process.


Councillor Bell referred to the involvement and engagement of local authorities in public consultation and suggested that NHS partners would need to give consideration to the potential impact that local authority election purdah may have on any consultation timeframes.


Councillor Loynes asked what any future proposals would mean for University Hospital Hartlepool. She referenced the loss of several acute services from the hospital including A&E and the apparent running down of maternity services at the hospital with women discouraged from giving birth at UHH. In echoing the sentiments of Cllr Loynes, the Chair suggested that alongside the potential service development proposals for North Tees University Hospital, James Cook Hospital and Darlington Memorial Hospital, there needed to be comprehensive long term strategies for University Hospital Hartlepool, Bishop Auckland Hospital and the Friarage Hospital, Northallerton.


In response, Ms McArdle indicated that those latter three points of service delivery referenced by the Chair were vital to the future of the former. She also stressed that the value impact assessments being drafted would aim to retain as much local access to services as possible.


At the conclusion of the discussions the following action was agreed:


1.       The report be noted; and

2.       The Value Impact Assessments and associated engagement plans   be brought back to a future meeting of the Committee in February 2019.

Supporting documents:


Democratic Services
Durham County Council
County Hall
County Durham
03000 269 714