Agenda item

Roger Gough (Cabinet Member for Education and Health Reform), Felicity Cox (Kent and Medway Area Director, NHS England), and Dr John Allingham (Medical Secretary, Kent LMC) were in attendance for this item.

(a)       The Chairman welcomed the Cabinet Member for Education and Health Reform and invited him to present an overview to the Committee. A copy of the PowerPoint is appended to these Minutes.

(b)       It was explained that the creation of Health and Wellbeing Boards (HWBs) formed part of the Health and Social Care Act 2012. They have become one of the most accepted parts of what was, in other aspects, a strongly contested piece of legislation. They are viewed as part of the architecture that works. The Health Select Committee at the House of Commons was originally sceptical of HWBs but is now a strong supporter of them.

(c)        Much of the membership of the Kent HWB follows the statutory requirement, but there are additions. There is more than one KCC Member on the Board and there are three representatives from the Borough/City/District Councils across Kent. It follows the principle that no group should have a majority and has a strong emphasis on consensus. There has not been a vote required thus far and it would in a sense be a failure if one was required.

(d)       In terms of its role, it took over responsibility for the Joint Strategic Needs Assessment (JSNA). It is responsible for the production of the Pharmaceutical Needs Assessment. This is a technical document and work on it is due to begin at the next HWB meeting. The third document, the Joint Health and Wellbeing Strategy (JHWS) takes centre stage as it sets out the vision for health and social care across the county. Health and social care commissioning plans need to be aligned to it. During the passage of the Health and Social Care Act, the role of the HWB in promoting integration was strengthened and this is now a key part of its role.

(e)       The Health and Wellbeing Board took on its statutory role on 1 April 2013 and its meetings have been webcast since this time. Before this, a shadow board was in existence from September 2011. During this time, GPs and local authorities have become increasingly used to working together.

(f)         Five priorities were set out in the first iteration of the JHWS earlier this year. These are: young people, prevention of ill health, long term conditions, mental health, and dementia. Thus far, each meeting of the HWB has concentrated on one of these priorities. At the next meeting, the focus will be on mental health.

(g)       In the days before the HWB took on its statutory role, the operating plans of all seven Clinical Commissioning Groups (CCGs) across Kent were considered in terms of how far they shared a common view. The additional point was made that more needed to be done on bringing the plans of social care, NHS England’s direct commissioning and public health to share with the HWB, though some work had already been done by public health.

(h)        The observation was made that the Health and Social Care Act was drawn up with compact urban councils in mind where a single local authority and one or two CCGs would be able to work together directly. One of the slides in the PowerPoint presented to the Committee contained a map designed to show the numerous overlaps. Across Kent there were three health economies, twelve Borough/City/District Councils, and seven CCGs. Only one of the latter was coterminous with the boundaries of a Borough/City/District Council. One of the challenges this posed for the HWB was how to effectively drill down into local concerns while retaining the focus of CCGs from other areas of the County. In September 2012 it was decided formally to establish seven sub-committees of the HWB aligned with CCG boundaries. This model built on something Dover and Shepway had worked on before. The HWB, which itself is a Committee of Kent County Council, is there to look at issues wider than one CCG. This includes large scale reconfigurations, data sharing, and performance across the patch. It also picked up on national policies and initiatives and saw they were taken up locally. The CCG level Boards were there to do the ‘heavy lifting’ in making integration work locally. Members were also informed that due to their local nature, the priority of each CCG level HWB was different. There was also a ‘mixed economy’ as to who chaired them. Some were chaired by representatives from the Borough/City/District Council, others by a CCG representative. Mr Gough explained that he was Chairman of the Dartford, Gravesham and Swanley CCG level HWB along with being Chairman of the Kent level HWB.

(i)         The overall aim of the HWB was to explore new ways of working to ensure the financial sustainability of both the NHS and local authorities. This involved moving care upstream with greater emphasis on prevention, self care, integration between the sectors, and looking to ensure there were no unnecessary admissions into acute or residential care. A slide with numerous examples of the work going on was presented to Members. Amongst these examples were the integrated health and social care teams in Dover and Shepway and work on year of care tariffs which looked to obviate the perverse incentives which currently existed. There was much good work going on and part of the challenge was to consider how it could be scaled up. 

(j)         Mr Gough drew attention to two national schemes that were of particular interest. The first was the Integration Pioneer Programme. This was launched earlier this year with bids invited for pioneer status to receive Department of Health support related to the work they were doing on integration. The Kent bid has made it past the first stage and it will become known this month whether it has been successful. When the bid was approved by the HWB, it was agreed to continue with the work set out in it regardless of whether the bid was successful or not. Among the areas being looked at as part of this programme is that of workforce planning.

(k)        The second policy was the Integration Transformation Fund. This was discussed at the September meeting of the HWB. Overall, it sets a faster pace for integration. Rather than new money, different funding streams are brought together to the sum of £3.8 billion nationally. This is for the creation of a pooled budget where the NHS and local authorities will be equal partners and where the responsibility will rest with the HWB. The ultimate aim is to have a fully integrated system by 2018. £1 billion of this money is at risk in that local systems have to deliver integration or lose the funding. Progress will be assessed in two tranches, one at the beginning of the 2015/16 financial year and the other at the end of the same year. This will necessarily reflect work done in 2014/15, the start of which is not far away. There is a need to progress with plans quickly, and the idea is to take this work forward through the group which had been established to produce the pioneer bid. The ultimate aim is to move activity currently carried out in the acute sector to the community sector. It was important to work with providers as it was necessary to avoid destabilising them. This could mean reconfiguration of acute services and this could be controversial. It was accepted there was a tension between local plans and Kent-wide ones, but it was hoped this would be a dynamic tension.

(l)         Following the presentation, there were a number of areas of questioning and discussion. On the topic of possible future reconfiguration in the acute sector, it was further explained that there was a decades’ long debate in the health sector over the need for centres of excellence where medical specialists were able to see sufficient numbers of patients to maintain and improve their skills against the need for patients to be able to access healthcare closer to home. These were arguments that the Committee were familiar with.

(m)      There is a separate argument around the shift of resources from the acute sector to the community and primary care sectors and what this means for the acute sector. The NHS West Kent CCG ‘Mapping the Future’ Programme was part of this discussion around moving activity to community and primary care settings along with enhanced self-care. This was considered by the Committee at its September meeting.

(n)        This connected with the ‘NHS A Call to Action’ and ‘Improving General Practice A Call to Action’ programmes. In the latter, the future shape of general practice was also under discussion. Connected with this, it was important to know that NHS England commissioned primary care and CCGs could not commission themselves.

(o)       With the year of care tariff, the price paid for treatment is separated out so some goes to the community sector. This could be a risk for the acute sector as it reduces their income. However, the costs of acute trusts could be reduced alongside the reduction in income. Acute trusts could also deliver some work in the community. The shift to community care needed to be managed to avoid the risk of destabilising acute trusts, which would be a particular problem in East Kent where there was no obvious alternative.

(p)       The point was made that unless there were services in the community and sufficient GPs, people would still go to acute hospitals. Services did need to be in the right place delivering the right care and Professor Chris Bentley had worked with Kent looking at areas of deprivation and whether they were able to access the right services.

(q)       Questions were asked about the relationship of KCC with Kent Community Health NHS Trust (KCHT) and Kent and Medway NHS and Social Care Partnership Trust (KMPT). It was explained that there was a continuing and developing partnership with KCHT on joint working, but it was explained that there was a tension for KCC with its dual role of commissioner and provider. Similarly with KMPT, there was lots of joint working and the example of the Live it Well programme was given. It was also pointed out that there were a number of providers of mental health services apart from KMPT.

(r)        There were a number of questions about children’s services. In response to a specific question about the location of Sheppey children’s centre, it was explained that this was for historical reasons but that there were moves to more closely integrate CCGs and children’s centres. On the question of Children’s Trusts, it was explained that their work had moved to the HWB and there was currently a discussion about whether it was better to have a sub-committee of the Board focusing on children’s issues or to have children’s issues as a regular item on the CCG level HWB agendas.

(s)        On the broader topic of wellbeing, a couple of Members raised the issue of what measures KCC could take around licensing laws and dealing with the impact of gambling. Mr Gough offered to continue this particular discussion outside the meeting. The observation was made that wellbeing was a broad concept which could mean the HWB could look at so many things it could risk losing focus.

(t)         Mr Gough also expressed a willingness to discuss further the report that a CCG level HWB had a rule excluding Councillors who were not on the Board from asking questions as a member of the public. This rule was not part of the Terms of Reference for the HWB.

(u)        There was a discussion about the care that KCC delivered in people’s homes. It was explained that Kent had always done well on the time allowed for care visits, but there was less information on the quality of care. Kent social services were part of the NHS England hosted Kent Quality Surveillance Group which did a lot of good work looking at quality issues across the County. This was not an area which the HWB had looked closely at, but it could in the future.

(v)        There was a discussion on the future relationship between the Committee and the HWB. Mr Gough explained that he had been to the Committee a number of times during the period of the shadow HWB, and was more than happy to attend in the future. It was for the Committee to determine its own work programme, but the integration agenda and JHWS along with others were all areas that the Committee could legitimately consider.

(w)       The Chairman proposed the following recommendation:

§         That the Committee thank Mr Gough for his attendance and contributions to the meeting and requests that the Committee continue to be informed of the work of the Health and Wellbeing Board.

(x)        AGREED that the Committee thank Mr Gough for his attendance and contributions to the meeting and requests that the Committee continue to be informed of the work of the Health and Wellbeing Board.