Agenda item

To introduce to the Commission the background to the Buckinghamshire, Oxfordshire and Berkshire West NHS Sustainability and Transformation Plan in order that scrutiny can be carried out.

(Councillor Richard Somner declared a personal interest in Agenda item 11 by virtue of the fact that he was employed by Royal Berkshire Hospital. As his interest was personal and not a disclosable pecuniary interest or other registrable interest he was permitted to take part in the debate and vote on the matter).

The Commission considered a report (Agenda Item 11) concerning The Buckinghamshire, Oxfordshire and Berkshire West (BOB) NHS Sustainability and Transformation Plan (STP).

Cathy Winfield gave a presentation to the Commission to outline the requirement for, purpose of and intended outcomes of the STP.

In December 2015, the NHS Planning Guidance required that health and social care systems in England would be required to work on larger footprints based on meaningful communities and patient flows. It was also intended that STPs would be used to develop a programme of financial sustainability, to address a funding gap of £22bn nationally as costs increased at a higher rate than funding.

Initial assumptions had been that the West of Berkshire Clinical Commissioning Groups (CCGs) would form an STP together, however NHS England wanted larger footprints. There were 44 nationally prescribed footprints and the Buckinghamshire, Oxfordshire and Berkshire West footprint was imposed as the 44^th. This meant there was a complex system to work from, in comparison to Gloucester which had one CCG, one Local Authority and one hospital.

The STP would address three gaps as identified in Simon Stevens’ NHS Five Year Forward View:

·         Health and well being gap – to improve health and reduce health inequality.

·         Care and quality gap – to improve treatment of cancer and other diseases where the UK is performing behind Europe.

·         Sustainability/financial gap – to address the financial gap.

Providing more detail about the STP finances, Cathy Winfield advised that the BOB CCGs combined allocation for 2016/17 was £2.55bn and would be £2.87bn by 2020/21 however demand, service developments and cost was likely to exceed this by £479m. The current draft plan provided efficiency solutions of £384m and there was further work to do.

Regarding the ‘BOB’ footprint, Cathy Winfield explained that it had a 1.8m population. Of the stakeholders, there were 7 CCGs, 6 NHS Trusts, 14 local authorities and several other arms length bodies which would maintain their statutory autonomy. There were also three distinct Local Health Economies and while there was some patient flow to the Oxford University Hospitals this was mainly for specialist services.

David Lowe enquired how the population and budget was distributed over the BOB geography. Cathy Winfield responded that the Berkshire West CCGs budgets totalled £650m and would provide a detailed breakdown. David Lowe further asked whether the Berkshire element might be considered a junior partner in the STP. Cathy Winfield advised that the STP included equal partners and in fact many of the project leads were Directors in the Berkshire West CCGs due to the good reputation attained from the Berkshire West 10 work.

Councillor Keith Chopping asked what the Commission was required to do in relation to the report. David Lowe explained that the Commission were asked to consider what scrutiny it might wish to carry out.

Returning to the presentation, Cathy Winfield explained that the Berkshire West Local Authorities were involved in programme and project delivery, including the Joint Care Provider programme in West Berkshire. There was strong governance at the Berkshire West level including the Berkshire West 10 Integration Board, currently chaired by Nick Carter and its associated Delivery Group.

Following a question from Councillor Keith Chopping, Cathy Winfield explained that the Berkshire West 10 group consisted of the 4 CCGs, 3 Local Authorities and 3 providers. It had been established since 2013 as a model of separate statutory bodies working together.

Councillor Mike Johnston joined the meeting at 18.50.

The STP had five key ambitions:

·         prevent ill health – the main focus would be on reducing obesity and increasing peoples’ activity levels. The Making Every Contact Count programme would provide training to professionals at all levels to improve confidence in speaking to patients about their weight. Digital solutions such as wearable technology would also be utilised.

·         improve access to urgent care – the NHS 111 service would be re-procured to include more support from clinicians in order to reduce attendances at Accident and Emergency departments. Calls to out-of-hours General Practitioners had already reduced by 25% and if they had more time they could offer longer appointments to handle the more complex cases.

Councillor Emma Webster joined the meeting at 18.56.

Councillor Dillon enquired how calls to 111 were routed to the local service centre. Cathy Winfield advised that software recognised the location of the call from the landline number or which mast the mobile phone had connected to. There was also a back-up mechanism for calls to be answered at another location if one call centre was compromised.

·         improve hospital services – housing growth was anticipated and so it was predicted that there would be a corresponding increase in the number of births. Maternity services would be planned on a regional basis. There had already been an increasing emphasis on home births and the Rushey Midwife led Unit had received positive feedback. There was also a need to improve pathology services to support increasing levels of screening.

·         improve mental health services – the focus would be to develop local specialist services for low and medium secure services to avoid expenditure on costly out of area placements.

·         co-commission specialist services – there was often a fragmented pathway to access specialist services and efficiencies could be achieved by targeting this area.

Councillor Somner asked for the reasoning behind choosing these ambitions. Cathy Winfield explained that excess weight was the underlying cause of many health issues and there was a lack of enthusiasm to talk about weight so it was felt that more could be achieved on a large footprint. There were also connections to the Joint Strategic Needs Assessment and Council’s Health and Wellbeing Strategy, as well as an emphasis on reducing inappropriate demand to create capacity in the system.

Councillor Dillon enquired why addressing Delayed Transfers of Care (DToC) was not one of the key ambitions. Cathy Winfield responded that the Better Care Fund projects targeted DToCs and they could be responded to better from a local level. The challenge for West Berkshire was recruiting care workers and its rurality played a part in this. Patients from West Berkshire also used hospitals in Swindon and Basingstoke which would not be covered by the BOB footprint so a local approach was needed.

Councillor Emma Webster expressed concern that there was sometimes a long wait between a patient’s need being identified and them receiving a service; one resident had reportedly waited two years to access the Child and Adolescent Mental Health Service (CAMHS). Councillor Webster also stated that the Commission had previously scrutinised maternity services at the Royal Berkshire Hospital and sought reassurance that this was still at the forefront of future planning. Cathy Winfield responded that £1.5m had been invested the previous year into CAMHS and there had been a significant improvement in wait times; she would provide an update. Maternity services remained a priority and Cathy Winfield reported that she would like to see the Rushey Unit expand as evidence had shown that mums who received one-to-one support from a midwife were less likely to require medical intervention. There had also been concern regarding high caesarean section rates at the Royal Berkshire Hospital which were 1 in 3, higher than at Oxford’s specialist maternity unit.

Councillor Webster advised that residents had asked how they could assist to expand or improve the Rushey Unit. Cathy Winfield stated that campaigns helped but the main issue was the lack of capital funding within the NHS.

Councillor Chopping asked whether other Local Authorities were scrutinising the STP. Cathy Winfield advised that it had been presented to Health and Wellbeing Boards but she would expect and welcome scrutiny.

Councillor Lazlo Zverko expressed surprise that there were still back office efficiencies to achieve in the context of several years of pressures on budgets. Councillor Somner commented that making efficiencies was cyclical. Cathy Winfield advised that many efficiencies had already been achieved but the Carter Review revealed that more could be done to achieve best value for money.

Councillor Dillon commented that after many years of devolution of powers, decision making was now being brought up to large regional levels.  He queried whether BOB might plan to build units. Cathy Winfield responded that CCGs maintained individual responsibility for planning but would consider the needs of the STP footprint.

Councillor Dillon asked how success would be measured. Cathy Winfield advised that each project would have a charter and define the outcomes, including savings, it would be seeking to achieve.

Cathy Winfield continued that to achieve the ambitions there were two enabling workstreams: workforce and digital solutions. New ways to improve recruitment and retention were being pursued, including rotational opportunities across organisations to keep work varied and it was planned to reduce agency spend. More digital solutions for self care and remote appointments were being investigated.

The governance arrangements were still a work in progress, for example at the Delivery Board there was only one Local Authority representative and the most effective way to include Local Authorities was yet to be determined.

Regarding the progress to date and next steps, Cathy Winfield advised that an initial draft plan was submitted for review by NHS England at the end of October 2016. The plan rated Level 3 out of 4, with 1 being ‘good’, so there was a lot more work to do. The revised plan was being submitted in January 2017 and publication of the full plan would follow.

The draft plan had been published by Reading Borough Council but it was not an accessible or well formatted document. A short public facing document would be published in the following few weeks and CCGs would be engaging on their Operating Plans in February or March 2017.

Councillor Mike Johnston gave his experience of NHS services and noted that there might be savings to be realised from reducing the number of letters and stamps used. He stated that he expected the software was available and more training might be beneficial. Cathy Winfield responded that she agreed there was more to do to become paperless and the digital workstream would address this, Councillor Somner commented that patient information needed to be held securely and this came at a cost. David Lowe suggested that digitisation of records and practice could be scrutinised in more detail, should the Commission be minded to add the STP to its work programme.

Councillor Webster asked what the impact was of the publication of the draft STP by Reading Borough Council. Cathy Winfield advised that the CCGs were unaware that it was going to be published until she heard about it on BBC Berkshire. There had been no follow-on from the publication but the document was still in draft and not helpful to the public. Councillor Webster agreed that the document was difficult to read but commended the structure which allowed the reader to read parts they were most interested in.

Councillor Dillon suggested that a Gant chart showing key dates for each workstream would be useful to see so that the Commission could plan its scrutiny appropriately.

David Lowe, referring to the STP governance, enquired on what level scrutiny was involved. He reported that he had spoken with his counterparts in other Local Authorities who had mainly scrutinised at a local level. He suggested that a Joint Health Scrutiny Committee at the BOB level and the Berkshire West level might be useful. Cathy Winfield responded that she would be grateful to have that involvement. The Chair and Vice-Chair agreed to send a formal letter to their counterparts in other Local Authorities on the matter.

Councillor Dillon asked how the STP would be scrutinised at a West Berkshire level and suggested quarterly monitoring. Councillor Webster suggested that it be scrutinised six-monthly.

Councillor Somner asked what might happen if one organisation link in the STP system chain broke. Cathy Winfield responded that the Berkshire West 10 organisations were bound through Section 75 agreements as part of the Better Care Fund. There had been a commitment from Chief Executives to the STP and she did not anticipate a problem because Berkshire West 10 relationships were well embedded. NHS organisations were linked at the Accountable Care System level by a Memorandum of Understanding (MoU) but an MoU should not be necessary at a BOB level.

Resolved that:

(1)       Scrutiny of the Buckinghamshire, Oxfordshire and Berkshire West NHS Sustainability and Transformation Plan be added to the Work Programme.

(2)       Cathy Winfield would provide more information regarding:

a)    the breakdown of budgets and population over the BOB footprint,

b)    CAMHS wait times,

c)    Key dates for each workstream

(3)       The Chair and Vice-Chair would send a letter to other Overview and Scrutiny Committee Chairs in the BOB footprint to invite them to carry out joint scrutiny.

(4)       The report and presentation be noted.