Agenda item

To receive the Developing our Integrated Care System - Discussion with Wokingham Borough Wellbeing Board presentation

This item was considered as the final item on the agenda.  A 15-minute adjournment was held to enable presenters to be able to attend the meeting virtually.

The Board received a presentation on Developing our Integrated Care System (ICS) from Catherine Mountford, Director of Governance at Oxfordshire CCG and governance development lead for BOB ICS.

During the discussion of this item, the following points were made:

·       Conversations around the development of the ICS were still at early stages.  The input of all partners into the development was sought.

·       The change in structure was based on the Health and Social Care Bill which was progressing through parliament.  Amendments were being proposed at the various stages, so the final position was not yet fully known.

·       Statutory status had been put back from 1 April 2022 to 1 July 2022.  However, the System would take 12-18 months to evolve and to be fully functioning.

·       The forthcoming structure had been built on several years of discussion from the NHS Long Term Plan and the commitment to needing to work more in collaboration and with integrated services.

·       The four goals of the ICS were:

Ø  improve outcomes in population health and healthcare;

Ø  tackle inequalities in outcomes, experience, and access;

Ø  enhance productivity and value for money;

Ø  help the NHS support broader social and economic development

·       Catherine Mountford outlined some of the key terminology:

Ø  Integrated Care System (ICS) – the whole System across Berkshire West, Buckinghamshire and Oxfordshire, including local authorities, provider Trusts, Healthwatches, practices and the Primary Care Networks.

Ø  Integrated Care Partnership (ICP) – joint committee with local authority partners.

Ø  Integrated Care Board (ICB) – NHS statutory body within the System.

Ø  Place Based Partnerships – local working though partnerships based at a Place level.

·       From July 2022, the CCGs would no longer exist, and the CCG staff would TUPE across into the ICB.

·       The System was made up of three Places (Buckinghamshire, Oxfordshire and Berkshire West).  Unlike some other South East ICS’ there was not a single point of focus.

·       The overall System would create strategy and delegation, whilst most care would continue to be managed and delivered at Place level.  Place would manage pooled budgets and deliver on Urgent and Emergency Care (UEC), Long Term Conditions (LTC) and integrated care.  Localities would deliver on inequalities.  Consideration would need to be given on how Provider collaboratives would deliver services beyond a specific Place.

·       The NHS wanted to work with partners to evolve the System and Place, and to discuss where it would add most value for integration and delivery to be at a local level and where it would best add value to work at a wider System level.

·       The Unified Executive in Berkshire West already brought together partners who were delivering on integrated care.  This would evolve in to the Place Based Partnership for the ICS, and could be a subcommittee of the ICB, meaning that authority and autonomy could be delegated to that committee, enabling it to take many of the decisions that were currently in the CCG’s remit.

·       The ICB Place teams would support the Place Based Partnerships.

·       The Board noted a high-level overview of the parallels between Place working and System working.  The Health and Wellbeing Boards in the Places would link into the ICP at System level, and the Place Based Partnerships would link into the ICB.  In Place there would be scrutiny via the established Overview and Scrutiny Committees and where appropriate the joint Overview and Scrutiny Committee.

·       The Board noted the minimum ICB membership as set out in the Bill (membership of 10).

Ø  1 x Chair – (designate) Javed Khan

Ø  2 x Independent Non-Executive Directors

Ø  1 x Chief Executive of Integrated Care Board – (designate) Dr James Kent

Ø  3 x Partner Members – brings sector expertise

Ø  1 x Local Authority Officer (from authority which delivers social care)

Ø  1 x Primary Care

Ø  1 x NHS Provider

Ø  1 x Finance Director

Ø  1 x Medical Director

Ø  1 x Nursing Director

·       Helen Watson commented that in other areas of the country, separate Boards were being established to ensure that children and young people’s needs were central.  She questioned whether something similar had been considered for BOB.  Catherine Mountford commented that there may be separate Children’s Boards at Place level.

·       Tracy Daszkiewicz, Director Public Health, asked whether it was likely to be a partnership of equals.  Catherine Mountford commented that the ICS and all the elements within it would be a partnership.  The ICB would be a statutory NHS body but would be set up in a different way.  Having partnership members on the Board would broaden and strengthen discussion.

·       Tracy Daszkiewicz went on to ask about the position of prevention, particularly primary, secondary, and tertiary prevention, and the influence and role of Public Health in that.  With regards to Place, the focus on prevention and reducing health inequalities was where joint working needed to be strengthened with local authority partners to drive and deliver.  Further consideration needed to be given to ways of working.

·       In response to a question from Councillor Cunnington, Catherine Mountford explained her role within the establishment of the ICS.

·       Councillor Cunnington questioned why there was only one local authority representative on the ICB, and how the voice of Wokingham residents would be heard.  Catherine Mountford emphasised that the representatives would come with sector expertise rather than be representatives of a particular local authority.  She emphasised the importance of Place.  The ICB would had the ability to delegate to Place level and work with the three Berkshire West local authorities to ensure that the different population needs were met.  In terms of the Board membership, conversations would need to be ongoing around maintaining a balanced membership between partner members, Executives and Non-Executives sectors’ geographies, without the ICB becoming too large and unwieldy.

·       Councillor Cunnington questioned whether there would be any change to Wokingham’s Better Care governance, which had been very successful, and was informed that pooled budgets would likely be governed and run locally, as they were now.

·       Councillor Hare expressed concern that local issues would be lost.  He emphasised that West Berkshire and Reading had different outcomes to Wokingham, yet they were considered one Place.  Catherine Mountford commented that there was a need to work at the appropriate geographical level.

·       Nick Fellows, Voluntary Sector asked how the Voluntary Sector could get more integrated into the planning, have its voice heard, and bring to bear what it had to offer.  Catherine Mountford emphasised that she would expect broad Voluntary Sector input into the ICP.  There would be a workshop with the Voluntary and Community Alliance about working with the Voluntary Sector.

·       Councillor Margetts referred to an issue with a particular surgery in the Borough.  He questioned how Wokingham could ensure that local issues were addressed.  A Place Director would cover the whole of Berkshire West.  Catherine Mountford agreed to take this question around operational delivery back for a response.

·       Councillor Margetts commented that the forthcoming structure was a big change and a lot of effort had obviously gone into the planning.  He sought a commitment that ICS members would come to the Wellbeing Board in future for constructive discussions, to ensure the needs of Wokingham residents were represented.  Catherine Mountford agreed that they would.  The ICS would be actively reviewing the way in which it was set up.  As a new organisation, not everything would be right immediately.

·       Councillor Halsall believed the new structure was remote, and that authority would appear to be taken away from local authorities.  Catherine Mountford commented that what made sense to be commissioned at a local level would not be taken away to a higher level.

·       Councillor Halsall commented that he was alarmed at the development of the new structure.  Wokingham had had considerable success with integration, locally and he was concerned that this positive momentum would be curtailed.  He went on to comment that he had not had any contact with the Chief Executive Designate.  Councillor Halsall was of the view that there should be representation from each of the five local authorities on the ICB.  Catherine Mountford emphasised that the ICS was still under development.  Dr James Kent, Chief Executive Designate of the Buckinghamshire, Oxfordshire, and Berkshire West Integrated Care System, stated that they were trying to design a system which was based on parameters set out in legislation going currently through Parliament, and with a set of guidance on how to do that.  He reiterated that the aim was to create Place Based Partnerships which would have most of the delegated funding.  There was some flex into how these Place Based Partnerships were arranged, so a dialogue on good representation across all the local authorities in Berkshire West and how this would work, and how these partnerships would be given oversight by the Wellbeing Boards, would need to take place.

·       With regards to the single local authority partner member on the ICB, Dr Kent emphasised that they were effectively a Non-Executive Director on the Board with expertise in that particular subject area, rather than representing a particular local authority.  This was the same for the Primary Care and NHS Provider representatives.  Dr Kent indicated that he understood concerns, but the intention was to build the system within the statute and the guidance, but also within each Place, to create a partnership that could take the majority of decisions over funding.

·       Councillor Halsall stated that statute listed a minimum representation but not a maximum.  Dr Kent stressed the need for an effective and manageable Board.  If the Board increased in one area it would come under pressure to increase in other areas.

·       Councillor Halsall sought assurance that GP disparity locally, was being addressed.  Dr Kent explained that primary care were independent contractors operating through a GMS contract, a national contract negotiated through NHS England and the BMA.  He indicated that he was happy to go through any issues identified with practices in Wokingham.  With regards to the specific practice, they had been given additional funding via the Winter Access Fund, to try and make improvements.  The Local Medical Council could also be contacted.

Councillor Margetts provided the following statement:

Thank you for your update.  I wanted to read out a statement to record formally the view of the Wokingham Borough Council and the Health and Wellbeing Board with regards to the ICS and its formation.  I have consulted key members of the Health and Wellbeing Board who deal with healthcare and Opposition politicians, and all are agreed on these comments.

We acknowledge the change in the NHS structure is a national directive and not up for negotiation, however we wish to state our concerns that the new structure as proposed is flawed, and we have concerns that the voice of the residents of Wokingham via representation in the Health and Wellbeing Board, Wokingham Borough Council, and local GP Practices, will be diminished or silenced.

Our understanding of the Central Government legislation, which has been confirmed tonight by Catherine, is that as much as possible in terms of healthcare should be passed to ‘Place’ to ensure that decisions are made locally.

The three local authorities in Berkshire West ‘Place’ have some specific different population needs.  They reflect the way communities are organised and are the boundaries within which social care are delivered, and therefore we believe that ‘Place’ would be better defined along local authority boundaries so that concerns on any particular subject within one local authority are not compromised by the specific needs of another.

On this Board our role is to represent the best interests of our Wokingham residents and we believe that they would be much better served by closer integration of health and social care within a Wokingham footprint.

We have an active Health and Wellbeing Board and Integration Board which works effectively.  It is our belief that these structures should coordinate directly with the future Place representative of the ICB and should represent the views of the Wokingham community.  We believe that these structures should be strengthened and developed rather than eroded by ‘integration’ across the Berkshire West footprint.

We have concerns, which have been expressed tonight, about the lack of representation for the local authority and local primary care within the ICB structures, resulting in a lack of local voices in the decision-making areas.  Another point which has been touched on tonight - We note that one Chief Executive from one of the five authorities will it on the ICP Board.  I note the comments that you both made about this being a NED, but they will be in a position where they will be asked to give advice and opinions on things happening in the area, and we cannot understand how for example, the leader of Oxfordshire Council, can have any knowledge of Wokingham, West Berkshire, Buckinghamshire issues.  We fear that this will lead to decisions being made with no accountability and minimal local voice, which in the end results in poor outcomes for our residents.

We note the intended recruitment of a Place Director for Berkshire West.  Our concern is that they will have a Berkshire West view and will not understand the requirement to allow innovation within the Wokingham footprint to support our population with their needs, which may be and will be different from those in other parts of Berkshire West.  This candidate should therefore be proactive in understanding the needs of the population of the Wokingham locality, and working with us to push them forwards.

We regret that we have to make this kind of statement, as we wish to have a constructive relationship with, and work in partnership with the NHS.  However, we do believe that the current approach is flawed.  Wokingham health and social care have always tried to work collaboratively and successfully with local NHS providers and Wokingham Borough Council.  The Covid pandemic accelerated some of this joined up approach, and we do not wish to see this eroded with the lack of the strong Wokingham voice in the ICB.

We wish to formally record that this is our view that Wokingham should have its own Place based partnership in the new structure.  Our motivation is not to cause unnecessary arguments or conflicts but simply to seek the the best health care possible for our residents, and we would ask that the ICS and the CCG listen to our comments, respond to our concerns, and adopt the plan to reflect our wishes.  We would be happy to engage in constructive discussions to try and move this forwards.

RESOLVED:  That the presentation on developing our Integrated Care System, be noted.