Agenda item

a.    Update on the Wellbeing Partnership (verbal)

b.    Developing an Accountable Care Partnership Across Haringey and Islington

c.    Discussion – Workstream on Cardiovascular Disease and Diabetes in Haringey and Islington

8A. Update on the Wellbeing partnership.

 

The Board received a verbal update on the Haringey and Islington Wellbeing Partnership by Sarah Price, Chief Officer Haringey CCG. The Chief Officer, Haringey CCG advised that over the summer, Haringey and Islington had consolidated their position in relation to the other boroughs within NCL; the work that was occurring across the two boroughs was widely recognised as being a key component of the sustainability and transformation of health and care in the five boroughs. A lot of work had been undertaken behind the scenes to clarify what the partnership was trying to achieve, and to set out its principles and objectives.

 

The Board was advised that the work that was being undertaken around Cardiovascular Disease and Diabetes would be significant in helping to deliver sustainable health and care services, both across the two boroughs and more broadly. The Board was also advised that the work being undertaken around mental health was also important and that work on MSK was due to start in earnest following the appointment of an MSK lead. A children’s and young people project was also being developed under the partnership, in response to feedback from staff that they wanted to see its inclusion as one of the initial workstreams. It was noted that Tim Deeprose had recently been appointed as the Interim Programme Director for the Wellbeing Partnership, and that establishing a team to support the work was a key task to help drive the project forwards.

 

In response to a request for clarification, the Chief Officer Haringey CCG gave some further background information on the reasons why it had taken longer to get the work around MSK going. The Board was informed that part of the reason was due to capacity and the need to identify resources to lead on delivery of the project, particularly in terms of coordination across the different organisations involved. A lead had been appointed and work was underway to develop this work stream.  The Assistant Director of Public Health LBOH, outlined some of the main factors behind why the MSK piece of work was so important. The Board noted that representatives from CCGs, local authorities and the Whittington and North Middlesex hospitals had met the previous week to look at the agenda around children and young people. The Board also noted that the work plan for children and young people would be reviewed to support the wider work of the STP around the demands on acute care and A&E, as well as to look at the pathways for children with long term conditions with community support needs. As a result of these discussions, Whittington Health agreed to lead on putting together a proposed work plan and this would be presented to the next Haringey Health and Wellbeing Board. The Assistant Director of Public Health reiterated that there were clear links between the children and young people workstream and acute community services.

 

Simon Pleydell; Chief Executive, the Whittington Hospital NHS Trust commented that it was felt that not having a dedicated work stream around children and young people was an anomaly.  The Chief Executive of the Whittington Hospital NHS Trust suggested that it was an encouraging sign that those contributing to the partnership were identifying additional areas, and that they were willing to put in the additional work to support. In response to a question on the pressures involved on A&E services at the Whittington, the Chief Executive of the Whittington Hospital NHS Trust advised that the issue was around what was the most suitable setting to receive care and whether that was in a community setting or whether this was at an emergency department. This was a key challenge faced across the health sector and it was commented that the whole of North Central London had some ambitious thoughts about how this could be achieved.

 

8B. Developing an Accountable Care Partnership

 

The Board received a report which provided an update on the work being undertaken to develop an Accountable Care Partnership. The report was included in the agenda pack at pages 21-28. The report was introduced by Zina Etheridge, Deputy Chief Executive LBOH and Charlotte Pomery, Assistant Director of Commissioning LBOH. 

 

The report set out the work achieved to date and the Deputy Chief Executive advised that the partnership was working sufficiently well that the consideration should be given to developing more formal governance arrangements. It was reiterated that there were significant issues with organisations making the transition to a more integrated model, given the piecemeal approach undertaken so far. However, there were also significant areas of commonality across the system. The system wide basis had been clearly set out through the STP case for change and the issues highlighted during the presentation at item 7, however the Deputy Chief Executive suggested that at present there was no the system wide response available to tackle them effectively.

 

The fact that each organisation had its own funding streams and its own contracting and commissioning arrangements was highlighted and, as a result significant inefficiencies existed. The Board considered that both commissioners and providers were increasingly moving towards pooled budget arrangements. The way funding flowed within an accountable care partnership was often significantly different from current, organisationally based funding. The Wellbeing Partnership was currently looking into what a single control mechanism across organisations could look like. The Deputy Chief Executive advised that there were challenges in working out pooling arrangements between two organisations, not least consideration of at what level budgets would be pooled, and that moving to new ways of thinking about population level pooling would add further complexity to the picture.

 

The Deputy Chief Executive outlined the Wellbeing Partnership had created a partnership at two levels; with a top strategic layer and also a number of work strands that existed from the bottom up. The proposals in the report would aim to facilitate the ‘bottom-up’ work of scaling up areas of good practice so that there was a constant iteration between new ways of planning, resourcing and delivering services and an organisational form that facilitated these approaches. The Deputy Chief Executive advised that it would be really important to ensure that there was sufficient leadership from clinicians, social care organisations and other professionals. It was commented that there was a significant amount of learning available about different organisational forms, but that the development of models of accountable care organisations was still at an early stage.

 

The Deputy Chief Executive suggested that the evidence base around aspects such population size was not strong and that a lot of the international examples were working with very different systems to those that existed locally. The Board was advised that they needed to be mindful of the huge complexity that existed within NCL; with a number of different providers serving different populations, as well as the different local authorities and different commissioning organisations that also existed.  As a result, there was no existing model of an accountable care partnership that could be used. Furthermore, the Board was advised that any different sort of partnership that Haringey and Islington set up would have to be able to work with other models, partnerships and providers that existed within North Central London and across other organisational boundaries more generally.

 

The Deputy Chief Executive emphasised that the Board was not being asked to agree to become an accountable care partnership at this stage but instead it was being asked to make a formal commitment to undertaking the next stage of work. Any formal move to becoming an accountable care partnership would need to be taken by a series of constituent bodies of the groups present. Agreement in principle to move to an accountable care partnership type organisation was sought by the Board. Work would be undertaken in the coming months in order to get to a position by next spring whereby the constituent bodies could start reviewing the proposals and taking them through their decision making processes.

 

 The Assistant Director of Commissioning, LBOH outlined the role of an accountable care partnership to the Board.  Accountable care partnerships were a fairly new and innovative structure, and the AD Commissioning commented that a key consideration was to ensure that the particular form of partnership chosen was right for the population of Islington and Haringey. The Board was advised that some of the feedback received during the formation of this report was around the need to ensure that it linked to local communities and also linked in to the wider STP and NCL work. The AD Commissioning advised that an accountable care partnership differed from a single accountable care organisation and that the Wellbeing Partnership was seeking to build on the assets and strengths of the different organisations involved. The Board was also advised that officers were keen to ensure stakeholder engagement was undertaken with local communities around this work.

 

Dr Josephine Sauvage, Chair of Islington CCG welcomed the commitment around engagement with local residents and commented that feedback from the recent Joint Overview and Scrutiny Health Committee was that there was a real appetite from the local population to be involved in the development of this process. The Chair of Islington CCG also added that the STP work undertaken could feel quite distant and removed to residents and that this offered an opportunity for engagement in a meaningful way, specifically to agree how to embed the process of co-production.

 

**Clerk’s Note – Cllr Caluori entered the meeting. **

 

The Chair advised that the key benefits of exploring more formalised arrangements around joint working were around the need to for both boroughs to have a significant influence going forwards; particularly as part of the STP process, and also to ensure that incentives within the system were in the correct place. The Chair suggested that this would be would be a very powerful tool for local authorities and NHS providers in terms of facilitating a more sustainable future. It was commented that the pressures on organisations through the health and care system were so severe that some form of structural fix was necessary in the medium term. It was felt that this was the best opportunity available to develop that fix, whilst ensuring that organisations also maintained control over their own destiny.

 

The Chair of Healthwatch Haringey cautioned that service users were having difficulty in keeping up to date with the number of changes that were going on within the health and care landscape.  The Chair of Healthwatch Haringey commented that the governance issues raised in the report were going to be very important going forward as service users needed to be able to understand how and where decisions were being made and be given an opportunity to influence those decisions.  The Chair of Healthwatch Haringey also suggested that service users would likely want to see more information in relation to the comments of the Chief Finance Officer with regards to the amount of money spent on setting up this additional partnership and what the additional costs were. In response to the query around the additional costs, the Deputy Chief Executive, LBOH advised that a business case would need to be developed before any changes were implemented, and that the costs involved would vary significantly dependant on the type of partnership sought.

 

The Chair acknowledged that clarity around governance arrangements was something that all partners were concerned about and that a key consideration was ensuring the transparency and accountability of any organisation established to the wider community. The Chair advised that the sponsor board would be tasked to focus on accountability issues in tandem with work that was underway on governance and that this would be brought back early in the new year. The proposal would be based around a decision on whether a joint committee was established and would also set out clear expectations and parameters around accountability. The Board was advised that it was important to get the structures right in order to ensure that the accountability and decision making capacity were there.

 

The Chair of the Islington CCG cautioned the need to consider where the other big health providers would sit within the context of the partnership, as service users would want to see that there was an equitable service offer across both boroughs. The Deputy Chief Executive, LBOH advised that both UCLH and North Middlesex Hospital were on the sponsor board and that both providers had attended the last meeting. 

 

The Chief Executive, the Whittington Hospital NHS Trust commented that, in partnership with social care, this was a unique opportunity to form something which was appropriate and relevant to the populations of both boroughs. Whilst acknowledging that the accountability issue was very important for services users, the Chief Executive of the Whittington Hospital NHS Trust urged the Board to seize the opportunity of developing their own model of service provision and the rules and governance arrangements around that.

 

 

RESOLVED

 

1. To adopt the principles and high level outcomes as developed by the Sponsor Board of the Haringey and Islington Wellbeing Partnership
2. To agree in principle to the development of a form of accountable care partnership which best supports the outcomes sought by the Haringey and Islington Wellbeing Partnership
3. To endorse further work to develop the detail of such a partnership, with the aim of gaining agreement on the final structure and form from constituent decision making bodies by April 2017
4. To require the Sponsor Board to report back on progress in developing and implementing a project plan 
5. To request the Sponsor Board to consider as a matter of priority how community and stakeholder engagement will be undertaken and involve key stakeholders including Healthwatch

 

8C. Workstream on Cardiovascular Disease and Diabetes in Haringey and Islington

 

The Board received a report and presentation which gave an overview of health and care needs relating to diabetes and cardiovascular disease (CVD) in Haringey and Islington. The report was included in the agenda pack at pages 29-36. The presentation was given by Dr Will Maimaris, Consultant in Public Health and Claire Davidson who was lead on self-management support and behaviour change at Whittington Health. Some of the key points raised in the presentation were:

 

• Haringey had the 2^nd highest rate of early death from stroke in the country. There were 23,000 people diagnosed with diabetes in Haringey and Islington and 1 in 5 of these people was likely to have depression.     

 

• 1 in 5 people had high blood pressure in Haringey and Islington and half of these would not have been diagnosed. People living in the most deprived parts of Haringey and Islington were more than 3 times more likely to die young from cardiovascular disease than people living in the most affluent areas.

 

• The highest level of spending was currently on those who had already developed diabetes, CVD and complex health needs. Dr Maimaris suggested that the biggest impact could be made by targeting interventions at the wider population such as Healthy high streets, as all of the interventions that made Haringey and Islington a healthier place applied to everyone including those with existing conditions.

 

• The self-management support approach at the Whittington was seen as a golden thread through all services for integrated care. This involved patient programmes which focused on building knowledge skills and confidence so that patients could effectively self-manage their health conditions. Support for clinicians was also involved, to build knowledge skills and confidence to support self management and build coaching and communication skills.  The approach also included providing support to services to embed the approach into their way of working.

 

• It could often take a significant amount of time for people to build up to being able to self manage their conditions. At present services were set up so that patients received short interventions and consideration needed to be given to think about how the system as a whole could operate to facilitate self-management and become more integrated.

 

• The diabetes self management programme could achieve a reduction in HbA1c (blood sugar control) of 0.6% which was equivalent to the reduction achieved through anti-diabetic drugs but was considerably cheaper. There were currently 200 places available per annum on the programme.

 

• Dr Maimaris advised that engagement with clinicians and partners to find the main opportunities for improving outcomes and value for money was already underway and that the Wellbeing Partnership was had the potential to be a vehicle to help drive improvements in CVD and diabetes. 

 

•  Two main opportunities for collaborative working were identified in the report: Working as a whole system to develop a sustainable integrated model of clinical and social care for people with diabetes and cardiovascular disease; and, developing whole population approaches to preventing cardiovascular disease and diabetes.

 

• Dr Maimaris advised that gaps identified locally were also highlighted within the NCL STP case for change: Challenges in primary care provision; a lack of focus on prevention across North Central London; gaps in early detection of disease and Lack of integrated care and support for people with long-term conditions. Whilst the NCL STP would provide a framework to tackle some of the challenges identified, many of the solutions would need to be implemented at a local level.

 

Following the presentation the Board discussed its findings and was asked to consider: How could improvements be made to outcomes and value for CVD and diabetes through working in partnership; and, in which areas could the biggest impact be made by working together. The Chair, Islington CCG commented that one of the first opportunities identified was around working collaboratively to pull strings and that diabetes and CVD was one of those opportunities for both authorities to exact greater control through working collaboratively. The Chair, Islington CCG also advised that she had recently attended a public engagement event around the STP during which the importance of building on social capital was discussed, particularly through engaging local communities in activities such as the prevention work.

 

The Deputy Chief Executive, LBOH emphasised the need for a whole community approach to activities such as healthy high streets and the Daily Mile, issues like this would never be solved from a hospital or GP’s surgery. The Deputy Chief Executive stressed that the Board needed to consider how the whole community and all council services could be genuinely engaged to resolve these problems. The Chair commented that both she and the Cabinet Member for Finance and Health, LBOH were very supportive of the Daily Mile and welcomed the fact that 15 primary schools in Haringey had signed up to the event but, given there was around 72 primary schools in the borough, there was still a way to go. The task for the Board was how to ensure that they sold the wider wellbeing benefits of schemes such as the Daily Mile got the buy-in from schools and fostered that culture across the two boroughs. The Executive Member for Health and Social Care, LBOI also shared her enthusiasm for the initiative and advised that work was also being undertaken around the Daily Mile in Islington along with work to support this, though mapping out how far a mile was in parks.

 

Joint Director of Public Health - Camden and Islington commented that the preventative work required to tackle the cardiovascular disease and diabetes on a population level was also fundamentally important to improving the whole health of the population. The same risk factors were present for mental health and cancer as cardiovascular disease and diabetes, and therefore the potential impact was huge and further reiterated the need for population level leaders. The Cabinet Member for Finance and Health, LBOH commented that the Haringey Obesity Alliance had been set up a year previously and that in terms of the preventative work, that there was an opportunity to bring together voluntary sector organisations and health organisations across the two boroughs to combine to tackle issues such as CVD and obesity.

 

The Chief Executive, Bridge Renewal Trust suggested that a key consideration should be where were the areas that the biggest impact could be made, and that this would likely include early work with school children and work around obesity. The BRT was working with the Healthy London Partnership to involve children and parents in a scheme to raise awareness of healthy eating and to make healthy food available at an affordable rate. One of the issues raised as a result of engagement with the wider voluntary sector was the number of disparate but small initiatives and how to scale those up.

 

The Chair remarked on the correlation between some of these issues and poverty and deprivation across both boroughs. The Board was advised that between health organisations and local authorities there was the capacity to use levers to effect change but, in order to utilise these levers fully, it was imperative that organisations worked collaboratively. By doing so, it was felt that there was a real opportunity to tackle broad issues of inequality and social justice. 

 

The Director Adult Social Services, LBOH highlighted the impact of the prevention work at the front end of the system on budgets and outcomes for residents. The Board was informed of an ongoing dialogue that she had with Corporate Director of Housing and Adult Social Services at Islington around a reciprocal peer review. The aim was to look at areas for collaboration following the peer review of the two respective Adults Social Services. Haringey Adult Social Services were looking at  a new target operating model which embraced the prevention and population level approach rather than focusing just on the delivery of services. The Director of Adult Social Services, LBOH advised that this would likely create a number of opportunities for Islington and Haringey to develop joint working. The Corporate Director of Housing and Adult Social Services, LBOI suggested that the mutual peer review piece of work was something that should be brought back to a future meeting of the Health and Wellbeing Boards. The Chair agreed to bring this item back to the next meeting of the Board (Action: Beverley Tarka & Sean McLaughlin).

 

RESOLVED

 

1. To note the issues raised and the areas of good practice highlighted.
2. To note the opportunities for improving population health outcomes and value for money for cardiovascular disease and diabetes prevention and care through the Haringey and Islington Wellbeing Partnership