Agenda item

To consider and discuss Integrated Care Systems (ICS).

Mike Cooke, ICS Independent Chair, Rob Hurd, Joint System Lead, and Frances O’Callaghan, CCG Accountable Officer and Joint System Lead, introduced the item which provided an opportunity to consider and discuss Integrated Care Systems (ICS). Mike Cooke noted that arrangements would need to be put in place for the 2021-22 financial year before the official legislation on ICS came into effect in 2022. It was explained that officers would be able to present the current thoughts and proposals for North Central London (NCL) and would welcome the views of the Committee but might not be able to answer all questions on the government proposals for ICS.

It was noted that the white paper proposed a national ICS framework which was intended to formalise the existing arrangements across the country. Although the white paper did not discuss the ambitions and purpose of health and social care integration, these were set out in the long term plan which was cross-referenced in the white paper. It was also noted that the white paper did not include social care as the government had decided to deal with this separately.

It was explained that the proposed approach for NCL for 2021-22 was set out on page 14 of the supplementary agenda pack. It was noted that there were five existing borough partnerships in NCL and the white paper was clear that the operation of these partnerships would be determined locally rather than detailed in legislation. In NCL, it was proposed to have a Partnership Board which would agree the overall ambitions and policies of the ICS and would include local authority Leaders. There would also be a NCL Steering Committee which would oversee operational activity and which would include local authority representatives. In addition, NCL would have a Community Partnership Forum to engage proactively and a Population Health and Inequalities Committee. It was considered that NCL was well placed to meet the ambitions set out in white paper and would be addressing some important priorities in 2021-22, including delivery of the Covid-19 vaccination programme, service recovery, and strategic reviews of community services and mental health services.

Some members of the Committee felt that the proposed structures reduced the involvement of councillors and stated that there should be some changes to the governance structure to ensure a continued scrutiny-based approach. Members enquired about the role that provider Chairs and prospective providers would play in decision making, particularly at the top level and in comparison to other parties, such as councillors and members of the public. Some concerns were also expressed about the lack of detail in the white paper regarding the relationship between health and social care.

Mike Cooke noted that he was an independent ICS Chair and explained that local authority scrutiny arrangements were not expected to change in any new arrangements. He explained that the white paper envisaged that the body making decisions about NHS spending would involve local authority representation and would be subject to the normal scrutiny arrangements. It was added that the integration of health and care was striving to bring NHS and local authority powers and decision making together in an active partnership.

It was stated that the role of provider Chairs was critical and their engagement with NCL ICS would assist them in redesigning services to be more community orientated. In relation to the community voice, it was highlighted that borough partnerships would continue to be an important element of the arrangements for NCL and would be maintained in the proposals for the ICS. In relation to social care, it was explained that adult social care colleagues worked closely with the CCG, hospitals, and community trust colleagues and a level of service integration had already been developed, particularly during the Covid-19 pandemic.

The Committee noted that some residents and local groups had concerns, particularly following the recent AT Medics and Centene decision, that they were not sufficiently included in decisions or informed about developments; it was enquired how the proposed structures would prevent future issues. Mike Cooke explained that primary care was provided by independent and sometimes private companies; this had not fundamentally changed and could not be prevented in the NHS.

The Chair understood that the white paper proposed to remove the power of scrutiny to refer matters to the Secretary of State. It was added that it would be important for the proposals to ensure transparency and accountability and it was suggested that there should be assurances that the ICS Board meetings should be held in public. Mike Cooke noted that the white paper was the first step and there were likely to be changes and additional detail following parliamentary consideration; he added that he did not envisage any changes to the current scrutiny process. It was acknowledged that the power for scrutiny to refer matters to the Secretary of State was not included in the white paper but it was suggested that this was likely to be raised during consideration of the bill. Mike Cooke stated that it was standard practice for all NHS Boards to meet in public; this would be the case for the arrangements in 2021-22 and it was expected that this would be required under any new legislation.

The Committee noted that the white paper did not mention whether there would be any public health representatives on the Board and stated that it would be important to include public health appropriately in the ICS. Mike Cooke noted that local authority Leaders were ultimately responsible for public health and could provide this input. It was stated that the membership of boards was often a finely balanced issue as groups which were too large often lost their ability to function effectively. It was added the Population Health and Inequalities Committee would require specific public health representation and that there would be opportunities for public health views to be presented.

Some members noted that the five boroughs’ CCGs had been merged into one NCL CCG which had removed some local powers and it was stated that this was demonstrated through the transfer of GP services contract from AT Medics to Centene. Frances O’Callaghan explained that the NCL CCG was the strategic commissioner for the wider area but also worked with the boroughs to deliver appropriate local arrangements. It was added that work had begun to ensure a more strategic approach to mental health and community services and to address inequalities. In relation to the AT Medics and Centene decision, Frances O’Callaghan explained that there had been some misunderstanding about what the CCG had been able to do in relation to this decision. It was noted that the CCG had a number of legal requirements in relation to service provision, including ensuring continuity of service. It was added that the CCG was committed to transparency and that the papers relating to the decision had been published online, although it was acknowledged with hindsight that it would have been beneficial to contact councillors to make them aware of the issue.

It was enquired whether the Partnership Board would report to one of the other committees and how this relationship would operate. Mike Cooke explained that the Partnership Board would not have a parent committee but that all of the committees would have some relationship, depending on the issues in question. Some members of the Committee stated that the proposals were being developed quite quickly and it was queried whether it was appropriate to wait until after the Covid-19 pandemic to allow for more planning and consultation. In relation to the timing, Mike Cooke acknowledged these concerns but explained that it was not possible to continue with ad hoc governance. It was noted that the proposals for 2021-22 had been developed across the partnership to enable NCL to transition well and to improve; it was added that the final proposals were, to a large extent, in the government’s control. It was also noted that the deputation had mentioned that the NHS would be controlling local authority funding but it was highlighted that this was not proposed in the white paper.

The Chair noted some concerns that the white paper proposed that the NHS would report to the Secretary of State which would result in more direct influence rather than a separation of power. Mike Cooke noted that the white paper and the corresponding communications suggested that the Secretary of State would have the power to make directions. It was accepted that this was a form of direct control but it was anticipated that this would relate to matters such as performance targets and would not be widely used in relation to normal operations. It was added that this sort of arrangement was not unusual and also existed between local authorities and the Ministry for Housing, Communities, and Local Government (MHCLG).

It was noted that any decisions about finances could be contentious and it was enquired how these types of decisions would be made, including the distribution of funding between different boroughs. Rob Hurd noted that, currently, funding was often allocated directly to hospitals, primary care, and other services. Under the new ICS proposals, there would be no changes to the formulas for calculating funding but all funding would be managed and locally allocated by the ICS.

A member noted that pharmacies had been very important during the Covid-19 pandemic and it was enquired how the proposals would ensure the equal integration of pharmacies. Frances O’Callaghan acknowledged that pharmacies had been critical in delivering preventative work and in reducing the strain on hospitals. It was explained that pharmacies came under direct commissioning through NHS England but it was envisaged that they would be more integrated into the ICS in future.

Some members stated that the purpose of the Community Partnership Forum was similar to the purpose of the Joint Health Overview and Scrutiny Committee. It was felt that this may lead to some duplication of work and that it may be more appropriate to strengthen the scrutiny arrangements rather than introducing a new forum. Some members noted concerns that the structure would need to ensure that residents were engaged in a meaningful way and that their comments, which often resulted in enhanced decisions, were taken into account. It was also enquired how the members of the forum would be chosen.

Mike Cooke noted that the Community Partnership Forum was not fully developed at present as more direct input was required from partners; it was added that any suggestions were welcome. It was envisaged that the proposals would enable community members to be equal partners. Frances O’Callaghan explained that the NHS had traditionally been monitored on targets, including those relating to A&E and finances, but that borough partnerships offered an opportunity to be held to account on a different set of population health outcomes. It was explained that the borough partnership and community arrangements would allow NCL to address complex issues in partnership.

The Chair noted that it would be useful to clarify the formal relationships of the boards within the proposed structure and to ensure that issues could be raised and dealt with appropriately. It was enquired whether all five councils would have distinct members or whether there would be a representative member and whether Directors of Adult Social Care would be included on any of the boards. It was also asked whether there would be any changes to the right for consultation and how councillors or members of the public could challenge any proposals. Mike Cooke noted that the ICS Steering Committee would likely have one council Chief Executive and one Leader representing the five councils; it was added that this would be done through mutual consent and that Cllr Watts from Islington had been identified as the initial representative Leader. It was explained that the proposals for 2021-22 would be in line with the current statutory arrangements and would be adaptable following the legislative proposals in late 2021-22. It was commented that issues relating to social care would need to be developed and would be further discussed with Dawn Wakeling, Barnet Executive Director of Adults and Health, who represented the five councils.

The Chair asked what powers partners would have to challenge decisions, particularly the relationship between the five councils. Mike Cooke explained that there would not be statutory arrangements for ICS until 2022 and that additional details could be developed over the next 12 months. He noted that, if there was a fundamental disagreement, the partnership would pause and discuss the best way forward. It was added that the legislation would likely set out relative voting rights.

Dawn Wakeling, Barnet Executive Director of Adults and Health, stated that the current proposals had very little detail and that social care would be covered separately which meant that it was difficult to comment. It was noted that there were a number of queries regarding how decisions would be made and how different organisations and partners would be able to contribute. She agreed that too much bureaucracy could be unhelpful but that, depending on the detail of the legislation, there could be flexibility for individual systems.

The Chair noted that this was a transitional period and that not all elements of the proposals could be influenced. It was agreed that the Committee would request further information on the proposals and would further consider ICS at a meeting in September or November 2021.

RESOLVED

To request further information in relation to the following issues:

·         More detail on what the Integrated Care System would look like, how it would be internally accountable (including the role of constituent organisations), and how it would be scrutinised.

·         It was suggested that the proposals would benefit from greater democratic accountability and that it would be important to include appropriate council representation within the structure. It was also suggested that the Partnership Board could be unwieldy and that the structure would benefit from something more sophisticated.

·         More information was requested on the anticipated role of Health and Wellbeing Boards, Directors of Public Health, and Directors of Adult and Social Care.

·         The importance of openness and transparency was highlighted and assurance was sought that meetings would be held in public and minutes would be available, in particular for the top level Board decisions.

·         Clarity was requested on whether there would be a right to public consultation in relation to all major proposals.

·         It was requested that there be a clear commitment for co-production and engagement and more information regarding the mechanisms or processes that would ensure the inclusion of patients’ and residents’ voices. Also, further detail was requested in relation to how the Integrated Care System would ensure strong communications.

·         There were some concerns that there was potential for work to be duplicated in the proposed structure and it was unclear what the role of the Joint Health Overview and Scrutiny Committee would be.

·         Additional information in relation to the capital proposal and how this would work, in particular whether the largest or certain partners would have more influence.

·         There was a significant concern that the scrutiny right of referral to the Secretary of State would be removed as part of the proposals. It was requested that consideration was given to reinstating this power or an alternative option in the case of any serious concerns.

·         The relationship between the NHS/ Integrated Care System and the Secretary of State and whether there would there be any option to derogate from a Secretary of State direction.

·         How pharmacies, which had been important throughout the Covid-19 pandemic, would be involved in scrutiny and integration within ICS and whether this could be equivalent to GP involvement.

·         It was requested that the suggestions outlined in the deputation from NCL NHS Watch were considered.