Gary
Sired, Director of System Financial Planning for the NCL ICB, and
Anthony Browne, Director of Finance Strategic Commissioning for the
NCL ICB, introduced the report on this item. Gary Sired explained
that NCL had a complex health and care economy and that the ICB had
a duty to lead collaborative working across the Integrated Care
System (ICS). The system in NCL was a net importer of activity and
there were significant differences in the size of the Trusts. The
underlying position of the finances was that there was a recurrent
deficit that needed to be recovered and that had been recently
managed with non-recurrent solutions to achieve balance. A balanced
plan for the ICS for 2022/23 had been developed but it contained a
large level of financial risk.
Gary
Sired and Anthony Browne then responded to questions from the
Committee:
-
Cllr Iyngkaran noted
that a surplus had developed in 2021/22 due to the underspends
resulting from the Covid-19 pandemic and asked how the backlog
would now be dealt with. Gary Sired acknowledged that this was a
challenge but noted that there was a national incentive scheme with
funding for elective recovery that Trusts could access when
achieving activity of 104% or more of their 2019/20 activity
levels. Asked by Cllr Iyngkaran about
the progress towards this target, Gary Sired said that some Trusts
were on target and some were not, but the target was not yet being
achieved overall in NCL. However, it was a tough target and the
performance in NCL was above average in London. Asked by Cllr
Hutton about the operational issues in achieving the target, Gary
Sired noted that there was a moratorium on the 104% target on the
first six months which allowed the Trusts more time to
adapt.
-
Asked by Cllr Cohen about the impact of the
non-recurrent solutions to achieve financial balance in previous
years, Gary Sired said that these should not affect services and
that the changes were largely technical balance sheet adjustments
such as releasing reserves. In response to a follow up question
from Cllr Atolagbe, he explained that
the timeframe for addressing the deficit had not yet been agreed
but that a financial plan for recovering a position like this would
typically be 3 to 5 years.
-
Following up on the previous questions,
Sarah Mansuralli
provided some further detail on operational issues. The approach to
elective recovery involved the Trusts working together, maximising
the availability of capacity by moving some patients to other
Trusts to have their procedures carried out faster. Underlying
efficiency issues were being addressed through the transformation
programmes including by reducing duplication and providing more
care in the community. Asked by Cllr Milne why the emphasis was on
moving patients rather than resources, Sarah Mansuralli clarified that surgeons were operating
at different sites as required and that, in dealing with the
backlog, further options about moving resources to meet patient
needs may need to be considered.
-
Cllr Clarke asked about the discrepancy in funding
between different Trusts, noting that the Whittington appeared to
get considerably less than others, particularly those with a
teaching component, despite the poor state of its A&E
Department. Anthony Browne explained that many of the others were
bigger tertiary Trusts that brought in much of their activity from
outside of the NCL area. Dr Jo Sauvage
added that capacity had to be centralised for a lot of specialist
services and that those services often required a great deal of
technology, innovation and research resource. Problems could also
have different causes in different organisations and could
sometimes relate to other estate or workforce factors for example
and not just funding levels.
-
Asked by Cllr Chowdhury about delays with hospital
discharge, Sarah Mansuralli said that
the ICB generally worked well with social care on this as a lot of
the discharge arrangements established during Covid were still in place. However, it could still
be difficult to find an onward placement, partly because the care
market had changed so significantly in recent years with more
complex care packages required than previously. For example, this
could mean NHS resources being added to domiciliary care packages
such as district nursing or mental health support. This work was
ongoing but the financial environment was a challenging one.
Anthony Browne added that a £12m package of additional winter
funding was being provided in the NCL area which would help to
support some of this work.
-
Asked by Cllr Clarke about the impact of the energy
crisis and rising inflation, Gary Sired acknowledged that the
funding originally allocated had been made on assumptions about
inflation rates expected at the time. However, the ICBs then got an
uplift in April/May which was then passed onto the Trusts based on
inflationary pressure. In terms of energy supplies, some contracts
across the NCL area were at fixed levels but not all of
them.
-
Cllr Cohen expressed concern that moving patients
between Trusts could potentially involve longer patient journeys.
Dr Jo Sauvage said that the aim was to
be as personalised as possible and that some people may prefer to
be seen locally whereas others may prioritise being seen as quickly
as possible. Elective recovery had been clinically led with
person-centred conversations with individuals about managing where
they can get treated in the context of their health needs. With
Trusts working together with this approach the aim was to use the
financial resource and clinical capacity to smooth the peaks and
troughs and optimise service at every level.
-
Asked by Cllr Anolue
about the practical measures that would be employed to address
health inequalities, Dr Jo Sauvage said
that the Covid pandemic had highlighted
the inequalities in society and that the data now available on
health inequalities was the most impressive they had seen. This
included data on multiple determinants of ill health including
employment, housing, and mental health and also included data on
ethnicity. These factors needed to be understood in the context of
particular interventions that were required such as vaccinations or
tracking of important priorities such as cancer or heart disease
and in working closely with communities to develop bespoke
approaches. Asked by Cllr Anolue how
communities would be approached, Anthony Browne highlighted a
£5m health inequalities fund which all the Trusts in the NCL
support. This enabled engagement with community leaders and was
part of the overall population health strategy.
- Cllr Anolue expressed concerns about the availability and uptake of
Covid booster vaccinations in BAME
communities. Dr Jo Sauvage said that
there was a well developed vaccination
programme in the NCL area with community outreach. However, the
general global anxiety about vaccinations was recognised and so
there was a need for a catch up on MMR, flu and also the need to
guard against the possibility of polio cases. Gary Sired added that
there was specific money set aside to work with the boroughs on
vaccinations. Sarah Mansuralli added
that there were different initiatives in each borough tailored to
specific local needs and suggested that an update on these
initiatives could potentially be brought to a future meeting of the
Committee. (ACTION)
-
Cllr Connor asked whether Hospital Trusts were
selling off parts of their estate in order to raise funds, but it
was clarified that this was not the case.
-
Cllr Connor requested further details about the
£5m outlined to fund virtual wards. Sarah Mansuralli said that this was a new development
which aimed to care for more patients in the community. It was
recognised that there could be a lot of deconditioning of frail
patients in hospital so there was a national programme on
increasing virtual ward beds which had started in NCL last year. A
co-design workshop had taken place including organisations from
across the ICS. The virtual ward model in NCL covered both health
and social care as an integrated approach was required. Funding had
been provided from the centre for the current financial year but
then matched funding would be required thereafter and could
potentially be reduced further in future. The service would
therefore eventually need to be self-sustaining by reducing the
length of patient stays in hospital.
-
Cllr Connor asked about the funding allocated for
community service provision and whether there would be a period of
double spending given that the acute care services would still need
to be provided until the pressure had been reduced by the
additional community service spend. Anthony Browne confirmed that
this would be the case and that there were no efficiency savings
required in the first year as there would be a year lead-in period
to establish the community services at the right level and the
necessary changes to care pathways. Across the NCL area as a whole,
there was a £57m investment programme over five years to
ensure that this core offer was delivered. The programme had been
backed with central funding initially but would be dependent in
future years on savings in the acute cost base as more activity
moved into the community.
-
Cllr Iyngkaran asked what measures were being put in
place to raise MMR vaccination rates in Haringey, noting that they
were currently lower than the average for England. Dr Jo
Sauvage said that this was recognised
an as issue and that there was a programme in place to address
this. The model predicated on primary care may not be sufficient,
so more outreach was needed as well as better work with community
pharmacies. The Committee recommended that the JHOSC keep this
matter under review. (ACTION)
The Committee
then discussed recommendations based on the discussion and the
information received.
Cllr Clarke reiterated her concerns about the
discrepancy in funding levels between the teaching hospitals and
the other hospitals and requested that further information be
provided to the Committee on what this funding was specifically
being allocated for in order to have a better understanding on
this. (ACTION) Gary Sired clarified that a significant part of the explanation
for this was illustrated by the column on page 20 of the agenda
pack which set out the funding provided by the NCL ICB as opposed
to the total overall figures which included funding from other ICB
areas.
Cllr
Hutton asked when the next finance report would be provided to the
Committee. Cllr Connor clarified that finance reports were
typically provided once per year. Gary Sired said that late summer
2023 would be about the right time of the financial cycle to
provide details of future plans. Cllr Connor suggested that the next finance
report should include further information about the funding to
address health inequalities and evidence on how this was working.
Risks to services or capital projects associated with
inflation/energy costs should also be included. (ACTION)
Cllr Milne commented that health inequalities was
not a new issue and so he would be interested in seeing more about
the efficacy of not just current programmes but also previous
programmes. Cllr Cohen reiterated that there should be ongoing
consideration of whether the joint working between Trusts could
potentially have an adverse impact on patient journeys. Sarah
Mansuralli commented that an update on
the inequalities fund could potentially be brought to the Committee
earlier than the wider finance report if required.
(ACTION)
Asked
by Cllr Connor whether there was any local authority or patient
representative presence on the ICB Finance Committee,
Sarah Mansuralli confirmed that the Board was chaired by a patient non-Executive
member of the Committee with a lay background. Cllr Connor welcomed
this and proposed a recommendation that a local authority
Councillor should also be included in the membership of the
Committee as they were embedded in local communities and could
bring that view to the discussion on strategic decisions. Anthony
Browne noted that the Committee tended to discuss detailed finance
issues and suggested that there should be consideration of whether
this would be the most appropriate forum for a local authority
representative given that finance issues were also discussed
elsewhere. Sarah Mansuralli agreed to
provide a written response on this recommendation.
(ACTION)