Agenda item

To provide a finance update for NCL including the overall strategic direction of travel, 2022/23 figures for the NCL ICB and for NHS Trusts that provide services to NCL patients.

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)