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Oxfordshire, is currently in discussion with Government over a County devolution proposal and this has been discussed in Council and other public meetings over the last few weeks. One strand of the Oxfordshire proposal is specifically about health and wellbeing and proposes the benefits for the public of working more closely across all Oxfordshire’s health, social care and public health services, and linking these closely with community planning. This builds on the close strategic work between CCG and County Council, NHS England , District Councils and Healthwatch through the Health and Wellbeing Board over a number of years. It also builds on increasingly close working relationships between our major NHS Foundation Trusts.
This direction of travel has recently been supported and given impetus by the Chancellor in his Autumn statement which proposes the integration of NHS and Adult Social Care services across England by 2020. Because of the nature of the discussion with Government, this topic is progressing rapidly. The views of the Health Overview and Scrutiny Committee will help shape the proposal and taking this work forward.
Minutes:
Oxfordshire was currently in discussion with the Government over a county-wide devolution proposal. This had been discussed in Oxfordshire County Council and other public meetings over the last few weeks. One strand of the proposal was specifically about health and wellbeing, and proposed the public benefits of working more closely across all Oxfordshire’s health, social care and public health services, and linking these closely with community planning. This built on the close strategic work between the Clinical Commissioning Group (OCCG), the County Council (OCC), NHS England, the District Councils and Healthwatch Oxfordshire through the Health & Wellbeing Board over a number of years. It also built on increasingly close working relationships between Oxfordshire’s major NHS Foundation Trusts.
This direction of travel had recently been supported and given impetus by the Chancellor in his Autumn Statement which proposed the integration of NHS and Adult Social Care services across England by 2020. Because of the nature of the discussion with Government, this topic was progressing rapidly. The views of this Committee were sought to help shape the proposals and take the work forward.
Dr Jonathan McWilliam gave a presentation which briefed the Committee on the current thinking behind the proposals made to Government. He emphasised that there had been no formal proposal made to Government, or local decision made on this subject. Dr McWilliam was accompanied by David Smith, Chief Executive, OCCG and Stuart Bell, Oxford Health NHS Foundation Trust (OH).
Dr McWilliam began by highlighting the problems with the current system which were:
· System was very complex, making it hard for the user to use and causing confusion for all. It also made it difficult to scrutinise;
· There were three decision – making systems, causing bureaucracy and duplication;
· Financial Plans were mis-aligned (NHS being over a single year, OCC being over 3 - 5 years);
· Value for money could be improved if there was a single plan;
· There were long-standing issues arising from its complexity, such as DToC.
Dr McWilliam made the following points on how integration and devolution could help:
· Although organisations had started to fix problems (integration of Health and OCC to the sum of £30m), devolution would help to finish the job by bringing together CCG, OCC, Health Trusts and NHS England services, eg Pharmacy, dentistry and specialised services;
· 3 - 5 year financial plans could be aligned;
· local political and clinical leaders would be able to make decisions in one place – thus bringing local democratic aspects to the fore and making one accountable body;
· Services would be easier to use and more easily accessed at a single point, and they would be commissioned in a unified way, via integrated commissioning. Delays would be reduced and duplication would be erased;
· Devolution would improve the health and wellbeing and prosperity for the 670,000 residents of Oxfordshire. By 2020 there would be a decrease in mortality from, for example, heart disease and a reduction in health inequalities.
Dr McWilliam stated that talks had been held, or were to be held, with all District Councils, the Local Enterprise Partnership, Oxford University, the Oxfordshire Health Science Network, the Oxfordshire Safeguarding Boards, the Oxfordshire GP Federations and Age UK. He and colleagues had held conversations and briefings with Healthwatch Oxfordshire who wanted to maintain their independence at this point.
David Smith then explained the process and timescale for the proposals, subject to legislation and full delegation of primary care commissioning for the county from NHS England:
Devolution would mean:
· Co-location of local commissioners for OCCG/Adult Social Care/Public Health;
· A pooled budget for Adult Social Care/Public Health/some Education care services/ OCCG with staff working closely together under a single accountable officer;
· Reporting to a strengthened Health & Wellbeing Board, with scrutiny by HOSC and Performance Scrutiny. All accountable officers were engaged in discussions regarding this;
· Major providers working more closely together. David Smith emphasised that the proposals were not just about co-commissioning, it was about getting the system to work as a whole to improve services and health outcomes for the people of Oxfordshire;
· Bringing together governance/strategy/plans/quality measures.
David Smith reported that, subject to consultation, and subject to OCC and OCCG Governing Body approval, phase 1 of the proposals would mean from 1 April 2016, the OCCG and OCC commissioning would be co-located. Phase 2 would implement a combined budget for Health and OCC (£1.3b).
Stuart Bell stated that Oxford Health supported the proposals as providers, wanting the best possible value for the people of Oxfordshire and improved health outcomes. He welcomed the possible removal of barriers to help focus on what was necessary. He explained that it was the function of the Transformation Board to look at how the Oxfordshire Health & Wellbeing Board could be enhanced to support the new proposals and it was his view that all the right people were on that Board to deliver them, it being a joint endeavour. He added that the most crucial long-term issue for joint discussion was that of the sufficiency of, and the best possible use of staff for the best possible outcomes. He added also that in his view the academic, life science, housing and domiciliary care linkages were also critical to the success of the proposals.
In response to a question from the Committee asking if they foresaw any problems in the differences in financial policies across both organisations, David Smith stated that the proposals would give a better chance of easing the financial pressures across the system. That the recent pilot measures to assist with DToC were a good example of this. He added that the heavier pressures on Local Government, in terms of financial constraint, caused a bigger divide, but they were trying to live with the realities of this in their quest for better value. He added that it would not solve all issues, and the ongoing work the Local Government Association were doing on this topic had resulted in the emergence of some issues. However, there was some evidence, albeit in Europe, that intermediate care was giving better value than traditional hospital care. It was too early to give concrete examples in the UK as yet.
A member commented that NHS bodies had been able to post budget deficits in the past, but OCC had had to balance its books: she thought social care should be strengthened by integration into the proposed system, rather than be made vulnerable by it. David Smith responded that the OCCG was statutorily the same as the Council in that one of his duties as the appropriate officer was that he could not breach his statutory duty to break even. Thus, though financial regimes differed, the dynamics each organisation were the same. Pooling budgets would give more of a certainty for the OCCG of 3 – 5 years funding to better align with OCC’S 3 – 5 year’s medium to long term plan. Dr McWilliam stated that the detailed rules and safeguards etc would follow, should agreement be given to the proposals. Stuart Bell explained that Oxford Health did have powers to borrow by virtue of its status as a Foundation Trust, but the Trust had chosen not to exercise it. In the current year the Trust had submitted a plan to monitor for a deficit. The Trust was running at 13% more efficient than the UK average, yet it was still expected to make large savings. He added that the aim of the proposal was to put the staff in the right place, and on staff working everywhere to keep patients well. The proposals would give organisations the ability to set the framework locally.
A member asked if the proposals would require legislative change. Dr McWilliam responded that it was not known at this stage and work would be ongoing with the Health & Wellbeing Board, the OCC Scrutiny Committees and the OCCG Governing Body to address this.
As a result of a query from a member of the Committee, it was confirmed that Oxford Brookes University would be consulted on the proposals.
A member asked the proposals were looking at the benefits of integrating Oxford Health, Social Care and private providers, as well as OUHT joining up with OCCG (GPs). Stuart Bell commented that that was why the relationship in the Transformation Board was so important. He expected that resources would shift over time across Oxfordshire’s care, voluntary and community organisations, as had been demonstrated in Oxfordshire Mental Healthcare partnerships. He believed that it was right to focus on developing ‘integration’ rather than just merging institutions. Dr McWilliam added that the proposals sought to balance both NHS and Local Government input in order to get the best of both worlds. John Jackson commented on the importance of professionals working together in a better way, via co-location of community workers with social workers, for example.
A member asked how much of the proposals could be developed without devolution. David Smith responded that it was probable that a large part of it could be achieved via S.75 provision. However, that would exclude a large part of specialised care and pharmacy, not currently commissioned by the OCCG. He explained that service provision had become fragmented as some services were run by the OCCG and some by NHS England. He added that if NHS England did decide to devolve the current joint budget in favour of the OCCG alone, this would put the OCCG in a stronger position to iron out the spend on services more fairly. He added if devolution failed to go ahead, then the OCCG would press to be represented on bodies such as the Growth Board to ensure their early awareness and involvement in planning for housing development etc and the opportunity to align plans. The Chairman welcomed this, highlighting the Committee’s interest in this issue and its intention, as part of its Forward Plan, to investigate how the district councils were engaging with the OCCG and NHS England when planning for housing development, with a view to raising any concerns with the appropriate bodies.
The Committee thanked Dr McWilliam, David Smith and Stuart Bell for the presentation and for the frank input of their views; and looked forward to the consultation if agreement was reached to go ahead with the proposals.
With regard to the issue of consultation, the Committee then asked John Jackson to remain at the table to answer questions on the current public consultation on the future provision of Intermediate Care in the north of the county.
Cllr Martin Barratt reported that West Oxfordshire District Council (WODC) had passed a formal motion questioning the consultation process. John Jackson responded that the comments made by WODC would form part of the responses to the consultation which would be considered by the County Council’s Cabinet on 26 January 2016. He added that all OCC’s public consultations had to be compliant with OCC’s consultation requirements and were subject to clearance by the County’s Monitoring Officer.
The Committee AGREED that it would raise any concerns with Cabinet with regard to the final process and recommendations, if it was found to be necessary.