Questions and answers to the Joint Committee of CCGs

February 2018

Written question received from Mr Tony Nuttall Question:

As the changes in hyper acute stroke services were implemented 14 or 15 months ago, before any consultation, what evidence do you have by now that a) patient outcomes have improved and b) access for relatives has not worsened?

Answer: Marianna Hargreaves responded by saying there has been a specific arrangements in place with some Barnsley patients being eligible for thrombolysis being taken to other HASU centres for thrombolysis, this has been relatively small number numbers, not large enough to understand with respect to outcomes, we have not had any feedback with respect of adverse implications for relatives and families. Peter Anderton added that informal feedback from Pinderfields is that the patients transported there and sometimes transported straight back if they have not been eligible for thrombolysis have generally been positive and supportive. Again, alluding to the Greater Manchester experience, it is worth noting that Greater Manchester centralised their stroke care in two phases so initially they only transported patients who were thought were eligible for thrombolysis and then in the second phase in 2015 they transported all patients in the hyper acute phase and it was only after that they have seen a reduction in mortality. It is worth noting that from their report published this summer they have had very good feedback from patients and carers and this is despite travelling large distances. There are 3 HASU centres in Greater Manchester and overnight only one which is Salford. So from as far north as Oldham and as far south as Macclesfield you get transported into Salford and their feedback is the patients and relatives are extremely happy with the high quality of care they are accessing so this bodes well in South Yorkshire and Bassetlaw.

From Doug Wright:

1. Have you changed your terms of reference to include other service decisions apart from Children's Surgery and Anaesthesia, Acutely Unwell Children and Hyper Acute Stroke Services?

Response: We are currently reviewing the delegated responsibility of the Joint Committee of CCGs and will report on this in due course.

2. Are Wakefield, North Derbyshire and Hardwick CCG's involved in decisions about South Yorkshire and Bassetlaw Integrated Care System new policies, procedures and budget setting at system level?

Response: This is a matter for the South Yorkshire and Bassetlaw Integrated Care System, not the Joint Committee of CCGs.

3. Can you please ensure that future agendas and minutes of JCCC's meetings are made public at least eight working days before the date of the meeting.

Response: The JCCCG adopts the standing orders of NHS Sheffield CCG in relation to the notice of meetings. These state that written notice will be given five days before the meeting and which we follow.

From Steve Merriman

Question:

Accountability to, and engagement with, the public.  I have lost count of the number of times I have listened to Helen Stevens (and her colleagues) claiming to put the public first. This assertion doesn’t quite fit with the reality, that the majority of your meetings are held in private. Why is that?

Response: Meetings of the JCCCG are held in public unless the JCCCG considers that it would not be in the public interest to permit members of the public to attend a meeting or part of a meeting. This is whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business.

From Peter Deakin member of the public and Chair person of Barnsley Save our NHS

My questions are with regard to and refer to the two NHS England documents Patient and public participation in commissioning health and care: Statutory guidance for clinical commissioning groups and NHS England (PPPCHC) and Involving people in their own health and care: Statutory guidance for clinical commissioning groups and NHS England.

Firstly, I refer to a question that I asked at the Joint Committee of the Clinical Commissioning Group Meeting, held 28 June 2017, 3.30pm - 5:00pm, at Doncaster CCG, and the answer received:

“Question 3. What is the representative democracy mechanism for the public to engage.?

Answer 3. The Joint Committee is made up of seven CCGs, NHS England and Hardwick CCG. Each has a legal responsibility under the Health and Care Act 2012 S.14Z2 to ensure public involvement and consultation in commissioning processes and decisions.”

Q1. When will the JCCCG start to follow this legal responsibility of public involvement in this process and will it follow the guidance documents referred to? PPPCHC guidance states: “Where involvement takes place via representatives, staff should seek assurance that the representatives offer a fair reflection of the views of others. Engagement through representatives should only be used where directly engaging with service users is not practicable or proportionate”. and “The NHS is accountable to the public, communities and patients that it serves and is therefore subject to public scrutiny. Building on the constitution, the Five Year Forward View sets out a vision for growing public involvement”

Response: The Joint Committee of CCGs has carried out pre-consultation engagement and formal public consultation on proposals to change the way hyper acute stroke services (first 72 hours of care) and some out of hours children’s surgery is provided in line with statutory guidance.

The communications and engagement plans, analysis and decision making business cases set out the approach and outcomes from the engagement. These can be found on the Commissioners Working Together and Health and Care Working Together websites here: https://smybndccgs.nhs.uk/what-we-do/critical-care-stroke-patients here: https://smybndccgs.nhs.uk/what-we-do/childrens-surgery and here: http://www.healthandcaretogethersyb.co.uk/index.php/about-us/commissioners-workingtogether/hyper-acute-stroke-services and here: https://smybndccgs.nhs.uk/what-wedo/childrens-surgery/decision-making-meeting-28-june-2017

Q2. Where is the evidence that the above PPPCHC guidance is being followed and, if it is being followed, why is it not reflected in the minutes of the meeting held on 24th May 2017 (the minutes do not mention involving/engaging the public)? Helen Stevens gave an Engagement Update at the Joint Committee of the Clinical Commissioning Group Meeting, held 18 October 2017. Helen mentioned an engagement presentation.

Response: The communications and engagement plans, analysis and decision making business cases set out the approach and outcomes from the engagement. These can be found on the Commissioners Working Together website here: https://smybndccgs.nhs.uk/what-wedo/critical-care-stroke-patients here: https://smybndccgs.nhs.uk/what-we-do/childrenssurgery and here: http://www.healthandcaretogethersyb.co.uk/index.php/aboutus/commissioners-working-together/hyper-acute-stroke-services and here: https://smybndccgs.nhs.uk/what-we-do/childrens-surgery/decision-making-meeting-28- june-2017

Q3. Is there a copy of the engagement presentation that is mentioned in the meeting update? Yes, see attached. I am aware of the formation of a Citizens Panel, by the commissioners, “to ensure that the voice of the local population is heard”. Such a panel has been referred to as 'self-selecting applicants, motivated to apply, but who cannot be seen as representing the population as a whole'. Please could you give more detail on where this was referenced?

Response: To our knowledge, this comment is a reference from the Independent Analysis of the Public Consultation on hyper acute stroke services and some out of hours children’s surgery and referenced in both decision making meetings, as well as at the Joint Health Overview and Scrutiny Committee meetings. It is not a reference to the Citizens’ Panel. See: https://smybndccgs.nhs.uk/what-we-do/critical-care-stroke-patients and http://www.healthandcaretogethersyb.co.uk/application/files/7215/1074/0077/Presentation _to_the_JC_CCG.pdf

Q4. With reference to the PPPCHC, which is a statutory guidance document, can the JCCCG be sure that they are fulfilling their legal responsibilities and that the Citizens Panel are able to speak for the population of South Yorkshire and Bassetlaw? What are the mechanisms for them to be in touch with the public or the public to be in touch with them, or to even know who they are?

Response: The Citizens’ Panel is being developed and set up to provide an independent view and critical friendship on matters relating to our Accountable Care System and is not a replacement for wider public engagement and consultation. For its purpose, aims and background information on the Panel, see: http://www.healthandcaretogethersyb.co.uk/index.php/about-us/whychange/latestnews/could-you-be-part-our-citizens-panel

Is the JCCCG?

Q5. A democratic organisation? Section 14Z3 of the NHS Act 2006 allows CCGs to make arrangements in respect of their commissioning functions and includes the ability for two or more CCGs to create a Joint Committee to exercise functions.

Response: The Joint Committee of CCGs has agreed to collaborate and take joint decisions in areas of work that they agree. Its membership comprises:  Voting members – two decision makers from each of the member CCGs, who are the clinical chair and accountable officer.  Non-voting members – two lay members, one director of finance chosen from the member CCGs, a representative from NHS England, a Healthwatch representative nominated by the local Healthwatch groups, ACS lead or deputy, ACS director.

Q6. Making decisions that will affect the NHS?

Response: As above.

Q7. Funded by public money?

Response: As above.

Q8. Answerable to the public?

Response: As above.

Q9. Who appoints the members of the JCCCG?

Response: As above.

Q10. Are the JCCCG members paid for their role on the commissioning group?

Response: Other than the lay members, all members of the JCCCG hold substantive roles within those organisations and remunerated by them. The lay members receive remuneration in line with lay member remuneration across the region.

Q11. Are the JCCCG members from democratic organisations?

Response: See above.

Q12. Is the JCCCG required to have Declarations of Interest relevant to the agenda?

Response: The JCCCG operates a register of interests and has a Conflicts of Interest Policy.

Q13. Who scrutinizes the JCCCG?

The South Yorkshire, Derbyshire Nottinghamshire and Wakefield Joint Health Overview and Scrutiny Committee is a joint committee appointed under Regulation 30 of the Local Authority (Public Health, Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013/218 and is authorised to discharge the following health overview and scrutiny functions of the authority (in accordance with regulations issued under Section 244 National Health Service Act 2006) in relation to health service reconfigurations or any health service related issues covering this geographical footprint:

a) To review and scrutinise any matter relating to the planning, provision and operation of the health service in its area, pursuant to Regulation 21 of the Local Authority (Public Health, Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013.

b) To make reports and recommendations on any matter it has reviewed or scrutinised, and request responses to the same pursuant to Regulation 22 of the Local Authority (Public Health, Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013.

c) To comment on, make recommendations about, or report to the Secretary of State in writing about proposals in respect of which a relevant NHS body or a relevant health service provider is required to consult, pursuant to Regulation 23 of the Local Authority (Public Health, Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013.

d) To require a relevant NHS body or relevant health service provider to provide such information about the planning, provision and operation of the health service in its area as may be reasonably required in order to discharge its relevant functions, pursuant to Regulation 26 of the Local Authority (Public Health, Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2014.

e) To require any member or employee of a relevant NHS body or relevant health service provider to attend meetings to answer such questions as appear to be necessary for discharging its relevant functions, pursuant to Regulation 27 of the Local Authority (Public Health, Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013.

Q13. Do all stakeholders include patients and public? How will the people of South Yorkshire and Bassettlaw be informed of the progress and updated?

Response: We inform patients, staff, the public and stakeholders of decisions and progress made by the JCCCG through internal and external communications mechanisms, which include:  Partners’ statutory bodies – such as governing bodies and boards  Press releases  Updates on our website  Updates to subscribers to bulletins  Briefings to stakeholders  Minutes of meetings  Partners’ internal communications mechanisms and networks

From Tony Nuttall for the meeting of the Joint Committee of Clinical Commissioning Groups Wednesday 28 February 2018, 4:15pm-5:30pm member of the public and Treasurer of BSONHS:

In response to Marianna Hargreaves answer to my question below:

Question 1 Could you tell us how many Barnsley patients have been transferred to date to HASU centres for thrombolysis, which centres they were transferred to, and what the outcome for each patient was?

Response:The current situation in Barnsley, where people with a suspected stroke are taken to Pinderfields Hospital in Wakefield or the Northern General Hospital in Sheffield is an interim measure that was put in place because Barnsley Hospital does not have substantive stroke consultants who can carry out thrombolysis. It is not as a result of the JCCCG decision to change the way hyper acute stroke services is delivered. The work to enable the decision to change how services are delivered is still preparatory. An audit has been carried out by Barnsley Hospital which will have the details and we are awaiting the report.

Question 2 When you say that "patients transported to Pinderfields have been generally positive and supportive", this implies that there has been some negative feedback. What specific negative feedback has there been?

Response: No negative feedback has been received.

Question 3 You seem to be relying on informal reporting of patient and carer feedback. Patients and carers will naturally tend to be appreciative of the care that they receive, and this feedback will tend to become even more positive when reported by staff. What research are you doing to assess objectively whether the patient and carer experience is better or worse, including whether access for relatives is more or less difficult?

The current situation in Barnsley, where people with a suspected stroke are taken to Pinderfields Hospital in Wakefield or the Northern General Hospital in Sheffield is an interim measure that was put in place because Barnsley Hospital does not have substantive stroke consultants who can carry out thrombolysis. It is not as a result of the JCCCG decision to change the way hyper acute stroke services is delivered. The work to enable the decision to change how services are delivered is still preparatory. The preparatory work includes developing a service specification which has a section on patient experience. We welcome the involvement of patients and the public in this and are seeking views from the Citizens’ Panel on what our engagement approach with patients and the public should look like to inform this. 1

Written question received from Mr Tony Nuttall

Question: As the changes in hyper acute stroke services were implemented 14 or 15 months ago, before any consultation, what evidence do you have by now that a) patient outcomes have improved and b) access for relatives has not worsened?

Answer: Marianna Hargreaves responded by saying there has been a specific arrangements in place with some Barnsley patients being eligible for thrombolysis being taken to other HASU centres for thrombolysis, this has been relatively small number numbers, not large enough to understand with respect to outcomes, we have not had any feedback with respect of adverse implications for relatives and families. Peter Anderton added that informal feedback from Pinderfields is that the patients transported there and sometimes transported straight back if they have not been eligible for thrombolysis have generally been positive and supportive. Again, alluding to the Greater Manchester experience, it is worth noting that Greater Manchester centralised their stroke care in two phases so initially they only transported patients who were thought were eligible for thrombolysis and then in the second phase in 2015 they transported all patients in the hyper acute phase and it was only after that they have seen a reduction in mortality. It is worth noting that from their report published this summer they have had very good feedback from patients and carers and this is despite travelling large distances. There are 3 HASU centres in Greater Manchester and overnight only one which is Salford. So from as far north as Oldham and as far south as Macclesfield you get transported into Salford and their feedback is the patients and relatives are extremely happy with the high quality of care they are accessing so this bodes well in South Yorkshire and Bassetlaw.

March 2018

Questions from the public

A query was raised regarding HASU, noting patients were being moved to Sheffield from Rotherham and in response it was confirmed that this was the case, that providers had to implement arrangements to ensure patients presenting across the area with stroke or suspected stroke received the best possible care. This was taking place without a formal arrangement with commissioners. A number of issues existed that the stroke services were facing and these existed prior to the development of the business case. The following questions were put to the committee that had been submitted in writing:

Question from Ms Nora Everett

We, the public, are aware that the Refresh of the NHS Plans published in February 2018 require the SYB Integrated Care System to:

- prepare a system operating plan that aligns key assumptions on income, expenditure, activity and workforce between commissioners and providers

- that this plan ensures that organisation plans, of the system partners, underpin and together express the system's priorities

- and that this system plan is submitted to NHS England and NHS Improvement for assurance by 30th April 2018

How do you propose to involve the public, and inform them of your intentions? - given that the Next Steps for the NHS Five Year Forward View, the original NHSE/I business plan, says on P35: "As STPs move from proposals to more concrete plans, we expect them to involve local people in what these plans are and how they will be implemented. The Joint Committee agreed to respond to this question in writing.

Response: Each NHS organisation is required, by NHS England and NHS Improvement, to submit an operational plan by the end of April 2018. These plans describe how they will meet their financial and NHS Constitutional targets (such as the four hour A&E wait, 62 day referral to treatment standard) for the year ahead. The SYB shadow ICS is reviewing all the organisational operational plans together to identify the financial and performance risks across the region, as well as ensuring their priorities align with those of the shadow ICS. The shadow ICS has made a commitment to involving the patients and the public in health service developments. During 2017-2018 the ICS engaged patients and the public in a conversation about the South Yorkshire & Bassetlaw plan.

The results of these conversations can be read here and here. In August 2017 it started to take forward its first piece of work, looking at hospital services in the area. Patient, public and clinical involvement has been key to the ongoing review, with engagement including conversations with seldom heard communities, a demographically representative telephone survey with 1000 people, an online survey and regional and local meetings, stalls and events. The findings from the engagement to date can be found here.

In 2017-18 the shadow ICS started to develop a Citizens’ Panel in recognition that the voice of local people is at the heart of the work. The panel brings together people from across South Yorkshire and Bassetlaw who can offer an independent view and critical friendship on matters relating to the work of Health and Care Working Together. Initial recruitment has taken place, with further recruitment to the panel ongoing.

Questions from Peter Deakin

Is there any point in public questions to the JCCCG when they are seen and answered by the Associate Director of Communications and Engagement, Commissioners Working Together/ SYB ACS. The Associate Director of Communications and Engagement is not a member of the JCCCG but an attendee.

Response: All JCCCG members receive the public questions and intended responses. The draft responses to questions asked at JCCCG meetings held in public are put together by a range of people who work across the CCGs in the collaboration as the knowledge and information is held by different individuals. Once collated, they are checked and signed off by the JCCCG.

How can they be called public questions to the JCCCG when seen and answered by one person? I asked fourteen questions to which answers were provided by the Associate Director of Communications and Engagement.

Response: All JCCCG members receive the public questions and intended responses. The draft responses to questions asked at JCCCG meetings held in public are put together by a range of people who work across the CCGs in the collaboration as the knowledge and information is held by different individuals. Once collated, they are checked and signed off by the JCCCG. The answers were not to all of my questions for instance I asked: Is the JCCCG required to have Declarations of Interest relevant to the agenda? The answer - The JCCCG operates a register of interests and has a Conflicts of Interest Policy. It’s not an answer to what I asked.

The Joint Committee agreed to respond to this question in writing. A comment was made in the meeting in response, noting that a Declarations of Interest register was available online, and members were asked at each meeting to declare conflicts of interest to members.

Response: The JCCCG has a register of interests which is published online - https://smybndccgs.nhs.uk/about-us/how-were-run - and updated on an annual basis. Members advise if there are any changes in the interim. In addition, there is a standing item on the agenda for members to declare any interests in relation to the meeting, which allows for any conflicts to be recorded and managed.

If a public question is not answered correctly or the answer is questionable, for example the facts in the answer are wrong, what recourse has the questioner got to receive an adequate answer. Is there a protocol for this to happen? The Joint Committee agreed to respond to this question in writing.

Response: Responses to questions from the public are seen and signed off by the JCCCG members. If a response is factually inaccurate, the matter should be raised with the Chair of the JCCCG.

The following questions from Mr Tony Nuttall were read out to the meeting.

Question: Whether an officer acting independently has a right to answer questions intended for a public meeting without the members having seen the questions or answers.

Response: All JCCCG members receive the public questions and intended responses. The draft responses to questions asked at JCCCG meetings held in public are put together by a range of people who work across the CCGs in the collaboration as the knowledge and information is held by different individuals. Once collated, they are checked and signed off by the JCCCG.

Question: Why 18 months after the changes to emergency stroke services at Barnsley Hospital no audit of whether outcomes are better or worse is available.

Response: Since September 2016, Barnsley has had to divert to other hospitals (Pinderfields, Doncaster or Sheffield) patients who present with symptoms suggestive of a stroke and who seek medical attention within the time window when thrombolysis may be given. The divert enables a small number of patients who would benefit from thrombolysis to receive it, improving their chances of a fuller recovery and better clinical outcome. If the Barnsley patients had not transferred they would not have been able to access thrombolysis at all and by default this will result in poorer clinical outcomes for those patients.

The clinical audit evidence for the effectiveness of receiving the treatment already exists. Stroke clinical outcomes and processes are monitored nationally and work takes places locally to look at patient experience and complaints. Anecdotal evidence from clinicians points to positive experiences for those patients who have been diverted, with no complaints received either formally or informally. Monitoring of the stroke data does not yet show any trends.

Question: Why 18 months after the changes to emergency stroke services at Barnsley Hospital there seems to be no assessment of the impact on patient and carer experience, why the CCG or Barnsley Hospital, as the responsible bodies, have not carried this out and how the Citizen's Panel is expected to be able to do this instead.

Response: Since September 2016, Barnsley has had to divert to other hospitals (Pinderfields, Doncaster or Sheffield) patients who present with symptoms suggestive of a stroke and who seek medical attention within the time window when thrombolysis may be given. The divert enables a small number of patients who would benefit from thrombolysis to receive it, improving their chances of a fuller recovery and better clinical outcome. If the Barnsley patients had not transferred they would not have been able to access thrombolysis at all and by default this will result in poorer clinical outcomes for those patients.

The clinical audit evidence for the effectiveness of receiving the treatment already exists. Stroke clinical outcomes and processes are monitored nationally and work takes places locally to look at patient experience and complaints. Anecdotal evidence from clinicians points to positive experiences for those patients who have been diverted, with no complaints received either formally or informally. Monitoring of the stroke data does not yet show any trends.

The Citizens’ Panel provides an independent view and critical friendship on matters relating to the shadow Integrated Care System (ICS). In particular, the group has been set up to ensure that the voice of the local population is heard and influences any developments. It does this by making sure engagement opportunities are created for citizens, patients and carers and that they are meaningful, targeted and relative to the changes suggested. It does not assess individual services.

Further questions were raised for the committee by the public: The Joint Committee agreed to respond to these questions in writing.

Why are questions being responded to when JCCCG members had not previously seen them. See above.

Why 18 months after changes to stroke services have no audit taken place? See above.

Why 18 months after changes to stroke services at Barnsley has no assessment of impact on patient care and experience - why have the CCG not carried this out and how can a citizens panel be expected to do this instead? See above.

Regarding the previous questions submitted, how does anyone not attending this meeting find out that questions have been asked and answered. It was confirmed that questions would be published and included with the minutes.

June 2018

Questions to JCCCG from Deborah Cobbett, Sheffield Save Our NHS

Q1.Geographical borders

We have asked before about the geographical borders of the HSR: SYB or SYBMYND and the issues this raises for democratic accountability. 

Response: The different geographies referenced in the report reflect the fact that different local health economies are involved in different recommendations for the Review. What this means for hospital trusts and services is explained in the Report (page 25). In summary:

  • South Yorkshire and Bassetlaw: the organisations in the Sustainability and Transformation Partnership (STP) for South Yorkshire and Bassetlaw (SYB) are now members of the Integrated Care System (ICS). For CCGs, this is Barnsley, Bassetlaw, Doncaster, Rotherham and Sheffield. For acute hospitals, it is the Foundation Trusts of Barnsley, Doncaster and Bassetlaw, Rotherham, Sheffield Children’s, and Sheffield Teaching. For mental health organisations it is the Foundation Trusts of Rotherham, Doncaster and South Humber and Sheffield Health and Social Care.
  • South Yorkshire and Bassetlaw, Mid Yorkshire and North Derbyshire. This refers to the geography of the organisations in the Joint Committee of Clinical Commissioning Groups (JCCCG) which has seven members. These are Barnsley, Bassetlaw, Doncaster, North Derbyshire, Rotherham, Sheffield and Wakefield. Hardwick CCG is not a member of the Joint Committee but has taken decisions in parallel with the JCCCG.
  • Working in parallel to the JCCCG, there is the Provider Working Together partnership, which is made up of seven acute hospital trusts. These are Barnsley Hospital NHS Foundation Trust, Chesterfield Royal NHS Foundation Trust, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Mid Yorkshire Hospitals NHS Trust, The Rotherham NHS Foundation Trust, Sheffield Children’s Hospital NHS Foundation Trust, Sheffield Teaching Hospitals NHS Foundation Trust.  These seven trusts are included within the scope of recommendations on the hosted network, ie they will be building on their collaborative history to develop shared working on clinical services.
  • South Yorkshire and Bassetlaw and North Derbyshire: these are the organisations above, minus Mid Yorkshire Hospitals NHS Trust and Wakefield CCG. The acute hospitals within the area are included within scope for potential reconfiguration options. Mid Yorkshire has already been through a reconfiguration so is not included in reconfiguration options.

Statutory accountability and decision making for all of these organisations remains with their respective NHS Foundation Trust Board or NHS Clinical Commissioning Group Governing Body. The various organisations come together for joint discussion through a number of different joint groups but none of these joint groups have any formal decision making authority about the Hospital Services Review, so the accountable organisations and decision making remain with their Boards and Governing Bodies.

Q2. Would you comment on the issue of accountability in the light of this quotation?

Current governance arrangements do not go far enough to give the system the level of control required to effect change. Any future model will require all organisations to cede some sovereignty to the system – this will be difficult, particularly without legislative change and while the end-state clinical model is not yet fully defined. (Hospital Services Review page 160) 

Response: The legislative framework of the 2012 Act means that the organisations in the system which have statutory authority are the Boards and Governing Bodies of the NHS providers and Clinical Commissioning Groups. This means that at the moment, discussions can happen in the governance groups of the Integrated Care System, but decisions are taken by Boards and Governing Bodies. The Integrated Care System cannot itself make binding decisions.

As we develop the governance of the Integrated Care System, we are developing ways for organisations to work more closely together, while respecting the existing statutory structures.

One way is through the existing legal vehicles such as a Joint Committee of Clinical Commissioning Groups for CCGs, and a Committees in Common for providers. Both of these exist but they do not currently have delegated powers around the recommendations of the Hospital Services Review. The HSR suggests that, going forward, the partners needs to continue to explore these approaches and develop ways, within the existing statutory framework, to allow organisations to work together when needed to deliver high quality, safe services for patients.

The HSR also suggests that the current legislative framework makes collaborative working more difficult. There is a recognition at national level that the current legislative framework is not suited to delivering the level of collaboration between organisation that is the basis of shared working going forward. The Health Select Committee into integrated care (published 11 June 2018, https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/650/650.pdf) recognised this, saying

The existing legal context does not necessarily enable the collaborative relationships local leaders are building, and in places adds significant complexities for them to grapple with. (p.75)

The committee concluded that:

The law will need to change to fully realise the move to more integrated, collaborative, place-based care. … The purpose of legislative change should be to address problems which have been identified at a local level which act as barriers to integration in the best interest of patients. We wish to stress again that proposals should be led by the health and care community. (p. 78)

Q3. Staffing issues

Given widespread evidence that staff are leaving our NHS in droves, sometimes immediately after qualifying, what grounds do you have for this optimistic outlook quoted below?

“By working together, the acute trusts will strengthen their workforce, building on existing expertise to improve quality of care for patients, enhancing the reputation of our hospitals. We will work creatively with schools and universities to attract new entrants to healthcare professions, as well as those who wish to return to clinical practice. We will become a leading innovative system, identifying and adopting new approaches to healthcare to solve some of our most complex challenges. We will make SYB(MYND) into a place where people want to come and work.”

Response: Work with our Clinical Working Groups explored the reasons why SYBMYND is facing such significant challenges around workforce. The reasons identified were complex and are laid out in the notes of the Clinical Working Groups, available on our website.

The proposals laid out in the HSR are designed to present solutions to many of the most significant concerns around workforce, for example

  • Recruitment: we do not currently attract as many potential recruits to the NHS as we could. The HSR proposes a workforce Institute which could include universities and working closely with schools, to encourage students to enter careers in healthcare, while also taking into account any national NHS responses to the national workforce issue.

An issue raised by a number of attendees at the public events was concerns around limited opportunities for young people who were interested in careers in healthcare, but were not coming through the traditional routes. A workforce Institute could look at developing apprenticeship schemes and other entry routes for potential trainees.

  • Retention: The CWGs identified a number of reasons why staff are leaving the NHS. Some sites and specialties said that staff have limited opportunities for career progression or training; the HSR Report proposes that Hosted Networks could build opportunities for staff to develop their careers through rotations and secondments between sites.

Staff in other specialties said that the main reason that people were leaving was because  existing vacancies and a reliance on locums mean extra pressure on substantive staff. The Report proposes that Hosted Networks would focus on strengthening recruitment and reducing reliance on locums, and the reconfiguration proposals within the Report are aimed at ensuring the right number of staff in those services which are currently most overstretched.

Q4. What impact have frontline staff (as opposed to clinical leads and managers) had on the HSR? 

Response: The main way that we have engaged with staff has been through the Clinical Working Groups, which engaged clinicians from across the specialties.

Each trust was asked to nominate clinicians and other staff (such as nurses and midwives) as members of the Clinical Working Groups. These members were asked to engage with their colleagues across their home trusts. After each meeting, the HSR team provided a short summary of the points that had been made (these are available on our website). The CWG members were asked to discuss these points with colleagues, and to bring back feedback from the wider staff groups to a session at the beginning of the following meeting.

In addition to this, the HSR team engaged directly with some frontline staff. The team spoke, for example, to groups of nurses in the trusts, and a number of staff attended the SYB-wide events and responded to the online surveys.

Trusts were also provided with regular updates on the HSR, which they were asked to share with staff across the organisation.

Q5. How will you resolve the concerns we hear about stress, unpredictability of end of shift times and failures to listen to staff requests for flexible working times?

Response: Issues around how staff are managed in an individual trust are for individual trusts and managers to address rather than being a matter for the HSR. However the proposals around Hosted Networks aim to develop a shared approach to some aspects of HR such as a shared policy around flexible working.

Q6. What response did you get by leaving paper based surveys in "areas convenient for staff"? (see page 16 of the report)

Response: The ICS communications team attended a number of events at healthcare sites across the footprints. Some of the hospitals invited members of the team to set up a stall in their reception areas, and the team also attended some GP surgeries. This gave an opportunity to talk directly with both patients and staff at the sites, and to distribute surveys to get their views on the issues. Copies of the survey were left at the sites for any staff who were interested and had not been able to attend. A number of staff were also interviewed in the telephone surveys. Staff briefings, as well as ICS organised nurse forums, were also held in many sites, and staff communications with links to the online survey shared through all partners’ regular communications mechanisms.

We do not know how many responses were from leaving surveys in staff areas as the survey did not ask people where they had heard about it. Of the 545 paper-based and online survey responses completed, 150 respondents indicated they were NHS employees (28%).

Q7. How often does the Staff Partnership Forum meet and where do you publish its minutes?  (This was mentioned only very briefly in one of the FAQ lists)

Response: The Staff Partnership Forum is a meeting between the ICS and regional trade union representatives. It is not a meeting held in public and therefore the notes from the meeting are not published in public. It meets bi-monthly.

Q8.  Meeting patients' needs:

Sheffield Director of Public Health, Greg Fell, in his 2017 report stated:

Demand for health and social care in England is currently increasing by about 4% per year, faster than the ageing population.  Moreover, there is now consistent evidence from a macro perspective that the key drivers of cost growth are: disease incidence (prevention); lack of attention to primary care, high cost technology (manufacturer pressure & patient expectation)’ and over diagnosis (clinical culture and system pressure).

In view of this, when will you drop the propaganda about the ageing population with complex needs burdening our NHS and admit that our NHS is exploited by private firms through Big Pharma and management and IT consultancies? 

Response: A recent report by the Health Foundation and the Institute of Fiscal Studies factors (https://www.ifs.org.uk/uploads/R143.pdf) looked at the pressures on NHS spending from a wide range of factors. It stated that:

Over time, all aspects of NHS spending have risen. The biggest element is spending on staff – doctors, nurses and others. Over the last 20 years, there has been an increase of more than 70% in the number of hospital doctors, and of more than 10% in the number of nurses, health visitors and midwives, per 1,000 population. (p.iii)

Looking forward, health spending is likely to continue to rise. Simply continuing to provide the services we currently expect will become more expensive as the population grows and ages, prevalence of chronic conditions increases, and the prices of inputs, including the costs of drugs and the wages of doctors and nurses, go up.

Central estimates suggest that by 2033−34 there will be 4.4 million more people in the UK aged 65 and over. The number aged over 85 is likely to rise by 1.3 million – that’s almost as much as the increase in the entire under-65 population. 

The burden of disease is also increasing. The number of people living with a single chronic condition has grown by 4% a year while the number living with multiple chronic conditions grew by 8% a year between 2003−04 and 2015−16. Looking forward, more of the UK’s population will be living with a chronic disease and very many with multiple conditions. This is because while life expectancy has been increasing, healthy life expectancy has not kept pace and the period of people’s lives spent in poor health has increased; particularly for the poorest. As a result, without major progress on the vision set out in the Five Year Forward View, over the next 15 years spending in acute hospitals to treat people with chronic disease is expected to more than double.  (p.v)

Q9. Why do you ignore the impact of austerity cuts in all public services, government policies which increase child poverty and mental ill-health, and other causes of ill health?

Response: The Hospital Services Review looked at the sustainability of acute services, focusing on how acute services could be made fit to meet the future needs of the population. Issues around mental health, prevention and public health are being addressed in other workstreams of the Integrated Care System and were not the focus of the Report.

Q9. Places

How does your review address the needs of each town, as presented in the section of the first annex, entitled Place Definitions? Why do these needs not appear in a more central position in the review?

Response: The HSR aimed to develop a more equitable access to acute health services for patients across South Yorkshire and Bassetlaw. However it did not make site-specific proposals: this was to ensure that the public and stakeholders could comment in principle on the proposed approach for services. In due course, Boards and Governing Bodies will agree any next steps, having taken account of public and stakeholder feedback. This could include a more detailed analysis of the impact on specific communities and places to develop a site-specific analysis. If this happened, the evidence collated in the Place Profiles would help to inform the analysis going forward.

 

August 2018

Question:

Barnsley Save Our NHS has arranged and funded a public engagement meeting on:

Saturday 27th October 2-4pm In Barnsley Town Hall Reception Room

on the proposed changes to Maternity and Paediatric services.

The will be Chaired by a Councillor who is a member of the Barnsley Metropolitan Borough Council Scrutiny Committee.

We are arranging wide publicity across South Yorkshire and Bassetlaw to encourage people to come and hear about the changes and reasons for them, and to ask questions.

We have purposefully aimed for balance and asked one of your officers to arrange for an appropriate South Yorkshire and Bassetlaw Integrated Care system (SYBICS) speaker.

Other speakers are:

- Stephanie Peacock MP, 

- a local union/staff representative, 

- a Labour Party Equalities Officer and

- a national speaker on Women's Health.

Unfortunately we only heard after 5pm last night (Tuesday 21 August) that no-one from SYBICS can attend.

Today is our only opportunity to appeal to this body to ask the JCCG our Question:

Question:

Is it really not possible for one of the many lead officers at SYBICS, who regularly attends high level discussions about the HSR and other proposed service changes, to give two or three hours to come to Barnsley and explain the changes, and reasons for them to some of the people who will be affected by them?

Response:

Thank you for the opportunity to attend the Barnsley Save Our NHS public engagement meeting on Saturday 27 October in which attendees will hear about the ‘changes and reasons for them’ in maternity and paediatric services.

The partners in the South Yorkshire and Bassetlaw Integrated Care System have now received the independent report following the review of hospital services and the next phase of involvement with the public will concentrate on the recommendations within it. These are recommendations, potentially subject to later public consultation and there have been no decisions made to change maternity or paediatric services.

The proposed approach to involvement in the next phase was set out at our meeting last week and starts with the data that tells us who uses the services, alongside qualitative insights from clinicians and also on-site surveys. This helps to inform which groups and communities we specifically need to involve in discussions.

These will take the form of deliberative workshops, where we will facilitate group discussions to enable participants to consider an issue in depth and to challenge each other’s opinions and develop their views to reach an informed position. This enables us to have a greater understanding of what lies behind people’s views and this insight, from the many conversations, will go on to inform the next phase.

To ensure we secure balanced input, maintain political impartiality, whilst securing a representative view from as wide a cross section of the public as possible including local political groups and politicians we propose to extend the deliberative discussion approach to Barnsley Save Our NHS. We feel this method will ensure we are capturing the views of your members and wider audience in a way that is impartial and meaningful.

A deliberative workshop takes around two hours and we could run this with up to 30 people at a venue in Barnsley. Please let our officer know if you would like for this to be arranged with you.

October 2018

Questions from Doug Wright 

Doncaster and Bassetlaw Keep Our NHS Public

1. Social Care is currently means tested. Hospital patients pay no costs. Will the South Yorkshire and Bassetlaw ICS model mean that in the future hospital patients will also incur costs if they remain in hospital?

Response:

No.

Procedural Question

2. This JCCG states (only on the website) 'we promise you we will allow 10 minutes before the start of each meeting for you to make a statement or ask a question about items on that day's agenda'. 

There has only been six public meetings of the JCCG  since 1 July 2017. (One scheduled public agenda item each meeting allows one hour for the general public to participate in JCCG meetings in fifteen months). Will you consider (a) extending the above ten minutes to thirty minutes and (b) deleting the above 'about items on that day's agenda'. 

Response:

The approach for asking questions in the JCCCG meeting in public was discussed and agreed by the Joint Committee members at their meeting in June 2018. Members felt that the timeframes, for both written questions in advance and also oral questions at the meeting, was in keeping with the practice of member CCGs and fair to the public. They also agreed that keeping questions to the items on the agenda was appropriate for the Joint Committee, which considers system-wide commissioning issues that have been delegated by each CCG governing body.

3. Follow up question after the meeting:

Please explain in theory and in practice what 'system-wide commissioning issues' means?

Response:

System-wide commissioning is where all CCGs have agreed to look at a service and commission it together where it adds value from a quality, consistency, efficiency, effectiveness and perspectives to undertake commissioning activities and functions once rather than five times across five CCGS. For the JCCCG, this has so far been for hyper acute stroke services and out of hours children’s surgery.

The vast majority of commissioning business occurs in CCGs with local partners. Each of our 5 places have well established relationships and arrangements to work collaboratively with its partners to improve health and care outcomes to improve population health through the Integrated Care Partnerships Boards. The ICPs are jointly leading transformation to integrate care in each place and developing joint decision making arrangements to facilitate and enable partnership working.   

Questions from Nora Everitt, Secretary SYBNAG

Q 1. STRATEGIC OUTLINE BUSINESS CASE:

Are you all aware that many paediatric staff do not support the HSR reconfiguration of paediatric services, and say the data used in making the HSR recommendations was inaccurate?

Response:

The Hospital Services Review, and now the Strategic Outline Case on Hospital Services, lay out the challenges across the five services that the Review considered, including paediatrics. The Clinical Working Group on Care of the Acutely Ill Child was involved in developing the analysis and proposals, and the group confirmed that they believed that the status quo was not sustainable. The report lays out a range of options to address the issues, and clinicians have not been asked to endorse any one solution.

Are you all aware that many paediatric staff … say the data used in making the HSR recommendations was inaccurate? Will the inaccurate data used in the recommendations for paediatrics be corrected before publication of the SOBC?

Response:

The data used in the Review was provided by and validated by the Trusts between October 2017 and April 2018. It is currently being refreshed to ensure that the modelling in the next stage of the Review is based on the most up to date numbers.

Who will carry out the proposed Modelling, and at what cost?

Response:

The modelling will be undertaken by Deloitte. The cost of the modelling is part of a wider contract so resources will be used flexibly as required by the project but the cost dedicated to modelling is likely to be approximately £240,000.                            

What methodology will they use?  How will the ICS convince the public that such modelling will be robust enough to provide valid conclusions?

Response:

The methodology for modelling is being developed at present, with oversight from a modelling steering group which includes representatives drawn from amongst the executive teams of the relevant trusts, as well as the finance team of the Integrated Care System, and Health Education England. The methodology has also been shared with the overarching group of all Directors of Finance and Chief Finance Officers and with other dedicated groups such as the Human Resources Directors and the Hospital Services Steering Group. It will be signed off by the Collaborative Partnership Board before modelling begins.

The data used in the modelling is being collected at present and will be validated and signed off by the Medical Directors of each Trust.                                                               

Why does the HSP timeline show the public being consulted after all decisions are made in 12 months time but not being ‘involved’ directly in commissioning proposals, plans and decisions as the law requires?

Response:

The public have been involved throughout the process so far, and the latest report on public involvement over the summer has been published on the SYB website. 

Going forward, the timeline for the programme shows the public being engaged throughout the development of all proposals, and consultation on the options being carried out on options as required by statute.

Q 2. HASU COMMISSIONING:

How are you going to involve the public in the commissioning arrangements for the new HASU model as required by law?

Response:

The new HASU model was set out in the proposals to change the way hyper acute stroke services is provided across the region. The consultation ran from 3 October 2016 to February 14 2017 and the decision to provide them differently was made on 15 November 2017.

The key themes from the consultation have informed the draft HASU specification and the JCCCG has agreed that Sheffield CCG will be the lead commissioner for service.

In the next phase, patients and the public will be involved in shaping how the service is delivered, with some areas already having been identified where meaningful involvement will be particularly beneficial. This includes designing the new pathways/patient flows and patient information and this will be done with people who have recently used or are currently using the services.  The specification will be agreed in the NHS Standard Contract that contractually requires communication and engagement with service users, public and staff.

Why is the Rotherham Acute Stroke service reporting that it now works less well since the HASU closure was announced?

Response:

The current model in Rotherham means that patients do not routinely have access to thrombolysis but under the new model they will.

Q 3. SYBICS : HOSPITAL SERVICES REVIEW DJS REPORT

How much did this report cost?

Response:

The cost was £17,500 plus VAT.

Could we have a copy of the brief provided to DJS?

Response:

The brief provided for the engagement analysis was:

“Hospital Services Review Engagement Analysis and Report

“The recent independent review of hospital services across South Yorkshire & Bassetlaw made a series of recommendations to create sustainable hospital services that are part of an integrated healthcare system.

“Health & Care Working Together in South Yorkshire and Bassetlaw is currently seeking the views of local people on some of the recommendations from the review to inform the next stage of conversations about local changes in each place. This engagement includes general feedback provided, a survey (online, but mostly in paper format) and a range of discussion groups across the region (where discussions have centred around the same questions as the survey).

“The insight gathered needs to be analysed and a final report is required by the end of September. Some of the insight can be provided immediately upon commencement of the contract, some however will only be supplied a week prior to requiring the report.

“We are looking for an organisation with the capacity to provide us with the independent analysis and reporting of the responses in our timescales.

If you have the capacity to deliver our requirements please submit a quote by Midday on Monday 3rd September. Costs should be inclusive of travel and expenses, and it should be clear whether the quote is inclusive or exclusive of VAT.”

Was this contract subject to competitive tender?

Response:

Yes.

We are always keen to hear from suppliers who have the credentials to carry out work that is commissioned to support communications and engagement. Suppliers who would like to register their interest for future work should contact helloworkingtogether@nhs.net

Did DJS conduct the research wholly themselves, independently of SYBICS staff?

Response:

The research was conducted by engagement leads in partner organisations within the ICS, the SYBICS communications and engagement team and facilitated in some cases by third parties (eg where the community group’s first language was not English). DJS provided the analysis of the data collected.

Q 4. PREVENTION OF ILL HEALTH

A claimed major plank of the SYBICS is prevention by focusing on “keeping people well”, “slowing or stopping ill health developing”, “supporting some of the most vulnerable in our communities to live healthier, more fulfilling lives”. SYBICS intends to achieve this by “bringing together the regions public services”, “to tackle shared issues that affect people’s life chances”, and “join up health and care and improve health and welfare across the region”.

Given the critical importance of prevention, what analysis, consultancy, and research has been undertaken to inform SYBICS and the JHOSC about the obvious and clearly adverse impact on mental and physical health of the Government’s austerity policies? 

Response

Our piority to improve the health and wellbeing of the SYB population is being delivered through greater integration of health and care in each of our 5 ‘places’ (ie Barnsley, Bassetlaw, Doncaster, Rotherham and Sheffield). It is built on our foundation of GPs and other health and care professionals working together in primary care networks or neighbourhoods. Each place has well-established integrated multidisciplinary working with health, social care, and the voluntary sector to provide high quality, seamless care for patients and service users. This is underpinned by a focus on prevention and population health management approaches that address health inequalities and the wider determinants of health. 

The SYB ICS has a plethora of public health data and intelligence to show the health needs of the SYB population which it uses to inform commissioning plans, services and interventions at system and place level.     

Questions asked at the meeting by members of the public

1. Question: Why are you still not involving the public in any NHS changes? Are you going about involving people the right way? The letter of Oct 16th says you haven’t been involving people and that you have been acting secretly.

Response: 

The JCCCG is a formal joint committee of the CCG commissioners within the South Yorkshire and Bassetlaw Integrated Care System (ICS). It has specific delegated responsibility from its member CCGs to make specified decisions on two services: hyper acute stroke services (HASU) and out of hours children’s surgery for some conditions. The Committee has no delegated authority to make decisions outside of this scope; all other decisions will continue be taken by the individual CCG statutory Governing Bodies.

In both HASU and children’s surgery, involvement with patients and the public to inform the proposals and formal consultation on the options has been carried out with decisions on changes made in the Joint Committee.  In addition to the feedback informing the service specification, engagement with recent and current users of the service is also a part of the ongoing discussions with providers as the new service is commissioned.

The involvement work on behalf of the JCCCG followed national guidance and was guided by advice from The Consultation Institute.

The letter from Simon Stevens and Ian Dalton (chief executives of NHS England and NHS Improvement) is to all Provider Chief Executives and CCG Accountable Officers and sets out the ask of NHS organisations once the NHS Long Term Plan is published. 

Question: Why is the JCCCG approach to improvements to Stroke services only focusing on the hospital (hyper acute stroke) and not the whole pathway? In West Yorkshire, they are looking at the whole pathway.

Response:

We have been working closely with West Yorkshire in relation to our proposals to change the way hyper acute stroke services are provided, as Mid Yorkshire Hospitals (Pinderfields) was identified as a receiving HASU for some patients who live in the north of Barnsley.

As part of the hospital services review, we are now looking at the stroke pathway that follows HASU to see where further improvements could be made. The recommendations from the review included looking at developing a hosted network for stroke, which as well as providing an opportunity to look at the whole pathway, we will also be able to look at prevention too.

Our close working relationship with West Yorkshire means we can also learn from the work they are taking forward.

Question: What is the JCCCG’s interpretation of the letter of 16 October from NHS England and NHS Improvement re five year view regarding planning for the next 12 months?

Response:

The letter from Simon Stevens and Ian Dalton (chief executives of NHS England and NHS Improvement), sets out the ask of NHS organisations once the NHS Long Term Plan is published. This includes a need to work together more across ‘systems’ (the ICS).

As members of the ICS, the CCGs within the JCCCG (noting not all members of the JCCCG are members of the SYB ICS) will respond individually as organisations, as well as with other partners in each ‘place, and with the ICS. This collaborative and collective way of working ensures that our approach is aligned so that all our populations can benefit.

Question: Are you a public body? You have delegated CCG responsibility for decisions? You should have every meeting in public. The decision to commission HASU services was not made in public and is not in your minutes.

Response:

The JCCCG is a formal joint committee of the CCG commissioners within the South Yorkshire and Bassetlaw Integrated Care System (ICS). It has specific delegated responsibility from its member CCGs to make specified decisions on two services: hyper acute stroke services (HASU) and out of hours children’s surgery for some conditions. The Committee has no delegated authority to make decisions outside of this scope. The vast majority of commissioning business occurs in CCGs with local partners. Each of our 5 places have well established relationships and arrangements to work collaboratively with its partners to improve health and care outcomes to improve population health through the Integrated Care Partnerships Boards. The ICPs are jointly leading transformation to integrate care in each place and developing joint decision making arrangements to facilitate and enable partnership working.   

The decision to commission new specifications for hyper acute stroke services and also some out of hours children’s surgery was made in public in November 2017. The minutes, presentations and recording of the decision are all available at www.healthandcaretogethersyb.co.uk