Questions and answers to the Joint Committee of CCGs

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.

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.

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.

 

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.

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 16^th 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

Questions from Nora Everitt, South Yorkshire and Bassetlaw NHS Action Group (SYBNAG)

Q. 1  SYBNAG members note the listed ten areas described at the bottom of P1 of Agenda Paper D as having been identified as ‘forming part of a good public engagement approach’:

However we wonder why these are not the same ten areas that are listed in the ‘Patient and public participation in commissioning health and care: statutory guidance for clinical commissioning groups and NHS England .‘The ten areas in the Statutory Guidance, (quoted below) are those used by NHS England as actions to be demonstrated by all CCGs in the assessment of how well they meet their 14Z2 legal duty for public involvement in commissioning plans, proposals and decisions. 
“This guidance sets out 10 key actions for CCGs and NHS England on how to embed involvement in their work. They should: 
1.     Involve the public in governance
2.     Explain public involvement in commissioning plans/business plan
3.     Demonstrate public involvement in annual reports
4.     Promote and publicise public involvement
5.     Assess, plan and take action to involve
6.     Feed back and evaluate
7.     Implement assurance and improvement systems
8.     Advance equalities and reduce health inequalities
9.     Provide support for effective involvement
10.     Hold providers to account”
The CCGs must have ‘due regard to the Statutory Guidance and it defines this (on P42) by saying:  ”Having ‘regard’ means that the guidance should be considered and taken account of. Where the guidance is not followed, this should be justified and the reasons clearly documented.”  See https://www.england.nhs.uk/participation/involvementguidance/

We feel that the SYBICS is collaborating with NHS England to imply that they are meeting their legal obligations for direct public involvement by meeting the ten areas of assessment when it can be proven that they don’t.  (e.g. not informing Rotherham Healthwatch about the Discovery Day). So we need to inform you that we are seeking legal advice on this
Can the JCCCG please provide us with evidence that they do meet each of the ten points in the statutory guidance?

Response:
The ten areas for good public engagement, as outlined in the ICSs approach to conversations with the public about the NHS Long Term Plan, are those issued by NHS England for ICSs. SYB ICS is using the areas of focus to ensure its approach follows good practice.

They do not replace the statutory duties or guidance previously issued by NHS England for CCGs and NHS England and each statutory organisation within the ICS (including the JCCCG members) continues to meet its legal obligations. Involvement with the public on any proposals for change is documented in the annual reports of all partners and evidence to support the work is available via each CCG or Trust. 

Rotherham Healthwatch, along with all the Healthwatches in SYB, was sent an invitation to the Discovery Day on October 4, 2018 and is documented on our email distribution system.

Q.2    Are the deputies for each CCG Accountable Officer full voting members of the JCCCG?

Response:
Deputies attending the JCCCG are acting on behalf of the accountable officer and can vote on behalf of the AO for the organisation they are representing provided the meeting is quorate. Deputies only vote in the absence of the AO, and as such hold the CCG Board’s proxy vote.

Q.3  SYBNAG members are concerned that treatment at Private Hospitals often goes wrong and the NHS has to sort it out. The SYBICS has recently developed significant changes to the NHS hospital in the area covered by the JCCCG based on safety and quality issues.
What steps are being taken to ensure that Private Hospitals work to NHS standards of safety and quality – such as having an Intensive Care Unit in case of adverse reaction to treatment?

Response:
All clinical practice in England whether independent or NHS delivered is governed by the same professional bodies and clinicians are guided by clinical standards, such as those set out by the Royal Colleges, National Institute of Health and Care Excellence (NICE) and the General Medical (or Nursing) Council. All clinical staff work to these, irrespective of who they work for (eg the NHS or a private sector provider). Private and NHS hospitals are also regulated by the Care Quality Commission (CQC).

Regarding intensive care provision in the independent sector, all care is consultant led (the vast majority are NHS consultants), and arrangements to treat patients are well established. Independent hospitals act in similar way to NHS District General Hospitals in the lower levels of ITU support they provide and clinical transfer protocols are in place with larger SYB hospitals to ensure that patients requiring more support are  rapidly transferred by ambulance to a larger ITU  
All services commissioned by the NHS must meet quality and safety standards and constitutional rights such as choice and access standards which are managed and governed within a standard NHS contact. You can read more about the standard contract here: https://www.england.nhs.uk/nhs-standard-contract/2017-19-update-may/

Q.4  There are 113 questions to the JCCCG recorded that have been asked by a member of the public since April 2017. However for 47 of these questions we feel that you did not answer the actual question asked.  When this was raised in March 2018 the questioner was told they could take the matter up with the JCCCG Chair.  However you do not publicise this opportunity to raise matters not answered with the JCCCG Chair to members of the public as a whole.
We feel that both these facts demonstrate a total disrespect for the public.
Why do you do this?

Response:
The JCCCG Chair offered to respond to matters where questions were not considered answered. There has been no correspondence or a request to meet the Chair to understand which questions and why they are considered insufficient.

We will update the website to publicise the process.

Q. 5  The JCCCG agreed that all written questions from the public submitted to their meetings would be responded to in writing to the questioner.
Why don’t you do this?

Response:
Individuals who ask written questions receive responses within three working days.  To date, all questions have been received by email and all have been responded to by email. The questions and responses are also posted onto the website.

Q.6  Given the lack of a written response to public questions the actual responses are only made public a few days before the next JCCCG meeting held in public, which again shows that you do not respect public contributions.
Why is this so?

Response:
All questions receive responses by email (in advance of the JCCCG) and the questions and responses are posted on the website after the meeting.

Q.7.  The public questions, concerns and suggestions raised and recorded at the JCCCG meetings are not included in your public feedback mechanisms and reports.
Why is this so?

Response:
All questions and interactions with the public are recorded in the JCCCG minutes and the questions and responses are posted on the website.

Q. 8   Given the Long Term Plan requirement for implementation of integrated services:
How does the ICS plan in practice to merge the budgets from Public Health services, Local Authority funded services, VCSE services, and private service provision with other primary care services in order to integrate them?

Response:
The work of the ICS is to bring partners together to explore integrated ways of working within the individual organisational budgets. There are no plans to merge budgets at this stage.

Questions from Doug Wright, Doncaster Save Our NHS 

1. Agenda item 9 Communication and Engagement, Page 26, 2 shows ten areas forming part of a good public engagement approach.   
Question is why can't members of the public attend various regional and local NHS committee meetings, with public questions/statements at the beginning of the agenda?
(this should at least include the Integrated Care Systems (ICS) Collaborative Partnership Board meetings and the five local ICS bodies, such as the Doncaster Joint Commissioning Board)

Response:
The Collaborative Partnership Board meeting of the SYB ICS partners is not a statutory body, cannot make any decisions and is not required to meet in public. It is a forum for strategic discussion between partners.  Each partner within the ICS is accountable to the public through its Board or Governing Body and any South Yorkshire and Bassetlaw ICS discussion that impacts on those organisations, or requires a decision, is discussed at individual Board and Governing Body meetings. The public can attend all Board and Governing Body meetings of the ICS partners where they can ask questions.

Meetings of the five ICSs (Barnsley, Bassetlaw, Doncaster, Rotherham and Sheffield) have local arrangements for meeting and discussing strategic ‘place’ matters and your inquiry should be directed to each ICS however, the public can attend all Board and Governing Body meetings of the ICS partners where they can ask questions.

 2. South Yorkshire ICS's budget originally had to be reduced by £571 million before the financial year 2021/22. Can you tell me what is the current budget estimate and detail where in our region these cuts will take place? If not who can tell me?

Response:
The £571m was the SYB share of the £30bn savings the NHS had to make by 2020 and referred to the ‘gap’ between the resources available and the likely demand for health and care services within the timeframe.

Two subsequent national allocations (£8bn in 2017 in £20bn in 2018) has reduced some of the challenges that we face while also allowing us to invest in key services such as mental health and cancer. However, each of the partner organisations within South Yorkshire and Bassetlaw Integrated Care System continues to work to efficiency savings. This is in line with all NHS organisations in England which are required to make annual efficiencies together with any local need, as identified by their Board or Governing Body.

The details of the efficiency plans are available in the papers of Board and Governing Body meetings held in public.

Q. 1 We wish to make a statement including a request:
The Draft Manual Agreement and JC CCG ToR was only made public on Wednesday 15/5/19 and has 36 pages of text that has some significant legal implications regarding public accountability and involvement. We feel that we cannot individually, or collectively, ask meaningful questions on this document within two working days as this does not allow us sufficient time for intelligent consideration and response.
We therefore ask that the JCCCG please accept and consider our formal response to
the Manual Agreement, including the JC CCG Terms of Reference. We will send our response to all voting members of the JC CCG to arrive by Monday 3/6/19, a full week before the next meeting of the JC CCG Sub-Group and just over three weeks before the next JCCCG meeting.

We wish however to say that we are pleased to see the Manual Agreement in the public domain as this was not the case with the original one, and we feel this can show, and has now shown, that the JCCCG recognises public accountability.

Response:
Thank you for your statement. We would like to clarify that the first Manual Agreement of the JCCCG was shared at individual CCG Governing Bodies in their meetings in public in 2017.

Q. 2    Questions on the JCCCG Sub Group Terms of Reference document

a)   Why can the public not attend the JC CCG Sub Group, observe the meeting and  receive agenda packs of the papers and reports discussed, as we do for Trust and CCG meetings?

Response:

The JCSG supports and coordinates the work of the 19/20 JC CCG work plan and priorities agreed by the commissioners it will also reduce the amount of operational detail that is currently being undertaken at the JC CCG.

The JCSG will not make any decisions on behalf of the JC CCG and the TOR have been included in the papers of the May Public JC CCG. Given the operational nature of this meeting, non-decision making and the JC CCG now meeting in public each month it is not necessary for the JCSG to meet in public.

b)   Will the JC CCG Sub Group minutes and the reports to, and by, the Sub Group be in the  public domain? 

Response:

The JCSG minutes will be included in the Private JC CCG papers for information  

c)    re. Paragraph 1

Is there an omission in the second sentence which refers to the JC CCG and not to the new JC CCG Sub Group?

Response:

No. the sentence refers to the role of the JC CCG that is supported by the JCSG

 d)    re. Paragraph 2 – 4th Bullet Point

Will the Sub Group not liaise with the Chair of the JC CCG in planning and managing the agenda and co-ordination of the JC CCG papers as this is normal meeting facilitation etiquette, or was such an omission an oversight?

Response:

The Chair of the JCSG is involved in planning of the JCSG agenda and papers and agrees the final version. The same process applies with the JC CCG where the Clinical Chair of the JC CCG is involved and agrees the final version of papers and agenda before being sent out within the agreed timeframes.

e) re. Paragraph 2 – 5th Bullet Point

Is it the case, as this implies, that workstream leads and programme directors will no longer report to the JC CCG meeting, only the Sub Group, which will deny the JC CCG members the opportunity to ask the officers direct questions and clarifications?

Response:

The JC CCG is established as a decision making committee of the CCGs, it is not an operational meeting (which it had become more of). The intention with the public JC CCG meeting is to split the business of the agenda into parts:

• Part 1 - any decisions to be taken (which would be a relatively short section) and
• Part 2 - a progress update of the work plan
• Part 3 - a strategic service focus part where the JC CCG would receive information regarding a specific priority on the JCCCG work plan with lead clinicians and programme directors attending for their item.

The JCSG will be required to assure the JC CCG of the work it is doing and reporting to the JC CCG. The JC CCG will also provide reports to the CCG Governing Bodies throughout the year.

 f)    re. Paragraph 2 – 7th Bullet Point

This gives little confidence and can you reassure us that the ICS officers are aware of the  three CCG legal duties for public accountability other than 14Z2?  These are, namely:

•14Z11 (a)

•14Z13 (2) and (8)(a) & (b); and 

•14Z15(2) and (6)(b)

Response:

See below.

g)  re. Paragraph 4

We ask the ICS officers and JC CCG members to note the following CCG legal duties relating to public accountability and to note there are implications for these in the changes currently being made in CCG commissioning arrangements and commissioning plans  across SY and Bassetlaw.

Response:

The JCCCG does not have its own list of duties set out in statute like a CCG or NHS England does, it only exercises those functions a CCG member specifically delegates to it. Therefore the legal duties are for CCGs, they do not apply to the role of the JC CCG – see manual agreement and JC CCG Terms of Reference.

It is for each CCG to fulfil their obligations to involve the public in accordance with s.14Z2 of the NHS Act with regard to determining commissioning intentions on a general basis. The JCCCG would only lead on involvement, which may include public consultation, if the constituent CCG members specifically asked it to do so.

h) re. Paragraph 10

i) It appears that the JC CCG will not be meeting in public every month for part of their meeting, as was suggested on the ICS website.  Are the JC CCG meetings in public going back to every other month now?

Response:

The JC CCG will meet monthly from May 19 and part of each agenda at all meetings will be in public

ii) Why was the Sub Group not mentioned at the meeting on 3/5/19, when we were invited to build a new working relationship that felt less adversarial?  But at that point the Sub Group was already meeting and we don’t understand why we were not informed of the intention to set one up to manage the JC CCG business.

Response:

The discussion at the meeting on the 3/5/19  was responding to questions from the public representatives and most of the questions did not specifically relate to the remit of the JC CCG. As a consequence,  we ran out of time to discuss it further. The JC CCG is keen to build a positive and constructive relationship with public representatives and our commitment to meeting in public and sharing the TOR and manual agreement in public are all steps we have taken to demonstrate our transparent approach wherever it is appropriate to do so.

       

Question received from Doug Wright, Keep Our NHS Public

Appendix 2 - JCCCG Terms of Reference

10.2 This paragraph does not give the right to members of the public to ask questions or participate in a JCCCG meeting, unless invited to do so by the Chair. This discriminatory paragraph is a late addition to the TOR. 

Will the JCCCG delete paragraph 10.2 in the interests of democracy and open and accountable JCCCGs?

Response:

No. JCCCG meetings are business meetings which we hold in public, they are not public meetings.

Appendix 5

Why can't an elected member of South Yorkshire and Bassetlaw NHS Action Group join up with the Citizens Panel and SYB wide Lay Members, to review and offer advice and support?

The opportunity to apply for both the Citizens’ Panel roles and JCCCG Lay Member roles were well advertised when we recruited. Recruitment to the Citizens’ Panel is ongoing and we are currently looking for more members from Barnsley and Rotherham. The JCCCG Lay Member roles will be advertised next year.

The Travel and Transport Group does have a member from the South Yorkshire and Bassetlaw NHS Action Group.

The following questions were received from various South Yorkshire and Bassetlaw NHS Action Group members via Nora Everitt.

Q1 

Warrington & Halton Hospital NHS Trust

i) Can the JCCCG  reassure the public that they will not allow a local NHS Trust to follow  the example recently shown by Warrington and Halton Hospital Trust and market treatments listed in the SYBICS Commissioning for Outcomes Policy as chargeable treatments that patients can self fund?

Response:

It is not for the JCCCG to comment on decisions that will be made by individual Trust boards and CCG governing bodies.

ii) Do you recognise the Long Term Plan funding average of 3.1% which, as 4.2% is widely agreed necessary to just stand still, is totally inadequate to;

a)     maintain an efficient and comprehensive free at the point of delivery health service without unrealistic expectations of patient self care or  self-financing by moving the  goal posts and claiming Limited Clinical Values where none existed before?

Response:

The question of funding is irrelevant. The JCCCG considers clinical evidence, quality and effectiveness and best practice using Royal College and NICE guidance to inform policy development.

b)     ensure a safe, stress free working environment for staff ?

Response:

This question is not relevant to the JCCCG or the agenda.

c)     ensure a safe treatment environment for patients ?

Response:

This question is not relevant to the JCCCG or the agenda.

iii) What steps are the  JCCCG taking to ensure central funding not only addresses ii)  a), b) and c) (above) but is set at a level which urgently addresses the workforce shortfall of 106,000?

Response:

This question is not relevant to the JCCCG or the agenda.

Q2

Minutes of May JC CCG Meeting

Can the JCCCG confirm that the SYBICS Collaboration Partnership board intends to revise its Terms of Reference shared in the Rotherham CCG public papers and will meet in public in 2019/20?

Response:

The JCCCG cannot comment on the Terms of Reference for the Collaborative Partnership. However, as part of redesigning the Collaborative Partnership Board it has been agreed in principle that it will meet in public in the future.

Q3

Final Draft of the Manual Agreement & JCCCG TOR

i)    Purpose of the JCCCG (P6) and JCCCG Guiding Principles (P17)

Rather than summarising minimal public feedback will the JC CCG ensure that all patients, carers and the public have ample opportunity to directly monitor and influence the effectiveness of the JCCCG’s chosen strategic approach for developing patient centred services; improved population health outcomes; more seamless services and equity in access to services  across the Integrated Care System?

Response:

The JCCCG is established as a decision making committee of the CCGs.The JCCCG does not have its own list of duties set out in statute like a CCG or NHS England does, it only exercises those functions a CCG member specifically delegates to it. Therefore the legal duties are for CCGs, they do not apply to the role of the JCCCG.

ii)    System/local Commissioning Intentions (P8)

a)  Given that plans are also intentions why is the Section 26 14Z13 (2) and (8) (a) & (b) not referred to in this section as this is a CCG statutory duty that must be met in writing or changing commissioning plans? (We note that the document repeatedly refers to ‘stakeholder’  ‘engagement’ when describing Section 26 14Z2 although the law refers to the “involvement” of “individuals”).

Response:

The JCCCG is established as a decision making committee of the CCGs. The JCCCG does not have its own list of duties set out in statute like a CCG or NHS England does, it only exercises those functions a CCG member specifically delegates to it. Therefore the legal duties are for CCGs, they do not apply to the role of the JCCCG.

b)  Following the Warrington fiasco of posting price lists and charging patients for low clinical value treatments that had NHS funding removed the ICS plan to remove NHS funding from more such treatments in SYB is now very contentious.

Response:

When are the JCCCG going to publish the full details the Commissioning for Outcomes – new stage 2 and share with the public their intended additions to the list of treatments they consider as of low clinical  value?

They will be published during 2019/20 when the work is complete.

iii)  Complying with Statutory Duties of CCGs (P9), Appendix 3 and Appendix 5

All points under this paragraph make it clear that the JC CCG must meet the statutory duties of CCGs and summarise these in Appendix 3.   However this final draft repeats all the major statutory duty omissions that SYBNAG made sure you were aware of. 

Appendix 3:

•           Includes 13Q which is the Section 23 statutory duty of NHS England and NOT of CCGs

•           Omits reference to Section 26 which lists all  new CCG duties that begin with 14, e.g. 14Z2

•           Omits new sections14Z11, 14Z13, and 14Z15, all statutory duties relating to commissioning

•           Omits reference to the clear advice of the Statutory Guidance about when14Z2 applies:

-           when to involve such as changes in;

-  commissioning arrangements

-  in procurement and contracts

-           and how to decide if 14Z2 applies

Response:

The Appendix refers to commissioners having regard to the other statutory obligations set out in the new sections 13 and 14 of the Act. It refers to ‘the following, amongst others’ and is not intended as a verbatim list.

Appendix 5:

• This document outlines a process for deciding whether a 14Z2 duty to involve applies but it bears no relation to the clear advice or the template provided in the Statutory Guidance:

•   CCGs have to justify not having regard to the Guidance and their reasons must be clearly documented

a)  Is the JC CCG going to rectify these errors and if not is it going to justify and clearly

b)  If not is it going to justify and clearly document why it did not have regard for the Statutory Guidance?

Response:

The document outlines the internal process for ensuring how 14Z2 forms are considered, it is not a 14Z2 form.

iv)  Governance (P10)

The SYBNAG’s detailed comments on the SYBIC’s JCCCG’s previous draft of the Manual Agreement and Terms of Reference summarises our view that the document reinforces our experience over the past three years that many areas of governance have been unclear and remain unclear.

We are aware that the governance arrangements and accountabilities of an individual Clinical Commissioning Group (CCG) are covered in its Annual Governance Statements (AGS).

We are also aware that from 2019/20, Joint Clinical Commissioning Group Committee decisions are binding on individual CCG’s regarding the operation of the South Yorkshire and Bassetlaw Integrated Care System (ICS).

How will this impact the governance arrangements?, for example, from 2019/20:

• Will the JCCGC and / or the ICS be producing their own Annual Governance  Statements?

Response:

The JCCCG is established as a decision making committee of the CCGs. The JCCCG does not have its own list of duties set out in statute like a CCG or NHS England does, it only exercises those functions a CCG member specifically delegates to it. Therefore the legal duties are for CCGs, they do not apply to the role of the JCCCG.

Member CCGs produce annual governance statements, outlining how they have fulfilled their statutory duties. The JCCCG will produce an annual report of its business.

• Will bad JCCGC / ICS decisions / actions that lead to patient death or injury, be attributable to it, or to an individual CCG?

Response:

The JCCCG is established as a decision making committee of the CCGs. The JCCCG does not have its own list of duties set out in statute like a CCG or NHS England does, it only exercises those functions a CCG member specifically delegates to it. Therefore the legal duties are for CCGs, they do not apply to the role of the JCCCG.

v)  Delegation (P11)

The purpose of delegation describes the JC CCG role as a ‘critical element’ of the interim governance arrangements by the SYB ICS executive and the mechanism by which future collective commissioning decisions can be made. 

 As ‘critical element’ implies a degree of independence from the ICS, are the JC CCG voting members fully confident that the ICS public involvement tools and mechanisms are as robust as their own, given that the CCGs to take full legal liability for any ICS actions relating to their delegated duties that fail to meet the legal requirements?

Response: 

Yes

vi)   Terms of Reference – Guiding Principles (P14)

 What principles are actually involved in ‘managing your stakeholders effectively?

Response:

‘Managing stakeholders effectively’ is one of the guiding principles in the Terms of Reference.

vii)   Procurement (P17)

a)  Will the JCCCG be having regard to the clear advice in the Statutory Guidance about involving individuals (who use, or may use, services provided) in the procurement of those services, as most of  the voting members of your committee do themselves? 

b)  If not will you justify and clearly document your reasons?

Response:

The JCCCG is established as a decision making committee of the CCGs. The JCCCG does not have its own list of duties set out in statute like a CCG or NHS England does, it only exercises those functions a CCG member specifically delegates to it. Therefore the legal duties are for CCGs, they do not apply to the role of the JCCCG.

Q4

Perinatal Services in Souty Yorkshire and Bassetlaw Integrated Care System 

i)   Why do neither of the two new Community Peri-natal Mental Health Services, in South and West Yorkshire mention close working relationships with the only Mother and Baby Unit for the region, as NICE and the Joint Commissioning Panel for Mental Health (JCPMH) guidelines both advocate?

Response:

This question is not relevant to the JCCCG or the agenda. They are more appropriate for Barnsley CCG.

ii)   How will the JC CCG ensure that access to a peri-natal mental health service is equitable across the population they are jointly responsible for when Barnsley mothers cannot use the new service in South Yorkshire and are expected to use the Dewsbury service, a three to five hour return journey by public transport from Barnsley costing an average £10?

Response:

This question is not relevant to the JCCCG or the agenda. They are more appropriate for Barnsley CCG.

iii)  As there are only 8 Mother and Baby Unit beds available in all of W&S Yorkshire but around 190 women, and their babies, in the region who have a need each year to access such a bed will the JC CCG confirm that this new service is just the start of beginning to meet the local need for a comprehensive peri-natal service and much more needs to be done? (4 women per thousand births, as per NHS England, NICE & JCPMH document data)

Response:

This question is not relevant to the JCCCG or the agenda. They are more appropriate for Barnsley CCG.

Questions from SYBNAG members to the JC CCG meeting on 24^th July 2019:

 

1. What exactly is the JC CCG responsible for?

 

Paper C from the June JCCCG meeting includes the JCCCG Terms of Reference, Manual Agreement and Workplan, setting out the role and responsibilities of the JCCCG. The papers can be found here: https://www.healthandcaretogethersyb.co.uk/application/files/5915/6096/1736/JCCCG_-_26_June_2019_Agenda_and_Papers.pdf

 

2. What powers have members of the JC CCG applied for to NHSE/I to enable the Long Term Plan approach for system wide commissioning?

 

The JCCCG is established as a decision making committee of the CCGs. The JCCCG does not have its own list of duties set out in statute like a CCG or NHS England does, it only exercises those functions a CCG member specifically delegates to it. The legal duties are for CCGs, they do not apply to the role of the JCCCG. Therefore, system wide commissioning takes place within existing legal frameworks with CCGs working together and using the JC CCG to enable any joint decision making where this has been delegated by CCGs (ref MA /TOR).

 

3. What we see from the JC CCG Sub Group minutes are reports being discussed that are concealed from public and we want to know why are you deliberately keeping information from the public?

 

JCCG sub group meetings are business meetings, they are not public meetings or meetings in public. Papers upon which decisions need to be made are heard in public meetings either by the JCCCG if it is a matter for which they have delegated authority, or at partner CCG Governing Body meetings in public.

 

4. How much will it cost to rebrand this statutory body (the JC CCG)?

 

The JCCCG is not a statutory body. The JCCCG is established as a decision making committee of the CCGs. The JCCCG does not have its own list of duties set out in statute like a CCG or NHS England does, it only exercises those functions a CCG member specifically delegates to it. There will be no cost to rebrand the JCCCG. 

 

5. What mechanism is there to report back to the people of the Footprint by those self-selected to sit on the ICS transport group?

 

The Transport and Travel Panel was set up by agreement of the Working Together on Hospital Services Steering Board to provide an independent view on issues which relate to travel and access in relation to the five services provided in our trusts, identified in the Hospital Services Review. The group has been set up to ensure that the voice of the local population is heard and influences any developments. The purpose of the group is to advocate for the general public in informing travel times modelling specifications and in raising any other transport issues that should be taken into consideration as options are developed. The Terms of Reference for the group does not include the requirement for members to report back.     

 

6. What is the cost so far of the required restructuring of SY&B health and care service commissioning and delivery since January 2016?

 

There has not been any restructuring of health and care commissioning, the focus has been on joint working across CCGs in SYB. There has been no cost as a result of restructuring.

 

 

 

1.     Hospital Services Programme Enclosure D Page 2 Third bullet point - Reconfiguration

There is a pattern with some hospitals nationally of reducing and/or withdrawing paediatrics services, then maternity services followed by closing Accident and Emergency Services because of hospital service changes and subsequent staff shortages.

Do you forsee either maternity services and/or the Accident and Emergency Services at Bassetlaw following this pattern and being closed in the next ten years?

In the early stages, the hospital services work looked at Accident and Emergency and determined that at this current time no change is necessary, other than the Hosted Network arrangements which are being put in place. (More information on the Hosted Networks can be found on the SYB ICS website, and in previous question and answers to the JCCCG).

The review also looked at maternity and paediatrics in Bassetlaw and identified that there are ongoing issues, particularly around staffing, however the review has found that there is no system-wide reconfiguration solution to this and has invited Bassetlaw commissioners and providers to work together to develop plans to address these current and forecast challenges.

Ten years is too far in the future to be able to say whether we can forsee any changes that would close these services at Bassetlaw

 

2.     Enclosure D Page 2  Fourth bullet point - Public engagement

This states 'the CCG MAY consider formal consultation with patients and the public' on any proposed permanent changes to services. Why can't the CCG AUTOMATICALLY have formal consultation with patients and the public on any permanent changes to services?

Bassetlaw CCG would engage with patients and the public on any proposed permanent changes to services. The level of the proposed change would determine whether the engagement would require formal public consultation.

Guidance on when formal public consultation is required can be found in the NHS England Planning, Assuring, Delivery Service Change for Patients document https://www.england.nhs.uk/wp-content/uploads/2018/03/planning-assuring-delivering-service-change-v6-1.pdf

The section on P10 describes ‘What is service change and when is consultation with the local authority and public consultation required?’ (detailed below)

The National Health Service Act 2006 sets out the legislative framework for public involvement (Sections 13Q (NHS England), 14Z2 (CCGs) and 242 (NHS Trusts and FTs)). Consultation with local authorities is provided for in the Local Authority (Public Health, Health & Wellbeing Boards and Health Scrutiny) Regulations 2013 (“the s.244 Regulations”) made under section 244 (2)(c) of the NHS Act 2006.

Broadly speaking, service change is any change to the provision of NHS services which involves a shift in the way front line health services are delivered, usually involving a change to the range of services available and/or the geographical location from which services are delivered.

There is no legal definition of ‘substantial development or variation’ and for any particular proposed service change, commissioners and providers should work with the local authority or local authorities Overview and Scrutiny Committee (OSC) to determine whether the change proposed is substantial. If the change is substantial it will trigger the duty to consult with the local authority under the s.244 Regulations. It is this that can trigger a referral to the Secretary of State and the Independent Reconfiguration Panel.

Public consultation, by commissioners and providers, is usually required when the requirement to consult a local authority is triggered under the s.244 Regulations because the proposal under consideration would involve a substantial change to NHS services.

Change of site from which services are delivered, with its consequent impact on patient, relative and visitor travel times, even with no changes to the services provided, would normally be a substantial change and would therefore trigger the duty to consult the local authority and would be likely to require public consultation. Decommissioning a service could also be a substantial change. Tendering a service by itself is unlikely to be a significant change unless the new service specification will provide a substantial change in service.

When proposals are first considered, discussion with the local authority will help assess whether the change is considered substantial. Public consultation may not be required in every case, sometimes public engagement and involvement will be sufficient. The decision around this should be made alongside the local authority.

 

SYBNAG Questions to the JC CCG September 2019 meeting

1.  (a) Can the members of the CCG tell us which section of which act describes the legal duty The HSP Final Report (to CCGs) on P82 where it states that, and repeats in item 9 Enc. D on this meeting’s agenda : “‘Individual Health Overview and Scrutiny Committees (HOSCs) are legally responsible for identifying whether a CCG needs to go to public consultation on a reconfiguration change” ?

Item 9 Enc D of this meeting’s agenda states:

Public engagement: Any proposed permanent change to services will need to go through public engagement, and (following discussion with the relevant Overview and Scrutiny Committee) the CCG may consider formal consultation with patients and the public. The timing of such a consultation and other issues that may also be included in a consultation process are matters for the CCG to consider.

This statement is correct and in line with the NHS England process.

The wording in the full report is a typo and should read: Discussions with Individual Health Overview and Scrutiny Committees (HOSCs) take place for identifying whether a CCG needs to formally consult the local authority on a change. If any CCGs wish to proceed with reconfiguration, or (in the case of Bassetlaw, consultation to confirm a temporary change), the process would be discussed with its own HOSC.

Thank you for drawing this typo to our attention, we will ensure the document is updated on our website.

      (b) Do the SYBICS officers and the CCG members of the JCCCG know that the legal duty is actually the CCG’s – to directly consult with the HOSC itself on the significant change to services they propose – as clearly set out in Regulation 23 of the Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013?

As has been illustrated with previous answers, SYBICS officers and CCG members of the JCCCG are aware of their legal duties to consult with individual HOSCs or the JHOSC.

SYBNAG yet again have a need to remind the CCG members of the JC CCG of their legal duties for public involvement, which is as the H&SC Act 2012 still says: “26,14Z2 Public involvement and consultation by clinical commissioning groups  

(1) This section applies in relation to any health services which are, or are to be, provided pursuant to arrangements made by a clinical commissioning group in the exercise of its functions (“commissioning arrangements”).

(2)   The clinical commissioning group must make arrangements to secure  that individuals to whom the services are being or may be provided  are involved (whether by being consulted or provided with  information or in other ways)

(a) in the planning of the commissioning arrangements by the group,

(b) in the development and consideration of proposals by the group for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are   delivered to the individuals or  the range of health services available to  them, and

(c) in decisions of the group affecting the operation of the commissioning arrangements where the implementation of  the decisions would (if made) have such an impact.

 

3.   As you have not addressed the duty (S.26 14Z2 (2)(a) or (b) for the SYB people about your proposed changes to the commissioning arrangements for your delegated  authority priorities (such as the collaborative commissioning for 999 & 111 contracts) –  do the members of the JC CCG recognise that you are proving our point for us – which is that you are not doing what you should?

From a patient perspective there is no patient impact of the joint approach for commissioning YAS ambulance services, it is a model of NHS lead contracting well established nationally in CCGs and in SYB.

It is for each CCG to fulfil their obligations to involve the public in accordance with s.14Z2 of the NHS Act with regard to determining commissioning intentions this question is not relevant to the JCCCG and should be asked of each individual CCG at their Governing Body meetings.

ADDITIONAL QUESTIONS FROM PETER DEAKIN SUBMITTED AT THE MEETING TO BE ANSWERED OUTSIDE THE MEETING

1. Previously the HSR review proposed that up to one, two or three consultants led maternity units and paediatric units should be considered for closure and then that the closure of one or two should be modelled.

My interpretation of the HSR programme report is apart from Bassetlaw overnight paediatrics with possible implications for maternity services, no other closures are being proposed in the short term – is this your understanding of this report as well?

Response:
The Report recommends transformation as the approach for all services considered as part of the Review and for the Hosted Networks to take this forward. With Bassetlaw, the Report recommends a more advanced (Level 3) Hosted Network approach in the first instance for paediatric and maternity services and for Bassetlaw CCG to consider the best way forward as the commissioner of all local hospital services. This might lead to consultation on options for the provision of paediatric and maternity services.

2. The report says that Transformation may not resolve all challenges and “if transformation fails to address the workforce issues in the medium to long term, reconfiguration may have to be reconsidered” – What is your understanding of “medium to long term” as measured in years?

Response:
We consider medium to long term to be two to five years.

3. In the earlier HSR review, reference was made to the introduction of personal budgets for maternity services which I interpreted as a proposal for privatisation of some maternity services. I found no reference to this proposal in the HSR Programme. Does this mean that this proposal is no longer being made, or that it is part of the changes that will be introduced under the heading of “Transformation”?
If the latter is the case, do you not think that this report is being dishonest in not spelling this out knowing that it will be a controversial issue?

Response:
Earlier Hospital Services Review Reports mention personalised care, not personal budgets. Personalised care for maternity services is outlined in the NHS Long Term Plan and refers to the commitments to delivering choice and personalisation in maternity services, complementing the recommendations in the national maternity review, Better Births. You can read more about it here: https://www.england.nhs.uk/mat-transformation/mat-pioneers/

4. Has the planning process for the Integrated Urgency and Emergency Care changes in the Yorkshire and Humber considered, or asked for, evidence of outcomes for patients after using the 111 services or from relevant coroner’s reports as there are growing concerns nationally about the safety of their processes?

Response below at item 6:

5. Why is there such inadequate information for people to say how they can be involved in the system commissioning planning meetings, or work-streams, and no information at all about what issues are considered in these meetings, given people should be involved in commissioning arrangements and plans?

Response below at item 6:

6. I received the Y&H MOU for Collaborative Commissioning of the Integrated Urgent and Emergency Care Services – can we see a copy of the Public Involvement Report for this commission.

Response :
The Y&H MOU is not a commission, it is simply a set of expectations and responsibilities that supports collaborative working for how the 21 CCG commissioners across the Y&H region will work together on the commissioning of UEC services and support the lead contractors on the management of the YAS contract. MOUs for lead commissioning and lead contracting in the NHS are well established and this is the second updated version of the MOU, the first version was agreed a number of years ago by Governing Bodies and covers the services YAS provides to all 21 CCGs. It has been updated to reflect the emerging ICS / STP footprints

a. Is there a survey of the service so for that has led to this conclusion, for public view?

Response:
N/A see above
 

b. How will public and patients be involved in the revision of commissioning?

Response:
See above. There are no changes to commissioning the YAS UEC MOU is an already established way of working for a complex contract across 21 commissioners
 

c. Is the revision of commissioning about saving money?

Response:
N/A see above

South Yorkshire and Bassetlaw NHS Action Group Questions for the JC CCG Meeting on 23rd October 2019

1. Commissioning for Outcomes Policy:

a)  How will people be involved in proposals and decisions about the clinical procedures that will be added to the list of those already on the existing SYB Commissioning for Outcomes Policy, given that this will reduce the range of services available to people in SYB?

Response:

The JCCCG invites written questions on the items on our agenda. Unfortunately, this item is not on the agenda. However, we will give some consideration to this when developing this work.

b)  What are the arrangements for monitoring how the Commissioning for Outcomes Policy has affected people in SYB and will these arrangements involve patients, carers and the public across SYB?

Response:

The JCCCG invites written questions on the items on our agenda. Unfortunately, this item is not on the agenda. However, we will give some consideration to this when developing this work.

2.  Hospital Services Review

a) What do you see as being the main drivers of the transformation strategy and what are the main outcomes that you are looking to achieve before you would reconsider reconfiguration?

Response:

The main drivers of the transformation strategy are concerns around the sustainability of acute hospital services: in particular, workforce shortages and the implications for quality and equality of services that result from these.

The main outcome that we would be aiming to achieve is a more stable and sustainable approach to workforce. In particular, this includes improved recruitment and retention, and better use of new workforce roles, enabling us to achieve sustainable levels of staffing without relying on locum and agency staff.

b)   What metrics will be used to measure the success of transformation and will these include a patient focus?

Response:

The NHS already has a large number of performance metrics which are measured and tracked at a national level. Part of the success of transformation would be whether we become more able to achieve these metrics: for example, does transformation of Urgent and Emergency Care make us more able to meet the national target for 4 hour waiting times in A&E; or has transformation improved scores against the Friends and Family Test which is one of the main measures of patient satisfaction.

In addition we will be asking each of the Hosted Networks to develop a small number of specific metrics to track the impact of transformation and to act as early warning signals if transformation is not having the necessary impact. These will be developed once the Networks are set up, but they might for example include measures of patient feedback, or measures around workforce.

c)   Will the six monthly review process considering the successful progress of transformation directly involve patients and will the findings be shared with patients and the public?

Response:

The review process to track the impact of transformation will be designed once the Networks are set up.

d)   Can you provide some information for the public explaining, in Plain English, the difference between transformation and reconfiguration, but in addition to the usual Easy Read versions of information?

Response:

Transformation is described in the reports of the Hospital Services Review as being about improving services in the settings where patients currently receive care, or about enabling acute care to be provided closer to home.

It is often about using the workforce in a different way, for example bringing in Advanced Medical Practitioners to support the traditional roles of consultants and nurses. It is also about making sure that all hospitals in the area provide the same care in a given situation, so that all patients are getting good quality care.

Reconfiguration is defined by the House of Commons Research Briefing as “changes in location or the type of treatment provided, usually as part of a reorganisation of services across a larger health geography.”

There can be some overlap between these two terms, and reconfiguration would usually be accompanied by transformation.

e)   What implications are there for patients in a hospital unit where experienced staff are moved to support another hospital’s unit that is struggling, as part of the hosted network approach?

Response:

None of the Hosted Networks are currently proposing to move staff from one hospital to another.

As the Networks are set up, there are many different ways that hospitals could support each other. At the moment, some of the hospitals regularly send consultants to other sites, for example where Sheffield Teaching Hospital consultants run regular outreach clinics in the other hospitals. Some hospitals have appointed staff who work half their time in one hospital and half in another, for example some gastroenterologists who work across Barnsley and Rotherham. This is designed as a standard part of job planning for the two sites.

 

 

Questions for the Joint Committee of CCGs 29th January 2020 submitted by members of South Yorkshire & Bassetlaw NHS Action Group

Question on Enclosure A

In the Minute C156/19 d) the question asked for information in “in Plain English” for the public explaining the difference between transformation and reconfiguration, but the question specifically asks for this information to be “in addition to the usual Easy Read versions of information”.

So please can you explain why:

• minute C156/19 e) and the Action Summary both report something completely different which the question did not ask for (namely a “simplified ‘easy read’ version of the Hospital Services Programme be produced for the public, explaining the difference between transformation and reconfiguration.”)
• are you making work for yourselves, or a subcontractor, when the question only asked for a Plain English definition of the two terms ‘transformation’ and ‘reconfiguration’  (please note - a definition of the difference between Plain English and Easy Read can be provided)

Response

As with all the Hospital Services Review reports, we have produced an Easy Read version.

The explanation for the difference between transformation and reconfiguration has been drafted in Plain English and we note your helpful comment regarding the minute.

Question on Enclosure C – JCCCG Progress Report

(a)  Paragraph 3.4 says “all JCCCG meetings now held in public” this implies complete openness and transparency, in line with the Nolan Principles of Public  Life; does this openness and transparency also apply to the delivery plan, the performance report and the specific decisions referred to in points 3.5 and 3.6?

Response

The JCCCG Progress Report will be received quarterly at the JCCCG meetings held in public and also the CCG Governing Bodies held in public. Delegated decisions made by the JCCCG will continue to be made in meetings held in public.

Question: (b)  Given we are still awaiting a response from the Joint Scrutiny Health Committee concerning lack of access to public transport for families and visitors, the increases in patient transfers between hospitals and health facilities, the severe bed shortages and specialist facilities and the continuing centralisation of services causing many severe hardship and stress, isn't it essential that the ICS Transport group be reinstated with a democratically representative group, a meaningful brief and the facilities to support and inform the public of changes, options and costs?

Response

A Transport Group was set up to support the potential for service change during the review of Hospital Services. Work also took place to look into transport issues during the Hyper Acute Stroke Services service change proposals.

With regards to the Hospital Services Review Transport Group, the Final Report did not recommend service changes and therefore the Group had no agenda and was stood down. With regards to the Hyper Acute Stroke Services as the pathway is now in place feedback is now routinely gathered as part of patient experience.

There are currently no JCCCG plans to change access to local services but if this changes the Transport Group will be reinstated. 

Question on Enclosure D - HASU Update

(a)  Post HASU transfers to Rotherham and Barnsley are working well in line with the agreed Regional Patient Flow Policy, with a very small number of delays reported.

Could you tell us:

• Reasons for the above delay
• How will future delays be avoided?

Response

Overall Rotherham and Barnsley residents have flowed well through the new regional pathway since the changes were enacted. There are a number of reasons why transfers may not go ahead as originally planned including a change in patient circumstances.

Monitoring is in place to ensure oversight of patient flows and to promote proactive conversations and continuous quality improvement to aid timely flow through the regional pathway.

Question: (b)  Section Lessons learned,

Very surprised and dismayed that the new model was installed on the agreed dates, when clinical leads were not properly ready to start the new model.   Staff with the appropriate qualifications, skills and experience need to be in Place to respond to the clinical needs of the patient in a timely and effective manner.  

Could you please answer following:

• Why did you decide to go ahead with the implementation of the new model on the agreed dates, when this very important element of the model was not quite in place?
• Why is that it was decided that the risks involved in this, were not important enough to delay the starting date to ensure a safer implementation of the model?
• Provide details of workforce structures and plans to address the above

Response

Strong clinical leadership was in place as a key component of the HASU work programme and this enabled us to implement the changes in line with the agreed implementation dates.

All HASU units successfully recruited additional staff, including nurses and allied health professionals with the skills and expertise ahead of the planned changes to ensure safe implementation of the model.

Each HASU unit has a workforce model that supports their service delivery and is linked into the delivery of the wider stroke pathway. 

Workforce planning is an area that will be taken forward by the new Stroke Hosted Network. 

Question: (c)  Evaluation, assessment and monitoring of the new HASU service model

It is stated that the new HASU model was installed successfully, but we don’t know the extent to which the new model is successful in terms of patient care, its impact on patients and the expected outputs and outcomes from the patient/carer perspective. Not just in the sense of staff being kind, understanding and caring, but also and very importantly, in the sense of timely clinical interventions and outcomes.

Could you please answer/ provide the following information:

• details of the evaluation system used to assess the above
• details of what is being evaluated/ assessed
• details of the monitoring system in place, including information of what is being monitored, who is involved in the monitoring, monitoring stages, data collation systems, products needed, reports systems etc.
• details of whether patients/ public have been engaged or consulted on this.

Response

The specification for the new SYB HASU model included reporting and monitoring requirements. Most quality indicators included in the reporting were based on the evidence based nationally identified indicators set out as part of the SSNAP (Stroke Sentinel National Audit Programme) to enable us to measure improvements in stroke care.

A monitoring dashboard has been developed to enable us to monitor these and the plan is for this to be monitored as part of routine contract monitoring.

The Stroke Hosted Network will have a key role in embedding the new model and enabling us to realise the benefits. This will need to include understanding the experience for patients and their families and using this to drive continuous quality improvement.

Question: (d)   If you did not have the above system in place, before the implementation of the new model (to start gathering systematic data from its incept)l, can you explain the reason for this.

Such an important service, which in many cases deals with life and death, and whose interventions can have long term quality of life consequences for patients, it needs a rigorous, effective, timely evaluation and monitoring system, to be able to avoid unintended mistakes in the future, as well as serving as a tool for service improvement.

Response

The monitoring dashboard was developed ahead of implementing the new model.

Data has been systematically gathered by providers in relation to key quality indicators set out in SSNAP. The dashboard aims to bring together data from a number of different data sources, including SSNAP, patient flows and activity data and there is a commitment to continuous quality and service improvement.

Question: (e)  In relation to risk management

Risk management is a very important supporting element in delivering a new service model, and more so when people’s lives depend on such a service.  Awareness of risks, sharing and reporting on them are of paramount importance. Risk systems are key to ensure the service is as safe as possible. It is important that a risk system is in place in order to raise the “alarm” when needed, to avoid fatal consequences.

Could you tell us why you think the decision to go ahead and implement the new model was a responsible one when a rigorous, well thought risk management system was not embedded in its structures, especially in its initial stages when anything could have gone wrong?

Response

The decision to change the way Hyper Acute Services is provided across South Yorkshire and Bassetlaw was made following a rigorous business case which addressed risks. Risk management was undertaken at both programme and organisation/service level throughout the programme.

 

Questions from the public

Questions from SYBNAG members to the JCCCG February 2020 meeting: 

Question 1 - Children’s Surgery and Anaesthesia

The report presented for discussion and support does not explain clearly what the changes will be to ‘unplanned’ services for poorly children from each of the five ‘places’ across the SYB ICS area.  Can you please tell us:

1 a) What exactly are the changes proposed to be made to each of the services currently offered at each place for the ”four non-elective children’s surgical pathways for children”?

Response

The only change planned is to appendicectomies for children under 8 years or with significant complexities or comorbidities from district general hospitals to Sheffield Children’s.

1 b) How exactly do these changes differ from those proposed and consulted on in the winter of 2016/17 and those in the Decision Making Case approved by this Committee in June 2017?

Response

The differences are:

• The Ear, Nose and Throat  (ENT) non-elective service models that are in place should stay as they are
• Torsion of the testis non-elective pathways should stay as they are
• Abdominal surgery (for suspected appendicitis) is the most complex pathway and the recommendation is that a change should be made to the non-elective treatment of appendicitis in young children. They would be seen and treated at Sheffield Children’s.

1 c) If the proposals will affect the “manner in which the services are delivered to the individuals or the range of health services available to them” such as “delivery at the point when they are received by users” then will the JCCCG insist on a public consultation?

Response

There has previously been public consultation, in line with statutory requirements, on a range of potential changes to Children’s Surgery and Anaesthesia. The Joint Health Overview and Scrutiny Committee will advise on whether given the proposed changes they would like us to re-consult with them formally, which will in turn influence our decision around further public consultation.

1 d) Who exactly will decide whether the proposed changes will take place?

Response

The Joint Committee of Clinical Commissioning Groups.

1 e) Will the services currently provided for elective surgery for each of these procedures be affected?

Response

No.

Question 2– Lay Member Representation

2 a) The report at agenda item six indicates that lay members are recruited to bring specific expertise and experience to the work of the JCCCG, to do with all aspects of governance.  Could Priscilla and Philip each give us a two minute summary of how their experience in systems of internal control, internal audit, external audit, performance management, financial management, risk management or Annual Governance Statements informs their approach to lay member scrutiny and challenge in the JCCCG?

Response

Both JCCCG lay members were recruited through an open process and were appointed based on their extensive experience and expertise. Both have held lay member roles in CCGs.

2 b) In March 2019, Susanne Hasselman, then Chair of the NHS Clinical Commissioners Lay  Member Network, produced a paper entitled “Lay Members & ICSs”.  She lamented that “We continue to hear that there is variability in the engagement that ICSs  are undertaking both with key partners across the system, and most importantly with patients  and their local populations as they plan and implement integrated approaches to health and care delivery. This is where lay member scrutiny and challenge is critical in driving progress”.  (Our underline).

This is exactly SYBNAG’s experience of SYBICS since it was formed – token public engagement and lack of lay member scrutiny and challenge. Do any JCCCG members (particularly lay members who we note have no voting powers) have any concerns that they want to share in this regard?

Response

This question is not relevant to the agenda.

The following question was received at the meeting from Peter Deakin, Barnsley Save Our NHS

The public have never been granted a vote and have had a very limited chance to voice our opinions in the JCCCG, ICS decision making process. A process set up without our consent in a way that hides almost every aspect of this process from our knowledge.

It is part of a larger legal and convenient method of transferring pubic money to the private purse.

Q. Aside from the recent survey when will the public be allowed to become involved in the decision making process and changes that are being made by the JCCCG, ICS. This could be an event which will inform the public and invite a response. Maybe the public will become informed about the ICS activities and who they are what they do, why they exist how they fit in to the future of the NHS. I am sure people will be interested to become enlightened regarding the decision makers.

Response

This question is not relevant to the agenda.

Public involvement in JCCCG work is ongoing and carried out by partners in line with their statutory duties. The public have also been involved in shaping the Five Year Plan for the region.

Going forward and as a result of the involvement work to inform the Five Year Plan, partners have committed to holding public events before each ICS Guiding Coalition to gather views to feed into the sessions and developing an online membership model to support involvement work on transformation.

The first of these events is scheduled for 25th March and this event will be widely publicised in the coming days, noting that the event could be postponed in the event of national guidance on public gatherings. The online membership recruitment is due to start in the spring.

Q. Does the citizen panel still exist?

Response

Yes.

Q. If so when will they meet again? 

Response

The Panel meets bi-monthly and met most recently on 2nd March. The next meeting will be in May.

Q. When will the JCCCG lay members and Healtwatch representative begin to ask these questions, as they are at meetings to represent the public.

Response

This JCCCG lay members and Healthwatch representative are involved in ongoing discussions about public involvement. There are additional opportunities at the individual CCG Governing Bodies for lay members to challenge the work and decisions that are made at the JCCCG.