Will a Cornish ICS be able to function with the underlying conflict of trying to merge 2 systems with very different funding arrangements, considering the clinical commissioning group and Cornwall Council are still in dispute over the funding for example.
ICSs are partnerships of health and care organisations that come together to plan and deliver joined up services and to improve the health of people who live and work in their area. Following several years of locally-led development, and based on NHS England and NHS Improvement’s recommendations, the government has set out plans to put ICSs on a statutory footing. It is clear that the ICS for Cornwall and Isles of Scilly already exists as a collection of partner organisations working together for the benefit of the population and includes a range of organisations. These include large public sector organisations such as the NHS and local authorities but also includes voluntary sector organisations, public engagement and independent oversight groups such as Healthwatch for example.
The establishment of the ICS Board as a formal entity will not materially change the existence of these partner organisations and how they will work collaboratively together. It is not a merger of council and NHS funding regimes.
We are working towards the ability to have a single funding arrangement for the appropriate health and care services. We are looking to integrate where appropriate to ensure economic viability for both organisations. With the legislating of the better care fund in the near future this will bring together a clear, auditable and transparent mechanism to understand how joint funds are spent. We are currently working with council colleagues to look at how we might do this together moving forward.
What are the key factors in achieving the aims and aspirations of the ICS?
A key factor will be adopting a system approach to transformation leadership and financial recovery, to get us on track to deliver. This will require making difficult decisions and leaders acting together to do the right thing for the system, ahead of their own organisation. When new pressures and problems arise, we will work together to find solutions. Success means that local organisations support each other to improve, so that we all deliver what is expected of the NHS locally. This approach has been particularly evident during the COVID response and our learning from the pandemic response has strengthened the effectiveness of this collaborative system approach. In working with a system first approach, integrated care boards (ICBs) and the boards of their constituent partners must be clear on the lines of financial accountability that will be maintained in any arrangements established to manage NHS resources. This includes meeting core principles for managing public money, the statutory responsibilities of partner organisations and other national expectations.
Collaborative working is the key to unlocking the success of the ICS as well as the ability to be transparent in all aspects of our business. The ICS legislation is advising all partners that they have a duty to collaborate so this is a key factor. Trusted relationships is also a key factor in our success as an ICS. We are about to enter a new phase with new key senior leaders in place and with whom we will be endeavouring to build those trusted relationships with. Equity is also another key factor between health and local authorities but also all partners.
Whilst primary care, hospital trusts, community and social care are all subject to different financial and regulatory regimes how can you create an ICS, that to the patient is seamless, places resources where they are most beneficial, but that could be to the financial, regulatory and statutory detriment of another ICS member?
The NHS financial framework sets out the national rules, expectations and guidance on how NHS resources are spent to deliver the requirements of the NHS mandate. This includes the actions that must be, should be and may be taken by NHS organisations to manage the NHS funding they are allocated. From April 2022, the NHS financial framework is expected to include ICBs as statutory NHS bodies, subject to legislation. Newly-established ICBs will spend most of the resources made available to the NHS and should do so focused on agreed system plans to meet the health needs of the population (all ages) within their area. ICB allocations will include the budgets for services currently commissioned by CCGs, which covers most of the acute, ambulance, community, and mental health services spending. It will also include budgets for primary medical care (general practice) services and, where agreed NHS England, other primary care services (dental, optometry and pharmacy services). Further delegation of some specialised services and other direct commissioning is expected from 2023/24. ICB allocations will not include funding for core social care or other local authority services.
Are you aspiring to a unified budget for all health and social care in Cornwall? If so how will you balance the immediate needs of, for example emergency admissions to the Royal Cornwall Hospitals NHS Trust (RCHT), with the acute and longer term needs of primary care and the care of those with long term needs in the community? If not (aspire to a unified budget) how will you achieve the aims and aspirations of the ICS?
Proposed legislation set out in the Health and Care Bill (2021) allows for collective financial duties for ICBs, NHS trusts and foundation trusts on the spending of local NHS resources (clause 21). This will require them to exercise their functions in a way that does not consume more than their share of NHS resources. This does not include local authority budgets and funding.
Joint committees agreed by the ICB and other statutory bodies can have decisions delegated to it by those organisations, with budgets pooled across these partnerships to support these decisions. This could be how ICBs and local authorities establish collaborative commissioning for local services as part of a place-based partnership, which legislation would allow to go further than currently.
Cornwall has geographical challenges. Will the ICS be sensitive to place-based care?
In Cornwall and Isles of Scilly we have set up integrated care areas (ICAs) to support the delivery of placed-based care. This also links to our vision of working with primary care networks and ensuring people are at the heart of our work.
Will the new ICS work towards having a common database that will work across all providers based on the patient’s history instead of the current multitude of different systems that do not talk to each other?
I believe this is a question about a single patient record. If that is the case then our chief information officer and the digital team are working towards developing this, alongside, colleagues both nationally and regionally. If you would like further information on this then please contact our communications and engagement team so that your questions can be forwarded on and answered appropriately.
To what extent do you envisage the ICS will be publicly provided and provided by not-for profit organisations? The argument that centrally organisations surely applies even more strongly to large multi-national companies providing social and/or health care?
Please could the originator of this question contact the system transformation team so that we can fully appreciate and understand the question and provide a good response.
Some other ICS from around the country have developed some innovative executive roles, such as director of digital and people development. Are you open to moving away from traditional senior leadership roles in order to develop a new approach to health and care delivery? Are you looking at the way other ICS are being constructed?
Yes, we are always looking to use innovative ways to be progressive with healthcare. Utilising learnings from other systems of care will enable us to develop more successful health and care within Cornwall and the Isles of Scilly.
We need to look at how ICS can link with the parish and town councils and use them to gain local information. I would like to see how we can develop links to help with those who need help at home. My concern is GDPR gets in the way!
Our communication and engagement is paramount to the success of understanding our population’s needs. We fully acknowledge your point about GDPR, and it would be good to understand what you are asking; please email our communications and engagement team.
How will the ICS ensure that there is true joined-up working?
The ICS in itself isn’t going to be able to ensure a true joined-up working process. The ICS is made up of 2 key bodies, an ICB and the integrated care partnership. We need to remember that the people who are working within the partner organisations are the same as will be in the new ICS and ICB. The new structure will be a vehicle to assist us in working together and improving joined up working. This is our opportunity to shape and develop how we want to work and how we are truly joined up. It would be great to get your thoughts on how we can learn and develop the ICS moving forward and how the public can or could be included in that learning, contact our communications and engagement team.
Where will the community diagnostic hubs be sited?
Bodmin for the first stage and then we are looking at Cambourne and Redruth and West Cornwall Hospital as places we would develop for future community diagnostic hubs. Point of care testing is really exciting. If we get the right point of care testing, in the right part of the county, you won’t need to go to an acute hospital, you’ll know straight away if you need to go to hospital.
Are the community diagnostic hubs in place of the CATUs or in addition to?
They are additional to the CATUs and will make them more functional, for example able to see more people.
As member of a PPG what support on ICS is there for GPs to educate patients. For example talks at surgery or network level to deliver support to patients on chronic illnesses to help reduce demand.
The development of social prescribing will support improved programmes of education for patients with chronic illness. The ICS has been helping to deliver the population health management programme across practices and PCNs which will also aid the development of support.
How do we get South Western Ambulance Service NHS Foundation Trust (SWAST) to buy into the Cornwall vision?
SWAST has recently developed a patient participation panel which will be used to gather honest feedback from patients and members of the public to help the Trust understand what each area or community, such as Cornwall and the Isles of Scilly, feel they need. The Trust is hoping the panel will provide a safe space for opinions to be shared in a non-judgemental environment with a you said, we did response.
The Trust is also working with the SWAST governors of Cornwall and Isles of Scilly to develop better relationships with patients and members of the public, identifying trends from feedback and implementing changes where appropriate and possible.
An increase in engagement activities will hopefully help achieve alignment between the Trust and Healthwatch strategies for each area, we are also looking to develop a communicative process wherein we work alongside Healthwatch to match their vision where we can.
How has COVID impacted on Cornwall’s most deprived communities? How will this feed in to the levelling up agenda?
The best place to find information on how COVID has impacted on Cornwall, including the most deprived areas is on the Let’s Talk Cornwall website. With the most relevant links being COVID insights dashboard which is updated regularly, and the impact of COVID in Cornwall and COVID equalities impact document.
The intelligence we gather on needs of the whole population and specific groups within it, is used to create our strategies and plans for the work of the Council, the services we commission, and the NHS. This continues to be the case as we respond to and recover from the COVID pandemic.
Going forward, the vaccine programme is not as successful as it was. Walk-in clinics where you don’t need appointments have stopped despite being very successful. Many people have to travel a long way now to get a vaccination. Will the mobile clinics restart?
Our vaccination programme is incredibly successful, with more than 1 million doses delivered since December 2020. We are seeing the majority of people eligible for their booster and at least 6 months from their 2nd dose, coming forward for their booster. We have more clinics than we had for the 1st and 2nd doses as more GPs and pharmacies have come online to deliver boosters, and 1st and 2nd doses. Booked and walk-in provision increases every week. Visit NHS Kernow’s website for information.
In her account of learning from the pandemic Rachel listed a number of recommendations expressed as should or address the various problems. How exactly do these aspirations translate into effective learning that lasts?
The director of public health’s annual report is an independent statutory report which enables the director to highlight a health topic of relevance to their population and outline recommendations. Each report by the director of public health in Cornwall contains an update on progress against the recommendations of the previous year.
Why do GPs continue to advocate virtual consultations as the future direction, when quite clearly their patients regard it as a seriously retrograde move?
Primary care in Cornwall and the Isles of Scilly is doing remarkable work in returning to face-to-face appointments which run at 60% of appointments offered (55 of 149 STP areas nationally). Face to face appointments have always been available for anyone who needs to be seen in person, but often initial appointments at a consultant-led clinic do not include any examination and a video or telephone call may be more appropriate.
Why is technology being misused or inappropriately used? For example, cardiac referrals from GPs to RCHT being given video appointments for an initial assessment. Asthma checks being done via a phone consultation.
Overall, the professional clinical view is that technology is being used where appropriate (another example would be virtual wards enabling patients to be discharged from hospitals more quickly) and face to face is being used where necessary. For some people, remote-technology-led appointments are preferred in terms of convenience for example.
To expand on the point about asthmatics, if they have their symptoms under control there is still a requirement for a regular review, so some of these are being done remotely. Decisions about this are being made by the nursing team who carry out the reviews and know the patients well. Where there are any concerns about management of symptoms or in some cases, where there are co-morbidities, patients are asked to attend a face to face appointment.
Please could you tell me whether Cornwall is currently gathering and collating diagnostic category data on all patients presenting to primary and secondary care. Is this data being collected in real time and, if not, what is the reason?
A data warehouse has been created to store information from GP practices, acute and community hospitals, community services and social care. The data is pseudonymised to maintain people’s confidentiality but it can be joined together across health and care services to show their journey. We are beginning to explore how this can be used through a new programme of population health management.
Initially we are working with 3 of our primary care networks and 1 ICA to focus on specific groups of people to understand how we could support them better. The 20-week intensive programme ends in December, and we plan to roll out to all areas in 2022. There are no quick fixes for changing how health and care are provided, and the data is extremely useful, but it is only the starting point for having multidisciplinary conversations about improving support for people. We are gathering the remaining consent from all practices to complete the dataset.
Example analysis of people within a primary care network (PCN) and the practices who have experienced an emergency admission and combines primary care, community, acute and mental health. Note not all social care data included.
Has NHS Kernow coordinated any guidance, training or financial support to Cornwall’s GP practices for the rollout of new telephone and online appointment systems, triage processes, and online consultations?
NHS Kernow provided funding for the implementation of online consultation systems as well as providing ongoing funding for those systems and practice clinical systems (which support both appointment booking and triage systems). It supported the implementation of online consultations systems by providing workshops (which practices were funded to attend) and named team members to support practices in setting up the workflow processes as the product was rolled out in 4 phases, the last of which was accelerated greatly due to the onset of the coronavirus pandemic. The team has remained available to support practices in their configuration and use of these systems, as have the predominant supplier of these systems, eConsult.
In terms of telephony systems, these sit outside of NHS Kernow’s remit so no financial or technical support has been made available to practices. Notwithstanding this, the team has been available to provide advice to practices who have been evaluating existing and new telephony systems within practice.
If data is anonymised how will it be applied to give individualised care or advice?
There is a process that has been set up to allow re-identification that has been approved by the information governance lead. The process is tightly controlled.
What impact have the primary care networks had on improving access to NHS services?
One of the main purposes of primary care networks (PCNs) is to improve practice resilience by increasing the workforce. PCNs are able to access national funding through the additional roles reimbursement scheme (ARRS) to employ a number of roles to boost the capacity within practices, thereby improving access. The 14 roles include physiotherapists, clinical pharmacists, mental health practitioners, social prescribers, paramedics, physician associates, dieticians and occupational therapists.
At the end of March 2021 there were an additional 100 whole time equivalent posts across Cornwall and the Isles of Scilly. A number of these have been supporting the vaccination clinics but the remainder have been working in practices and with communities. It is extremely difficult to quantify an improvement in access, particularly given the past 18 months but the range of practitioners now available within general practice has freed up GP and practice nurse time so they can see those who are most in need of these professionals.
The pressure on frontline acute services is unrelenting. Whilst acute services are under such strain how can primary, community and social care be significantly enhanced to provide such care, improve wellness, reduce the determinants of ill health and manage ageing better?
Much of the responsibility for this transferred to local authorities during the 2012 health reforms and will not transfer back to the NHS as part of this legislative change. Some example local authority responsibilities include local programmes to address inactivity and other interventions to promote physical activity; tobacco, drug and alcohol misuse services, prevention and treatment; local programmes to prevent and address obesity and weight management services; healthy child programme, including school nursing, assessment and lifestyle interventions; any local initiatives on workplace health.
The NHS and Cornwall Council recognise that managing the demand that we are seeing on all services is needed. A more wholistic prevention-based approach to wellbeing and health is recognised as a long-term solution to addressing the pressures on health and social care. Achieving this in the face of the acute pressures we are seeing is a challenge. The public health team are working with colleagues across organisations to develop a long-term vision for preventative interventions which will collaboratively contribute to improving wellbeing and improve healthy ageing of residents.
Is the provision of vital support services by volunteers somewhat contradictory to the provision of paid work needed to tackle economic disadvantages?
It doesn’t have to be either/or. Volunteers can add value and enhance the statutory offer. For example, the NHS can give you a new hip, social care can provide your personal support needs while you recover but the community and volunteers can help with the things that matter to people for example:
Through the pandemic that’s all people giving up their time to help others purely out of kindness. That kind of volunteer involvement builds resilience into communities and we need that more than ever as we face multiple, significant challenges ahead.
Rachel referenced town and parish councils which is great. How is that being followed up?
The ICA and linking up with the Cornwall Association of Local Councils provide a lot of opportunities for linking up with health and social care teams. This has been successful during the COVID crisis and will expand upon work currently undertaken in a variety of areas including suicide prevention, mental health first aid training, Healthy Cornwall teams on the ground.
Physical accessibility is also vital because if people can’t get into our buildings they are excluded from services before they start.
Physical accessibility is very important. The Equality Act 2010 says reasonable adjustments, or changes, should be made to ensure people with a disability can access services. This is to ensure people with a disability can receive the same services, as far as is possible, as someone who’s not disabled. Some examples of reasonable adjustments can be seen on the Citizen’s Advice website. If people have concerns that a building is not physically accessible to them, we suggest that they address their concerns to the provider of the service they are wanting to access.
Can care come to the people rather than people going to the care?
The NHS was set up primarily to provide episodic treatment for acute illness, but it now needs to deliver joined-up support for growing numbers of older people and care closer to and at home. As a result, the NHS and its partners need to work differently by providing more care in people’s homes and the community and breaking down barriers between services. ICSs are the latest in a long line of initiatives aiming to address this by integrating across local areas and bringing care closer to and at home.
Do we know how much of the ringfenced £5.4 billion will be allocated to Cornwall and how it will be administered?
There is no definitive answer at this present time to what proportion for social care or what proportion for Cornwall or how it will be administered.
How does the funding formula work for Cornwall? Are the panel happy with it and, if not, what do they think can be done about it?
Resources allocated to ICBs will be a fair share of the NHS funding agreed by the Secretary of State for us to deliver the objectives and requirement in the NHS mandate.
Core ICB funding will be distributed based on the current national needs-based formula (aggregated from GP practice data to ICBs and the same as clinical commissioning group allocation formula) and a policy to manage how quickly ICBs move from current spending towards their target allocation. The methodology lets funding to flow to reflect the fair share of NHS resources for each ICB without destabilising local health economies.
This approach has been used by the NHS for a number of decades, is evidence-based and provides the best opportunity to narrow inequalities in access, experience and outcomes. This would build on existing Section 75 agreements that will continue to enable clinical commissioning groups and local authorities to work together to commission health and social care. These arrangements would be mostly unchanged by proposed legislation with ICBs and local authorities continuing to contribute to the better care fund that supports these arrangements. NHS England and NHS Improvement will continue to specify minimum better care fund contributions by ICB for each upper tier local authority.
Are initiatives assessed to determine whether cost versus benefit is sustainable? Especially important for recurrent funding. Are benefits weighted in some way to account for vulnerable, disadvantaged groups?
Most of the initiatives we are involved in have outcome and impact measures, monitoring the effectiveness of the interventions and approaches but there is always room for improvement.
Government funded support for adult social care services is significantly lower in county and rural areas. This creates health inequality nationally. What can Cornwall Council realistically do about this?
Cornwall Council, like all county councils and in particular those in rural areas, works hard to ensure that its funding challenges are recognised.
What imaginative ways can be employed to recruit, train and expedite the number of carers needed, now and in the future, who are community based so that the Royal Cornwall Hospital can deal with acute frontline care? What multi-disciplinary approaches are being considered to make this happen before acute services grind to a halt?
What are the short term and longer term plans around accommodation for new staff? To attract new staff into the county there needs to be somewhere for them to rent or buy. Currently we cannot recruit new staff due to this issue.
The shortage of accommodation in the county is well documented and this is affecting the health and care sector along with many others. Efforts have been made to secure some temporary accommodation for out of county workers, but this is limited by availability and access to short term funding streams. The ongoing challenge of offering affordable accommodation sits within the wider housing strategy for Cornwall.
What is very clear is that health and care cannot work alone. A lot of the inequalities relate to living conditions (housing) finance (work opportunities) and environment and facilities (open spaces for example).
The impact of the environment and communities we live in on our health has become more widely recognised and this is very welcome by public health. The public health team is working with colleagues across the council and Cornwall on better understanding the how their roles impact on the wellbeing and health, and how to best design and deliver services to improve lives of residents.
How are you going to staff the service if there is already a shortage of people in the care sector?
No easy answer. We are trying our best through all the methods as listed in question 7.
Kate Shields mentioned that there would be additional social care staffing. There was also a mention of a care hotel and contracting with social care providers. Please clarify how the additional staff will be recruited and employed. Is it the intention to have a private contractor providing the additional staff?
The care hotel is currently being staffed by agency workers.
Is it time to set up the discharge units again like the ones we had in hotels at the start of the pandemic? There is to be a new ward in Treliske to do that but it is only 28 beds and we have about 200 people in our hospitals that need to be discharged. When will it be ready and will we be receiving extra funding to do this to cope with the critical incident?
28 beds will be available from 11 November 2021.
We have a lot of learning from setting up care hotels doing this during the first wave of the pandemic and are applying that learning to open a care hotel in Newquay in November. There are still some elements to sort out before we know if this is an entirely viable option as our learning from the first wave of the pandemic tells us that we need to consider suitability of physical environment, fire safety for less mobile patients, GP input and access to therapy for instance. We are in the final stages of our planning.
There is no separately identified funding associated with the critical incident but we have been allocated national funding, as have all systems, for additional costs incurred in implementing the national hospital discharge policy.
Issue of links between patients leaving hospital and social care has been on agenda for years. This doesn’t seem to be improving. Is this still a priority?
All parts of England including Cornwall and the Isles of Scilly are now covered by 1 of 42 ICSs. The central aim of ICSs is to integrate care across different organisations and settings, joining up hospital and community-based services, physical and mental health, and health and social care. It is hoped that they will be a vehicle for achieving greater integration of health and care services; improving population health and reducing inequalities; supporting productivity and sustainability of services; and helping the NHS to support social and economic development.
Social care is limited by eligibility criteria and means testing. How will this be managed?
Eligibility for social care support is assessed using criteria and an assessment process specified in the Health and Care Act 2014. The extract from the Care Act factsheets provides an overview of the assessment criteria and arrangements for assessing financial contributions
What plans are in place for re-enablement places for people who need to be out of hospital?
Cornwall Council commissions the STEPS service from Corserv Care to provide reablement services for people who need to be out of hospital.
Between September 2020 and August 2021, 2,637 people completed a STEPS reablement programme. The following outcomes were achieved:
NHS Kernow launched a new care hotel in Newquay in November. It is a joint initiative paid for by NHS Kernow and supported by adult social care and care provider Abicare.
Anyone who is ready to leave hospital when they have no clinical reason to be there but needs some extra support to get back on their feet, will be moved to the care hotel while their needs are assessed. The NHS has purchased a floor of 20 beds to accommodate people and they will have help on hand from Abicare’s in-house team until they are ready to move home. Abicare has been commissioned to provide the service for 6 months to support our system during the winter.
As a provider of live-in care, we have good capacity to support Treliske with hospital discharges over the winter period, is there a person who would be best to speak with about this?
Kate Shields. Email Kate for more information.
If the quiet voices speak out, they stop being quiet voices. If you prioritise quiet voices does that mean that anyone speaking out can be ignored?
Everyone’s voice and opinion is important to us. We want to create opportunities where people can feel confident in having their say and having their voice heard. This is really important to us to make sure we are understanding the needs of our communities to understand what is important to people and what services and support they need. We will endeavour to do this in a variety of ways using emails, fact to face meetings, being more visible in our communities and we welcome suggestions of ways we can improve this.
Can we have email contacts all for your speakers please?
Email NHS Kernow’s engagement team and we will ensure that gets to the person you wish to contact.
How are you communicating all these initiatives to local parish and town councils so they are aware of them?
The Voluntary Sector Forum is the voice of the sector and they have just relaunched website, social media and newsletter to allow them to promote all of the work the voluntaty care sector is undertaking. We try to attend the annual town and parish council conference to raise awareness of what we do (COVID interrupted that) and we work with town and parish councils where we can, for example the HAIRE project in Feock.
What is being done to educate the public that seeing a GP is not necessarily the best solution for them?
We are working with the media, and sharing information online and with partners to raise awareness of the range of health and care services to support people manage their conditions. Printed information is also being sent to GP surgeries, pharmacies, supermarkets, community and acute hospitals, tourist locations and hotels and bed and breakfasts. We are working with clinicians to produce videos on a range of conditions that can be treated with over the counter medicine, or by a pharmacist. Details of the range of services is available from the NHS Kernow website.
Our Healthy Cornwall service has lots of information about keeping well, groups and training.
Totally agree communication is a huge issue, is the role of PPGs underused?
Making sure people’s experiences of care are heard and understood is a key priority, and our ICB board will have patient experience and involvement representation. Our PPGs provide insight into what is working well, and areas of improvement in surgeries. As we develop our place-based approach to health and care services, patient voices will remain at the heart of this work. Some PPGs are better established than others, and despite previous work to support PPGs to develop, it’s clear that more work is needed. During the 2019 PPG conference we discussed how groups could develop and learn from groups which are working well. Unfortunately this work stalled due to COVID, but we would welcome people’s thoughts on how to reenergise this work.