Agenda item

[To Scrutinise the future commissioning proposals for the Black Country and West Birmingham area]. 

The Managing Director of Wolverhampton CCG introduced the report on the CCG Merger proposals.  He stated that the CCG in Wolverhampton had been very successful and had been rated as outstanding in the last four years by NHS England.  There was a changing landscape in the NHS, with the development of Sustainability Transformation Partnerships (STP) and Integrated Care Systems (ICS).  The expectation in national policy was that the ICS would play a key role in how the systems would work and that within the ICS there would be a single Commissioning voice.  In order for Wolverhampton to be a successful Commissioner it needed to be part of an Integrated Care System with the national expectation of there being one single CCG across the Black Country and West Birmingham.  As part of any Black Country and West Birmingham CCG, they did not want to lose the critical local relationships in Wolverhampton with General Practice, the local public, the local authority and local providers.  Any future CCG would be organised with local decision making critical to its governance structure.  They would continue to have a clinically led decision making body in Wolverhampton which would have governance responsibility.  There would also be a management team, led by himself, which would support the decision making body and provide support to partners and the public. 

The Managing Director of Wolverhampton CCG remarked that the Panel had previously asked for a list of benefits that a formal merger of the four CCGs would provide.  Section 3.1 of the report circulated with the agenda listed the benefits.  A clear benefit was the advantages of working at scale and collaborating, which could benefit Wolverhampton, but keeping certain elements which worked best at a local level within Wolverhampton. 

The Chair of Wolverhampton’s CCG Governing Body stated that whilst there were benefits of working at scale, including cost savings which could be re-invested into patient care, it was important to ensure that they did not become distant from local decision making and local care needs.  There would be a local Wolverhampton based structure including a local Office, local GP and patient representation on the local board would continue irrespective of there being a single organisation at system level. 

A Member of the Panel commented that it was hard to argue against an Integrated Care System and she questioned why this had not been put forward in previous decades.  She also highlighted that reducing duplication and costs and increasing partnership working were all beneficial.  She commented that smaller voluntary sector providers tended to lose some of their influence when organisations became larger.  She sounded a word of caution that they needed to have good communication with them to ensure local need was fully taken into account. 

The Managing Director of the CCG responded that he agreed with the Member on the importance of the voluntary and community sector.  Ensuring they had a voice would be very much the responsibility of the local Committee and team.  The structures that they were currently organising to support a single Management Team across the Black Country, were actually looking to enhance the level of capacity within the Management Team for engagement with the Public and local voluntary organisations.  The Chair of the Wolverhampton CCG Governing Body added that the voluntary sector would play a large role in the Integrated Care Partnership to ensure local needs were accounted for within Wolverhampton. 

The Vice Chair asked how the Health and Wellbeing Board and Health Scrutiny Panel would work within any new system.  He stressed the need for openness and transparency.  He also asked how any new CCG would work directly with City of Wolverhampton Council departments and conversely how City of Wolverhampton Council departments would be able to engage directly with the new CCG on a daily basis in an efficient and productive manner.  The Managing Director of Wolverhampton CCG responded that he would be based in Wolverhampton and it was his role to ensure that the system would work.  They would continue to engage with the Health and Wellbeing Board, the Health Scrutiny Panel and other strategy groups within the City.  He did not envision the Health Scrutiny Panel having to act differently and the Health and Wellbeing Board would remain a good place for partners to continue to work together. 

The Scrutiny Officer asked for the CCG representatives to explain the governance process for the proposed formal merger of the four CCGs.  The Managing Director of the Wolverhampton CCG outlined that the CCGs were membership organisations.  As a merger was a change to the constitution the decision on whether to proceed with a merger proposal was made by the Member Practices.  In Wolverhampton the Member Practices made decisions on a one practice, one vote basis.  The Transition Oversight Group had been set up by the Governing Body to consider the outcome of the consultation and to manage the process of taking forward the merger proposals.  The decision would be made through a vote by the practices in each of the CCGs areas, which would take place in mid-October 2020, the outcome of the vote would then be considered by the Governing Body.  If a merger was supported, because it was a change in the constitution, the proposal for a merger for the four CCGs would then be sent to NHS England for approval.

The Chair of the Wolverhampton CCG Governing Body stated whilst the formal requirements had been outlined by the Managing Director, she was acutely aware of the need to take views from a wider area such as the Health Scrutiny Panel, local authority colleagues, multiple stakeholders, the acute trust, patient representatives and the general public.  Engagement events had been held, where their views would be fed into a document that would be sent to all Member practices.  If the GP Membership voted no to the proposed merger then the process could not continue.  Once they had voted, it would go back to the Governing Body meeting in Common which had representation from each of the four CCGs.  Any merger proposal would require ratification by this Governing Body meeting in common, before the proposal was sent to NHS England and NHS Improvement for a final decision.

A Member of the Panel commented that she had heard the phrase that “it was a done deal” in the community.  She also asked about the various different GP Surgeries under different control, such as those within vertical integration.  She asked if all GP surgeries would have a vote.  The Chair of the Wolverhampton CCG Governing Body confirmed that all GP surgeries would have a vote including those run by the acute trust, those that were independent or sub-contracted.  She also had heard people referring to the proposals as a “done deal.” She commented that the reality was any CCG would have to work within an Integrated Care System as was the national long term requirement.  They could therefore either continue as a collaborative unit working with other CCGs with its own difficulties of decision making or merge, which would make decision making easier with a more stream-lined governance process.  It was not a done deal as any merger could not proceed unless there was a majority yes vote from the Members. The Managing Director added that the sense of a “done deal” had come from the fact that national policy was very much driving in the direction of mergers to give ICS’s a single commissioning voice.  The majority of other areas had already gone down the merger route, Wolverhampton would be an outlier if they didn’t proceed with a merger. 

It was asked how any new commissioning arrangements would help reduce health inequalities within Wolverhampton better than the current system.  The Managing Director responded that a merger would bring into Wolverhampton the benefit of collaborating at scale and the opportunities arising thereof to do things differently.  Working at scale would not take away from the work being undertaken in Wolverhampton to reduce health inequalities, it would hopefully support the current work and work in the future.  As an example, he cited the work taking place within the new STP Academy with PCNs, on improving the uptake of cancer screening to ensure people had an earlier diagnosis.  Cancer screening uptake was related to levels of deprivation. 

The Chair of the Wolverhampton CCG Governing Body commented that it was important to compare Wolverhampton with the national picture and regional picture.  Generally speaking the health outcomes within Wolverhampton were poorer than the national average.  A merger would help all the four CCG areas to pool resources to help improve health outcomes and inequality.  The work with the STP Academy on cancer screening would unlikely have been able to have been completed on a purely local Wolverhampton level.  The other area of focus she referred to was the appointment of a Transformation Director, who’s key role would be to work on health inequalities specifically.  This extra resource had been made possible through the collaboration of the four CCGs.

A Panel Member commented that there was a considerable number of staff in the Black Country and West Birmingham CCGs Senior Management Team, which had been established earlier in the year and referred to at the last Panel meeting.  She asked if all of these posts were actually required and whether the management costs, taking the four CCG areas collectively, had increased or decreased.  The NHS seemed to have considerable management structures and her main concern was to ensure that funds went into delivering patient care for citizens.  The Managing Director of Wolverhampton CCG declared an interest on this point as a member of the Black Country and West Birmingham CCGs Senior Management Team.  They were going from four CCG management teams to one CCG management team, so there were fewer posts than there were collectively across the four CCGs.  Management costs were set nationally and they had to operate within the limitations of that fund.  For the current year they had been set a 25% reduction in their management costs, as had all CCGs nationally.  One of the ways they had been able to achieve this reduction was through the benefits of working at scale.  Some tasks were no longer being duplicated at each CCG as a consequence. 

It was asked if there were any appraisal or options documents available which looked at the proposed merger, particularly form a pros and cons analysis, other than that which was currently in the public domain.  The Chair of the Governing Body commented that she didn’t think there was anything available which was not already in the public domain.  The majority of the work had commenced following what was in the NHS Long-Term Plan.   A slide set had been used in some of the stakeholder events which outlined the pros and cons of the proposed merger.  She was happy for these to be shared with the Panel.  The King’s Fund had completed some reports on the NHS Long-Term Plan and ICS systems.  The Managing Director of Wolverhampton CCG commented that there had been an engagement exercise last year which looked at CCG Collaboration and working practices.  The pros and cons had been set out in the documents through the merger engagement exercise.

A Panel Member stated that in 2013, 152 Primary Care Trusts had been abolished and 211 CCGs had been created.  He said the key issue was a local service was needed for local people and the local community.  The service needed to make a difference to the medical needs of the local community.  If the new structure was going to provide this, then he would be in favour.  It was important to address the key health issues which he felt different commissioning systems had not done enough of in the past.  Policy and strategy formulation and how these were implemented were very important in ensuring a positive impact on people’s health within the City.  He believed the Government were keen to have bigger Commissioning organisations to make cost savings. 

The Managing Director of Wolverhampton CCG responded that the proposed merger would help to ensure that the health system worked effectively at a neighbourhood, local and regional level.  The Chair of the Governing Body of Wolverhampton CCG commented that whilst cost savings were part of the reasons for a merger, the public’s healthcare needs were vitally important.  People’s health needs were becoming more complex as people lived longer, which required effective partnership working at scale to cope with the demands.  The improvements to breast cancer treatment in Wolverhampton was testament to how working at scale could have a positive impact.

Clarification was sought on whether Wolverhampton patients would be sent out of area for certain services which were currently delivered locally.  The Chair of the Governing Body of Wolverhampton CCG reassured Members that patients would still be able to request treatment where available, such as at New Cross Hospital.

Resolved Unanimously: The Health Scrutiny Panel:-

a)    Asks for the report going to the CCG Governing Bodies on the proposed merger to be sent to the Scrutiny Officer to the Panel for circulation to Members of the Health Scrutiny Panel. 

b)    Requests any detailed appraisal and options documents on the proposed merger arrangements to be sent to the Scrutiny Officer to the Panel for circulation to Members of the Health Scrutiny Panel. 

c)     Asks the Wolverhampton CCG Governing Body and the Black Country and West Birmingham's CCGs Leadership Team to note that the Health Scrutiny Panel wants to ensure that "Local needs" are not lost in any potential new commissioning arrangements.  High quality Health Services need to be delivered for the people of Wolverhampton and inequalities addressed. 

d)    Asks the Black Country and West Birmingham's CCGs Leadership Team to note and provide a written guarantee to the Health Scrutiny Panel, that Wolverhampton would not suffer from any decline in available finance, currently allocated to improve the health of the Wolverhampton's citizens, as a direct consequence of any new commissioning arrangements and asks them to detail the safeguards in place to ensure this would be the case not just in the short-term but also long-term future.  

e)    Asks the Black Country and West Birmingham's CCGs Leadership Team for a formal detailed written response on the strategy of how any new commissioning arrangements would help reduce health inequalities in Wolverhampton, better than the current commissioning system. 

f)      Asks the Black Country and West Birmingham's CCGs Leadership Team for a formal detailed written response on the working arrangements for how any new CCG would work directly with City of Wolverhampton Council departments, which have responsibility for health matters and conversely how City of Wolverhampton Council departments would be able to engage directly with the new CCG in an efficient and productive manner.    

g)    Requests from the Black Country and West Birmingham's CCGs Leadership Team a formal written response about their views on the role of Health Scrutiny Panels and Health and Wellbeing Boards in any new proposed commissioning arrangements.

h)    Reserves judgement on whether it supports or is against the proposed merger of the four CCGs, until it receives the further information requested and hears more from the City's General Practitioners.  

i)       Reserves its right to write directly to NHS England with its views regarding a potential merger, after the formal vote of each of the four CCGs on the merger.