Health and Adult Social Care Policy and Scrutiny Committee

13 April 2021

Report of the Director of Public Health

Plans for the future of the health and care system in York

Summary

1. The purpose of this report is to highlight to Members how health and care services in York have increasingly worked in a collaborative and effective manner during the COVID-19 pandemic, and to update on plans currently being prepared to extend and improve on this positive working for the benefit of local communities across York.

2. These plans are being led by a number of health and social care partners in York (including the council, NHS commissioners and providers, and voluntary sector organisations) and include the establishment of a new ‘York Health and Care Alliance’ for the city, details of which are laid out below .

Recommendations

Members of Scrutiny are asked to:

· Note and comment on the collaboration and joint working between health and social care, both prior to and during the COVID-19 pandemic, and the opportunities this work presents in improving health services for citizens in York in the long term

· Note that national policy direction and reforms, which encompass both health and social care, have implications for local authorities in terms of integration and collaboration with NHS partners.

· Note and comment on the decisions by council Executive on the 18^th March 2021, ratified by Full Council on the 22^nd March 2022, to:

o Endorse the plans being proposed in York to respond to the national legislative changes, including current plans to establish the ‘York Health and Care Alliance’.

o Agree the council’s participation in this new Alliance, including the interim governance arrangements in 2021/22 in its ‘shadow’ year.

o Recommend the adoption of this Alliance as a subgroup of the Health and Wellbeing Board, subject to approval at Full Council.

o Support the proposed priorities and areas the Alliance will focus on in its first year aims for the Alliance, and the aims of the Alliance to be people centred, integrate services and deliver timely and appropriate care

o Agree that future reports will be considered by the Health Scrutiny Committee, the Health and Wellbeing Board and the Executive on progress and future arrangements for the York Health and Care Alliance

Background

3. The impact of COVID-19 on healthcare, social care, and our voluntary sector partners across 2020 and 2021 has been huge, with unparalleled challenges faced by staff and organisations to save lives, keep existing services going and support the health and wellbeing of our residents. Despite these challenges, the pandemic has forced services to work more closely together, in order to deliver timely and effective care to the people of York. Positive changes to integrate services, which would previously have taken months to develop, occurred within the space of days. The necessity of the crisis led to swift response from partners: rapid redeployment of staff and resources; joint working on caseloads; system oversight and decision-making on issues such as beds and discharge; and voluntary sector collaboration to support the vulnerable.

4. Examples of this collaboration can be found across sectors, and include:

· Work between primary care and the voluntary sector to support people with COVID-19 and spotting signs of deterioration through the COVID Hub Single Point of Access

· Work between social care and health to implement the Hospital Discharge Requirements, avoiding acute care being overwhelmed by collaborating on the provision of ‘hot’ and ‘cold’ sites across the city

· Work around testing, tracing and outbreak management (for example with universities and colleges, or with care homes)

· Co-working between GP practice nurses and the hospital’s district nursing team to support people to access primary care, therapy and specialist nursing whilst shielding

· The COVID vaccination efforts which have seen many partners contribute to a swift and very successful rollout of vaccine so far

· The work of the Outbreak Management Advisory Board

5. These achievements show what we can do when we services and partners together closely, and in many ways build on an existing effort over the past years to focus on the integration of health and social care – for instance the partnership work around the pooling of commissioning resource for schemes which promote independence and prevention through the Better Care Fund. The potential benefits for residents and the Council of this work are large, with the potential for higher quality services delivered to York residents, and better value for money by what is the largest sector of public investment in the city (health and social care).

6. On the 11^th February the Government published a white paper, ‘Integration and Innovation: working together to improve health and social care for all’. This sets out a series of reforms to health and care which the Government intend to bring forward and implemented at the start of April 2022. This white paper is summarised at section 8 of this report.

7. Building on our track record of collaboration, partners locally have been working together on plans to prepare the system in York to respond to these changes and put us in the best place to benefit from them, including the establishment of a new ‘York Health and Care Alliance’.

8. These plans are set out in this report and the accompanying annex, along with implications for the council. Together with COVID recovery and work on the emerging 10 Year City Plan, there is a clear opportunity to strengthen health, care and public services, to build healthcare locally around local residents, rather than around our organisations. By doing so, we can tackle health inequalities which existed before COVID, but have been magnified by it, and to improve the general health and wellbeing of the York population.

Integration and Innovation White Paper

9. The Government’s white paper ‘Integration and Innovation: working together to improve health and social care for all’ announces a series of reforms to local arrangements for health and care which will take effect from April 2022. In summary:

· 42 Integrated care systems (ICSs) are to be established on a statutory footing in England through both an ‘NHS ICS board’ (this will also include representatives from local authorities) and an ICS health and care partnership. The ICS NHS body will be responsible for the day-to-day running of the ICS, NHS planning and allocation decisions. The partnership will bring together the NHS, local government and wider partners such as those in the voluntary sector to address the health, social care and public health needs of their system. In our area, the current non-statutory ICS (Humber Coast and Vale) will take on a statutory footing.

· ICSs will take on the statutory and allocative duties of Clinical Commissioning Groups (CCGs) in April 2022, and from this point the Vale of York CCG will cease to exist.

· A duty to collaborate will be created to promote collaboration across the healthcare, public health and social care system. This will apply to all partners within systems, including local authorities.

· There will be new powers for the Secretary of State for Health and Social Care over the NHS and other arm’s-length bodies (ALBs). Under the proposals, the Secretary of State will be able to intervene in service reconfiguration changes at any point without need for a referral from a local authority. The Department of Health and Social Care will also be able to reconfigure and transfer the functions of arm’s-length bodies (including closing them down) without primary legislation.

· Underneath the ICS, the principle of subsidiarity will be followed whereby decisions on NHS and care will be taken at the geographically lowest sensible level. There is therefore emphasis in the white paper on the primacy of ‘place’, considered to most often be coterminous with a local authority area. However the legislation will not specify one particular model of ‘place’ governance arrangements. It does allow for a number of mechanisms, including joint committees at place level, delegated budgets and powers, provider collaboratives, and strengthened clinical and professional leadership of health services.

· Locally, it has been agreed that York will be designated a ‘place’ within Humber Coast and Vale area and be invited to send a representative to the ICS board. It may also be able to retain a set of responsibilities for health locally, including some commissioning budgets, if appropriate governance arrangements are in place. Other areas within the region are currently in the process of agreeing their ‘place’ geography. Additionally, for primary care purposes, patients registered to Pocklington Group Practice will be included in this ‘place’ area.

10. These policy changes recognise that organisations within health and care systems have become increasingly independent and autonomous, with separate and often competing goals and objectives, therefore becoming more disconnected from one another. Yet the actions of health and care partners are intimately connected, with impacts being felt throughout a local place. Recognising that we are ‘all in it together’, it is therefore both a fundamental mind-shift and an essential prerequisite of effective system working.

York Health and Care Alliance

11.In York, our response to this has been to propose the establishment of the York Health & Care Alliance, in shadow form during 2021-2 and then formally in 2022 when the legislation takes effect. The Alliance will be made up of the different organisations involved in commissioning or delivering care in York namely:

Vale of York CCG;

York Teaching Hospitals NHS Trust;

Tees Esk and Wear Valleys NHS Trust;

Nimbuscare (Primary Care services provider in York);

City of York Council;

Community & Voluntary Services; and

St Leonard’s Hospice

York Schools and Academies Board

Representatives of Primary Care Networks

These organisations have been collaborating on these emerging plans, and have already shown strong commitment to working together more closely. When making recommendations as a shadow Board, they will consider what is best for care in York as a whole and work to understand the impact of their decisions on service users and other organisations in the Alliance.

12. Local residents and patient voice will be a core component of the work carried out by the alliance, working with existing channels and partners, such as Healthwatch and provider patient involvement networks.

13. At its first meeting of the shadow Alliance Board, the following aims will be proposed to be adopted by the body, which have been previously identified by partners through initial workshops:

· People centred: The development of public services and the right conditions for people and communities to stay well, enabling them to remain independent and lead more healthy lives

· Integrated services: The development of primary, social, voluntary and community care to support people and communities in the place they live and provide a point of on-going continuity, which for most people will be general practice

· Timely and appropriate care: The freeing up of mental and physical health specialists to be responsive to episodic events, to provide complex care and support, and to give specialist advice as part of multi-disciplinary teams

14. In terms of its priorities, at the first meeting it will be proposed that the Alliance work to existing outcomes and aspirations for the health and wellbeing in the city, set out in the Joint Health and Wellbeing Strategy. These include:

· Helping children achieve the best start in life

· Helping adults live well

· Helping older people age well

· A focus on mental health.

15. Partners have also, in initial workshops, set three ‘areas of first focus’ and seven other key priorities for the Alliance in 2021/22. These are the areas of service integration and change that the partners want to concentrate focus on together to achieve better outcomes. The areas of focus for the next twelve months are:

· Diabetes prevention and healthy weight

· Learning disabilities and autism

· Integration of joint complex care packages

The other priorities are:

· COVID recovery

· Community Mental Health

· Dementia care and support across the whole pathway

· Loneliness, isolation and wellbeing

· Self-harm and suicide

· Childhood resilience

· Alcohol harm and substance misuse

16. The partners have chosen these areas because:

· They are key population health needs identified by the JSNA and the rapid Health Needs Assessments for York 2020

· They are all areas in which we can have an impact on health inequalities;

· It is anticipated that improvements can be achieved within the next 12 months; and

· They each involve services delivered by many partners (so provide an opportunity to demonstrate new models of closer working).

17. As part of this, from April 2021, a joint ‘Population Health Hub’ will be set up between partners, which will involve officers from public health, business intelligence and finance/contracting teams across the CCG, council and others in a virtual team to provide population health data and insight into the work of the Alliance. This will ensure it is informed by the needs of our residents and a solid evidence base in commissioning decisions.

Governance

18. Governance arrangements for the Alliance during its 2021/22 shadow year will be proposed to the board at its first meeting, and the key aspects from a Council point of view are summarised below:

· The Alliance Board will lead the Alliance. The Alliance Board will be made up of senior leaders from each of the Alliance Partners. Neither the Alliance nor the Alliance Board will be a legal body itself, and so they are not able to make decisions in their own right. Each Alliance Partner will then continue to take its own decisions and implement them. The Alliance cannot require any Partner to act in a particular way, nor can any Partner or group of Partners “overrule” any other.

· In shadow form, the Alliance will not be making decisions and members will report back to their own organisations, including The Alliance will be reviewed over its shadow 12 months, including its relationship with the Health and Wellbeing Board, with further reports to be presented to the Council.

· It is recommended that Alliance is adopted as a subgroup of the Health and Wellbeing Board for the 2021/22 year, subject to approval at Full Council.

· The Executive of the Council will continue to exercise all its usual governance functions to make decisions on council services, with Alliance recommendations for the council taken back through this route for agreement. NHS partners and the voluntary sector will likewise take decisions back through their own governance arrangements.

· The intention is that through working together more closely – including by senior leadership meeting regularly at the Alliance Board – decisions can be more co-ordinated, with a better understanding of their wider implications for York. In the Alliance discussions, the aim is to reach consensus across all Partners over what action is best for York and move us towards the maximal level of integration of decisions and services which we are able to achieve.

· During the shadow year, the Alliance Board will report on its progress to the Humber Coast and Vale ICS, through a nominated ‘place leader’ from the NHS. It will not be accountable to this body and the senior leaders who attend the Alliance Board are each responsible for reporting to their own organisations.

· It has been requested that the Leader of the Council, following the role as Chair of the Outbreak Management Advisory Board for York, be put forward to chair the Alliance board at its first meeting. Each Partner organisation is asked to nominate one senior officer representative to sit on the Board. In addition to the Council’s officer representative (plus the Leader’s role as chair), the Director of Public Health will also have a place at the board recognising their statutory responsibilities.

19.During the shadow year of the Alliance Board there will need to be work undertaken on the relationship between the Alliance and Health and Wellbeing Board, with a report and recommendations being presented to the Executive and ultimately Full Council for consideration and approval.

20. The proposed ‘Concord’ and ‘Terms of Reference’ for the Alliance Board while in its shadow year are attached in an annex to this paper.

Options

21. National legislative changes mean that the commissioning and planning of local health and care services will change in York as of April 2022. However locally, partners have been anticipating these changes and indeed they present an opportunity to achieve what is recognised as the ‘triple aim’ of high-performing health and care systems, which is 1) integrated care around the individual, 2) improved population health and 3) value for money. The ICS leadership considers York an ‘exemplar’ area for how the new structures at ‘place’ level are being developed.

22. Presented in this paper is York’s response to national changes, which senior partners across all key sectors in the city have agreed are the best way forward for the city.

23. The alternative to the arrangements outlined in this paper would be for York ‘place’ to have no governance structure or partnership arrangement in place sufficient to take responsibility for many of the CCGs commissioning functions, to handle and spend large amount of NHS resource coming into the city, and to meet our aspirations for integrated care. In that case, decisions pertaining to all of these functions would most likely rest at a regional level, and thus be taken outside of York.

Analysis

24. To participate in this Alliance involves a commitment of officer and member time and resource, which should not be underestimated; integration and closer working between the NHS and local government will require detailed work to initiate and maintain. However this key point in time where local health arrangements are being altered presents one of the best opportunities to improve care and support for our community in many years, and on that basis should be supported.

25. It is therefore recommended that the current plans to establish the York Alliance represents the most sensible response to national changes in NHS structure and the new ‘duty to collaborate’ resting on the NHS and Local Authorities, and as an option participation should be pursued by the Council.

Council Plan

26. These recommendation align with the Council Plan 2019-2023, including the aspiration to ‘work closely with our partners in the health and care system… to meet challenges when they arise’

Implications

· Financial

The establishment of the York Health and Care Alliance does not at this stage represent any financial commitment on behalf of the council. However it does signal a willingness to move towards further integration of health and care, which may include the pooling of resource and budgets with partners where appropriate. This is already regularly done within the York health and care system, for example the joint Better Care Fund between the CCG and the council.

· Human Resources (HR)

There are no direct HR implications of this report. Officer time and input to the Alliance, as well as future integrated working between health and care teams, are noted as HR implications of joint working which the council will have to take into account in future workforce decisions. There may be future HR issues which will have to be addressed as the preparations for launch in April 2022 progresses, and these will be reported as and when necessary in a future report.

· Equalities

There are no direct equalities implications of this report at this stage, However all partners will be mindful of the need to consider the Public Sector Equality duty as part of their decision making processes. Population health and tackling health inequalities are key values which the Alliance will share with the York Health and Wellbeing Board.

· Legal

As the establishment of a Shadow Alliance Board falls outside the remit of the Council’s Constitution, it will not have a decision making ability which is binding on City of York Council. Any recommendations arising from the Shadow Board will require approval from the Council via established decision making process. The formal launch of the Alliance in April 2022, and the Council’s involvement in that will require approval of Full Council. This includes the appointment of Elected Members to represent City of York Council on the Alliance Board from April 2022.

Legal advice will be provided as and when required and or necessary as part of this process to formally establish and launch the Alliance in April 2022.

· Crime and Disorder

There are no Crime and Disorder implication of this report

· Information Technology (IT)

There are no IT implication of this report

· Property

There are no Property implication of this report

Risk Management

27. Entering in to the Alliance does not at this stage entail any significant risks to the council, whereas declining to participate could mean that decisions which affect York residents on the future provision of health and care services are taken on a regional, rather than local, level.

Recommendations

Members of Scrutiny are asked to:

· Note that national policy direction and reforms, which encompass both health and social care, have implications for local authorities in terms of integration and collaboration with NHS partners.

· Note the decisions by council Executive on the 18^th March 2021, ratified by Full Council on the 22^nd March 2022, to:

o Endorse the plans being proposed in York to respond to the national legislative changes, including current plans to establish the ‘York Health and Care Alliance’.

o Agree the council’s participation in this new Alliance, including the interim governance arrangements in 2021/22 in its ‘shadow’ year.

o Recommend the adoption of this Alliance as a subgroup of the Health and Wellbeing Board, subject to approval at Full Council.

Contact Details

Author:

Peter Roderick

Consultant in Public Health City of York Council / Vale of York CCG

Tel: 01904 551470

peter.roderick@york.gov.uk

Chief Officers Responsible for the report:

Sharon Stoltz

Director of Public Health

Report Approved

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Date

30/03/21

Specialist Implications Officer(s)

Wards Affected:

All

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For further information please contact the author of the report

Background Papers

HMGov White Paper ‘Integration and Innovation: working together to improve health and social care for all’.

https://www.gov.uk/government/publications/working-together-to-improve-health-and-social-care-for-all

Annexes

Annex 1 - York Health and Care Alliance Concord and Terms of Reference

List of Abbreviations and Terms Used in this Report

PCN: Primary Care Network, a group of primary care providers serving a population of between 30-50,000 people. York has five PCNs.

ICS: Integrated Care System, the system of organisations that are responsible for planning, paying for and providing health and care services within the Humber, Coast and Vale area, serving a population of 1.7 million people.