Can partnership plan for Lancashire's NHS improve care and bridge funding gap?
“We’re good at coming up with acronyms in the NHS,” says Denis Gizzi, chief officer at the Greater Preston and Chorley and South Ribble clinical commissioning groups (CGGs).
That fact means people like him have to be equally adept at coming up with inventive ways to explain them to the general public.
But it is not the organisations which he leads - which plan and purchase healthcare services across Central Lancashire - that require the greatest explanation. Rather, it is the wider and rapidly-evolving health and socal care ‘system’ of which they are a part.
So as he embarks on a description of the all-too-similar-sounding Integrated Care System (ICS) - which covers the whole of Lancashire and South Cumbria - and Central Lancashire’s Integrated Care Partnership (ICP), Denis reaches for an analogy.
“It’s like a Russian doll,” he says of the arrangements, which involve NHS organisations, local authorities and the voluntary sector co-operating across organisational boundaries.
"At the ICS, we all come together to see what it makes sense to organise at that level. Stroke care is a good example - those who are knowledgeable about this kind of thing understand that you can’t do something like that very well at a Central Lancashire scale.
“So we’ve got senior people doing long-term strategic planning [aiming to] spend money wisely and configures the type of services that are really important at that level.
“At the ICP, there is a model of providing care in [more local] patches and they fit on top of each other to form the ICS. The central ambition is to improve the way people receive care, not just when they’re ill, but to help them lead long-term healthy lives by providing resources at a local level.”
Central Lancashire’s ICP is one of five across the wider county - and, to stretch the analogy of the Russian doll, each one has the potential to be decorated slightly differently depending on the needs and priorities of each area.
At a recent meeting of the Greater Preston CCG governing body, vice chair Paul Richardson sought - and received - an assurance that the process is sufficiently “bottom up” - from the ICP to the ICS.
“It needs to be genuine collaboration and not someone from above saying ‘this is how you will do things’.” he said.
The concept of the ICS and ICP was developed last year as a replacement for a previous collaborative model introduced across England in 2016. Lancashire and South Cumbria was one of the first regions to move to the new set-up, which is a prominent feature of the NHS 10-year plan, published back in January.
But there is currently no legislation which permits either the ICS or ICP to exist as formal entities - and they are sometimes described as operating in “shadow form”.
NHS England has suggested that legislative change could speed up the process of integrating health and social care systems. But for now, the powers of the two groupings are only as strong as the statutory bodies from which they are comprised.
That has been reflected in the way in which CCGs from across Lancashire had to form a joint committee before they could design policies to standardise access to certain treatments - whether that was by rounding up or down.
Last month also saw the whole system swing into action to support Blackpool Victoria Hospital during waiting time difficulties in its breast screening service.
"We want to take the same approach to all of the areas where hospitals may be struggling with their special services - the question is can hospitals join together a bit more with their workforce?" Gary Raphael, executive director of finance at the ICS, asked a recent meeting of the Lancashire health and wellbeing board.
For Denis Gizzi, such co-operation could prove more effective than compulsion.
“More authority could give the ICP the power to make decisions quicker and enforce them, but if...partners vest [their existing] powers, then the arrangement becomes more potent.
“Partnerships work well when each partner is geared to delivering the objectives of the other. If you’re only interested in the furthering of your own ambition, then there’s no point being a partner."
As part of its long-term plan, NHS England has proposed that hospitals trusts and CCGs should be able to reach joint decisions, breaking down the competitive barriers that have been built up over decades between providers and commissioners of services - and which were strengthened as recently as 2012 under the coaltion government's Health and Social Care Act.
“We need to start to put an end to this 20-year fixation we’ve had [about] everybody vying for their part of the cake - it doesn’t make a great deal of sense to those of us in the NHS and if you’re a member of the public, it makes no sense at all.
“And ultimately, the 10-year plan is just that, a plan - so this is the first time we’ve had a chance to design the future rather than have it come down to us as a policy to be implemented,” Denis adds.
WHOSE MONEY IS IT ANYWAY?
All of the NHS organisations across Lancashire and South Cumbria have signed up to a shared financial target to be delivered by next spring.
Yet such is the financial pressure on the sector that the aim is not to come in on budget, but to limit overspending - to no more than £112m across the region.
The so-called “system control total” - set by NHS England - is the sum of the permitted overspends of every NHS organisation in the area during 2019/20.
In Lancashire and South Cumbria, the collective deficit is derived exclusively from the region’s hospital trusts and stands at seven percent of their combined annual budget of £1.6bn. The area’s CCGs, however, are aiming for financial balance.
Savings will be required to limit the overspend - and, ultimately, the full £112m gap will have to be bridged, because permission to overshoot the collective budget has only been granted in the short-term and deficits will eventually have to be eradicated. The Local Democracy Reporting Service understands that the underlying deficit for Lancashire and South Cumbria is higher than £112m, when one-off savings are excluded.
Gary Raphael, executive director of finance for the region’s Integrated Care System (ICS), said the overspend was “not a good thing, but reflects the financial realities of the situation”.
“Quite frankly, we can’t make £112m of savings without changing some services,” he told a meeting of Lancashire’s health and wellbeing board.
“We know that when we benchmark our services against other [regions], we come out as inefficient in many areas. Individual organisations have probably gone as far as they can [to make savings] within their own confines and that’s why we need [a] group approach.
“We’re not talking about mergers, but better ways of working together,” he added.
If the control total is met, the region will receive an extra £76m in funding as a reward. The shared nature of the target also means that there is some flexibility which enables the burden on individual organisations to be shifted if necessary, providing the overall control total is not exceeded.
In Central Lancashire, the Greater Preston and Chorley and South Ribble CCGs have gone a step further, with a £4.5m support package offered to Lancashire Teaching Hospitals - the trust which runs the Royal Preston and Chorley and South Ribble Hospital - to help it meet its own individual control total, dependant on certain circumstances.
Gary Raphael said that ringfencing for primary and community care £4.5bn out of the additional £20.5bn which has been pledged to the NHS across England by 2023, will cause “a big problem” for acute trusts.
He said that affordability will be a “key issue” for the Lancashire-wide plan for the NHS over the next five years which is currently being drawn up.
The health and wellbeing board also heard that former Salford Royal boss Sir David Dalton is currently advising Lancashire and South Cumbria on a way forward for its acute sector.
WHAT IS BEING DONE?
The Integrated Care System (ICS) for Lancashire and South Cumbria is required to publish its own five-year plan for the NHS by November.
The document - demanded by national NHS bosses - must demonstrate that the region has “robust and credible” ideas about addressing the challenges which it faces within the resources available. It is expected to reflect the longer-term England-wide vision for the next ten years set out by NHS England in January.
The ICS has been developing commissioning recommendations in areas such as adult and children’s mental health, cancer care and out-of-hospital services. Other work encompasses use of data, diagnostic testing and prevention programmes.
Meanwhile, at a more local level, Central Lancashire’s Integrated Care Partnership (ICP) has been focusing on six ‘platforms’ of work - including the sustainability of urgent and emergency care services, the nationally-driven programme of developing services within local neighbourhoods and financial reform.
At a recent meeting of the Chorley and South Ribble CCG, lay member Linda Chivers wanted to know “what difference this work is actually making to patients”.
“We need to understand what effect it is having on their healthcare and experiences,” she said.
CCG chief officer Denis Gizzi agreed that the discussions and the planning “have to translate into something”.
“There are early signs that the volatility in urgent care [performance] is evening out, because the time it takes to recover from a bad day is reducing,” he said.
“So for the people coming through the [hospital] door, that means they will be managed better and will get better clinical outcomes.”