Commissioning for change: transforming the way we deliver health and care for patients – with a Liverpool case study A joint seminar by the All-Party Parliamentary Health Group and NHS Clinical Commissioners (NHSCC)

Date: Tuesday 8th March 2016, 9.00 - 10.30 am

Venue: The Jubilee Room, Palace of Westminster

Chair: Peter Dowd MP

Speakers:

o Julie Wood, Chief Executive, NHS Clinical Commissioners (NHSCC)

o Dr Phil Moore, Chair, NHSCC Mental Health Commissioners Network

o Katherine Sheerin, NHSCC Board and Chief Officer of Liverpool Clinical Commissioning Group

o Margaret Carney, Chief Executive, Sefton Council

Introduction by the Chair: Peter Dowd MP

My name’s Peter Dowd, I’m the Member of Parliament for Bootle. For those people who should know where Bootle is, I always say it’s a small fishing village north of Liverpool. It adjoins Walton constituency and Riverside constituency, and, of course, it’s part of the Liverpool City Region. Until the Election last year I was leader of Sefton Council and Margaret Carney is the Chief Executive at Sefton Council. I was a member of the City Region Combined Authority, and that’s moving on apace. When we were trying to set up the schedule for this year, I suggested that, as part of our work programme for the All-Party Parliamentary Health Group, we should perhaps look at the whole question of integration - health and social care integration - and use Liverpool City Region, as a case study, so the meeting developed from there. So, can I welcome everyone this morning. Can I welcome some of my Parliamentary colleagues here. We’ve got Margaret Greenwood here from Wirral West, and also a member of the Shadow Work and

Pensions team and other Parliamentary colleagues – thank you very much for coming today. As they say, it’s a packed programme, so there will be that basis both the opportunity for people at the table to address us and then, of course, an opportunity for questions and a little bit of interaction. And on that point, can I just actually ask people to introduce themselves, if they will. I think you’re on first, Julie, and then I’ll go across the table. Julie Wood, Chief Executive, NHS Clinical Commissioners (NHSCC)

Good morning everybody, it’s fantastic to see so many people here. I’m Julie Wood, I’m the Chief Executive of NHS Clinical Commissioners, which is a membership organisation of Clinical Commissioning Groups across England. Margaret Carney, Chief Executive, Sefton Council

I’m Margaret Carney, Chief Executive at Sefton Council, and also the lead Chief Executive for Health and Safe Communities in the Liverpool City Region. Katherine Sheerin, NHSCC Board and Chief Officer of Liverpool CCG

I’m Katherine Sheerin, I’m the Chief Officer and Accountable Officer for Liverpool CCG, and I’m a Board member of NHS Clinical Commissioners. Dr Phil Moore, Chair, NHSCC Mental Health Commissioners Network

Good morning, I’m Dr Phil Moore. I am a GP but also the Chair of the Mental Health Commissioners Network of NHS Clinical Commissioners, and Deputy Chair of Kingston CCG. Chair: Peter Dowd MP Thank you. On that note, shall I pass over to you, Julie. Julie Wood, Chief Executive, NHS Clinical Commissioners (NHSCC)

Good morning again, it’s great to see so many people. I’m not going to speak from a Liverpool perspective, I’m going to speak from a national perspective. My job is really to warm us up in terms of giving us an introduction to how CCGs work, a bit about where they came from, and a bit about how commissioning works, because it’s a term we bandy around, and basically some of us understand it in great detail because it’s what we live with, but other people don’t, so I’ll tell you a bit about how commissioning works in outline. Then I’ll talk a bit about the importance of clinical commissioning in terms of what it’s been achieving and some of the challenges, and then talk a bit about the context that we’re working within with CCGs across England, and the context of the Five Year Forward View and where we might be going. So literally some introductions before I hand over to Phil who I think is going to go next. So, Clinical Commissioning Groups (CCGs) were established in 2013, formally established through the Health and Social Care Act in 2012. What’s unique about them is that they are clinically-led, statutory NHS bodies, so people like Phil Moore and other lead clinicians are occupying key roles on CCGs across the length and breadth of England. The other unique thing about them is that they have their general

practices as members of the CCG, so the CCG is made up of the membership of general practices, supported by expert managers like Katherine and colleagues who act as Chief Officers across the country. There are currently 209 of them, and they vary in size considerably; the smallest actually, near where I come from, is in Corby, which has a population of 73,000, and the largest is down in Devon, with a 897,000 population, so you can see the massive difference in size, but all of them have the same statutory functions. The median size is around 250,000-252,000 in population. The role of the CCGs is. at one level. very simple, but actually how they transact that is actually quite complex, because the job of a CCG is to use the resources allocated to them via NHS England as a result of the Parliamentary vote that Government gives to the NHS to use those resources to plan and commission, to buy healthcare services from the whole range of providers – and we’ll hear more I’m sure about some of the providers that different people are working with – to best meet the needs of their patients and their local population, balancing individual patient need with population need, and working out what is the best way to use the Liverpool Pound, the Kingston Pound, whatever pound that we’re talking about, to actually improve the healthcare outcomes of those patients and those populations, to get the best effect in return for the resources that have been allocated to them.

How they do that will be slightly different in that their governance arrangements will differ. They are set out in their constitution, so I would urge you to go and find the CCG nearest to you – or if you are a Parliamentarian, the ones that you represent – in terms of what their constitution looks like. Some will be slightly different, but actually all of them have to have a governing body that meets in public, with certain essential members like a clinical leader, but also an accountable officer, someone who is accountable personally for what happens in that CCG, working through their governing bodies. Katherine described herself as Chief Officer and accountable officer, so Katherine is that for Liverpool.

When they were established, they were not involved in a few things that they now are increasingly are. They were not involved in the commissioning of primary care or specialised services, that was reserved for NHS England to do directly as a direct commissioner. But that is changing and has changed quite quickly, because of the inadvertent fragmentation that we saw, following the Act, of the commissioning system. So, we now see the majority of CCGs are commissioning primary care through a series of delegated arrangements by NHS England or in joint commissioning arrangements, so we join back up those pathways that are so critical, given that so much happens in primary care and it’s the gatekeeper to the wider NHS. CCGs absolutely need to be able to be influencing what happens in primary care, in general practice particularly.

But also, they’ve now been encouraged to collaborate across bigger footprints for specialised services commissioning; again, the recognition that for some services we really need to join them back up such that we have a complete care pathway. For people who are obese, some parts of the obesity pathway have been in specialised services commissioning, but the main issues are in CCG commissioning and prevention within the local authority, so we actually need to join that care back up so that we do the right thing for local people and local populations.

So, what else were they not responsible for - and they still aren’t responsible for this - is the commissioning of public health services. That was also transferred to the local authority in 2013 for various and good reasons, but actually we do need to connect back up those pathways so that we get the best for the population, whether they’re a member of the public enjoying healthcare services or enjoying services that are commissioned by the local authority - and so the need to work increasingly closely with local authorities through the Health and Wellbeing boards and beyond, to influence what happens in terms of care commissioning as well as prevention and health inequalities, as well as healthcare and joining it up together. CCGs are definitely seen as the key commissioners of the local healthcare system, but working with their colleagues across the sense of place.

How does commissioning work? You’ve seen this before, but it’s the standard commissioning cycle that the NHS uses, again, using the resources that is allocated to it to do the best that it can for its population.

It gets involved in three main headline activities in this inner circle. So, first of all, strategic planning - really understanding and assessing the needs of the population. Joint Strategic Needs Assessment that’s conducted by and published by the local authorities is critical to actually understanding the differing needs of the different population groups within a CCG, and assessing those needs and deciding what we need to do about it, reviewing service provision, but then deciding on the priorities we need to focus on to get the very best return for the money that is invested in improving that population’s health. The second bit is about procuring services, which is the transaction bit, which is about, once you’ve decided what you need to do, going and doing it, in terms of designing services, and working positively between commissioners and providers to do this, and then shaping the structure of the supply to ensure that it can deliver what you want, and then planning the capacity and managing the demand to being able to deliver what it is you need. The third bit is monitoring the evaluation, basically making sure that what you’ve said you want to be delivered to meet the needs of your population “does what it says on the tin” and will do that for you, and reviewing and seeking the public’s views to make sure that it is actually delivering what you’ve set out to do. That’s how commissioning works, What are CCGs achieving? CCGs are still relatively young. I know we feel like we’ve worked with CCGs for a long time, and we have, but actually, in the life cycle of NHS systems and structures and reorganisations they’re still relatively new, young organisations, but actually they have proved themselves to be able to deliver change within their resources, and provide an increasing focus, and very good focus, on the patient and on quality and safety and outcomes. I’m really struck when I sit in a room with CCG leaders, particularly clinical leaders, where the focus on the patient comes through time and time again, and actually that’s really, really welcome and to be applauded. These two documents, you’ve got one of them there - Delivering a Healthier Future - but our previous document Leading Local Partnerships, are just two documents that we’ve recently published that describe what CCGs have been doing. The first one is about integration, so driving integration, so things like Bexley CCG where they are looking at integrated care through multidisciplinary teams (MDTs), using social workers to wrap around the needs of the patient. And in our most recent publication, Delivering a Healthier Future, we focus on prevention and early diagnosis, supporting people to actually get diagnosed earlier or prevent the onset of things like diabetes, or providing services for homeless people which has been described in another example in that document. So, what do we see now? The context within which CCGs are working is increasingly difficult, and there is absolutely a need to refocus on the need to work very differently. We’ve got the Five Year Forward View that was the NHS’s own plan, signed up to by all of the arm’s length bodies, to help the NHS reform and think about how it needs to work very differently to actually respond to the triple aims of: trying to rise to the challenge of meeting the health and wellbeing gap which requires this radical update in prevention; the care and quality gap which requires working differently across commissioners and providers with new models of care; and the funding gap which requires a very hard look at efficiency and investment so that we do ensure we are able to balance the resource position. Because of course we find we’ve got huge pressures on the money, both in terms of this year, seeing the large deficits that we’ve seen in the provider sector, but actually where we’ve also seen increasing pressure to find resources in the commissioning sector, to balance that off. But if you think about the future in terms of the implication of the spending view on the NHS, there are some impacts on the cuts that we see elsewhere on the NHS, the question of whether the NHS has actually been protected. And of course that still leaves the £22 billion of efficiences that we’ve got to find by the end of this Parliament, if we are to be able to deliver the Five Year Forward View. So, finally, that brings with it an urgent need then to transform services as well as get the money right, and to transform where care is delivered. We need to shift the focus of care outside of hospitals into community settings, working with third sector and other providers to actually deliver care in a different way. The vanguards developed in the Forward View are breaking the first ground, but we’ve got to

make sure that they are able to do that, and then we can let everybody else follow so that we do things differently. The role of the commissioner in all of that is central, but increasingly we see the need to work very much more collaboratively, both across CCGs, so it’s not just each individual CCG doing things 209 times, and with providers and with local authorities across the footprints, and that’s becoming very, very clear. So, we now have this new focus on five-year Sustainability and Transformation Plans, STPs; it’s the new language we need to get used to, as the way to deliver the radical change that’s needed to transform care for our population and for our local people. Having said that by way of introduction, I’ll hand over to Phil who I think is going to take us through mental health and how things are happening across Kingston. Thank you.

Dr Phil Moore, Chair, NHSCC Mental Health Commissioners Network

Thank you so much for the invitation to this meeting. It’s exciting times for mental health, challenging times as well, and I’m delighted to be able to talk a little bit about parity of esteem. Really, what is it going to take get parity of esteem? It’s a phrase that’s been bandied around a lot, and I just want us to take a little look at this and see how we take it forward. What’s the current situation with mental health? The Mental Health Taskforce recently published its report, The Five Year Forward View For Mental Health and it produced some of these phrases: one in ten children between the ages of 5 and 16 has a mental health problem, one in five mothers has depression or anxiety or some other mental health condition during pregnancy or after childbirth, one in four adults experiences at least one diagnosable mental health problem in any given year, one in five older people living in the community, and 40% of older people living in homes, are suffering from depression, and yet up to three-quarters of people with a mental health problem don’t get the right treatment or the recommended treatment. In addition to that, people are dying because of mental illness, and suicide rates have been going up, they peaked in 2014, and in crisis only 14% of people felt that they had been provided with the right response.

That’s the current picture of mental health, even though people are now talking about it, which I’m delighted about, and people are owning up to the mental health problems that they are experiencing. If we go to perhaps London, we can see that the numbers in London are higher than the rest of the country. If you look at the next slide, you will see that the cost in London is £26 billion, and there are enough Londoners of school age with a mental health problem to fill 3,700 classrooms; of those, about 2,700 don’t get the right treatment; and finally, you’ll see the cost of perinatal illnesses to people who are pregnant. Huge things, and London is just a microcosm of what’s going on around the rest of the country.

So, what is parity of esteem? Let me ask you a few questions. A young lady came into my surgery, acutely unwell, mentally. We asked for an assessment, she stayed in the waiting room for four hours with her dignity being threatened because of her behaviour, disturbing everybody else. At the end of four hours we were told, “Sorry, we don’t have the capacity to see her,” so the police came and took her to a Section 136 suite. Is that parity of esteem, when somebody with a heart attack would have been scooped up in eight minutes? Somebody with an acute mental health condition is admitted to a ward that was built in Victorian times and which is really not suitable for mental health care. Is that parity of esteem? Life expectancy for those with a serious mental illness is 15 to 20 years less than the rest of the population. Is that parity of esteem? In physical health we have all kinds of alternatives in the community: we’ve got not only general practice and the surgeries they provide, we’ve got walk-in centres, we’ve got minor injuries units, we’ve got all kinds of things being set up. Where are they for mental health? They’re coming, but do we have

parity of esteem at the moment? I think the answer is no, because… NHS England came up with this phrase, that ‘my family and I will have access to services which enable us to maintain both our mental and physical wellbeing.’ If I become unwell, I use services which assess and treat mental health disorders or conditions on a par with mental health illnesses. Have we got there? No. Can we get there? I believe we can, but there are some quite big challenges. If we look at the importance of clinical commissioners, the issue is most of the clinical commissioners are front-line GPs or nurses or consultants, and they have contact with the people we’re talking about, and that’s why clinical commissioning has such a strength ,because we’re in day-to-day contact with the people who need those services and we work at the heart of our communities, right with the people that we have got to make sure are getting their treatment. And do you know what? They meet you and they say, “Why haven’t you? Why don’t you? Are you going to? When is it going to happen?” and therefore we are very directly accountable. And we see daily the impact on our patients and our local populations of years of underfunding in mental health services, and we understand the importance of investing in mental health services in the future. Are we really coming up to the measure in terms of investing? Well, 90% of CCGs increased their investment in real terms in mental health by at least the level of their baseline uplift and many went beyond that, that’s NHS England figures. Local CCGs increased mental health spending by 5.4% across the country, when their overall funding rose by 3.7%. I think that’s a decisive move towards parity of esteem, it doesn’t achieve it, but it’s a move in the right direction. However, CCGs are part of a health system that’s really facing enormous financial pressures, and we have got to argue the case against all the other pressures that are there, and I want local commissioners who are interested in mental health to have all the levers they can get to make sure we can get that money into mental health services. That’s why we’ve written a letter that’s been sent, saying, “We think that the CAHMS money, the children and young people’s money that has come out, should be ringfenced.” Normally I don’t like ringfencing, but in this case it should be so that we’re assured that that money gets into children and young people services, because we are desperately in need of it. And I would maintain that the future is not sustainable, unless we invest in our young people, and prevention and early intervention; very, very important. And we’ve got to shift the funding, as Julie was saying, from the acute sector and acute illnesses into prevention, into early intervention and into the services that keep people out of those acute inpatient and other services. I’m sorry, I’m talking very quickly. Can everybody hear me alright? Good, well done. I’ve got a loud voice – they always tell me I’m a loudmouth. [laughter] Right, let’s move on. How effectively are we using that new investment? It’s new investment, but are we using it well? See, the truth is, what we need is new models, not more of the same; if we simply invest in more of the same, we’ll get more of the same, and more of the same simply isn’t ‘cutting the mustard’. So what we need to be doing is we need to be transferring a lot more services into the community, close to people, so that they’re maintained in their homes, in their communities, in their socialisation groups. That is the place where we need the services to keep them there, and we are developing new partnerships with all kinds of providers, from the voluntary sector to the trusts to primary care, in the community, so that we can achieve that. And it has to be done by partnership; it can’t be done by one person doing it over the head of another. And in that, the good news is that in 14/15 commissioners invested £1.9 billion outside of the traditional mental health trusts. Sometimes you hear the mental health trusts saying, “We’re not seeing the money come to us, so mental health is not being invested in.” Yes it is, It’s just not being invested in the trust, because we’ve got the voluntary sector, we’ve got community groups, we’ve got primary care beginning to do very, very much more around mental health, and it’s worth remembering that as we go through some of the things that are going on.

So, what kind of things are we doing? I’m going to start here, because my view is that primary care has to be at the heart of mental health. We are training up people in primary care so that we are much more effective at delivering care and knowing when to pass them on to others. Around that we’ve got a Primary Care Mental Health Support Service, you’ve got substance misuse services, dementia services, and what we call iCope which is your psychological services, all within the community, because that’s where we want to keep people, and the primary care services there to assess people and say, “Do they really need secondary care, or can we manage them within our community?” If we go outside of that, you’ll see there’s a lot of other things. There’s the psychiatric liaison service in A&E, there are alternative places of safety being developed so that not everybody goes to a Section 136 suite, so we’re developing crisis houses. A lot of disputable evidence around those, but if we don’t try these things we’re never going to succeed. And the police often say, “We don’t think this person is going to need to be admitted, but we don’t have an alternative to a Section 136 suite.” So let’s have some alternatives, where for 72 hours they can be brought down, because crises are often short-lived in mental health; not all are long-lived, and sometimes people just need a bit of care and attention to get through that. We’re developing crisis cafes in the community, very good evidence that they’re effective in avoiding admissions. And then there’s the traditional services around enhanced crisis service, challenging behaviour services, the community mental health teams, the home treatment teams and all the other things that we need to keep people at home, or at least in their communities. Outside of that, we’ve got all of the other stuff that goes on for those who are acutely unwell, with inpatient services, Section 136 suites, specialised services and very, very much more beyond that. However, what we want to achieve is the recognition that there are other things that we aren’t directly responsible for: things like housing, that’s a real prevention for people getting out of hospital. Employment: people want to be in some kind of employment; whether it’s voluntary or paid, they want to have a sense of worthwhileness, they want to feel that they’ve got some worth in their communities. Socialisation, recovery, we could say very much more about all those things. They need to be in place, otherwise we’re not going to be able to do what we want to do, which is to move people out of acute beds; this is very much Lord Crisp’s paper in a nutshell. We need to keep people out of inpatient beds, unless they really, really do need them and it’s going to be for their benefit. So, we’re working towards that, so that that achieves the kind of parity of esteem that we should be going for. And I think it only remains for me to say thank you very much for listening. I’ll take some questions later on, but hopefully that’s given you a little bit of flavour around parity of esteem. Chair: Peter Dowd MP Thank you. So, we’ve had the commissioning structure, we’ve had the mental health perspective and the issue of parity of esteem. Now for Katherine Sheerin, Chief Officer of NHS Liverpool CCG and a Member of the NHSCC Board. Katherine Sheerin, NHSCC Board and Chief Officer of Liverpool CCG

I’m Chief Officer and Accountable Officer for Liverpool CCG, and I’ve been asked to try and give an overview of how it feels to work in a CCG and the things we’re delivering, so I’ll be talking about Healthy Liverpool which is our transformation programme. So, first of all, just a bit about Liverpool. I think most people have ideas and perceptions about Liverpool, whether you’ve been there or not. It’s a real city of contrasts: on the one hand we have fantastic leisure, sport, music, architecture, parks. On the other hand we’re known for deprivation, we’re known for unemployment, we’re known for poor educational attainment, and those contrasts play out really well in the health world as well.

We have one CCG and one local authority, a really close, one-on-one relationship. As a CCG, financially, we’ve been quite sound over the last few years, although that is changing with what’s coming ahead of us; the local authorities had some of the biggest cuts of any local authority in the country. Contrast that one-on-one relationship with a very complex provider landscape. We have six hospital trusts in the city, we have another one moving in, Clatterbridge is moving over. We have a mental health trust, a community trust, 93 general practices, and over 100 dentists and pharmacists, so a lot to make that relationship work. We have world-class health services; we’ve got Alder Hey, Liverpool Women’s Hospital, Liverpool Heart and Chest Hospital the Walton Neuro Centre, they’re known nationally and internationally. On the other hand, really poor health outcomes, some of the poorest in the country. We’ve got fantastic estate, a brand new Alder Hey hospital, a brand new Royal Hospital on the way and Clatterbridge moving over. We’ve got a fantastic primary care estate, but we’ve got massive health inequalities within the city, so a difference of over 10 years in life expectancy between different wards. People can expect to die of cancer, five times more likely in Kirkdale than where I live for example. So, real contrasts within the city. In terms of what we spend though, there are 500,000 people that we’re responsible for. We spend over £1.2 billion on health services, and by “health” I mean across the CCG, NHS England and the local authority, so that £1.2 billion we need to make that work in the best way we can. As a CCG we’re responsible for £840 million of it, but we need to get the whole lot working as well as it can do to improve our outcomes. Just to give a bit of context: we have an elected mayor in Liverpool, as I think most people will know, a few years ago he set up a Health Commission and made 10 recommendations about how we needed to take health and health services forward in the city. We have our Health and Wwellbeing Board, of course, with our Joint Strategic Needs Assessment; those two things give us our direction of travel as a CCG, and our response to that is Healthy Liverpool, which I’m going to talk to you about now. So, Healthy Liverpool. Three years ago, when the CCG was launched, what we felt was that given the challenges and the opportunities of the city, we didn’t want to be a CCG that just stood still; we wanted to really think about the next five-ten years and what could we really achieve in terms of improving things for the people that we serve, so we set out the Healthy Liverpool programme. I think this would now be very familiar to lots of people, and what we hear in the Five Year Forward View and more recent planning guidance really echoes what we were thinking of three years ago. So, our vision for Healthy Liverpool is that we have a healthcare system that’s person-centred, supports people to stay well and provides the very best in care; there’s a real focus on prevention, outcomes, quality of care. Our high-level outcomes though are that we want to improve the outcomes for the people of Liverpool compared to the rest of England, to reduce inequalities within the city, that the quality of healthcare should be first-class, and that we have a new model of care which is clinically and financially sustainable. It’s going back to what Julie said, a real emphasis on clinical services, quality and outcomes. We set ourselves some measurable outcome ambitions, because we wanted to understand where we were making progress essentially. We have five strategic outcome ambitions, all of which we can measure. The first one is to reduce life years lost by 24.2%. If we did nothing, and if life expectancy continued as it has been doing, although that’s arguable now I think, we would’ve improved this by 19%. We’d improved anyway because the country was improving anyway, but for us to catch up with the rest of England we set ourselves a target of 24.2%. That’s very specific, which was raised with me recently, and the reason it’s so specific is we looked at what we were doing, going back three years, at the time that was different to other CCGs and what they were doing that was better than us that would improve mortality for the city.

So, things like, as an example, pulmonary rehab. If you go into hospital with an exacerbation for COPD, so for respiratory disease, ideally you should do a course of pulmonary rehab after that, so that’s a six week programme out in the community. We have really low uptake rates for the pulmonary rehab. If we reached 60% of people who were eligible, doing the course and completing it, we would save over 100 lives over the period of the programme and reduce emergency admissions to hospital by I think it was 450, so really quite big numbers and that’s per year, 450 emergency admissions. So, we looked at all the things that we weren’t doing and said, “Okay, how can we start to commission for those things to happen?” And with that example, pulmonary rehab, it was only about getting 60% of people to complete the course, so if we talked to people that needed it and designed the course around what worked for them, we’d have a much better chance of cracking that one. These are our five outcome ambitions, all built up in that way: reducing life years lost by 24.2%, improving the quality of life for people with long-term conditions to 71% – and, again, that’s measured through the GP survey each year; reducing avoidable emergency admissions by 15% – again, built up with evidence of what we knew we weren’t doing; improving hospital patient experience to the average of the top 10 CCGs – we were already doing well on that, so we wanted to do even better; and out-of-hospital patient experience, improving that to be in the top five CCGs. So, in terms of how we cut the cake then, and I think it’s really difficult actually, cutting the health cake and kind of breaking it down into manageable chunks. This is how we did it: we have five system-wide transformation programmes and we have six continuous improvement programmes. All of these are led by a clinical member of our governing body, and some of them are joint programmes with our local authority, because we absolutely can’t do this on our own, and some are joint programmes with other CCGs and NHS England. So, the system-wide transformation programmes: Living Well, and that’s all about physical activity. We’ve agreed that that’s what we’re going to really go for, because at the moment 86% percent of our population don’t do enough physical activity to be healthy. If all adults did 30 minutes five times a week, we’d save over 400 lives a year. I think if that was a drug, we’d have a much bigger petition from the public than we did for childhood vaccinations last week, about over 800,000 people; people certainly want that, so we’ve really got to go for that. Joint programme with the local authority, we’ve put £3 million into doing that. Digital health is about patient records, it’s about promoting more use of digital technology. Community transformation is about how we transform primary community and social care services, I’ll come back and talk a bit more about that in a minute. Urgent care, how do we have the right pathways for people to go to the right place at the right time when they need care urgently. And then hospital transformation is a joint programme across the three neighbouring CCGs, NHS England, and three local authorities as well. We’ve got now, as I said, a really complex hospital environment in Liverpool, with more specialist trusts than anywhere outside of London, and as a CCG I think we’ve got the most hospital trusts that we coordinate the commissioning of. They’ve all agreed now, with us, a vision for hospital services, where we talk about a centralised university teaching hospital campus, we talk about single-service, city-wide delivery, and those hospital trusts coming together to deliver services. We then have the six continuous improvement programmes: mental health, healthy aging, learning disabilities, children - all joint programmes with the local authority - long-term conditions and cancer; but as I said, all clinically-led, these programmes. So, just to sort of give you an example of how this works. This is our community transformation programme: we have a model, four quadrants. one’s about integrated primary community social care teams in every neighbourhood in the city, we’ve now got 12 neighbourhoods serving a population of about 40,000 people. We talk about specialist clinical integrations, that’s about more integrated work with hospital providers, so that pulmonary rehab example, for example, we have the specialists and the trusts working out in the community to enable that to happen. Managing complex needs, what do we need for more vulnerable groups in the city, and obviously that won’t be provided everywhere but

where do we need to focus that? And then neighbourhood collaboratives are about how do our clinicians in the primary community social care teams connect better with the community and voluntary sector across the city, so we have examples like we commission advice on prescriptions which they can access really easily. But then our community model is made up of all of these projects, and each of these projects is supposed to set out how it contributes to those five, high-level strategic ambitions. How will that project contribute to improving mortality, how will the project contribute to improving the quality of life for people with long-term conditions? I won’t get into that obviously. So, the next steps then. We have an investment programme for all those five settings; Living Well, digital health, community, urgent, and hospital services. I think we’ve got challenges ahead of us in terms of where we thought we were going to be with investments compared to where we are now, so it’s going to be much more about looking at what we’re doing that we don’t need to do, and saving that money to invest in some of these programmes. We’ve got the estates realisation happening, so the new Royal coming up with fewer beds, so that’s driving us to make these changes. The trusts are coming together, talking about different organisational models. There was an announcement on Friday that the Liverpool Women’s Hospital doesn’t work clinically anymore, financially it’s not going to live the life of the next five years, so that needs to change. In primary care we have a different contract for all our GPs and primary care, all of those 93 practices which we introduce at the end of a PCT, but it was the CCG people doing it, that will help us to look at what the organisational models needed in primary care so we can kind of move ahead with all of this. And just in terms of our key lessons: high-level backing, really working with the local authority, with the Mayor has been absolutely essential in this, to make sure that we’re joined together in our direction of travel. Stick to the story: we set this out three years ago, we set out our ambitions and our aims, we’re sticking to those and just need to. We may need to change tack with how we get there, given the change in financial environment, but we still need to go for it. Back the leader’s time and support, so our clinicians have time to do this work, we have permissions from the trusts, as I say we’ve got people’s seconded from the local authority to work with us on all of this. Loads of front-line engagement with patients in the public, and that’s both in each individual project, but overall with the concept and the direction of travel. And then finally, keep it simple; well, as simple as possible.

Chair: Peter Dowd MP Thank you. Can I ask Margaret Carney to share her presentation now, please.

Margaret Carney, Chief Executive, Sefton Council

Good morning everyone. I’m Margaret Carney, the Chief Executive of Sefton Council, and this is unashamedly a local authority perspective on this matter. I’ll skip over some of the clinical stuff; in fact, you probably won’t even see it in any of my slides. Most of you will not be surprised, the graph on your right is people’s view of their own health, and the one on the left is the deprivation, and you won’t be surprised to see the correlation between the level of deprivation and how people feel about their own health and wellbeing: a direct correlation, and there always has been. The problem that we have is that those inequalities are growing. I just wanted to give you some context from the Sefton perspective. This is the change of our older people population forecast between 2012 and 2037, drawing your attention to the very last figure: our 90+ will go up by 210% over that period, as opposed to our 50-59 which is going down by 18.5%, so you can see, not just an ageing population, but a very elderly population growth, all of which will require a different way to support care for those people. So, integration of health and social care. It’s

certainly been the policy direction of successive governments. I think it’s fair to say progress has been patchy. Some places have done remarkably well, others have perhaps not even started the journey significantly, and I think some of those issues are around differences in culture, differences in funding, accountability and regulatory regimes. We don’t make natural bedfellows, and yet the system absolutely needs to be symbiotic. So, how do we get those differences? In my view this is not about how we reorganise. This is about how we work together, how we collaborate, how we align, how we just join things up for the benefit of the people that we serve. And there actually is very little evidence that integration saves money, so if the reason for doing it is to save shedloads of cash, then let’s forget it. There is evidence that it produces better outcomes and certainly better experience for those people who access those services, but we’ve got to be really clear on the why we’re doing it, and I think part of the issue for me is there seems to be this constant drive towards it creating an efficiency and saving money, and actually national and international evidence does not back that up, as yet; there may very well be future research that indicates a different position. And we tend to focus on acute. We hear a lot about hospitals, we hear a lot about the challenges in hospitals, and that’s absolutely right. There is significant pressure in hospitals, and I’m really pleased that everyone speaking here today has talked about prevention, because actually I think we do look at it through the wrong end of the lens. We look at acute, and we assume that if we sort out the hospitals the rest will take care of itself. I kind of look at it the other way round, and we have actually got to have different services in communities, and the self-reliance and the self-confidence of our communities to actually care for themselves a lot more than we currently do. So, just some questions that I ask myself constantly about what is integration. Is it about commissioning? Is it about provision? Is it about organisational change and decision-making? Why are we doing it? To save money, deliver sustainability? I argue that it probably isn’t going to do that, so it has to be around people’s experience and outcomes, and I much prefer aligned and co-ordinated care to integration, and I suspect that some of our partners think it’s cost shunting. So, NHS real term increase in funding, I hear the challenges around that. And this is the Government’s figure, so in terms of front-loaded transformation and all the extra money going into the NHS, I make no comment on that, but I do know that local government funding will be cut by 24% over the same period. We’ve been given the ability to increase council tax by 2%. From my authority that’s £2 million, and I will just compare that with the estimated cost to my council of the national living wage for social care only of £6 million, and my own council’s £64 million cuts between 2017 and 2020. Now, any integration of health and social care, any focus on prevention and early intervention has to take account of that context, and how we reconcile those two in what is, as I’ve said, in my view, a symbiotic relationship. There is no local government transformation funding; the LGA made a bid through the Spending Review for some transformation funding, and that was not successful. There are some Better Care Fund resources coming in 2019, which is very welcome, but it’s the back end. So, we’ve got front-ended NHS transformational funding, and we’ve got back-ended social care funding; again, it’s quite a difficult position to reconcile. And Simon Stevens said this, so it must be true, [laughter] about a radical upgrade in prevention and public health, a direct quote from the NHS Five Year Forward View. So evidence tells us that contributions to health and wellbeing, about 30% is about effective, accessible clinical supervision and 70% is reliant upon those wider determinants. Have you got a job, have you got the right community networks, have you got aspiration, best start in life, homes and communities? My council spends 60 pence in every pound on acute adult and child social care, it spends 30p, and that’s stretching it, on the wider determinants, and 10p on those core services that every council taxpayer still expects to receive – getting your bins emptied, getting your streets swept, getting your grass cut – all of those things that we’re doing an awful lot less of, but actually every council taxpayer deserves to have good quality services.

So, you can see the investment is actually in direct disproportion to where actually it should be, and we need to be able to reconcile that. So, just in that context, 62 pence in every pound on acute; that’s risen from about 45 to 50 pence in 2010. You can see that the Council has attempted to protect those front-line acute social care services, of course to the detriment of those wider determinant services, and we will see that percentage rise, no doubt, over the next three to five years as further cuts hit, and the impact of things like the national living wage, national insurance and the demographics, so not even coping with more people who need our care and support, but actually just dealing with the cost increases associated with, what is predominantly, in adult social care particularly, a minimum wage workforce. Now, don’t forget these people are doing some of the most personal care that any of us would want to receive, and we have got to address the workforce in adult social care and value it for what it does for us and for our loved ones. We talk about investment in prevention, and, again, my own council has already had a 10% cut in the public health grant that was only devolved to local authorities a couple of years ago, and if a new formula is introduced, which is being trailed, then there will be, at least, another 10 to 15 percent cut in a formula that seems to have a disproportionately negative impact on those areas of higher deprivation. I said before that I think we’re looking at it through the wrong end of the lens, and in terms of community empowerment we know that greater community control and individual control leads to better health, better wellbeing, better mental and physical wellbeing. We know that low levels of control have the opposite effect, and therefore governance and structural change are going to bring around very marginal financial benefit. We do have to manage and reduce demand, there is no doubt about it. We cannot afford to cope with the demand in the way that we’re currently coping with it, and therefore how we deal with things like prevention, early health and self-care, particularly, and long-term gains, I think is what we’ve got to focus on; it’s not about the next two years, it’s about the next decade. And empowering communities will, in my view, bring that sustainable change and we should be talking about integration at at a community level, and working with those organisations that support people at the community level. This is what the system sometimes feels like, and those of you of an age will know of Rubix’s Cube. I never managed to do it; maybe one of these days?. And therefore in conclusion from me, is it integration or is it collaboration? Who knows. What will devolution bring? We’ve got obviously a major devolution agenda, particularly in Manchester, but in other places looking at how that wider footprint and how local decision-making can have a positive impact on health and social care; I think that’s a long journey still to tread. It is about whole system change, and it starts with the individual and goes to the Government, it is a whole system change around attitudes and culture and financial accountability, and about how we all want to live our lives in the future. I’ve said we’ve looked at the wrong end of the lens, and in my view it is about community first, that’s where we should be starting, that’s where we should place our energy and our emphasis. And those investment profiles, we’ve got to find a way of shifting them round. I don’t know what the way is yet, but between us we have to find a way so that actually 30% is spent on the acute and 70% is spent on those wider determinants of health, and I think that should be a challenge for the whole system. Thank you, Peter. Chair: Peter Dowd MP Thank you. Right, we’ve got until 10:30am for questions. So, we’ve moved from Julie’s presentation on the role of CCGs, the importance of commissioning and the challenges facing commissioning, through to Phil talking about the struggle for mental health parity in the world of CCGs and that and other things, with Katherine talking about Healthy Liverpool and the five outcomes and the transformation, and we’ve got Margaret’s “wrong end of the lens” concept and the whole question about community empowerment and the management of demand.

So, I wouldn’t intend to ask everyone on the panel to respond to each of the questions, that’s going to take too much time, so I’ll have to make a judgement. So, if we take them in threes maybe… that’s the usual number, isn’t it? This lady here first, then Lord Hunt and then Margaret. The Q & A Session The Questions (Q) and Comments (C) in bold below were raised by the attendees. The answers (A) are provided by the speakers. Q: Baroness Walmsley: Thank you very much. I’m Joan Walmsley, the Liberal Democrat Health Spokesperson in the House of Lords. I’ve only heard the word “children” mentioned twice, I haven’t heard “maternity” and “infant care” at all. I have heard a lot about prevention and sustainability, which is absolutely right, but I wonder if any of you would like to comment about the role of children’s health and laying down the building blocks for a healthy life right from the get-go. Chair: Peter Dowd MP: Next question, Lord Hunt. Q: Lord Hunt of Kings Heath: Hi, thanks for the great presentations! Can I just… not challenge but just question this issue about spending too much on acute care, because it’s kind of a mantra that is said by many of the leading think tanks, etc.? If you look at the figures, look at the latest OECD comparisons, in the UK we spend less on hospital beds, we have less doctors, we have less nurses, less access to good-quality, new equipment, less access to new drugs. The question is, is it really right that we should continue to disinvest in our acute care sector? Clearly the whole system is short of resources. You said, Margaret, and I agree with you, that there is no money in integration, there’s no evidence at all that we have seen yet that shows integration reduces cost. I suppose my question is is this really doable, when we spend so little of our GDP on health? We’ve had some great presentations about the future and where we’re going, but I’m sort of wondering, pondering whether this really does all add up. Q: Margaret Greenwood MP: Margaret Greenwood, MP for Wirral West. My question is I’d like to understand a bit more about what the drivers are for this assertion that there’s a need to collaborate across CCGs and why there is this need for bigger footprint? Chair: Good. Shall we take those three? Julie, will you deal with the children question? A. Julie Wood: Yes, so, when I talk about patients and local populations, by “patients” I mean from the

get-go right through to end-of-life care. The job of a CCG is a whole population one, so it has to marry up

the needs of the very young and the very old, with some of the challenges that I think Margaret so

eloquently put to us. It’s a difficult job to balance all of the differing needs, without wanting to invest

upfront in prevention, to ensure that children have a much better, earlier start and are more school-

ready, because we know the evidence suggests that therefore their life experience, their health

outcomes, everything improves, at the same time as having to invest in the acute end, if we take Philip’s

comments, it’s a constant, if you like, dilemma.

The important thing I think is where Katherine’s been coming from in terms of being clear what we need to invest in and why and what we’re going to realise as a result of that investment, and taking your

population with you about why you are investing disproportionately more or less in this as opposed to that. Because you can only spend the pound once, you can’t spend it more than once, and how much pounds we have within the health system is a political decision, so CCGs have to spend their resources in the best possible way. Could they spend more? Absolutely. Could local authorities spend more, do they need more? Yes, absolutely. It’s how we get that balance right. Chair: Well, spending on acute care, I’ll ask Margaret to answer that one. A. Margaret Carney: My definition of “acute”. in my context. is about adult and children social care, so my sort of 60% that we spend is on that level, and I think we spend too much. I do think we spend too much, and we don’t spend enough in terms of those early intervention, prevention, keeping people in their homes longer, keeping people close in their communities. I deliberately use proportions, because actually there isn’t enough money in the system. Adult social care in this country, and actually children’s social care is going the same way, is unsustainable in my view. With those numbers that we’ve talked about, my council will have no resource for anything else in five year’s time other than the money it spends on adult and children social care, and that can’t be a sustainable situation. So, I do think that there is not enough money in the system, but I also think that the idea that we assume that a frail, elderly person wants to go into a nursing or a residential home as opposed to staying in their home, the evidence does not support that. And yet if we do a financial calculation, actually it is probably cheaper, and I’m going to use that word “cheaper”, for us to put frail, elderly people into a residential home at this time than it is to support them in their own home. So, I think there’s a real dilemma between choice, quality and cost that we’re going to face over the next three to four years, if we’re not already facing that. And we have a mantra around choice, and I have to tell you that in the social care system that is becoming less and less a choice for individuals, unless they choose to have a personal budget with all of the [complications] that go with it. In terms of acute hospital care, I couldn’t possibly comment. Well, I could, but I might get sacked. Chair: Drive to collaborate. Katherine, do you want to tackle this? A. Katherine Sheerin: I guess just going back to one of Julie’s starting points, CCGs all have the same statutory responsibilities, but we are very different in size. What was the smallest…? A. Julie Wood: 73,000 in population. A. Katherine Sheerin: So from 73,000 up to a million; we’ve got about half a million that we’re responsible for in Liverpool. So, what you can achieve as a commissioner responsible for 73,000 patients compared to what you could achieve as a commissioner responsible for a million patients is different. Now, I suppose to give a real life example, Aintree Hospital is on the cusp… it’s actually geographically in Liverpool, but it’s on the cusp of Liverpool Local Authority, Sefton Local Authority and Knowsley local authority, so similarly on the cusp of three CCGs; Liverpool, South Sefton and Knowsley. So, for Aintree Hospital to really work, they need to know that we’re doing things in the community to make sure that we agree at what point patients should need hospital care. At what point in the stage of their illness do they need it, and are we doing things to make sure they don’t get to that point as far as possible, and also that when they’re in hospital, we’ve got services available out in the community so that people can come out in the same way? In hospitals people can’t think, “Is this patient from

Liverpool, Sefton or Knowsley?” we have to make it work for them in a way that makes sense, so we have to collaborate across Liverpool, Sefton and Knowsley in order to do that. I’m not sure we’ve always done that as well as we could do, but as the money gets tighter we’ve got to do it more and more. The thing though I do think about footprints and collaboration is there is an optimal size, and that probably relates to the number of organisations and statutory bodies that you need to work with, and making sure you’ve got things in common to work on so I think having huge footprints to work across and saying, “Right, we’ll all work together and achieve things,” I think that would be at the detriment of actually being able to achieve things on that sort of population size of probably about a million or so. Chair: Yes, at the very back there…[three more questions] Q. Baroness Finlay: Thank you, Laura Finlay, Crossbench peer. Two separate questions. One is, when you talked about mental health, I was concerned that there was no mention of projects to improve the implementation of the Mental Capacity Act, because empowering people and understanding what they need may well avoid some unnecessary interventions that they wouldn’t want anyway. But the other one is, to ask both Kingston and Liverpool what impact your policies have had on attendance in emergency departments, or whether you see the same trends that seems to be happening elsewhere, which is that patients go to where the lights are on, and that actually you can have all kinds of things going on out in the community, but in crisis and in medical emergencies they go to A&E. A&E Departments generally are buckling under the strain, and that it may well be, picking up on Philip Hunt’s question, that we need more medical assessment beds and more surgical assessment beds that patients can be put in and monitored because when they’re unstable they need to be somewhere where they can be monitored closely until they are stable, until it’s clear what the diagnosis is, and you can’t determine that stability on a one-off assessment on a trolley. Q. Claire Tyler: Thanks. I’m Claire Tyler, I’m the Lib Dem spokesperson on mental health in the Lords and my question is on mental health. You talked I think about a letter that’s been sent from CCGs, talking about the need to actually ringfence money going into children and young people’s mental health, something I think I personally support, given all the problems that there have been, both of underfunding and money not getting where it’s intended. Could you tell me whether, in your view, that just applies to money going to CAMHS, or will it apply to money which is intended for wider children mental health services, including things like the voluntary sector which you mentioned, because in my view it’s the totality of services, both provided through CAMHS but also schools and the wider voluntary sector which is important here?. Q. Baroness Armstrong: I’m Hilary Armstrong, I’m in the Lords, a Labour Peer. I was for a long time in the Commons, I come from the North East. One question, which is a technical question really, for Julie: are you now thinking of changes in governance of CCGs, given the level of suspicion around some GPs wanting to put services into the GP service rather than maybe into the voluntary sector or other services because of their interest, and that causes a bit of anxiety around place? We argued for a different system during the passage of the Bill, so I’m sort of being consistent there. But the second thing really is around the whole challenge that Margaret was outlining, which is leading us, certainly in the North East, to be really worried about the falling over of some of the private sector and social care, and the figures that she gave around the 2% are incredibly stark. If you were in Surrey, 1% of your people in residential care are publicly funded, so your 2% in Surrey, will pick up a hell of a lot more than in Sefton or in Newcastle, because they’ve got properties at the top end, rather than most of their properties at the bottom end; in Newcastle I’m

told it’s around 83% of people in residential care are publicly funded. So whatever you do, there is massive inequality in that. And the other problem about reorganising funding formulas that the Government are intent on at the moment, both in health and they’re doing it at the moment in education, we’re looking at that now in education, and, as you were saying, that is as an important prevention factor as anything else among the populations that you’re serving in Liverpool and Sefton, and we are in the North East, then they too are being cut and changed so that our areas are going to suffer. I hate this “divide and rule” business that goes on, it’s just bad decision-making. But I do think that integration is absolutely important, because the poor patient out there doesn’t understand how we’ve created all the differences, and so we’ve now got to get over those differences so that we actually provide proper care. And I’d love to have another go about mental health and the homeless, but I’ll do that on another day. Chair: Thank you. So, we have a few questions there - and Parliamentarians abusing my generosity

[laughter]. So, we’ve got a mental health question – pick that up if you would, Phil – and there was also the mental health question in relation to ringfencing, perhaps you could pick that one up as well, if you would Phil?

A. Dr Phil Moore: The Mental Capacity Act. It’s a bit of a nightmare area, isn’t it, and I think some of the rulings that have come out of it created knock-on effects that we are still struggling to deal with. I think it’s very important that in all of this we put at the centre what the wishes of the individual are and endeavour to honour those. I think that that has to be set against the pressures that we’re experiencing around choice and having endless choice; it may not be sustainable, but ultimately we shouldn’t be overriding the wishes of the individual, so the Mental Capacity Act should serve that ambition. At the moment, I feel that sometimes it’s a bit difficult to operate, and, frankly, in some areas it has become an absolute industry. We have been talking to the Department about how we can look at improving that for the benefit of the individuals so that they get a better deal with this. I can talk a lot more about it, but I think that’s the essence for me. It should be serving the interests of the individual, and to some extent society, but primarily the individual, and I think we may need to do some modifications for that. The second question was around ring-fencing. As a commissioner, generally speaking I don’t like ring-fencing, because the Government says, “Do this, and here’s a pot of money to do it,” but you think, “We’ve already done it,” but they say “No sorry, you’ve got to invest that money in it even more.” And actually, I prefer to have the principles set out and the high-level aspirations set out, and then we interpret that for our local populations, that’s a much more effective way of getting the funding flowing. However, my view of children and young people services is they’ve been underfunded and under prioritised for so long, and the NHS and local authorities are in such parlous financial situations at the moment, that I want to give, particularly the mental health commissioners, but also commissioners in general, the leverage to say, “We really need that money here, even though there’s competition for that money elsewhere. In this specific circumstance, I would change my general view and say I think it needs to be ring-fenced. Should it be just the CAHMS money? That’s where I started because that’s really my remit. I think you could argue that it should be wider than that for children and young people, because that comes onto the maternal stuff. Absolutely, we should be focusing there, because that’s the start in life, and that’s where we can affect certainly the mental health outcomes but also general health outcomes much later. It’s a conundrum, but I do think in this case ring-fencing is appropriate. Chair: The impact on A&E. Do you want to do that one?

A. Katherine Sheerin: Yes, so, in terms of our A&E attendances and emergency admissions over the last few years, we actually saw a decrease going back a few years, but now they’re increasing again, but if you take the sort of three-year period they haven’t increased as much as elsewhere, so the stuff that we do now in primary community care is helping. I would say that we were 68th out of 68, bottom of the pile CCG in the North of England for emergency admissions when we started. We’re now about mid-table, so you could say, “Well, low-hanging fruit – we’ve kind of tackled the stuff that’s easy.” Yes and no I think. We’ve got significant demands in Liverpool, and we’ve got a population that are kind of used to turning up to hospital because the lights are on, as you said. Overall though, and I suppose this goes back to the question about are we spending too much on acute compared to primary community services or prevention?, I think overall there are things… We’re not spending all of our money in the best way possible, and, we should definitely, be moving money around the system. But have we got enough in the health and social care system over the next five years? No, we haven’t, not looking, at those figures that Margaret presents, not looking at the figures we’ve got in Liverpool. We need more investment in the health and social care system, no question. Chair: Well, there were two elements to this. One was the governance of CCGs, and the other thing -

and I’m going to take a very neutral position on this – let’s call it financial realignment. A. Julie Wood: So, the ‘techie’ question that Hilary talked about. So, very early in their lives, CCGs saw that it was a mistake for them not to be commissioning primary care. Maybe, maybe not, but it actually got in the way of them being able to transform what they need to out of hospitals for their population, so we needed to find ways of actually making that happen. NHS England very early on, in Simon Stevens’ lifetime as Chief Exec, has set out an optional, delegated model or increased involvement in commissioning of primary care, which CCGs have taken up very largely. We need to ensure that in doing that we are mindful, CCGs are mindful of the perceived conflicts of interest, and the potential for there sometimes to be actual conflicts of interest - but to be proportionate about it. What we don’t want to do, and mustn’t do, is actually tie CCGs up in so much bureaucracy in governance, review of their governance, such they don’t take the right decisions for their population. But, we also need to make sure that enough governance is there in a defendable, transparent, very open way that says, “This is the sort of decision we need to take to join up these services and invest in out-of-hospital care.” It could be from their local general practices, it could be from the voluntary sector, and that that is very transparent. So for example CCGs have to have very clear conflict of interest policies, as you’ll know, but also need to think about how they manage the process of that decision-making, and at what point in the commissioning cycle, that I showed you… If it is about investing in local general practice, at what point those local general practices step away and the decision is taken free of their involvement? They need to be involved in the designing bit because actually, for the reasons that Phil’s talked about, they’re doing it, but actually we need to make sure that the process is very fair and transparent and reasonable such that everybody can see it and they can defend it and challenge it. We’ve got “Sunshine Rule” coming in; that isn’t just about the relationship between CCGs and pharmaceutical companies, it is also about how CCGs manage their commissioning of primary care and conflicts of interest generally, so we’re working with NHS England to make sure that works. Clearly additional role for lay members, lay members are chairing the sub-committees of the governing body who do handle those primary care co-commissioning decisions; so again that is not a GP leading those, it’s a lay member chairing those. And we need to make sure we’ve got it right, supporting CCGs to be able to make the right decision in the right way such that it’s defendable and transparent.

Chair: Well, we have [the financial realignment question], does anybody want to pick that one up? A. Julie Wood: Yes I’ll start. I talked about needing to spend the Liverpool health pound. I think Katherine really beautifully described the fact that the Liverpool health pound has been sort of okay up until now, but the Liverpool care pound and local authority pound hasn’t been. What we’ve got to do is somehow get them together and have the Liverpool public pound, and how do we then rise up to the challenges that Margaret has talked about, which is shifting it; and it may not be about shifting 70-30 – it’s been completely reversed, or it may be – but actually it’s having a conversation in the round, together, about what’s the right thing to do in Sefton as opposed to Surrey, and it’s going to look very different. Yes, the funding formula does make a difference. I used to be a PCT Chief Executive. On the 31st of March I went to sleep having a population that was apparently 3% overfunded; I woke up the next day to have a population that apparently was 3% underfunded. That didn’t quite change overnight, so we are at the behest of those formulas. Clearly, as a national membership organisation, half our members say, “No, no – it needs to look like this,” and the other half is saying, “No, no – it needs to look like that.” It’s about getting right or as best as you can, but it does have some effects depending on where you sit in the country, and that’s a real challenge. Chair: Can I just thank Julie for that one? You sat on the fence fantastically [laughter] in regards to that

one. Phil… A. Dr Phil Moore: I think that ultimately we’ve got to have health and social care working very, very closely. But I would go a bit further. I think unless we’re working with housing, employment, leisure, socialisation, recreating communities, we’re not going to be sustainable, because people who live without communities are going to have ever-increasing needs, so I see that our job is to really work very closely with our local authorities. For me that’s about building a relationship of trust with them, and I think that has not always been there, and I think we’ve got to work very hard to recreate it on both sides, and ultimately we need to put the money together and say how do we use this money to get the best health outcomes for our population? I think that’s a real public health issue, and I’m very keen that we keep public health working very closely with clinical commissioning groups, even though they’ve moved over to local authorities. The problem is, how do we care for that ever-increasing elderly cohort of people as well as putting in the prevention? I don’t quite know how we stretch to both of those things, but if we don’t, in another 50 years we won’t have solved the problem any more than we have now, so we’ve got to get the best minds on to this, working together and not separately, otherwise I don’t think it will work. Chair: Thank you. Well, we’ve got around 10 minutes left. I’ve got a colleague here, and then you, Sir,

and then Andrew and then … I’ll break my rules; we’ll take a fourth over there. Q: Baroness Masham: Sue Masham, Crossbench peer. I speak now as President of the Spinal Injuries Association, and you have one of the seven spinal injuries units in England in Southport. We are extremely worried about the doctor and nurse population. We used to have excellent, excellent doctors, and so many of them have retired. Are there the new ones coming on? Housing. We deal with people who break their necks and their backs and they’re paralysed from the neck downwards, some of them on respirators; it’s exceedingly difficult work. If they don’t have houses to go out to, what happens? They block the beds. So housing is a big issue. I want to know a bit

about the specialised funding of these services. And also, what hasn’t been mentioned today is the problem of mental health in prisons and the link between prisons and the community, because the NHS is now responsible for health in prison. Mental health is such a big problem; I’ve worked with young offenders for years, and a lot of them came from Liverpool. Chair: Thank you. Q: I’m Paul Saper from LCS. I have three questions on commissioning for change. The first question is, looking across the country are we beginning to improve the big variance in performance and cost for various different services in different parts of the country? Secondly, are seeing changes in the way we contract, where risk is transferred to the provider, and perhaps the provider is rewarded if they perform well and the patient does not go back into hospital after one month or three months? And the third question, which may also be for Katherine, is, given the focus on outcomes, are we seeing evidence of CCGs doing analysis and assessment, that they focus at least at first, on those types of outcomes where they can make the maximum amount of saving or they can actually get the best return on their money? Q. Andrew McCracken: Hi, I’m Andrew McCracken from National Voices, a coalition of health and care charities. My question is around sustainability and transformation plans, so the five-year plans that local areas are having to develop at the moment to help deliver services over the next five years, given the really brutal timescales of getting those plans submitted, how are CCGs and local authorities and trusts really meaningfully engaging people in communities in the development of those plans that are going to set the scene for the next five years? Chair: Fine. Now, I think this will be the final question, because we’ve got five minutes. Q. I’m Varsha Dodhia from Harrow clinical Commissionign Group working with a Pioneer. What we have not addressed is people who work in the system: a social care worker who has a 15-minute visit, or hospital staff - everybody. Can we as a country really address the situation of disenfranchised workers, because by shifting all these chairs we’ve actually made the front-line staff not feel very valued. What can we do to make sure that people who deliver care are actually valued? Chair: Thank you. Well, I’ll take that last question first, I’ll ask Margaret to comment on that one:

disenfranchised workers. A. Margaret Carney: I agree, first of all. I think we’ve got to work really hard in what are big and complex organisations, both where those staff work for us and where we commission those services from others. How do we commission that work, and what kind of provisions do we put within those commissions that place staff in a really important part of the development of that organisation? That is really tricky to do, particularly in large, complex organisations, but I think it can be done. So, the extent to which staff… it’s a bit, as I was saying, about communities being involved: staff who are involved in the organisation who are listened to, whose views are taken account of and actioned upon, are by and large more motivated than most of the workforce. I do think there’s an issue around the terms and conditions, and I use the social care workforce as an example because I’m closest to it. I don’t think it is sustainable as a minimum wage, poor quality, potentially, and training programmes that seem to concentrate only on the narrow aspect of

safeguarding, as opposed to some really care and compassion training, so I think there’s a whole range of activities. We need to invest in our workforce, in the care and social care workforce we need to invest; we need to give them jobs that are fulfilling and sustainable. Most people go into that profession because they care, and then actually we spend a lot of time sort of trying to get that out of them and they become company people. Fifteen-minute care visits: there may be on a very rare occasion for medication purposes as part of a bigger package of care, but absolutely the dignity of people that we care for is reliant upon those very front-line workers and we need to invest in them accordingly. Chair: Thank you. The spinal injuries question, housing and specialised funding. A. Katherine Sheerin: Well, spinal injuries, that unit is a really good example of a very specialised service on quite an isolated site. To protect that service for the future and to actually improve it for the future, we need to think about the relationship of the staff working there, with the staff working in the Walton Centre for Neurology, which is a good few miles down the road, with Aintree Hospitals, which is a major trauma site. We need to think about how the staff from all those sites work together and how can we get the best service for patients. That might require some difficult decisions, and that’s what we’re going to need political backing for, because not everybody is going to be happy with some of the decisions that we need to make. In terms of the funding, that’s about the overall cut of the cake. NHS England would fund a lot of those services, but I think what we need to do is to make sure we’re working closely with them so we get the money to the right services to get the best outcomes for patients. Chair: Thank you for that. C. Baroness Masham: We’ll give you all the support we can for these spinal injury services. C. Katherine Sheerin: Thank you Chair: Can I ask Julie to deal with the issue in relation to the three questions about variance in cost, the

contract risks and the outcome analysis? And can you pick Andrew’s comment up as well, the question about the five-year plans?

A. Julie Wood: Yes, so, Paul, the answer to all three is: yes, but not enough. On the variance question, I would really draw your attention and I suggest you go and look at what we can see in Right Care. So, the NHS Atlas of Variation, there’s an amazing atlas that shows at a CCG level the level of variation across CCGs for a number of services, so if you haven’t looked at that I would draw your attention to that, and then some of the Planning All Care Together (PACT) programmes that support you actually understanding why that might be. Commissioning for Value PACTS, the Opportunity Locator PACTS, will all help local CCGs look at, “Well, why have we got this variation?” That variation may be totally warranted and justified, in which case, fine, we’re not going to see the same everywhere, but it may not be. Have we gone far enough in terms of understanding variation? Absolutely not. One of the key things I talked about is the £22 billion. One of the ways in which we’re going to draw out some of those efficiencies is doing just that, a big focus on Right Care, and we’ve got 60 CCGs going in the first wave of actually focusing on Right Care, and the rest of the CCG population needs to follow on in terms of understanding the variation, understanding why it’s there and what we can do about it, if it is not justified and if it’s unwarranted. That may mean making some really difficult decisions about what we don’t do or we do less of, or we do more of, but if we’re trying to get these efficiencies out, it may mean actually saying, “This isn’t warranted, and in terms of the relative priority that has to be lower priority than something else,” which gets you right into the difficult commissioning decisions that have to be made. I expect more of that as we go through the rest of this Parliament.

Change in contracts, are we seeing some of that? Yes. Are we seeing enough of it? No. CCGs are looking at different contracting arrangements, alliance contracting, all sorts of different ways of actually working together. We’re also beginning to see through the vanguards, particularly in the first wave, some blurring in the boundaries between commissioning and provision, and we need to—so, the idea that we get some accountable care systems, not to reorganise, statutorily or anything like that, but accountable care systems that put groups of front-line professionals together, looking at what can we do across the piece to deliver the health outcomes for our population. That will require different transactions, if you like, in the middle bit of my commissioning cycle, to actually pull then those levers. That may be about shifting some of the risks, so some risks and some rewards. If you do focus on delivering these outcomes, take Katherine’s example of pulmonary rehab, really clear evidence; if you do do that, that will have a positive impact on your mortality rates for people with COPD. So, if we incentivise you to do that, what do I gain in terms of the risk, so that a CCG, a commissioner could say, “I’m commissioning for outcomes quite how you organise your services with what you do, with maybe what the voluntary sector does, maybe some other provider, that’s fine, it’s your business, but I want to see these outcomes for my population, because we know the evidence suggests that’s the right thing to do.” The final question, are we doing enough about the analysis and investment on outcomes? Again, no, it’s really hard to do. Again, in my former life I was only ever judged on price and activity; it really didn’t matter, it did to me, about quality and outcomes for my population, but actually what I was held to account for was not the whole package. That is now very different, and CCGs are held to account for the quality of the outcomes that patients experience and the spend. But it takes a long time to actually shift your commissioning into outcomes, and we’ve seen in the press some examples of where CCGs have tried to do that and have come into difficult territory actually about how they do it. We need to do more, but it’s not about shifting overnight all of your commissioning to outcome-based, because it’s too hard to do, and the evidence base about which intervention leads to what outcome isn’t clear across the board. Andrew’s question about the timeline. Yes, I agree. And actually, we are seeing some kickback from our members around the STP footprints. We’ve heard all this conversation about the need to be close to communities – for prevention, community development, community engagement – yet we’re being asked to go into big, big communities for the STP footprints. What we’ve got to do: CCGs have not just woken up and said, “Okay, someones told us we’ve got to do this in five years,” we’ve been doing it since 2013. Each STP footprint will have mini footprints in it, but you’ve got engagement galore going on, so it’s not as though they’re just starting from scratch. What we have got to do is be clear about how we transact things at an STP footprint level and what that looks like, and how that relates to each individual CCG’s statutory responsibility and accountability for its spend and what it delivers for its population. Yes, they need to collaborate, but I think there’s going to be some challenges as we actually try to say, how do we reconcile the gap? I am sure Liverpool, Sefton, Knowsley… are all going to be in the same STP footprint? Probably. I don’t know actually? A. Katherine Sheerin: We are, and we’re fine. A. Julie Wood: How do we recognise and reconcile some of those differences and what does that mean for engagement and involvement of our various different populations, given the diversity that we’ve got? Chair: Thanks. And the final question on mental health in prisons. A. Dr Phil Moore: I’ll be very brief on this. I want to link together prisons, homeless and also veterans, three groups who’ve got big mental health issues that we need to address. It is beginning to happen, but

not enough is happening. And part of it you’ve got to say: how many are there because of mental health problems, and how many have got mental health problems because they are there, and I think that both are true. We’ve got one trust that is beginning to work into our local prison and is beginning to have some effect; it’s not easy work, but we’ve got to keep persisting with it and I think it’s got to come up the agenda. Where do we find the funding for that in addition to everything else is a problem, but we’ve got to continue to look at this, otherwise what we do is we will pay for the consequences of that for the lifetime of the individuals and we’ve got to deal with that. One little story and then I’ll finish. I was listening to somebody with lived experience of being in a forensic psychiatric unit, and he made a comment that I thought, “I know that, but I’d never realised it.” Do you understand? He said, “Everybody in a forensic psychiatric unit, a secure unit, has had something dreadful happen in their families,” and I thought, “Actually, that’s where we need to be concentrating.” That’s why I think maternal care, parenting skills is important in dealing with mental health problems in parents, and then we can make a difference that maybe will affect that as well. Chair: And just quickly, housing in relation to spinal injuries. A. Margaret Carney: I think that the link between housing and health is a really important one, whether that’s at the specialist end or whether it’s at the preventative end, so how we deal with those people who don’t have a home, it’s probably a whole new session in terms of that. All I would say is we talked about social care and the potential crisis of social care. I think we’ve also got to put housing in that category, not just in terms of supply and demand, whether it’s at the affordable end or the specialist end, but because we’re seeing increasingly registered social landlords becoming much more commercial in their outlook, they’re having to be because of the rules and regulations around it. I think that presents a real challenge for us in terms of how housing contributes to health, not just from an affordability, but from the supply and demand point of view. And of course we’ve got all of the challenges about how we fund, particularly the specialist end, and we’ve seen significant reductions of things like special facilities grants, etc. in terms of being able to fund that within people’s own homes or within social housing. So, I think housing and health is almost a whole new session. Conclusion by the Chair, Peter Dowd MP Thank you for that. Just one comment from me: I think looking into the future, the whole question about devolution is going to gather pace as time goes by. I’m not talking about the next two or three years, but about in five to ten years’ time and that’s something to keep an eye on - not necessarily in structural terms - but, I think, in terms of governance in relation to the whole question of health. And not least of which because we politicians like to accrue power to ourselves, even if that’s at a local level, and that’s going to start to happen whether we like it or not - I suspect. That leaves me to thank Julie, Margaret, Katherine and Phil for their presentations and for taking the questions - thank you very much for that. I thought they were very helpful, very insightful, very informative. These sessions always help Parliamentarians to get a bit of a context as well. Although quick, sharp, and short, we really do appreciate these sessions, it really does help us to put a bit of meat on the bone, so thank you very much for that. Can I thank Judy and her team, and I use the word “team” in the sort of looser sense of the word; it’s a very good team, thank you very much for that. And can I thank all the questioners; most of them were Parliamentarians as it happens and there were a lot of questions, so thank you very much for those. And thank you the non-parliamentarian questioners, and thank you very much for everybody for coming to today’s session and a safe journey home. Thank you. [applause]

END Note: This transcript of the meeting is as accurate a representation of the discussion as possible, within the limits of the audibility of the recording.