Agenda item

Reduction of Thurrock Clinical Commissioning Group Budget 2019-20 and wider NHS England proposals to merge five Clinical Commissioning Groups across the Mid and South Essex STP geographical footprint


The Chair welcomed Wayne Bartlett-Syree, Director of Strategic Transformation/Locality Director, NHS England, to the meeting and explained how difficult it had been to get someone from NHS England to attend this evening. The items discussed under this item would be:


           £490K funding taken from Thurrock Clinical Commissioning Group to Cambridgeshire and Peterborough STP

           The proposal for a single Clinical Commissioning Group Accountable Officer

           The merger of the five Clinical Commissioning Groups


Wayne Bartlett-Syree introduced himself and provided Members with an overview of his broad background.


Wayne Bartlett-Syree stated that money was interesting in the NHS and had always been a significant challenge and recognised and had sympathy for local authorities on the challenges that they faced. How monies worked in the NHS was that it would be passed from Government through the Treasury to the Department of Health and Social Care and onto Clinical Commissioning Groups. The majority of that money would go to NHS England who had a strategic responsibility to balance their books which meant that commissioners and providers across the country had to be in a position where the money balanced but the accountability would sit with the Secretary of State and also Simon Stevens now the Joint Chief Executive between NHS and NHSE. There were Trusts and Clinical Commissioning Groups that run surpluses and deficits and what the National Director of Finance would like at the end of the year for deficits and surpluses all to total back to a net zero position but as years had gone by this had become increasingly more challenging where money had been asked from systems or monies been moved from systems to ensure that net zero. For 2019/20, rather than this to take place at national level, regions were asked to balance within NHS England. Currently within the East of England there was a significant gap when coming to the planning element and that gap existed in Cambridgeshire and Peterborough of around £70 million. The approach taken in the East of England was that a contingency reserve could be deployed, this would be a large ask for Cambridgeshire and Peterborough in regard to their savings plan. The said ask for the five STPs with a contribution of £5m each into that deficit in order to balance the books.


Councillor Rigby arrived into the Committee Room at 7.13pm.


Wayne Bartlett-Syree moved onto the mergers of the Clinical Commissioning Group that the long term plan set out the commitment to ICSs over the next four years and the move would mean that each ICS would be covered by one Clinical Commissioning Group. That all regions had written out to their Clinical Commissioning Groups in line with the long term plan. That the first draft is expected by September 2019 asking about each Clinical Commissioning Group were thinking on this and what their expected timelines would be for this merger. Some Clinical Commissioning Groups were further on and looking to merge, some had merged and some were yet to start those conversations. The letter that NHS England sent out was initial to start the process in order to get people’s ideas and understand views on their thinking. If the mergers are going to be made by 2021 there was a lot of engagement and work to be done at both locality and governance. Wayne Bartlett-Syree stated those Clinical Commissioning Groups that had already merged, some over large footprints, the success of those mergers had been down to ensure that Place was well represented. Wayne Bartlett-Syree commented that Thurrock had done well in ensuring that Place had been vital to its success. That going forward to the single merger to create one Clinical Commissioning Group it was vital as part of the merger that Place was well and truly represented and recognised.


The Chair thanked Wayne Bartlett-Syree for attending and noted that he had only been in post for three weeks but questioned whether he was the right person here this evening to answer Thurrock’s questions in regard to the depth of the answers that Members were expecting to hear this evening.


Councillor Muldowney questioned how the decision to move funding had been made, who had made it and what process had been followed. Wayne Bartlett-Syree stated that it had been the regional teams and the STP executives who had agreed to move the funding. With concerns raised it had been agreed how the £5m would be distributed and divided at Clinical Commissioning Group level. That NHSE did not have any mandate and it would up to each STP on how the money was divided amongst themselves in that locality.


Councillor Muldowney stated the decision had focused on the attention to Place. Wayne Bartlett-Syree stated that impact was on Place and how the money was divided up in the STP. That a Equality Impact Assessment had been carried out to identify what services would be affected.


Councillor Muldowney asked to see sight of the Equality Impact Assessment. Wayne Bartlett-Syree stated that this document would sit at the STP and ICS level.


Councillor Halden, Portfolio Holder for Health, applauded Wayne Bartlett-Syree for attending this evening as other NHS England colleagues had avoided these questions in the past. Councillor Halden noted Thurrock had moved on at a great pace and one concern would be that with the merger in the attempt to bring other partners along at a fast rate might actually slow Thurrock down. Councillor Halden questioned whether NHS would take a proactive approach on what powers should remain locality rather than system wide. Wayne Bartlett-Syree stated as they moved forward as a system, the system would move to the merger and one factor on the merger would be to look at governance and how decisions are made through one Clinical Commissioning Group, with Place being key to that success.  Wayne Bartlett-Syree stated he would be happy to have a separate discussion on the Memorandum of Understanding outside of this committee.


Councillor Halden thanked Wayne Bartlett-Syree for the response and explained that Thurrock had positive experiences and questioned what Place meant and how money would be allocated to projects and what Place would mean going forward.


Wayne Bartlett-Syree stated that following Councillor Halden’s conversations with Paul Watson changes had been made in response to the publication of the Long Term Plan and the Implementation Framework. There was now a clear policy which Clinical Commissioning Group should now look to operate on. Wayne Bartlett-Syree concurred that Thurrock would have their voices heard in those conversations as to why it would be important to keep services at Thurrock level.


The Chair asked whether that confirmation would now be put into writing. That not only Members here this evening but Members widely are in agreement and had concerns that the Memorandum of Understanding should now be written and firmed up and asked for NHS England assures this would be undertaken. Wayne Bartlett-Syree questioned who would now put that into writing and based on how NHS England are operating under the model the policy stated that would be an STP and ICS role to come back to NHS England around their plans on the merger and how this would be tackled, with the help of some national guidance around managing mergers, process and governance. Wayne Bartlett-Syree stated NHS England would not be required to write to Thurrock on that subject as the plans would need to be received back from the Clinical Commissioning Group on the merger and look to see what needs to come first, review and address those issues.


The Chair stated that with some uncertainly still on the process did NHS England now understand Thurrock Members concerns and their need to feel confident in this process. Wayne Bartlett-Syree understood the real challenge around local Places having their voices heard in decisions and that to ensure as we go through the process it would be covered off in the establishment of one single Clinical Commissioning Group across Essex.


Ian Wake posed a question on Money and that no assessment on equity had been taken place before the decision to remove the money from Mid and South Essex to Cambridgeshire and asked why. Wayne Bartlett-Syree stated he was not party to the full discussions but the £25m between five Clinical Commissioning Groups it had been the agreement of the STPs to divide by five ways.


Ian Wake stated that people living in the Cambridgeshire and Peterborough area are healthy people and would live six years more than Thurrock residents and questioned why the time was not taken to undertake an impact assessment before the money was taken rather than after the decision had been made and asked where the money went. Wayne Bartlett-Syree stated the money had been divided by the five Clinical Commissioning Groups who all faced challenges and all had chosen to deal with the money in different ways.


The Chair stated that the decision had been forced upon dependent on how the funds were distributed out. That Cambridgeshire and Peterborough had a platinum service and overspent on their budget by millions of pounds. Thurrock had not and had managed to live within their means and balanced the budget. The tricky and difficult thing situation for Thurrock was that the mental health crisis services had to be delayed by months and was now “tricky” for Thurrock residents to access this service.


Kim James, Healthwatch, and Ian Evans, Thurrock Coalition, who represented people independently, repeated what Members had already discussed that it was those much needed services that would now be delayed. People of Thurrock would not know how the impact assessment was undertaken and would look at their local Clinical Commissioning Group. That the Thurrock Clinical Commissioning Group had no say in the decision, the decision had been forced upon them and for them to now have to make decisions on how they are going to find that money and what services Thurrock will lose for the people of Thurrock was an absolute disgrace.


Councillor Ralph stated that NHS England seem to be passing the buck to the Clinical Commissioning Group and that how NHS England looked at how the money would be divided it appeared that Thurrock had been penalised for being successful and that NHS England would not be accountable for the services that had been reduced as this had been passed down to the next level which had been irresponsible. Wayne Bartlett-Syree stated that it was important that when difficult decisions are being made about local services they are made by the local commissioners and by the local areas. That when difficult decisions are made NHS England had a strategic responsibility to balance the books and NHS England could not get away from that. In terms of how this would then be prioritised on local services NHS England could only defer to Mandy Ansell as it was at the STP level that decisions were made about how that money was to be apportioned. Wayne Bartlett-Syree stated that this was done by NHS England and appreciated that there had been some difficult and complex decisions that had been made which had an impact on local services.


The Chair reiterated that the reason for Thurrock inviting NHS England to the committee and had not accepted the initial decline of the committee’s invitation and deferred to Mandy Ansell was because as Members they did not believe that was what had happened and that the responsibility fell to the Clinical Commissioning Groups decision.


The Chair questioned whether the Clinical Commissioning Group could refuse to transfer the money and what would the implications be if it did and would NHS England be taking more monies from Thurrock in the future. Wayne Bartlett-Syree stated that there was no option to refuse to transfer the funding as monies had already been managed and moved at a national level rather than at regional level. Wayne Bartlett-Syree stated that taking extra money in the future the NHS England did not want to be a position to have these difficult and controversial conversations with systems after they had received their money but ultimately this would come down to balancing the books. The long term planning implementation guidance would provide new financial projections that would be coming out for all systems with the NHS expectations being that each systems would live within those financial projectors that had been set for them so should not be looking after the money had come out to move money around the systems. Wayne Bartlett-Syree stated that there would be one caveat as there could be in-year complications or very complex patients that could mean a single system or a single Clinical Commissioning Group having a very large financial hit which could be very difficult to plan in the way that NHS finances work. This would be an example when conversations would be held with systems on how best to help to do that but the plans would be to create a contingency at regional level which would help smooth those situations.


The Chair stated that Thurrock Clinical Commissioning Group were able to manage their budgets within those hurdles and assumed that all Clinical Commissioning Groups are told not to overspend by millions of pounds already and assumed they are not already spending money that they do not have, so which would mean that in the future no further moneys would be taken from Thurrock. 


The Chair stated that the money was a loan and questioned how and when this would be repaid. Wayne Bartlett-Syree stated this would be repaid within three years starting from next year.


Roger Harris stated as statutory Corporate Director of Adult Services and statutory Interim Director of Children’s Services and with Ian Wake being the statutory Director of Public Health they had been disturbed not to have received one single piece of communication from NHS England who are driving this process and not the STP and questioned why that was. Wayne Bartlett-Syree stated that NHS England expectation was that the local STP and ICS would be having and engaging in those conversations and that NHS England were merely the regional tier for national policy and stated how this was implemented was down to the STP and ICS to be having those conversations. That NHS England had not written to all authorities’ chief executives and would not expect NHS England to do so.


Roger Harris stated that he did not accept that answer as a member of the STP Programme Board where a range of issues are discussed, it was clear that all the letters had been sent from the regional office. Roger Harris stated he was deeply concerned that as strategy accountable officer for a number of duties which Thurrock had a strategy duty with the Clinical Commissioning Group not to have had any communication from NHS England was thoroughly deplorable.


The Chair echoed comments made and agreed that Councillors and Cabinet Members had also not received any communication either and had been aware that colleagues in other areas had not received any communications. The Council had relied on the great relationship with their Clinical Commissioning Group to update Officers and Members on what was happening in this process and it was just not acceptable.


Councillor Kelly echoed Members comments and questioned whether extra money had already been spent on setting up projects and implementing ideas that had now been delayed and had this money been picked up in the process.  Roger Harris stated that would be a question for Clinical Commissioning Group but Thurrock were trying to manage that process as much as possible but the concern was that it had come after the budgets had been set, it had come after our plans, agreements had already been made on the mental health transformation plan and after the 1 April. Roger Harris stated that although it was deeply regrettable that the money had been taken away following the amount of time spent on the planning, this would not result in any cuts but would cause significant delays and implementation of some services.


Mandy Ansell stated that money had not been lost just services would have to be pushed back and that reflected in the testament partnership around this committee table this evening.


Councillor Muldowney stated there had been no accountability on how the books were balanced and questioned how we had ended up in this situation were money was being clawed back from budgets that had already been agreed from other areas in order to balance the books and questioned what measures are being put in place so this did not happen again. Wayne Bartlett-Syree stated that NHS England would not want to be in a position where half of the budgets had been released and plans had been set to release money rather than in exceptional circumstances so would not expect that to happen. Wayne Bartlett-Syree stated the underlying issues in Cambridgeshire and Peterborough were very long standing and very historic around the finances and had noted the position had got increasingly worse over the most recent years. To ensure that did not happen again and that local systems had an opportunity to scrutinise the works and efforts going into Cambridgeshire and Peterborough in terms of balancing their books and getting back into a financial balance an Oversight Group had been set up which would be formed of different health systems, the five Clinical Commissioning Groups and their constituents who would question the Clinical Commissioning Group and STP Leadership in Cambridgeshire and Peterborough about their in-year budget management and actual finance plans going forward. Therefore Cambridgeshire and Peterborough would be reviewed and scrutinised by NHS England as regulators but also be reviewed and scrutinised by their peers. Wayne Bartlett-Syree stated that Cambridgeshire and Peterborough were working hard and recognised that the proposed review and scrutiny would be challenging.


Councillor Muldowney stated if there had been historic problems why NHS England had not intervened earlier.  Wayne Bartlett-Syree stated there had been several interventions in the Cambridgeshire and Peterborough systems around its finances for quite some time but each time had yet to be able to get themselves back into financial balance. Councillor Muldowney questioned whether NHS England accepted any responsibility for this situation which had been going on over time.  Wayne Bartlett-Syree stated that taking the fact there was a system with such financial challenge it had been taken very seriously and would be working very hard with that system to get back into financial balance. Councillor Muldowney questioned when the money would be paid back into Thurrock’s budget. Wayne Bartlett-Syree could not give details as to how much would be paid back but would be paid from next year over three years.


Councillor Ralph stated that Wayne Bartlett-Syree could say the words “bailing out other authorities” in his response. Wayne Bartlett-Syree stated that Cambridgeshire and Peterborough were facing financial challenges and financial difficulties and hoped this would be the last time that any other organisation in East of England would have to receive funding to help it out of their financial challenges.


Roger Harris made a final statement that Thurrock was very proud of the work that had been done around Place locally in terms of the work, in terms of the transformation, how the better care fund had been used, with some very strong partnership working, working with Healthwatch and the voluntary sector, working with the emerging primary care networks and the involvement in the rolling out of the mental health crisis networks working with Mark Tebbs team working across the STP. Roger Harris stated this concern were how would Thurrock be able to “lock in” that Place based work in a real meaningful way. That work had been undertaken with a lot of areas of the NHS over the last 10-15 years and with moving away in to a much larger configuration it would make Place based working more difficult. That Thurrock did not support the direction of travel but realised that the long term plan had set that direction of travel and the need to ensure that Thurrock had as much as possible locked into those place based arrangements and would work with NHSE on this. Wayne Bartlett-Syree stated that Place was very important and those conversations should be with the STP, with the other Clinical Commissioning Groups around the establishment of a single Clinical Commissioning Group and what that would mean but from a NHS England point of view would be supporting those conversations.


The Chair thanked Wayne Bartlett-Syree again for his time this evening and hoped that the tough questions asked this evening demonstrated how passionate Thurrock felt about the plans and how strong Members felt about the successes in Thurrock and how these should be continued. The Chair stated that Thurrock should be involved to all discussions that were taking place particularly those that would have such fundamental changes to Thurrock’s areas and would not expect to have to fight with NHS England as a partner. Thurrock was aware that we all formed part of a system and NHS England was also a partner in that system and would expect all parts of that system to come and speak with Thurrock Members as requested and hoped in the future would not have to fight to get someone from NHS England here to speak.


Councillor Halden and Wayne Bartlett-Syree left the Committee Room at 8.00pm.

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