Dear Sir Ian

`Commissioning a patient led NHS': proposals to reconfigure Strategic Health Authority and Primary Care Trust Boundaries

I am responding on behalf of Hampshire County Council Health Overview and Scrutiny Committee (HOSC) to the proposals to reconfigure Strategic Health Authority (SHA) and Primary care Trust (PCT) boundaries in Hampshire. You will be aware that we responded separately and in detail, to the proposals relating to the configuration of Ambulance services.

The HOSC supported the views our Chief Executive shared with you about these proposals last September and we remain committed to the direction of travel set out in that correspondence. We therefore wish to confirm our support, albeit with a number of misgivings, for the proposal for two SHAs in the South East region and remain firmly committed to the reconfiguration of PCTs to ensure co-terminosity with local authority adult and children's services boundaries. The anticipated review of Local Government will introduce some uncertainty about the form that this may take in Hampshire. At present this would mean one PCT for Hampshire County. We would not support a configuration of PCTs that splits the Hampshire county area.

The emphasis placed by the Department of Health on regional boundaries remains unhelpful and does not reflect the way in which our communities access health services. This will create avoidable complexities in the arrangements that need to be put in place to support commissioning that is focused around patients rather than administrative expediency. In particular we will wish to see appropriate arrangements put in place to secure services for our communities in the south west and north east of the County and I know that this will be an area of continuing interest to the HOSC.

There are 5 further issues that we would wish to see addressed as part of the restructuring process. These are outlined below:

1. Improved Partnership Working across the NHS and local authorities. We have previously stressed the importance of partnership working across the county to ensure that the changes to the NHS put service users at the heart of the decision making process that supports the planning and delivery of care. Whilst there have been excellent examples of this happening in some parts of the County we believe that more needs to be done to embed this way of working into care provision across Hampshire. More work needs to be done at both strategic and operational levels to engage key partners and build a shared vision of the way in which we meet the needs of our respective communities. The County Council, District Councils and Local Strategic Partnerships all have a role to play in this respect, working with health. We would therefore wish to see tangible commitment from the NHS to taking this work forward, even though this may, in the short term, challenge traditional patterns of working. Existing vehicles to support the delivery of this agenda, such as the local area agreements, can be developed and strengthened to support further progress with partnership working.

2. Commissioning arrangements that are responsive to local needs and accountable to local communities. We have already highlighted the need for organisational structures that are able to balance a strategic overview with robust arrangements for local commissioning across communities and neighbourhoods. The series of seminars that you initiated to explore this further have provided a helpful opportunity to explore this issue further. Many of the concerns expressed by local government about the reconfiguration proposals centre on the perception that highly valued local links will be lost as PCTs in particular become more remote and less responsive to the differing needs of our communities. We therefore welcomed the emphasis placed on aligning practice based commissioning (PBC) areas with district council boundaries. We would now wish to see further work on commissioning arrangements to ensure that there is scope for genuine flexibility across our communities and the `clout to commit' in response to differing local needs. This of course presupposes the existence of effective mechanisms to assess health needs.

If commissioning is to be driven by the patient needs, as opposed to historic activity, then we need to understand clearly how services will be accessed as well as the quality and value for money that they represent. This is a major piece of work in its own right and is essential if we are to be successful in ensuring that services are provided as locally as possible. To succeed there will need to be early action to design a framework able to support the differing `tiers' of commissioning that are required well as clarity about the different health needs of the diverse populations that we serve in Hampshire. We would also wish to explore further the way in which elected members can contribute to the commissioning process.

3. Clarity about the delivery of the public health and health improvement agenda. Linked with commissioning, a second recurring theme in the discussions that have taken place since last September has been the need for closer working with regard to the health improvement and well being agenda. Examples of excellent partnership working and joint appointments already exist, public health in the South West being a case in point. We would wish to see good practice shared and disseminated across the county to allow for our shared commitment to this work to progress still further.

4. Business continuity and leadership during the transition. We have previously commented on the disruption caused by the local management restructuring last year as well as the financial challenges facing the health economy in Hampshire. Since your appointment in June we have seen real progress made to address the budgetary position and improve delivery against national targets. In particular we have welcomed your leadership, which has provided a more strategic and coherent approach to planning health services reducing inter-organisational conflict and fragmentation. The introduction of payment by results, PBC, choice and the proposed shift of care from acute to community services will bring further challenges that will require clear and consistent leadership. We are therefore deeply concerned that the disruption caused by the restructuring will shift attention away from these issues and that the progress achieved may be lost.

5. Capacity and Capability. Linked to the above point, and regardless of the final decision about the form of the restructuring, is the need for there to be a swift move to the new structure and appointments confirmed as quickly as possible. Commissioning arrangements in particular need to be clear and transparent if the real benefits for our population are to be achieved. Historically commissioning has not been a particular strength in the NHS and locally arrangements have, on occasion, appeared fragmented and inconsistent, with limited understanding of what is being commissioned and why. This will need to be addressed at the earliest opportunity.

I hope these views are helpful and look forward to working with you to deliver the challenging agenda that faces both local government and the NHS.

Yours sincerely

Cllr Dr Raymond J Ellis C.Chem FRSC

Chairman, Health Overview and Scrutiny Committee