Archived decisions
Hampshire County Council
Health Overview and Scrutiny Committee Item 6
11 April 2007
Health Review Programme: Update on the Public Health and Wellbeing, and the Out of Hours Reviews 2005 - 2006
Report of the Chief Executive
Contact: Martin Combs [email protected] 01962 847479
1. Background
1.1. Two reviews were taken to the Health Overview and Scrutiny Committee in 2006. The first was the Public Health and Well-being Review in January 2006, the second, the Out of Hours Review in March 2006. Since then there has been a period of extensive and profound changes in NHS organisations in Hampshire and in Hampshire County Council's Adult Services department. In addition both organisations have been under severe financial pressures.
1.2. Since January 2006, there has also been a series of white papers produced by Government that are significant for both health and social care. This update outlines how the context has changed, and suggests that both the Hampshire and national contexts have never provided a better opportunity to take forward the reviews and recommendations from early 2006 as the organisations are forming or reforming to better address the challenges of health and social care in Hampshire.
1. Hampshire Context
Commissioning a patient-led NHS and local health re-organisations
2.1. Taking forward the reviews through a period of multiple organisational changes presented significant challenges for NHS organisations. The reviews followed consultations in late 2005 on reconfiguring the NHS ambulance services, strategic health authorities, and primary care trusts. As a consequence, in the months following the reviews, all of the NHS organisations responsible for Public Health and out of hours planning and services were very unsettled, and uncertain about who would be in a position to take forward any recommendations. The situation was further compounded by unprecedented pressures as trusts sought to implement financial recovery plans. This added to the uncertainty since there was a reluctance to commit resources or engage with new initiatives unless there were clear and immediate prospects of reducing costs.
2.2. On 1 July 2006 the South Central Ambulance NHS Trust was formed and Hampshire Ambulance Service Trust was dissolved. At the same time South Central Strategic Health Authority was launched with the dissolution of the Hampshire Strategic Health Authority. Hampshire Primary Care Trust came into being on 1 October 2006, taking over from the 7 Primary Care Trusts that previously covered the area. At the end of January 2007, both structural issues and some senior appointments have yet to be finalised. Much work lies ahead of Hampshire PCT to develop its own organisation and coherence as well as to bring a coherent and equitable level of healthcare across the County, and within budget.
Hampshire County Council: Adult Services changes
2.3. While major restructuring and reorganisation has been occurring in the NHS, the Adult Services Department has also begun a period of restructuring and has had to deal with significant funding challenges. The changes in management and structures are planned to continue until approximately October 2007. Relevant to taking forward the Public Health and Well-being review are two key appointments. In January 2007 Dr Jean Bradlow was jointly appointed by Hampshire PCT and Hampshire County Council to the post of Director of Public Health, and took up her post on 19 March 2007. In addition Adult Services has created an Assistant Director post for Well-being and Community; currently this post has an interim incumbent. The timing would seem very appropriate for including consideration of the Committee's recommendations in the emerging work plans and priorities for these areas of responsibility.
Alignment of locality boundaries
2.4. Hampshire PCT, Adult Services and Children's Services have now agreed to align their administrative areas within Hampshire such that all services now recognise a three area structure, with 11 districts sitting within these areas. The areas are now referred to as:
West Hampshire
Eastleigh
New Forest
Test Valley
Winchester
North and East Hampshire
Basingstoke and Deane
East Hampshire
Hart
Rushmoor
South East Hampshire
Fareham
Gosport
Havant
2.5. This alignment of local NHS and social care boundaries contrasts with the situation when the Public Health and Well-being Review was undertaken. The January 2006 report attempted to map local government district areas to those of the old primary care trusts. The new situation not only marks a major step forward in rationalising administrative boundaries, but it also promises good potential in improved partnership working.
2. Hampshire Summary
3.1. In summary, the new Hampshire context offers the following new opportunities for taking forward, particularly the public health and well-being agenda, and to a slightly lesser extent the out of hours developments:
· Alignment of local authority and NHS administrative and service boundaries
· Joint appointment of Director of Public Health - post was taken up in late March 2007
· Adult Services, Assistant Director post for Well-being and Community, currently filled on an interim basis
· Period of re-organisation in the local/regional NHS is now in the development phase rather than the dissolution and stalled phase of 12 months ago. This formative phase offers good potential for taking forward these areas of work.
· A single PCT for Hampshire offers much improved opportunity for developing consistent and equitable health services across the county, rather than the variable and inconsistent provision based on the old 7 PCT structures.
3.2. The following risks, however, still exist:
· Re-organisation in the NHS is still in progress, with both structural issues and key posts to be filled, particularly in Hampshire PCT. Meanwhile a number of executive and senior managers are significantly stretched.
· Re-organisation is planned to continue in Adult Services for several months of 2007, although the senior management team is now in place and developing service plans for forthcoming years.
· Financial pressures in both the NHS and local government.
3. Public Health and Well-being Review - Update
4.1. The Public Health and Well-being Review was taken to the Committee at the 31 January 2006. At that meeting the Committee agreed recommendations a) and b); at the meeting on 28 March, recommendation c) was also agreed:
Public Health and Well-being Recommendations
a. The report be shared with Adult Services Restructuring Board Working Group that is taking forward joint working with the Public Health Network. This will include:
· A more detailed mapping of public health plans and programmes across the county, including opportunities to share best practice and identify gaps in delivery.
· The developments of LSPs and LAAs
· Identification of the health improvements to be delivered by local people
b. That lead officers from Adult Services and the Public Health Network will report back to the Committee on progress with this work on 28 November 2006 detailing the outcomes of the review.
c. That a small working group of members is convened to oversee the rollout of the Public Health and Well-being agenda, including representation from different parts of the county.
Taking Forward the Public Health and Well-being Review
4.2. Despite organisational and funding challenges in 2006, progress in Public Health and Well-being can be reported. In response to the Committee's recommendation a) a written update was provided for the 28 November 2006 Committee meeting by the Director of Adult Services. The main points made in the update were:
· That implementation of Commissioning a Patient-led NHS, had resulted in profound organisational changes in the NHS
o Hampshire and Isle of Wight SHA becoming part of the new South Central SHA
o 7 PCTs consolidating into one Hampshire PCT
· There has been consequent difficulty in producing a detailed mapping of public health programmes as envisaged in January 2006.
· Adult Services has continued to work with the Director of Public Health at the SHA to identify further opportunities for integration and collaboration.
· A report was taken to CMT in June 2006 with following recommendations:
o A model was proposed for developing leadership across NHS and local government
o The model identified opportunities provided by a single Hampshire PCT for joint planning, commissioning and integration of services.
o There should be a joint appointment of Director of Public Health
o Establishment of Assistant Director post with responsibility for well-being
o Agreement for PCT and Adult Services to align their structures on a locality basis to improve opportunities for joint planning, commissioning and integration (see above)
o Localities to have specific links with district and borough councils
o Localities be co-terminus with locality based commissioning areas.
· That Adult Services also continue to work alongside the PCT to achieve Local Area Agreement (LAA) targets to reduce health inequalities / improve health and well-being of people in Hampshire
4.3. The response from Adult Services was unable to address the issue raised in the recommendation about more detailed mapping of public health plans and programmes across the county, however with the alignment of the PCT and County Council boundaries, and the joint appointment of Director of Public Health, the Committee will be interested to see their recommendations taken forward to a degree that was not possible in early 2006.
4.4. The Public Health Network in Hampshire agreed in mid 2006 that Dr Christine Jackson, the Director of Public Health for Eastleigh and Test Valley PCT would take forward the review on behalf of the Network.
4.5. The recently appointed Interim Assistant Director of Wellbeing and Community is currently exploring how the Public Health and Wellbeing agenda might be taken forward in the new organisational contexts in Hampshire. A draft discussion paper has been produced (March 2007), proposing that a new statutory partnership for health and well-being is established under the Local Strategic Partnership with the following responsibilities:
· Agreement of shared outcomes
· Common assessment framework
· Single budgets where appropriate
· Joint commissioning and planning
· Delivery of joint LAA targets
· Development, implementation, monitoring and evaluation of DPH reports
· Consistent approach to patient and public involvement
· Support for high quality personalised provision
4.6. It is thought that the `Health and Well-being Partnership' might provide a mechanism to reduce the complexity inherent in the considerable array of formal and informal partnership working arrangements across the County.
4. Out of Hours Review - Update
5.1. The Out of Hours (OOH) Review was taken to the Committee on 28 March 2006 at which the following recommendations were agreed:
Out of Hours Recommendations
9.1 The SHA Review provides a useful summary of information about current performance of Out-of-Hours in Hampshire, and is helpful in identifying a way forward that will support the development of an integrated pan-Hampshire model for OOH services. The Committee has previously acknowledged the complexity of OOH care and the additional challenges that national policy changes will pose for local service delivery. In taking this work forward it is recommended that the Committee continues to take an active interest in the development of OOH services. In the first instance it would be helpful to have a response to the queries raised in section 7.8 of this report.
9.2 In addition the Committee will wish to have a response to the following:
· Feedback on performance against the National Quality Requirements and appropriate Quality Standards relating to:
o Response
o Timeliness
o Patient and Public Involvement
· Confirmation of the clinical evidence and needs assessment underpinning the proposals
· Feedback from current providers about the proposals (including the LMC)
· Confirmation of the way in which Section 11 engagement will be build in to the planning process
· Details of the impact on service delivery as a result of implementing the proposals
· An assessment of key risks and dependencies
· Confirmation of the governance arrangements that would underpin the implementation process, taking account of the reconfiguration proposals for SHAs, PCTs and Ambulance services, that are currently out to consultation.
5.2. The SHA leads be invited to the May meeting to advise members of their response to the issues raised and confirm the next steps in moving this process forward.
Taking forward the Out of Hours Review
5.3. The SHA leads, who had the remit for taking Out of Hours forward, attended the May 2006 meeting of the Health Overview and Scrutiny Committee and addressed questions raised in the report and responded to others from Members. However it was also indicated that responsibility for taking the OOH work forward would pass to the Hampshire PCT when formed. The Hampshire and Isle of Wight SHA became a constituent part of the New South Central SHA on 1 July 2006. An executive lead at the Hampshire PCT was identified in December 2006 to take Out of Hours forward, but it is unclear how this workstream is to be prioritised.
5.4. It has not been possible to obtain further information from Hampshire PCT about how they plan to continue and develop the work begun at the Hampshire Strategic Health Authority. However the extensive Care at End of Life Review, recently completed by the Committee, has provided additional understanding about developments and limitations in out of hours services in the County.
5.5. The Care at End of Life report identified issues of significance arising from evidence of stakeholders. Three of the report's recommendations are relevant to out of hours and have been directed to Hampshire PCT as the responsible lead body:
4.2.14 Timely communication and sharing of information across all care providers, both formal and informal shall be addressed as a key part of the roll-out of a Hampshire wide approach to out of hours care. Learning from work already underway with the Ambulance Service in Southwest Hampshire shall inform this to ensure that patients' needs and preferences for care are met.
4.2.15 Arrangements for accessing appropriate pharmacy support (including controlled drugs) both in and out of hours shall be reviewed to identify and implement good practice to ensure that the needs of patients in their own homes or other community settings are responded to in a timely and appropriate manner.
4.2.16 Access to specialist palliative care advice and support shall be identified across all areas and effectively communicated to formal and informal carers, including those providing OOH services.
5.6. Responses to the above recommendations have been requested for the 11 April Health Overview and Scrutiny Committee meeting.
5.7. In addition, on the basis of evidence provided, the report made the following observations:
· Community Support, particularly `red eye' (ie. midnight until 8am) nursing and night sitting, is not available consistently across all areas of Hampshire, leading to carers not being able to cope and triggering emergency admissions.
· Nursing homes - evidence suggests that some community and out of hours staff will not attend nursing homes
· Access to equipment was universally agreed to be problematic in the area served by the Basingstoke Joint Equipment Store
· Patients' notes are not always available to out of hours staff over weekends, thus frustrating attempts to provide the most appropriate care.
5.8. The Committee will therefore be keen to see these issues addressed as OOH is taken forward by the PCT.
5. In Summary
6.1. In summary the time seems particularly opportune to be picking up on the Public Health and Well-being, and the OOH reviews of early 2006. As new structures and management posts are confirmed, it is well that the reviews can be taken forward in a context where local authority and NHS share the same administrative boundaries. It is also helpful that a jointly funded Director of Public Health post is filled in March 2007.
6.2. The recent white papers (see Appendix for summary) provide a supportive and timely backdrop, particularly for Public Health and Well-being in Hampshire. With renewed emphasis on the democratic process and partnership working, the national direction of travel provides a favourable environment for taking forward the reviews.
6.3. The views and recommendations arrived at by the Committee in 2006 can now be more effectively addressed by both the NHS and Local Authority agencies. In addition the work subsequently undertaken on Care at End of Life has reinforced the need for the Committee to continue to engage with and inform work on the development of out of hours provision in the county.
6.4. The Committee will be actively monitoring developments in both areas, and looking to receive full responses to any outstanding questions.
6. Recommendations
Public Health and Well-being
7.1. That the Committee receive an update on progress made towards achieving Public Health and Wellbeing objectives during 2006-2007
Lead responsibility: Director of Public Health (Hampshire PCT/Hampshire County Council)
Timeframe for response: Response to be provided to the Committee for the 4 July 2007 meeting (ie. before 13 July 2007)
7.2. That the Committee be appraised of County-wide and local arrangements and plans to achieve Public Health and Wellbeing objectives and priorities for 2007-2008
Lead responsibility: Director of Public Health (Hampshire PCT/Hampshire County Council)
Timeframe for response: Response to be provided to the Committee for the 25 September 2007 meeting (ie. before 14 September 2007)
7.3. That the Committee be appraised of the detailed mapping of Public Health and Wellbeing plans and programmes across Hampshire, including opportunities to share best practices from localities and districts, as well as identifying gaps in delivery.
Lead responsibility: Director of Public Health (Hampshire PCT/Hampshire County Council)
Timeframe for response: Response to be provided to the Committee for the 27 November 2007 meeting (ie. before 16 November 2007)
Out of Hours
7.4. That the Committee receive an update on progress made during 2006-2007, and be appraised of plans, objectives and priorities for 2007-2008
Lead responsibility: Director of Care Services/Chief Executive (Hampshire PCT)
Timeframe for response: Response to be provided to the Committee for the 25 September 2007 meeting (ie. before 14 September 2007)
7.5. That the planning and development of out of hours services by Hampshire PCT undertakes to address the issues and concerns raised by the report on Care at End of Life as part of its remit to provide equitable out of hours care across the whole of Hampshire.
Lead responsibility: Director of Care Services/Chief Executive (Hampshire PCT)
Timeframe for response: Response to be provided to the Committee for the 25 September 2007 meeting (ie. before 14 September 2007)
7.6. That the Committee is appraised of progress with respect to consistent and equitable:
o Provision of community support, particularly `red eye' nursing and night sitting, across all areas of Hampshire.
o Provision of community and out of hours support to nursing homes
o Access to equipment provided from the Joint Equipment Store in Basingstoke
o Availability of patients' notes to out of hours staff, including over weekends.
Lead responsibility: Director of Care Services/Chief Executive (Hampshire PCT)
Timeframe for response: Response to be provided to the Committee for the 25 September 2007 meeting (ie. before 14 September 2007)
Appendix One
7. National Context
8.1. Relevant to taking forward the Public Health and Well-being review has been the publication of the following government documents:
· Our health, our care, our say: a new direction for community services (DH, January 2006) - This white paper emphasises:
o The need for directors of public health to work closely with local authorities, requiring the directors to provide reports directly to OSCs
o The need to strengthen the `local voice' in health AND social care
o The need for local councillors to be `advocates' in the context of the `community call for action'
The document places a "new emphasis" on prevention and has the four main goals:
o Better prevention services with earlier intervention
o More choice and a louder voice
o Do more tackling inequalities and improving access to community services
o More support for people with long-term needs
To be achieved through:
o Practice based commissioning
o Shifting resources into prevention
o More care to be undertaken outside hospitals and in the home
o Better joined up services at the local level
o Encouraging innovation
· A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services (DH, July 2006) - this white paper continues to develop the theme of accountability, emphasising:
o The potential role of Local Involvement Networks (LINks) - LINks will have the flexibility to work with the changing landscape of the NHS and social care systems...
o How LINks can provide or refer matters to OSCs as a result of their ability to gather information from a "wide range of people and a wide range of sources" in terms of experience of delivery of health or social care services.
· How OSCs have a vital role in scrutinising health and social care services, and in particular asking:
o Whether decisions are appropriate to the needs of local people
o Whether decisions are based on evidence
o Whether experiences of patients and users or services are leading to improvements
o NHS commissioners will be required to have arrangements in place for engaging service users and the public as part of their planning arrangements - "constant theme" those affected by change should be involved in planning and consulted on proposals for change.
o Plan to merge health and social care regulators
· Strong and Prosperous Communities: the local government white paper (Dept of Communities and LG, October 2006) - Annex B: Health and well-being - this white paper picks up on `Our health, our care, our say' and the `stronger local voice' papers and re-emphasises the following:
o New duty for upper tier LAs to prepare LAAs in consultation with health
o New duty for LAs and partners to co-operate in agreeing targets
o Joint appointments of Directors of Public Health as well as other senior manager posts
The paper also proposes:
o New statutory partnership for health and well-being under the LSP
o New duty for PCTs and LAs to co-operate
o Their responsibilities include:
· agreement of shared outcomes
· common assessment framework
· single budgets
· joint commissioning and planning
· delivery of joint LAA targets
o Consistent approach to patient and public involvement
o Members would be expected to have a key role
o Establishing a single performance framework for everything done by LAs and in conjunction with health bodies
Note: this paper throughout puts a strong emphasis on securing participation from citizens.
8.2. National Summary
8.2.1. The white papers state and reinforce some key messages:
· It is important for local politicians to be `advocates' for their constituents and to strengthen the `local voice' - to help ensure that public health is responsive to local need
· It is important for there to be mechanisms to help make local democracy work such as LINks as a flexible way to monitor and feed into NHS and social care
· It is important for the role of scrutiny committees to be strengthened as a means to improve the democratic accountability of NHS and local government organisations and services
· Encouragement for the appointment of joint Directors of Public Health between health and social care
· Encouragement of better partnership working, such as a new statutory partnership for health and well-being under the LSP
· Securing participation of citizens
8.2.2. The white papers provide a supportive and timely backdrop for taking forward both reviews, particularly Public Health and Well-being in Hampshire. However the development of coherent and equitable out of hours services across Hampshire will also benefit from local `advocates' reporting on the experience of local populations, and from partner organisations working more effectively together.