Agenda item
North West London NHS Financial Recovery Plan
To receive and consider a report from Brent Clinical Commissioning Group (CCG) providing an update on the financial position of the North West London (NWL) Collaboration of CCGs and the financial recovery programmes in place.
Minutes:
The Chair advised that he had received a number of request to speak on the Financial Recovery Plan, which he advised he had allowed and would consider, before proceeding to hear from the presenting Officers.
He then invited each speaker to address the Committee in turn.
Councillor Daly (Local Subdury Ward Councillor) reminded Members of the Committee that Brent was one of the poorest Boroughs in London and felt that the report did not reassure the local community. Councillor Daly was of the opinion that the financial recovery plan aimed to avoid patient referrals to hospital by creating fear in GPs, and felt that this was due to lack of funding in the NHS. Referring to the planned changes to prescriptions, concern was expressed that many patients were not taking their required medication due to lack of affordability. Councillor Daly expressed concern that those who were seriously ill at A&E, such as those with pneumonia, would not be given a hospital bed under the planned changes.
Councillor Nerva (Local Queens Park Ward Councillor) thanked the Committee for convening the meeting. It was felt by Councillor Nerva that there was a lack of local accountability in the plan and there was fear of a double cut to Continuing Healthcare (CHC). It was questioned whether patient choice would remain following the planned changes, and the presenting Officers were asked whether these changes would be proposed should the health service be in balance. Councillor Nerva felt that detailed scrutiny of the proposals by the Committee was necessary.
The Chair advised that he had allowed Councillor Colacicco (Local Mapesbury Ward Councillor) 2 minutes to read out a statement on behalf of Dawn Butler MP (Brent Central). The statement objected to the proposed financial recovery plan, specifically in relation to the planned closure of the 24-hour Urgent Care Centre at Central Middlesex Hospital. Dawn Butler MP was of the opinion that the cuts to health services were falling disproportionately on the constituents in the south of the Brent Borough, particularly Harlesden and Stonebridge areas, which were pointed out to be ranked top in Brent according to the Index of Multiple Deprivation. The statement referred to both the 2014 closure of the A&E service, which was on the proviso that a 24-hour Urgent Care Centre would be available, and the planned closure for the Urgent Care Centre as part of the financial recovery plan. Dawn Butler MP argued in the statement that the decision to close the Urgent Care Centre removed 24-hour NHS services from the constituency, and conveyed that those constituents without access to a vehicle would be required to travel for over an hour to the nearest available hospital. The statement referred to concern regarding the lack of public consultation on the decision to close the Centre. Dawn Butler MP believed that the falling attendance figures referred to in the report were a product of design, and asked the Clinical Commissioning Group (CCG) to invest in the Central Middlesex hospital to create a fully functioning Urgent Care Centre. The statement concluded with a request to the Committee to recommend that the Clinical Commissioning Group (CCG) reconsider the plans for the future of the Urgent Care Centre and put any proposals to full public consultation.
Following the statement on behalf of Dawn Butler MP, The Chair advised that he had also allowed Councillor Colacicco a further 2 minutes to provide her own statement. Councillor Colacicco therefore, focused on the proposed closure of Cricklewood walk-in centre. Councillor Colacicco informed the Committee that members of the community had attended one of the consultations referred to in the report. Further recalling the visit, Councillor Colacicco explained that the consultation asked demographic questions about the respondent and where they would go if the walk-in centre was not available. Councillor Colacicco criticised the consultation, which she felt lacked a question regarding whether constituents agreed with a closure of the walk-in centre, and recalled that the question was put to social media where a majority of respondents disagreed with the closure. Councillor Colacicco argued that this showed there was a need for the walk-in centre. In concluding, it was felt that equality needed to be considered within the planned changes, and Councillor Colacicco was of the belief that those who would need the centre the most, citing the elderly, disabled people and those in monetary deprivation, would suffer the most.
Continuing to focus on the planned closure of the Cricklewood walk-in centre, Councillor Anne Clarke (Barnet Child’s Hill Ward Councillor), believed that the health centre was at the heart of the community and that the threat of closure now and in 2014 was not welcomed. It was observed that there were plans for 7,500 new homes to be built near the health centre due to the Brent Cross regeneration project, and Councillor Clarke was of the opinion that it was illogical to close the centre at a time of growth and when patients attending the walk-in centre were there due to the inability to make an appointment with a GP, Councillor Clarke asserted that without a walk-in centre those patients would otherwise turn to A&E. Councillor Clarke also conveyed to the Committee that it was felt the walk-in centre was well-used and that the appointments service was underutilised, therefore questioned why the appointment service would be retained while the well-used service would be closed.
The Chair thanked the speakers for their contributions to the meeting and then asked Mark Easton (Accountable Officer, North West London CCG) to introduce the report for the North West London NHS Financial Recovery Plan.
Mark Easton (Accountable Officer, North West London CCG) introduced the report, providing an update on the financial position of the North West London (NWL) Collaboration of CCGs and the financial recovery programmes in place. Mark Easton summarised their role within the CCG and explained to the Committee that the CCG did not run London North West Hospital but worked closely with the Hospital Trust. The Committee heard that those Boroughs in areas of deprivation received more allocation than more affluent Boroughs. Brent was under target and therefore received higher growth than those that were over target. It was explained that the while the budget for the NHS had increased, at the same time service demand had also increased, attributed to an increasing and aging population, and that the 5% increase in population was outweighed by the 16% increase in demand for acute services. Mark Easton told the Committee that to cope with cost increase a Quality, Innovation, Productivity and Prevention (QIPP) savings programme had identified £100 million savings, £15 million of which was in Brent, and emphasised that the actions to be taken were to return to the planned deficit. Mark Easton summarised aspects of the report that would tackle the deficit, including better procurement, changes to GP referral behaviours, better enforcement of existing policies and reviews to eligibility criteria for services. In concluding, Mark Easton expressed that the CCG intended to abide by the NHS constitutional standards including the Mental Health investment standards.
The Chair thanked Mark Easton for the introduction, and invited questions from the Committee.
In the subsequent discussion, the Committee queried the financial sustainability of the proposals. In response to questions regarding the disparity between expected and actual demand, Mark Easton indicated that the CCG received an activity report at each meeting, and explained that these showed they were spending ahead of the plan, which was why they would be undertaking investigations with GPs. It was explained that there was both demographic and non-demographic growth which led to incorrect estimates. With regard to the CCGs confidence that they could return to the planned deficit, Mark Easton responded that some of the actions were already showing signs of delivery, while others were still to materialise .
The Committee was also informed that the development of additional expenditure was unknown until 4 months into the financial year due to a delay in the information received from acute services, with trends in data not immediately apparent. Sheik Auladin (Managing Director, Brent CCG) expanded that the trends for the Brent CCG followed the previous year, which ended with a deficit of £4.9 million, and that the same patterns became evident at 4 and 6 months of this year. Sheik Auladin was of the opinion that finances remained under pressure, and felt that the position was not likely to improve during the winter period.
Regarding requests for a breakdown of figures in Appendix 1 of the report, the Committee were informed by Sheik Auladin that the £7.9 million figure for savings in Continuing Healthcare did not relate only to Brent, and that the figure for Brent specifically was between £150,000 - £200,000. It was explained that the CCG aimed to make improvements in appropriate care to lessen the burden of Continuing Healthcare for the Council. The £16 million savings for Reserves referred to in Appendix 1 was the result of a request to all CCGs to identify £2 million based on under-delivering contracts.
Representatives of the CCG responded to concern over the £8.1 million deficit forecast for Brent, explaining that Brent was spending more than it was receiving due to pressures on the system and the CCG were of the opinion that the financial recovery plan would help Brent return to the planned deficit.
Responding to queries over whether the same proposals would be made if the financial situation was in surplus, Mark Easton answered that they believed there to be nothing in the plan that would have a negative impact on patients. It was believed there was a higher cost of patient visits to the Urgent Care Centre after midnight than there was to A&E. With reference to the Cricklewood walk-in centre, Mark Easton highlighted that the service provided was replicated in many urgent care facilities as well as 111 out of hours services. Fana Hussain (Assistant Director for Primary Care, Brent CCG) also highlighted the challenges in relation to the location of the Cricklewood walk-in centre and whether this was best placed to meet patients’ needs.
The Committee also scrutinised the impact the financial recovery plan would have in relation to patient safety, access to service, and patient choice. Sheik Auladin responded to queries regarding the perceived diminished service of primary care, asserting that primary care services in Brent had not been reduced but expanded with 6 Hubs and an investment of between £1.6 million to £1.8 million, with the Urgent Care Centre as the only proposed change in primary care service provision. Following on from this, Committee members were concerned that primary care services would not have the capacity to care for additional patients and that as a result patients would go to A&E, increasing costs there, or to their GP which would increase waiting times. Fana Hussain advised that the CCG had recognised the increase in demand for primary care, which was why they had invested in primary care and support for GPs and pharmacists. It was also highlighted that tech consultations were supporting the increased demand through e-hubs, and that access hubs were available for patients not able to get GP appointments.
Mark Easton assured the Committee that to ensure the safety of patients and quality of service, a clinical assessment would be undertaken before any implementation of changes, and where there were any changes in policy an Equality Impact Assessment would be conducted. It was explained that it was not necessary to conduct an Equality Impact Assessment for strand 3 of the plan enforcing guidelines on prescriptions because this was already existing NHS policy that GPs were expected to follow. It was explained that there were discrepancies in the way GPs followed the guidance and there would be investigations to understand the differences and ensure the policy was being followed. Responding to concern over patient access to prescriptions, Dr M C Patel (Chair, Brent CCG) asserted that the guidance was very clear regarding access to free and repeat prescriptions and informed the Committee that information was to be delivered to GPs, pharmacists, and dentists regarding exemptions.
Mark Easton asserted that implications for patients as a result of the increased demand for services would be managed by ensuring patients were on the right pathway and getting the most appropriate care, and through enforcement of policies and efficient procedures at GP surgeries.
Committee members felt that the requirement set out in the report for patients to be treated at a specific local service compromised patient choice. There was discussion about the treatments available through different services, and Dr M C Patel conveyed that they personally would not have supported a reduction in patient choice. It was acknowledged that it would be appropriate to hold conversations with GPs regarding patient’s requests for specific services, but felt that in the majority of cases patient choice would be respected.
The Committee asked CCG representatives for reassurance concerning how equality had been addressed in the plan, challenging why strand 4 required an Equality Impact Assessment and not strands 1, 2 and 3. Of specific concern was strand 2 and the aim to change GP referral patterns and speed up patient discharge. Dr M C Patel informed the Committee that they would look at both high and low GP referrers to understand variations and agree good practice. It was therefore felt that strand 2 did not need an Equality Impact Assessment as the service was not being changed but improved. With regard to speeding up discharges, Dr M C Patel highlighted that patients often suffered when kept in hospital for longer periods of time and preferred to be at home, and Sheik Auladin conveyed that a clinical decision would be taken by the multidisciplinary team regarding if the patient would be ready to be discharged. It was emphasised that this part of the plan was not a new service but an exercise in implementing expected standards of practice. The Committee re-emphasised that conducting an Equality Impact Assessment was critical, due to Brent being a high deprivation area that had a high referral rate. Jonathon Turner (Deputy Managing Director, Brent CCG) explained that the data for referral rates was standardised according to certain weightings of data, including the multiple deprivation index, and when this was standardised there was still inconsistency in referral patterns in Brent. Jonathon concluded by reiterating that the plan optimised the existing clinical decision process, and Mark Easton informed the board that the plan was scrutinised by lay members of the governing body and some of the work streams, such as transportation, had patient representation.
Other issues raised by the Committee were:
· Queries over whether analysis and discussion was held with Brent Voluntary Services on the impact of the changes to those organisations. Mark Easton responded that should there be any consequences for any organisations as a result of the plan, they would be discussed, but that the CCG were confident the consequences were retained within the NHS.
· Committee members emphasised the importance of taking into consideration the cost of accessing healthcare for the user and asserted that accessibility to care was a human right.
· It was felt that a time limit was necessary where consultant to consultant referrals were sent back to the GP, referred to in section 6.3 of the report.
As there were no further questions, the Chair thanked everyone for their contributions and the Committee then RESOLVED to recommend the following:
1. To ensure that under the financial recovery plan local services are maintained at a sufficient level to continue meeting the needs of Brent residents.
2. To request that the CCG undertake an Equality Impact Assessment in relation to all four strands of the overall strategy.
3. To request that the CCG review changes proposed to the Urgent Care Centre at Central Middlesex Hospital and the Cricklewood Walk-In Centre with regard to their impact on Primary Care, and be asked to reconsider their plans regarding the future of the Urgent Care Centre and put any proposals for its closure to a full public consultation.
4. That the CCG be requested to reverse their decision to close the Urgent Care Centre at Central Middlesex Hospital.
5. That the CCG be requested to provide a further update regarding the Financial Recovery Plan in 6 months’ time following the winter period.
Supporting documents: