Agenda item

To set out the NHS’ Joint Forward Plan for 2025/26 to 2029/30 and receive feedback from the Health and Wellbeing Board.

The Chair welcomed Toby Lambert (Executive Director of Strategy and Population Health, NWL ICB) to the Board meeting, explaining that he would be presenting the 5-year Joint Forward Plan that the ICB was required to produce every year and present to all 8 NWL Health and Wellbeing Boards.

Toby Lambert began by highlighting that the ‘joint’ part of the Forward Plan referred to ‘joint’ between NHS organisations and not between the NHS and local authorities and other partners. He advised that this did not mean ICBs did not value the opinion of local authority colleagues in relation to the content of the plan or that it could not work with the local authority in developing it, but was purely what was required by legislation. The Health and Wellbeing Board had a statutory duty to provide an opinion to the ICB on whether it believed the plan adequately met the needs of Brent residents as laid out in the Joint Health and Wellbeing Strategy and Joint Strategic Needs Assessment (JSNA). He also welcomed comments from Board members about how the ICB could improve the process of developing the plan and work together with partners to implement the plan, and how the ICB could support the Council as a local system to achieve its priorities within the context of the Plan. He added that the ICB had prepared a ‘light touch’ refresh this year due to the upcoming 10-year plan for the health service due in Spring, which would act as a trigger for a more in-depth refresh for the next iteration of the Joint Forward Plan. He then highlighted the following key points:

• The ICB had aimed to be more rigorous in terms of prioritisation for this iteration of the plan, concentrating on a few priorities in year one, moving to another set of priorities in year two, and so on, so that cumulatively more could be done by putting larger effort behind a smaller number of priorities each year. He added that this did not mean those priorities appearing in later years were less important.
• The Plan tried to draw a link to the NWL Shared Needs Assessment, which had been produced using each of the 8 boroughs’ local JSNAs. The Plan highlighted the links to how particular actions supported the needs of NWL residents.
• The ICB had also tried to work better on how it developed the plan, and he felt that the ICB had been better at inviting colleagues to the key meetings in relation to the plan and attended Health and Wellbeing Boards earlier in the process.
• The same 9 overall priorities had been retained, outlined in section 3.4 of the cover paper, which were; to establish neighbourhood teams with primary care at their heart; to continue to reduce inequalities and improve health outcomes, particularly using population health management; to optimise the ease of movement for patients throughout their care; to embed access to consistent high quality community services by maximizing opportunity, which referred to a core common offer across NWL and improving the productivity of services; to improve mental health and community care for children and young people; to improve mental health services in the community and services for people in crisis which is consistently applied across the 8 NWL boroughs; to transform maternity care; to increase cancer detection rates and provide faster access to treatment; and transform the way planned care worked which provider colleagues were leading on.
• The cover report detailed the priorities being focused on for Brent which had been worked through by the Brent Borough-Based Partnership. There was a strong link between the 9 NWL priorities and the priorities for Brent, including Integrated Neighbourhood Teams, health equity and reducing inequalities, primary care and access.
• In terms of mental health and crisis, there were a number of outreach projects across NWL trying to identify where crisis was arising in the most deprived communities to direct support further downstream before those individuals presented in crisis. In terms of approaches to mental health, some boroughs were using a more generalist model compared to Brent which was more specialist on mental health.
• He highlighted that, across all areas, there was an aim to have a common offer, and the focus for the next year would be on getting that core offer in place. Once that was implemented, the ICB would move on to better tailor the offer to the various communities in NWL, recognising that no two communities were the same and some communities may need something more bespoke.

The Chair thanked Toby Lambert for the presentation and invited contributions from those present, with the following points raised:

• The Board welcomed the Joint Forward Plan and felt there was much to be supportive of, including ongoing work that the Council and the ICB shared ambitions for such as health inequalities, child health hubs and community-based healthcare.
• The Board asked when they would see the NWL Children’s Mental Health Strategy coming forward. Members were advised that this was being scoped now, chaired by Sarah Newman, Director of Children’s Services in Westminster and Kensington and Chelsea. As the scope for that developed, it would be brought to all Directors of Children’s Services in NWL to get their input. It would likely be brought to members and directors in October – November.
• The Board highlighted that waiting times for autism and ADHD referrals was a priority for year 2 in the plan, but emphasised the impact those waiting lists had on Council services, as many children with autism and ADHD were waiting for Education Health and Care Plans (EHCPs). Toby Lambert advised that an extra £5.4m had been invested into supporting ADHD assessments, with CNWL and other providers in the process of rolling that out currently. The next focus would be on autism assessments.
• In noting that the main workforce challenge identified was low productivity rather than recruitment and retention, the Board asked what the main barriers were causing that. Toby Lambert explained that there was more staff currently employed within the NWL ICB system than ever before, but the amount of activity being done was lower than the activity being done before the pandemic. He felt NWL had done a good job across the system to reduce the redundancy rates across the past 2 years, as well as agency and premium staffing rates. Given there was more staff than before and the likelihood of no new money coming into the system, the focus had now shifted to supporting staff to operate in the most cost-effective way possible. For example, if A&E had a backlog of ambulances, staff were having to spend a lot of time looking to place extra patients rather than providing care, which was not the most efficient way of working and which had a knock-on effect for usage of intensive care beds, in turn affecting theatre productivity. As such, excess flow through the system inhibited the ability to operate as efficiently as possible. He highlighted that there was a role for the local authority to play to support that productivity in terms of discharge. In addition, where there were older facilities and equipment, this impacted staff ability to operate effectively if equipment was breaking down often. Capital investment into facilities and equipment was needed to address that. The final way the ICB was looking to address low productivity was around deployment of new technology to support staff. He advised that there were exciting new AI products which were able to summarise patient notes for the clinician and capture the consultation to save clinicians time and ensure appointments utilised as much time as possible for the consultation and care rather than note taking.
• Board members asked for an example of how productivity would be improved through the core common offer. Using community mental health teams as an example, Toby Lambert explained that a piece of work had been conducted looking at the number of patient-facing appointments the community mental health team delivered day to day. Both CNWL and LNWT had set a goal to see 3 people per day, and the most productive borough team was currently seeing 2.6 mental health patients per day in the community. The least productive borough team was seeing 1.2, so there was a significant range in terms of numbers of appointments being delivered, and none were at the target. When looking at what the least productive borough was doing, it was the only team who were going into the office first to pick up files, then going to see the patient, then returning to the office before seeing the next patient. Some other boroughs had technology to enable them to go straight to see their patients rather than needing to go to and from the office. As such, there was scope to improve productivity in the way some boroughs worked. Another example was outpatient consultations, where some boroughs had implemented AI products and saved approximately 20% of their time on outpatient consultations. This meant there were potential productivity improvements coming from more consistent utilisation of staff and application of the technology. He advised the Board that he felt relatively confident that if the system was able to implement those improvements there would be a productivity surplus to enable the ICB to meet a number of service gaps. The Board highlighted that redistribution of funding was needed alongside those productivity improvements.
• The Board was aware that distribution of funding was based on historical patterns and not current need, but asked if there were any plans to review that funding arrangement or lobbying that the Council could support. They were advised that as the ICB worked through the common offer it was looking at the distribution of funding within those services to see how that could be evened out. The ICB was on course to cover around 50% of community services over the coming year and about 20-30% of mental health services.
• Noting that the ICB had been asked to reduce costs by 30%, the Board asked what impact that would have on the delivery of the Joint Forward Plan. Toby Lambert explained that the need to reduce costs by 30% had been a challenging process, but recognised that there were many organisations dealing with budget constraints. The reduction of costs was one of the reasons that the ICB had been more rigorous in its prioritisation, as there would be fewer resources available to deliver those priorities.
• The Board highlighted that the Brent Centre for Young People contract was due to expire, and asked for clarity around next steps for that service, as it was felt to be a vital source of support. Tom Shakespeare (Director of Brent Integrated Care Partnership) explained that the Integrated Care Partnership (ICP) was in discussions regarding the contract and had a business case due to be submitted to ICB colleagues in relation to the Brent Centre for Young People. The steer that had been given was that a procurement process would need to be undertaken, so the ICP was working with colleagues to maintain service and sustainability whilst that procurement process happened, given the critical role the contract played in supporting statutory services. He agreed to brief the Cabinet Members separately as that procurement progressed.
• Noting that the NWL Integrated Care System (ICS) had been placed in level four of the NHSE System Oversight Framework, meaning intensive external support was required to develop robust financial recovery plans, the Board asked if the Plan had identified the right priorities, given those deficits. Simon Crawford (Deputy CEO, LNWT) explained that LNWT was one of 2 acute trusts likely to post a deficit in the current financial year, which was why it was part of the INI process. The deficit was driven by 3 key factors:
  • One factor was the ongoing demand in the emergency pathway, with winter pressures continuing beyond winter into the summer. The additional services and beds implemented during winter continued well into the summer, which had not been budgeted for as those services would have been planned to close after winter. This was the first year that the Trust had kept those winter services open to the extent it had. It was added that LNWT was not the only provider that needed to do so.
  • Another factor was the sustained pressure at a level over and above the previous year that LNWT was seeing, and the number of admissions being made had caused the Trust to open additional beds. Across the country there were long waits in emergency departments and patients were being offloaded from ambulances into emergency department corridors, which required extra staffing to support those patients, increasing the costs associated with that. One measure that had been put in place once a patient had been assessed, stabilised and made ready for a bed was to transfer that patient to the ward, and up to two patients maximum on any one ward would be on a trolley by that ward waiting for a discharge before they could get a bed. This meant further additional staff for nursing, feeding and portering.
  • On the planned pathway for elective care, the pandemic had caused a backlog of people waiting for operations, diagnostics and assessments, so more activity was being delivered there. A new electronic patient system had been implemented the previous year which took time for staff to familiarise themselves with and operate effectively, further contributing to additional pressure on the waiting lists. Extra activity was being put on to treat people in line with standards and expectations.
• In terms of funding, the Board were advised that the ICB was lobbying the government to set the budget which would help with finances. NWL was impacted by the national formulas suggesting that it was one of the healthier places in the country and therefore needed less money per head than other places, given London’s generally younger population and London as a whole being more affluent. In addition to this, NWL was one of two systems in the country which was below the target level of funding. As such, NWL was impacted twice as much as other boroughs by being further down in the national funding allocations formula and provided with funds that were uniquely lower than the goal allocation. There was a need for continual lobbying to get closer to that allocations formula. He added that the allocations gap was almost identical to the deficit gap.
• In relation to the new service model for mental health in NW2, NW10 and HA9, Tom Shakespeare highlighted that the Brent ICP had been successful in getting additional investment to support the work of CNWL as the mental health provider in that area. There were significant numbers of people appearing in crisis in secondary care settings who had not been known to services previously, so the pilot looked to develop deeper connections within the community to try to address the drivers of crises earlier. That model would then be developed and rolled out further, building on what worked.
• Noting that the legislation required the plan to set out the steps the ICB was taking to implement the Joint Health and Wellbeing Strategy and for the Health and Wellbeing Board to provide an opinion on whether the plan did reflect that, the Board highlighted that the Brent section of the plan did not reference the Brent Joint Health and Wellbeing Strategy, and welcomed thoughts on how the Board could identify that the ICB had looked at the strategy and it was reflected in what the ICB was doing. Toby Lambert explained that the ICB had reviewed all JSNAs and Joint Health and Wellbeing Strategies to feed into the NWL Shared Needs Assessment, which was then used to develop the NWL Joint Forward Plan. The ICB then interacted with the borough teams to ask them to reflect in their own sections the priorities of their borough. As such, if the plan was not reflecting Brent’s Joint Health and Wellbeing Strategy then that needed to be corrected.
• Dr Melanie Smith highlighted where she felt there were important themes from the Joint Health and Wellbeing Strategy missing in the Joint Forward Plan. Whilst both did look at inequalities, Brent’s focus was developed working with communities and with co-production as a very important part of the approach which she felt was essential. Another theme of the strategy missing from the plan was around the wider determinants of health. Toby Lambert responded that he would be happy to work with the relevant teams to ensure that was appropriately reflected in the plan.
• The Chair hoped for the Department for Health to expect a review of achievements following each plan year in order to evaluate joint forward plans ahead of their next iterations, rather than having a new plan each year without reference to the past.
• The Chair thanked Toby Lambert for his responses to the questions, highlighting that, whilst it felt like the forward plan was being scrutinised, this was because the legislation had required the ICB to bring a Forward Plan to Health and Wellbeing Boards for challenge and scrutiny and review, which members felt was not the most satisfactory way of working. Going forward, Brent’s Health and Wellbeing Board would prefer a plan where there were common themes that the ICB and local authority were willing to sign up to.
• In drawing the points to conclusion, the Chair proposed writing a formal letter to the NWL ICB outlining some of the key points raised during the discussion, including health inequalities, the Joint Health and Wellbeing Strategy, finances, use of AI, shared IT and a suggestion to write to the Department for Health asking for a more joined up approach going forward that all partners could sign up to. Toby Lambert confirmed he would be happy to receive a written response, and acknowledged that a lot of engagement work was within the gift of the ICB. As such, as the NHS 10-year plan came through in Spring and the ICB moved into the cycle of the next refresh, he was grateful to have a clear expression of willingness from local authorities to play a fuller role in how that plan was developed.

As no further issues were raised the Board noted the report and the comments raised.