Appendix: Responses to consultation and engagement

Consultation responses

Local authorities

CONSULTATION RESPONSE: HAMMERSMITH AND FULHAM COUNCIL

Dear Jo

Consultation on proposed merger of CCGs in NHS NW London

Following your conversation with Cllr Coleman and Lisa Redfern last Friday, H&F Council welcomes the opportunity to respond to the consultation document on the proposed merger of the eight Clinical Commissioning Groups (CCGs) in the North West London (NWL) area.

As you know, the council is determined to do all we can to enhance the health and wellbeing of our residents. Our long, successful battle to save Charing Cross Hospital is one example of this.

We have been delighted by the new flexibilities that the NHS in H&F has enjoyed during the Covid pandemic. H&F Council and our local NHS have been able to work together in a deeper, more integrated and less bureaucratic way than ever before to protect residents and save lives.

We are hugely keen to build on this and we look forward to the opportunities that our co-chairing with the CCG of H&F’s Integrated Care Partnership will bring.

Turning to the merger, while we appreciate the nature of the pressure that NHS NWL is under, we regret the continuing lack of evidence and detail in the consultation document. It is not the significant improvement we had hoped for on the consultation of a year ago.

On the basis of the consultation and related information, we are not persuaded that the merger would improve the health and wellbeing of H&F’s 185,000 residents more effectively than is possible under current arrangements. Indeed, we have concerns that it could lead to some NHS services being reduced in the name of standardisation for 2.2 million people across NWL.

We regret the limited financial detail in the consultation. While you provided us earlier this week with further information about deficits and allocations, the details of management costs and anticipated savings, which would usually be considered as part of any merger, are not addressed. Nor is it clear not how financial planning and review between NHS NWL and local stakeholders will operate.

We fear that the proposed Board makeup of the merged CCG would so reduce the local authority role in the CCG’s deliberations as to threaten the legitimacy of the project.

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We also have reservations about the way in which the merger is being presented as a given when it still depends on the votes of a sufficient number of GPs to go ahead.

We set out our concerns in more detail under the headings below and hope you find this helpful.

1 The right lesson from Covid is that local works best

2 Inadequate case for change and consultation

3 Potential reduction in services and access

4 Lack of financial detail

5 Inadequate resident participation

6 Forced ‘tri-borough’ amalgamation

7 Insufficient local authority representation.

1 The right lesson from Covid is that local works best

Decisions which affect the health and wellbeing of 2.2 million people should be made on the basis of evidence about the impact on patient outcomes. However, the consultation does not support with evidence its vague claim that “working to a common framework and set of standards” across NWL would be better than the current situation.

On the contrary, the clear lesson from the pandemic is that improved integrated planning and working at a borough level is what has most protected residents. There is nothing to suggest that the proposed merger is the right way of locking in these improvements. We are concerned that the top-down NHS system may not be learning the correct lessons from the Covid-19 experience.

Examples of the outcomes of deeper partnership working between H&F Council, H&F CCG, Imperial NHS Trust and College, Primary Care Networks and local volunteers are in the following:

• Regular testing for staff and patients (asymptomatic as well as symptomatic) in H&F’s care homes

• Purchasing and provision of sufficient high-quality PPE • Engaging hospital staff to support care homes • Managing hospital discharge, including 70% through Pathway 1, including those

significantly further off their baselines than the norm • Mobilising major volunteering resources for more than 10,000 residents through the

Council’s H&F Community Aid Network and H&F Shield, and resident-led Mutual Aid Groups.

2 Inadequate case for change and consultation

When the eight-CCG merger was proposed last year, H&F Council obtained legal advice from leading Counsel Fenella Morris QC, of Essex Chambers, to assist in our representation. Many of the concerns we raised about the previous case for change in our letter of 2 August 2019, which we attach, are still relevant.

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A basic element of any consultation must be to make the case why the proposed arrangement would be better than the existing one. However, the proposal does not attempt this justification.

Economies of scale are claimed but not costed. There is a singular lack of evidence in terms of patient outcomes (which are what matter most) for why a single CCG serving 2.2 million people would be better than having eight CCGs now. As noted, the evidence on the ground does not support the claim that Covid-19 proves the value of having “one NHS” operating on a larger scale. What has saved lives in the crisis – and what should be the development priority now – has been better integrated and more pacey working at borough level.

Last August, we raised concerns about the process of the consultation then. We have similar concerns now. This consultation began on 3 August 2020 and has largely been run over the holiday period. Responses to it are to be considered on 10 September 2020, one day before the formal date on which the consultation closes (11 September).

The rules require a merger application to be submitted by 30 September 2020 for the merger to take effect from the new financial year (1 April 2021). It is our view that that the CCGs cannot properly consider all of the consultation responses in order to take this complex and important decision properly by the 30 September deadline (just 12 working days after the consultation closes). We are concerned that this suggests the decision is predetermined.

Insufficient resources were made available to mount effective consultation across NWL. It is unclear what patient and public involvement has been undertaken, if any, in accordance with sections 14U and 14Z2 of the NHS Service Act 2002. Such engagement as there has been has lacked reach and depth, without sufficient justification for a CCG with a 2.2 million footprint, or explanation of how the merged entity might be effectively managed, or consideration of how the financial constraints will operate.

The merging of the eight CCGs into one is described as an “internal” process which does not require external consultation. The centralisation of clinical and non-clinical functions is being implemented in advance of consultation. This further suggests a predetermined decision to merge.

3 Potential reduction in services and access

We are concerned that standardising services and equity of access through the merger could lead to a cut in NHS services and an increase in health inequalities in those boroughs whose access and standards are currently better than others, but which may be reduced following the merger. What are the local safeguards for services?

The proposal shows no evidence of learning from the disproportionate negative health impact of Covid-19 on Black, Asian and Minority Ethnic communities. It is silent on how the new structures could help to tackle health inequalities. We consider this a significant shortcoming. We also note that we are yet to be sighted on the full equalities impact assessment of the merger.

4 Lack of financial detail

We are most grateful for the Financial Framework presentation provided after the meeting last Friday. However, having reviewed this, it only appears to relate to deficits and allocations and how these might be dealt with within the NWL CCG.

While it shows the proposals for funding allocations across the boroughs and how standardisation affects each borough, it doesn’t cover other financial details such as management costs. These would usually be considered as part of any merger.

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The presentation appears to suggest that half of Harrow CCG’s deficit could be written off and that there would be a limited £7 million deficit across the NWL patch, as surpluses would largely offset deficits. This is very much welcomed.

However, to ensure effective commissioning, there is a need for a transparent process for financial planning and review between NHS NWL and local authorities and other borough-based stakeholders.

No financial evidence is provided to support the argument that there are significant economies of scale to be achieved in commissioning, staff cuts and back-office rationalisation. This was also a complaint made by many stakeholders when the merger was proposed last year.

5 Inadequate resident participation

Consultation and co-production are central to H&F Council’s approach to developing and commissioning services. The Council is committed to implementing co-production with residents across our activity. We are also working with PCNs, Imperial Healthcare Trust and College, West London MHT and H&F CCG on developing community engagement and resilience initiatives, not least in responding to Covid.

As mentioned, NHS consultation on the merger with NWL’s 2.2 million people has had limited reach and effectiveness. There is no indication in the proposal that the merged entity will be better resourced to communicate with this vast population, let alone to undertake effective co-production on NWL-wide initiatives across NWL.

6 Forced ‘tri-borough’ amalgamation

The report asserts that there has been agreement on the interim allocation of health leads in each Borough. This matter has not been raised with H&F Council.

NHS NW London has long been fully aware of the objections that our borough and the bi-borough have to being placed together under a single management structure. We are deeply disappointed that you have disregarded the views of three democratically elected councils.

Our three boroughs have spent recent years moving on from our former tri-borough structure. We fear that your forced amalgamation will make it harder for H&F Council to continue to develop and shape services that respond to its own residents’ needs.

We draw limited comfort from the statement that borough-based partnership arrangements will be co-designed with health leaders. We welcome the proposal’s attempt to suggest a division of responsibilities between CCG borough teams and the merged CCG. We look forward to discussing the detail.

7 Insufficient local authority representation

Experience to date with NHS structures suggests a centralising, inward-looking, opaque culture that finds it challenging to operate in an equal and authentic partnership with local authorities.

Recent evidence of this is that, in May 2020, NHS London required CCGs in NWL to submit their plans for a revised Integrated Care System (ICS) with a week’s notice. Although local authorities are integral to ICSs and to NHS London’s requirements (e.g. “A plan on how the system plans to further align and join together institutions within the system, including with local authorities and social care”), neither NHS London nor the CCGs asked local authorities for their views.

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As discussed last Friday, we believe that providing greater local authority representation at both the CCG Board and the ICS Board is essential if NHS NWL is to persuade local authorities that it is genuine about collaboration with them.

At the moment, each local authority is represented on its local CCG Board. We are deeply worried by the consultation proposal to replace this with a single local authority to represent all eight councils on the Board of the merged CCG. We are concerned that this would cast doubt on the legitimacy of the Board.

Democratically elected councils are bottom-up, grassroots organisations. Although the Covid crisis has enabled more local freedoms for now, the NHS is still heavily a top-down one. We do not consider that a single council can adequately represent the health priorities of all eight boroughs’ residents across the numerous areas that the merged CCG will consider.

In our view, each local authority should have its own representative on the Board. Four local authority representatives (each representing two councils) would be the minimum acceptable, with the authorities themselves deciding how this representation should operate.

We look forward to the further opportunity of discussing these points with you.

Yours sincerely,

Kim Smith

Chief Executive

CONSULTATION RESPONSE: LONDON BOROUGH OF EALING

Dear Jo, Thank you for sending your internal consultation document on proposals for the North West London CCG. Firstly, Ealing Council would like to note its appreciation of the close working between the Council and the NHS, at a sub-regional level during the CV19 crisis. Whilst the whole system faced significant challenges in responding to the crisis, the strong lines of communication at the NWL level between the Council and its NHS partners, has contributed to supporting us in better meeting the needs of the community in Ealing. Ealing’s response to the CV19 crisis with its NHS Partners, saw the local system building on the already strong local relationships. Effective local working during this period has reflected and demonstrated the usefulness of the open, and yet close working arrangements within our area. Without these relationships, and the local capacity in terms of staff resources, the impact of CV19 on the local population is likely to have been far worse. As you are aware Ealing Council responded to the previous consultation on the 28th August 2019 and again to further proposals in November 2019. Within our previous responses to NWL CCG consultations, Ealing Council highlighted a number of areas of concern. These included:

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• The very strong belief that the people of Ealing are best served through services, which are provided and commissioned at a local level, which are therefore able to best reflect the specific needs of our community.

• That it is vitally important that any structural/organisational changes to the CCG are implemented with full consideration of their impact. We are disappointed that the April 2021 deadline continues to drive the agenda, despite the huge challenges and pressures the system has faced following CV19.

• The longstanding concern that any restructuring of CCGs will see a relaunch of the ‘Shaping a Healthier Future’ programme, which as you are already aware, we have strongly opposed in the past and will continue to do so going forward.

• Concerns over the allocation of funding reflecting the needs of our community, and that as an absolute minimum, we would expect the current levels of funding for Ealing

residents to be maintained. However, we strongly believe that funding levels should increase in order to reflect the diverse community living in the borough. In addition to these previously stated concerns, Ealing Council would also like to raise the following issues:

• The alignment of Ealing and Hounslow as a shared patch appears to be driven by arbitrary system requirements due to the size of Ealing and some shared degree of commissioning integration. In our view these do not reflect opportunities, which will better support the community in Ealing, or for that matter Hounslow. Whilst Ealing and Hounslow Councils have good relationships, Ealing does not have regular joint working arrangements or shared patient flows with Hounslow, and this raises the question as to why this is seen as a suitable arrangement for Ealing. The single Chief Operating Officer for both Ealing and Hounslow is not in our view a viable position as would mean that neither area has sufficient representation at this senior level. We would therefore propose that each authority area has its own Chief Operating officer to ensure that there is sufficient representation of local need.

• The overall context of the consultation documentation that has been provided, does not refer to how the proposed changes will benefit or improve outcomes for local populations. It is our strongly held view that the restructure should be driven by community need, rather than structural or financial impetuses.

• The proposals also cause us significant concern in terms of the reduction of senior

staffing capacity at a local level, which will impact on both decision making and the delivery of services at a local level that best meet the needs of Ealing’s community. The gap between decision making and the point of service delivery will be widened, and amidst this, there is a genuine fear that Ealing’s voice will not be heard. We do not believe that there will be sufficient senior staffing capacity or local functionality within the proposed model to ensure that the specific needs of the residents of Ealing to be effectively met. With the loss of a single authority senior point of contact being indicative of the lack of commitment to local working.

• We are pleased that the commissioning of community services, including mental health

services, will remain with the Ealing ICP, this will mean that Ealing residents will continue to benefit from the close working between the Council and NHS providers at a local level.

• There are no references to work force planning with the consultation document and we

believe that this is an opportunity missed and that there should be consideration of including this aspect within your planning.

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With regard to the 6 areas of focus included within the consultation document:

1. Ensure consistency in services across NW London Whilst appreciating that there are opportunities for improving consistency across the NWL foot print of the CCG, it is vital that there is continued recognition of the variations in communities across the sub-region. You will be aware that Ealing is the largest authority in the sub-region and has a very diverse community with significant levels of depravation in a number of wards. And with this comes a host of health inequalities that need to be addressed urgently, particularly in view of recent reports on the greater vulnerability of some sections of the population to COVID-19 and other diseases.

2. Ensure equity of access to services of outcomes, to enable our providers to improve outcomes for patients and reduce health inequalities

We are supportive of the drive to reduce health inequalities throughout the sub-region and within Ealing. However, it is important that this happens on the ground with tangible measurable results and with the appropriate level of funding to tackle health inequalities in our borough. We strongly hold the view that local population health improvement needs to have a local focus and that the proposals will not support effective responses to the different needs of communities in NWL. This concern is further compounded by the centralisation of safeguarding activity and we have yet to see clear structures or functionality which will support effective working at a local area in terms of adults or children’s safeguarding. We believe that strong local ownership of the safeguarding agenda is a key tenet in terms of organisations working together to safeguarding vulnerable adults and children in our community.

3. Move resources across NW London and within boroughs to reduce inequalities over the next four years

As stated above, Ealing Council is of the very strong view that current levels of funding should be maintained and improved to recognise the diversity within the borough. We believe that rather than using the restructure as an opportunity to drive funding arrangements “to the bottom” it should be used to ensure that funding arrangements are levelled up and in line with funding for the Bi Borough. We strongly support the increased allocation of funding to Ealing but believe that the current timescale of 5 years to resolve the underfunding of Ealing communities is too long. We would therefore propose that a much shorter timescale is applied to support reduction in health inequalities with specific regard to the diversity of the population in Ealing.

4. Increase our proportion of investment in out-of-hospital services, as a first step we will level up investment in primary care services outside the core contracts

Whilst Ealing Council is supportive of the greater levels of investment in out-of-hospital or community services, we are clear that this should not be achieved at the cost of any reduction of services provided to the residents of Ealing in any area of the NHS including Ealing Hospital, which has already been subjected to heavy cuts. We know that the diverse community of Ealing has been negatively impacted in terms of health outcomes and that CV19 has further impacted on these variations in outcomes. We therefore believe that greater investment should be made into NHS services for Ealing.

5. Patients, residents and GP member practices will continue to be involved in the single CCG and at local level

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The engagement of Ealing residents on an ongoing basis is a key area of focus that we are obviously supportive of. The views of the diverse local communities regarding ongoing levels of hospital capacity in borough, should be reflected in service provision decision making. We will devolve decision making on delivery and integration of services to neighbourhood and borough level as our integrated care partnerships develop. We are very supportive of the need for there to be local decision making and oversight of delivery in Ealing. However, we are concerned that the proposed senior representation for the Ealing ICP is much reduced from previous levels of capacity. We are therefore concerned that this staffing reduction in the senior roles will impact on the viability of the ICP in ensuring that the needs of Ealing residents are both recognised and met through the provision of services. Further to this we would appreciate greater clarity regarding the lead Director role for Ealing, which we understand will be sourced from one of the provider Trusts. Whilst supporting the leadership this will provide locally, we would like to understand whether this represents additional capacity or whether the expectation is that this will need to be provided from within existing local resources. Whilst we value the close working relationship that we have all worked so hard to established, we have major reservations about the implementation and the consequences of these proposals for Ealing and its people, which we hope you will take into account. We would be happy to meet and discuss further, as it could prove very helpful. Yours sincerely

Cllr Julian Bell – Leader

Cllr Binda Rai - Cabinet Member for Health and Adults Services

Judith Finlay, Executive Director, Children, Adults and Public Health

CONSULTATION RESPONSE: ROYAL BOROUGH OF KENSINGTON AND CHELSEA AND WESTMINSTER CITY COUNCIL

Dear Jo and Lesley Thank you for sharing the local authority consultation documents for the development of the ICS with us, as well as giving us your time to discuss them prior to the consultation deadline. We welcome sight of these draft proposals and wish to work with NHS partners to imbed some of the improved ways of working realised as part of the covid-19 response. We agree with the need to capitalise on the relationships developed as part of the covid-19 response and wish to continue working closely together to support and engage with Bi-Borough residents. We are pleased to be able to share our feedback on these documents. For ease of reference, we have focused on five key areas (see below with recommendations).

• Finance The Bi-Borough is deeply concerned about the proposals to reduce funding to residents over five years to RBKC (by £31m) and WCC ( by £10m). The rhetoric has been about levelling up, which suggests a continuation of existing services in the Bi-Borough and expansion of services in neighbouring areas to achieve a consistency of service offer. In the consultation, it states clearly though that core funding will reduce in the Bi-Borough.

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With the amounts being referenced (over £40m in total) we are very concerned that this will result in a reduced service offer to bi-borough residents. It is proposed that Bi-Borough NWL CCG and the local ICP should work together closely and transparently on the financial proposals to ensure no reduction in service offer for residents, as well as considering the impact on our budgets and the integrated BCF programme. As part of any financial strategy, we would expect that a full EQIA should be undertaken, including for all proposals impacting on local services.

• Governance We would welcome an open discussion on the selection, the role, and the

numbers of local authority (LA) Governing Body representatives to find a solution that works for both the NHS and LAs; clarity also to be given on how the new board will work with the HWBB. We would propose that the membership on the NWL Governing Body include four representatives from Local Authorities, and not the one that has been mooted. Furthermore, we would seek to have the four Local Authority representatives drawn from Lead/Cabinet Members across the eight local authorities affected by these proposals.

• Inner London CCG: We would propose that NWL commits to work with us to create one CCG/ICP across the Bi-Borough, mirroring existing council social care services, and provide a clear timeline for this work.

• Senior Appointments We are proposing that LA representation is mandatory on any NHS in-borough and regional senior recruitment panel related to this process and that NWL will work closely with LAs to develop and embed the new structures.

• Autonomy The role of the local committee and their decision-making powers should be clear to all parties, including LAs. We recommend that the borough committee should be independently chaired and membership to include councillors.

We would like to reiterate that we remain committed to working closely with you to ensure any changes that are implemented enhance the service offer to the residents we all serve. Please find attached our previous consultation response. You will see that our position has not changed since we last wrote to you in March 2020. You previously agreed and confirmed at the Health and Wellbeing Board that we would have a Bi-Borough ICP. As part of your response to us, it would be helpful to understand why your position has changed on this. We thank you again for discussing our concerns with us as part of this consultation process. We are very much looking forward to working with you to develop the final NW London ICS and local ICPs. If you have any questions or comments, please let us know. 1. Finance and maintaining high-quality services There is an ambition to ensure financial resources are distributed equally across the NWL ICS in the next five years, faster than the national timetable. As such, the Bi-Borough allocations will reduce (Westminster 3% (£10m) and RBKC 8% (£31m) at the end of 5 years). We are extremely concerned about the NWLCCG deficit and the proposed reduction in financial allocation to our local CCGs and the potential related impact on our residents. With the information provided, it is not possible for us to fully understand what the impact of these changes will be on our services, as well as the Adult Social Care Budget. Whilst, we do appreciate and acknowledge the reassurance given in the meeting to discuss the document that in the first instance the savings will be achieved through efficiencies, we remain concerned though that savings of this magnitude

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will inevitably impact upon existing services, and inhibit the development of a new or enhanced service offer for Bi-Borough residents. As such, for reassurance, we ask for clarification on what the impact of the proposals will be through a detailed and robust EQIA. We are happy to work with you to develop the necessary EQIA. The EQIA issued informally does not satisfactorily address the potential harmful impact of these proposals on our residents. We would value greatly your commitment that the Bi-Borough will be part of any health or integrated service (re)design from the outset. In the Bi-Borough, good partnership working with the local CCG to the benefit of our local populations is clearly evidenced in RBKC. For example, both the council and NHS partners are transparent about our efficiency programmes and work closely together to achieve them. Such partnership working is a highly efficient model that should be replicated across the whole sub region. Any other working approach should build on the partnership model, which has proven itself to be most conducive to achieving effective results for residents. Recommendation: The Bi-Borough is seeking assurance that current service levels will not be impacted by these proposals. The Bi-Borough proposes to work closely and transparently with NHS partners at both levels on financial proposals to ensure there is no impact on residents, as well as on our budgets, or integrated BCF programmes. As part of any financial strategy, a full EQIA should be undertaken, including any proposals impacting on local services. The EQIA and financial strategy should be developed and agreed jointly with the local Health and Wellbeing Board. 2. Governance The consultation documents clearly recognise the role of LAs. We welcome your openness and willingness to work in close partnership with us. We also appreciate that you acknowledged during our meeting that any investment in adult social care has a positive impact on health services. However, clarity is needed on what our representation will be on the newly created boards. For example, the consultation documents indicate that there will be only one LA representative from the eight boroughs with a non-voting role, intended to be a Director of Public Health, and there is no explanation for why Local Authority representation has been limited or even on how that person will be selected. There is no local authority-equivalent of the NWLCCG Governing Body i.e. eight local authorities representing our interests against one NHS representative in the ICS footprint. Each Governing Body decision should acknowledge that LAs are sovereign, and the relevant LA should be able to directly provide feedback on decisions that affect their borough. We also ask why the Governing Body representative should be limited to a single Director of Public Health, rather than Lead/Cabinet Members or a senior social care representative. Given previous collaboration between our organisations, we have a strong track record of partnership working to the benefit of our residents’ health and wellbeing. It is reassuring to note that the NWLCCG Governing Body will be aligned to the Health and Wellbeing Boards (HWBBs). We would like more clarity on how the new board will work with the HWBBs, towards shared objectives. Although we understand the challenge of having multiple representatives on the NWLCCG Governing Body, we are of the opinion that one LA representative would not be able to effectively cover all eight boroughs’ needs and stances. As such, we would welcome an open discussion for this to find a better, mutually agreed solution. Recommendation: We would propose that LA representation on the Governing Body be expanded from one to four and that representation is drawn from the lead members of the eight Local

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Authorities impacted by these proposals. We would welcome an open discussion on the selection, the role, and the numbers of LA Governing Body representatives to find a solution that works for both the NHS and LAs. Further clarity also needs to be given on how the new board will work with the HWBB. 3. Inner London CCG: Although not included in the official consultation documents, we understand that NWLCCG is still proposing a Tri-borough CCG. We have serious concerns about this and have openly and repeatedly raised them with you in person, and in writing. You told us that this is merely a structural arrangement that it would not affect our borough-based health services. We feel it is important to write to confirm our position: we do not think a Tri-Borough CCG is the right way forward for Bi-Borough Adult Social Care. The Bi-Borough previously shared social care services with LB Hammersmith & Fulham but this arrangement was disaggregated due to our differing visions, direction of travel and service priorities for our residents. We would like NWLCCG to respect this and align health service structures with those of the Bi-Borough in the interest of consistent services and not bring us back to a situation we worked hard to move away from for two years. In addition, as part of our in-person discussions about the consultation, it was welcome to hear NHS colleagues acknowledge the difficulties experienced with the boundaries between CL & WLCCG, which do not align with RBKC and Westminster’s borough boundaries. This presents several challenges, including complicating data collection, service design and the work of frontline staff, as well as creating inequality in accessing services. As the ICP aims to support integration, we want the boundaries between the two (comparatively small) CCGs to be lifted. Recommendation: We would propose that NWL commits to work with us to create one CCG/ICP across the Bi-Borough, mirroring existing council social care services, and provide a clear timeline for this work. 4. Senior Appointments We must ensure that LA work effectively with local NHS bodies to realise the integration of health and social care services. We are very encouraged by your enthusiasm and commitment to investing in integration and closer partnership working between our organisations. As discussed with you, LA representation is critical to any NHS in-borough and regional senior recruitment panel. In the spirit of closer partnership working, we would expect that LAs input into NHS senior staff recruitment in our boroughs, as well as ensuring LAs are represented on recruitment panels for NWL appointments. Likewise, we would like to offer NHS partners a seat on our senior ASC recruitment panels. Recommendation: It is agreed that LA representation is set as mandatory on any NHS in-borough and regional senior recruitment panel related to this process and that will work with LAs. 5. Autonomy We have been very clear about the importance of local decision-making. We know our populations’ needs best, and our boroughs’ individual challenges in terms of inequalities. We are concerned about NWLCCG interference in local decision making, and the new single CCG may impact local autonomy. Although we welcome the development of local committees, we have serious concerns about their autonomy to determine local health priorities. We would like your commitment that decisions about our residents’ health and care will be made locally and, as stated

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in your documents, NWLCCG will hold the strategic oversight and decision-making responsibilities across the footprint. Recently, most decisions are deferred to NWL. This may be appropriate in a pandemic situation, but in ordinary times, we must retain local decision-making autonomy, as expected by our residents. Recommendation: The role of the local committee and their decision-making powers should be clear to all parties, including LAs. We recommend that the borough committee should be independently chaired and membership to include councillors.

Kind regards, Cllr Sarah Addenbrooke Lead Member for Adult Social Care and Public Health Royal Borough of Kensington & Chelsea Cllr Tim Mitchell Cabinet Member for Adult Social Care and Public Health Deputy Leader Westminster City Council

CONSULTATION RESPONSE: LONDON BOROUGH OF HILLINGDON

Dear Jo Re: Proposed Merger of eight NWL CCGs from April 2021 I write in response to the consultation meeting you and NHS colleagues had with Fran Beasley, Tony Zaman and Kevin Byrne and I, about the proposed merger of NWL CCGs. Thank you for the full and open discussion, please treat this as our formal response. You will see reference to the CCG merger and the development of the ICS/ICP, as we have some quite distinct points about both. We share our views being well aware of the drive from the NHS centrally, but still urge consideration reflection during the design, given the unique nature of our health and care system vis-à-vis other areas: well over 80% congruence with services for the single population of Hillingdon. The ICS and CCG question are intrinsically linked in our view, as we believe that the provider base is neither financially stable enough or offering sufficient ‘challenged’ quality and/or value for money, to be left to reorganise and make up the deficits they carry, without a strong commissioning and challenging role of the local CCG. Even accepting the CCG merger, driven through under the cloak of the pandemic, is an NHS fait accompli, there is the scope to maintain a much stronger local presence, to reflect the congruent system described above; it makes little sense to consume this activity into the more complicated patient flows across the rest of NWL, other than to crudely make management savings at the expense of Hillingdon and hidden behind a rationale of a grand design. Hillingdon CCG and the Council have made great strides aligning activity in order to add value to the whole system, mainly through the BCF, which houses a range of innovative service and financial designs. We quite deliberately use the term ‘aligned’ to point out that with the complete lack of clarity around the financial modelling of the CCG and ICS design, it becomes a bigger problem for a greater number to share, as such the local authority has had to maintain a robust single sight of its budgets and align, rather than the greater

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opportunities that may arise from pooled ‘right’ shares not weighed down by the significant local NHS deficits. Further, in relation to the ICS we shared our view, that if there were earlier more clear and open engagement with LAs, there may have been an opportunity to challenge providers to be in a much more fit state, or replaced through open completion, before the competition rules were changed for the NHS and incumbent providers, irrespective of their performance or viability, were directly awarded a contract and a seat to shape the local system. This is quite at odds with extant rules for LAs and particularly for Hillingdon, which will only take decisions based on residents’ benefits and value for money. I also understand that the rationale behind the Brent /Harrow /Hillingdon cluster as being primarily to reduce management overheads, and we note the current staffing consultation. We wish to reiterate the point that the coterminous nature of having one local authority, one main hospital and one community provider and one voluntary sector consortium provides a strong foundation for local solutions in Hillingdon to be local by default. In terms of governance we note the proposals for the borough leadership team and the new CCG borough committee. We will work with the HHCP delivery board and see this as reporting upwards to the Health and Wellbeing Board as the place where senior leaders shape the strategic direction of heath and care in Hillingdon (as well as upwards to sovereign governance bodies such as Hillingdon's Cabinet). You will be aware of the strong track record that Hillingdon Council and the CCG have of working together, to be creative and innovative; without the honest brokering of a strong CCG presence for Hillingdon, we fear that the pace of change is too quick for providers to think out of their sovereign status and into the collective greater good, a stronger transitional ‘commissioning’ steer would support required challenge and decommissioning and re-commissioning that will be required to reduce the current base costs. This notwithstanding, you have our assurance that we shall continue to work with whatever the system emerges to be and continue to provide the balance of innovation and challenge that is a Hillingdon system motif. Kind regards. Yours sincerely Cllr Jane Palmer Harefield Ward and Cabinet Member for Social Care, Health & Wellbeing

Additional feedback received through engagement

From: West London NHS Trust

Dear Jo, Re: Proposed merger of the eight North West London Clinical Commissioning Groups (CCGs) - your letter dated 5th August I am writing with the Trust’s response to the above proposal as part of the North West London CCGs consultation. As you know, the Trust is unequivocal in its support of the merger of the current eight North West London CCGs into a single CCG in April 2021. The frustrations and inefficiencies inherent in

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delivering high quality, responsive services commissioned across eight separate bodies are widely recognised. The move to one CCG and local population based health – building on existing borough partnerships - also presents a clear opportunity for some functions and budgets to be delegated to providers, building on work already underway on the integration of physical and mental health. This could, for example, include the development in Hounslow of a community health partnership similar to Ealing Community Partners and the Trust would be well placed to lead this. In line with national policy, the Trust is leading or is a partner in a number of provider collaboratives, including the North West London CAMHS Provider Collaborative, with delegated commissioning functions and budgets delivering demonstrable service and financial benefits. As you will know, work is also well underway on the development of a consistent core offer for mental health, learning disabilities and autism via the North West London Collaborative in partnership with Central & North West London NHS Foundation Trust. Before the Covid-19 crisis, there was a discussion with Ealing CCG about West London NHS Trust taking on some delegated functions and/or hosting some elements of the local commissioning and/or delivery. The Trust is keen to reconvene this discussion as soon as possible. The above has been our position for some time and our experience during the Covid-19 crisis – during which the NHS in North West London worked effectively across organisational boundaries and in partnership with local authorities and other organisations to ensure a co-ordinated response – has only served to reinforce this. There are some areas of the current proposal, however, about which we have significant reservations and would ask either for clarification or for changes to be made to the final structures:

• Mental Health, Learning Disabilities & Autism (MHLDA) Programme Structure

The MHLDA programme has a wide and complex remit, underpinned by the national commitment to meeting Mental Health Investment Standards and ensuring parity of esteem. There are a raft of Long Term Plan targets to meet. The phase 3 return includes detailed investment proformas, which is not the case for other programmes. There is, however, no parity between the structures proposed for the MHLDA and local care structure programmes. The resources proposed for the latter are double those for the former.

We would ask for these resources to be looked at again and allocated more evenly across the two programme structures.

• Case for change

There are concerns from the boroughs about loss of local voice and clinical leadership. The proposed Hounslow and Ealing CCG grouping overlooks the lack of sufficiently joined up working between the two boroughs, both in terms of the CCG and local authority leadership. Nor does it reflect existing referral patterns, the way in which services have developed or in which voluntary sector organisations work.

• Executive structure

The size of the Director of Nursing portfolio in the Integrated Care System (ICS) is substantial, both in terms of its remit (including governance and operational delivery) and of geography. Experience during the Covid-19 crisis has demonstrated that it has not always been feasible for a single directorate to co-ordinate effectively and that, in some cases, the quality oversight, assurance and delivery functions need to be separate. Our concern here is that these critical functions are at a risk of getting lost in such a broad directorate.

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• Communications & Engagement structure

It would be helpful to have more detail as to what the engagement resource (five posts, plus local engagement teams) in the proposed structure would cover and how this would marry (rather than cut across and/or duplicate) with engagement at a local level, where knowledge and strong relationships already exist.

I look forward to hearing from you on the above. Please let me know if you need any clarification on the above. Kind regards, Yours sincerely Carolyn Regan Chief Executive

From: London North West University Healthcare NHS Trust

Dear Jo,

Re: Proposed Merger: North West London Clinical Commissioning Groups

I am writing on behalf of LNWHT NHS Trust in support of the above. This proposal us the most appropriate way forward for commissioning in NWL for the reasons stated in your later dated 5 August 2020.

Achieving the balance between NWL and place based activities will be essential for maintaining the support of our local authority partners.

Kind regards,

Chris Bown

Chief Executive

From: Brent Patient Voice

Brent Patient Voice representations on: 'The Case for Change': Proposed Merger of 8 NW London NHS Clinical Commissioning Groups 7 September 2020

Ms Jo Ohlson Accountable Officer NW London Collaboration of CCGs Dear Jo In your letter of 5 August you invited us to send in any further representations after our ones dated 23 August 2019 which we attach and continue to support. Brent Patient Voice is a cross-party members voluntary association with a constitution designed to give a voice to the health care interests of the residents of the London Borough of Brent. We now write to express our increased grave concerns.

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Over and above all detailed considerations, we find it tragic that the leadership of the NHS in NW London should have so far lost its vision of what the NHS is for that it is pursuing a major administrative and governance upheaval in the middle of the worst global pandemic to affect the UK in the last 100 years. Once again we urge a rethink to put the needs of patients first and to focus all energies and resources on preparing the NHS and the public for the next wave. Even in the last two days national infection rates have increased alarmingly. We submitted our response to the first iteration of the Case for Change in our document of 23 August 2019. We argued that the case was not made. We pointed out that the speed of the process at the time did not bode well for the co-operation with local authorities and other stakeholders which was essential for improved delivery of services. We suggested that huge size of the NW London population and the lack of any identity for the area of coverage chosen constituted major disadvantages and that more local groupings should be examined. At that time the absence of a proposed constitution and financial plan left major questions about a Brent voice and fair shares for Brent hanging in the air. We expressed concerns about WSIC and the use of digital information to allocate resources on a “capitated” basis. Since last summer a draft constitution has appeared and a low key debate about future finances has begun. We are not aware of any active public debate about the draft constitution but as far as we can see it contains significant loose ends and does not provide assurance that in any crucial discussions about policy or resources Brent representatives will have a decisive voice – or that any Brent representatives will be accountable to anyone in Brent. This is not surprising since the whole project is a centralising one, designed to stifle local voices and local independence. Turning to finance and fair shares it is now admitted that Brent, as one of the most deprived boroughs among the eight, has fared worst in recent years. In response we are told that the aim under the new scheme will be to eliminate Brent’s overall disadvantage in 5 years and its disadvantage in resources for primary care in 4 years. To help us believe this we are offered in the letter from Lesley Watts of the “ICS” her personal assurance that she is committed to this objective. We find this to be an illusory assurance. Officials are not permanent and cannot offer personal assurances or guarantees on major policy issues. What a NW London CCG will do with its resources will depend first on the amounts it receives from NHSE and the accompanying instructions and secondly on its own corporate decisions. Furthermore the ICS remains a shadowy entity, with no legal basis, virtually invisible and certainly unaccountable. Moreover the recent past on these matters is the very opposite of re-assuring. The removal of health inequalities was, if we recall correctly, the first of the praiseworthy objectives with which Brent CCG came into being in 2013. This doubtless reflected the findings of the major report by Sir Michael Marmot on the social determinants of health. In the real world we have seen the downgrading of acute hospitals, the closure of A&E Departments and the CMH maternity unit to the great disadvantage of patients in areas of high deprivation, as well as various re-configurations of GP practices which have not helped patients. Why should anyone believe in the light of this experience that Brent will fare better or even fairly as part of a merged body in which it has no decisive voice? Beyond this there is the impact of wave 1 of Covid-19 disease on Brent. Without doubt we have been the hardest hit area in the UK and one of the hardest hit in Europe as regards both patient and healthcare staff deaths. We applaud all our local heroes. Yet we have seen no empathetic or tangible response from NHSE to the depletion of local resources. We believe that the Brent CCG Governing Body on 19 August 2020 was right to ask many questions. So far we have not seen relevant answers. We express the hope that the 8 Clinical Commissioning Groups will not vote for the merger next week but put the whole question on ice for the time being, not least until Parliament has sanctioned

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the creation of ICSs as a major delivery mechanism in the NHS – if it chooses to do so. Yours sincerely Robin Sharp CB Chair Brent Patient Voice Background Brent Patient Voice (BPV) is an independent voluntary body in the London Borough of Brent with a publicly elected Steering Group which expresses views on healthcare issues to the NHS and other public authorities, as well as to the wider public. We are pleased to have this opportunity to give our views on current plans to merge 8 North-West London CCGs into one mega-CCG for the same area. We understand that the resulting body would be the largest such merger in the country (Health Service Journal, 23 July 2019). We have taken account of three “consultation” documents: The Case for Change, June 2019; The Case for Change: further details, July 2019; and JOHSC paper: an update on the Commissioning Reform Case for Change, 22 July 2019. We have also had the benefit of a direct meeting with Mark Easton and Rory Hegarty on 24 July. Notes from this meeting have been agreed between us. We attended the special local authority JHOSC on 22 July. We have requested but not yet seen any draft Constitution for the proposed merged single NW London CCG, nor a financial plan for it. We have been advised that a draft Constitution exists but that it is not yet in the public domain. Some of the issues that concern us (not comprehensive) 1. Speed of the engagement process Although we consider that the re-organisation proposed is intended to have an effect on the way in which clinical services are delivered (whether or not this involves changes in pathways to level clinical services up or down in the name of removing health inequalities) and that accordingly section 14Z2 of the 2006 Act applies, we do not intend to split hairs on this topic. The broader point is that the borough authorities through the JOHSC have made clear their deep unease about the speed and lack of detail with which the exercise is being conducted in order to meet an artificial deadline being encouraged by NHS England. This seriously risks jeopardizing relationships between boroughs, CCGs and hospital trusts which have been painfully and gradually built up over the last few years and are essential if hospital discharges and other community services are to be effectively integrated. It is ironic that all this is supposedly being done in order to implement the NHS Long Term Plan aspirations for Integrated Care Systems, which will require even deeper involvement of local authorities than anything so far seen. It is also evident that in the last analysis the merger can go ahead whatever the local authorities think. This cavalier approach does not engender co-operation but leaves local authorities and other key partners with the impression that there is a hidden hand in the higher NHS bureaucracy driving the proposals forward for their own purposes. It is clear that the merger proposal is not a response to local pressures or frustrations with the borough CCGs as currently organized, notwithstanding the signatures of the CCG Chairs on the first of the Case for Change documents. At present the scheme looks like a power grab by the largely unaccountable centre of the NHS. The history of centralized top-down planning in public organisations in this country and around the world over the last 100 years does not bode well for an NHS operating in this way. Moreover few

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would deny that there has been too much organizational change during the 70-year history of the NHS or that overall such change has done little to tackle its fundamental problems. Deck chairs and The Titanic come to mind. Irrespective of the merits or otherwise of an 8 CCG merger, BPV considers that agreeing to postpone the target for a new body to April 2021 would be much more likely to gain the understanding and co-operation of the key partners the NHS needs to work with in order to deliver joined-up healthcare services over the next 10 years. The reasons given for undue haste are not convincing. 2. Why NW London as the area selected and why such an enormous population to be covered? As we have noted the new mega-CCG would serve a population of some 2.2million and would be substantially the largest of the wave of mergers now in train in England. It might also be the largest CCG. CCGs are authorized by the Health & Social Care Act 2012 and their creation represents the principal provision of what was agreed to be one of the most controversial pieces of legislation of that era. While it is the case that the Act does not lay down the precise number of CCGs to be created nor the maximum population to be covered by an individual CCG there was a broad understanding that each CCG would deal with at least one mainstream hospital trust and relate to a principal local authority for essential co-operation on health and social care matters via a Health and Wellbeing Board. Similarly, while there is statutory provision for CCGs to merge with each other there is no express limit to the number of CCGs in any one merger operation. However if anyone had suggested during the passage of the Bill that it could lead to what is in effect a regional CCG needing to relate to 8 London boroughs with a population of over 2 million they would have been met with derision. If the fact that there is no express limit on the number of CCGs that can merge into one was taken literally, this could result in one CCG for the whole of the country. This would be manifestly absurd and contrary to the scheme of NHS re-organisation debated by Parliament and laid down by the Act. Since the Case for Change papers offer no analysis for selecting the particular 8 NW London boroughs for a mega-CCG, it seems to us that the reason derives somewhat lazily from the structures already in place for two recent discredited NHS schemes for the same area. In 2013 the eight NW London CCGs and the population of the eight matching boroughs were grouped together as the subjects for the Shaping a Healthier Future plan without having any say in the matter. (The title was a classic example of spin over substance.) This plan has now been formally abandoned because its central premise – that 500 acute hospital beds could be saved – has proved fallacious. In the process much damage was done to A&E and maternity provision and some £70 million was wasted on management consultants for no clinical benefit (see calculations by Colin Standfield). When the so-called Sustainability and Transformation Plans (STPs) were created in an enormous rush in 2016, including one for the eight NW London boroughs, we asked senior figures for the rationale for 44 STP “footprints” in England. We were told that it was to enable the NHSE leadership to deal directly with the 44 local leaders, which was not feasible with around 200 CCGs. Indeed we heard the Chair of NHSE say at the annual Olympia Health Show that he wanted to use the STPs to “work around” the legislation. In simple language he meant “bypass Parliament”. This STP was never a practical reality. It did not produce sustainability (i.e. financial recovery) nor transformation of clinical care. It has now faded away to be replaced by the even more nebulous “Integrated Care System” heralded in the Case for Change.

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We are surely stating the obvious when we say that North West London is not a recognizable area of local or any other expression of government. It has no structures with which the NHS could co-operate. It means nothing to the person in the street. 99% of people in Brent would not be able to distinguish Hillingdon from Hounslow and vice-versa, let alone list the boroughs to be covered by the proposed organization. Identity is linked to accountability. It is hard to avoid the conclusion that NHSE top management wish to make NHS commissioning less accountable than it already is. The reason for this may be to enforce a top-down financial system through allocating a fixed sum per head for each patient in the area (the capitated budget) or to promote the novel and as yet unexplained Integrated Care Systems. The Case for Change says that we must have one CCG for NW London because the centralizing NHSE Long Term Plan ordains that the CCG should align with the “Integrated Care System”. But where has the “Integrated Care System” for NW London been set out, much less discussed with all relevant partners and the public? The ICS concept, as far as it can be pinned down at all, raises a host of legal, contractual, practical and clinical issues which have NOT been aired, let alone debated. Adopting a new payments system for care services and ending the purchaser/provider split may sound to be highly desirable but, even if the cultural changes needed could be realized, legislation would also be essential if all this were to happen. There is as yet no sign of any legislation, but rather Parliamentary turmoil for some time ahead. In our view the case for the ICS needs to be made BEFORE any CCG merger to support it. Without being convinced that the present system of borough level CCGs is so deficient that organizational upheaval is justified we believe that alternative re-configurations should be examined and presented for engagement if the NHS is determined to proceed at this juncture and if it has any desire to take key stakeholders with it. For example Brent, Harrow and Ealing share various population characteristics and relate mainly to one hospital trust. Westminster shares profiles and providers with Kensington and Chelsea and so on. We accept that one valid point that has been made about the present framework under the Act is that a regional or strategic element is missing. However this is what the current scheme of delegation to the Joint Committee secures, while leaving the CCGs to deal with community and primary care issues at borough level. Surely that should be given a chance and thoroughly evaluated before any further move is made? The fact is that NHS commissioning should ideally take place at a variety of levels but in practice compromises have to be made. Primary care must be done at local level and it would seem absurd to gather it to a NW London centre and then pass it down again to some borough level entities surviving from the abolished local CCGs. 3. Where is the draft constitution for a mega-CCG and how can GP practices who constitute the membership of the existing CCGs realistically vote on it without a process lasting several weeks to seek advice whether to surrender their statutory independence or propose amendments? Among the major questions that CCGs, doctors, local authorities and stakeholders are asking is the nature and scope of borough-level NHS entities that will emerge to deal with community and primary care. We have heard a suggestion that the borough LMCs will elect the clinical leads that are planned to represent each of the 8 boroughs on the mega-CCG but this would mean giving bodies outside the formal NHS structure and largely invisible to the public the majority vote on a body spending £3-4 billion of public money annually. The likelihood that a constitution which stretches the scheme of governance well beyond anything envisaged by the 2012 Act will be “right first time” is completely unrealistic. There must be a process for debate before any version is finalized. The fact that a draft constitution was not available when the first Case for Change paper was issued is a tacit admission that the proposal has not been fully thought through by NHSE. This alone demonstrates the case for delay till 2021 at least.

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4. Finance matters Both meanings are intended. We were grateful to be told in our meeting with ME about the principle of distributing healthcare resources according to the Fair Shares rule and the admission that Brent had fared least well at the time the CCG was set up. It is generally understood that organizational mergers are most likely to succeed if extra funds for services can be provided as part of the package. Beginning a new mega-CCG or tri-borough CCGs with a fair and transparent allocation of funds related to population needs under the Fair Shares principle, together with a writing off of current historic debt would be most likely to win support for the new body. Instead we are faced with a supposed debt of £100 million across NW London and a series of unpalatable service cuts to address it, notwithstanding the £billions the previous and present Prime Ministers have announced for the NHS. Without a paper setting out in detail how Fair Shares and health inequalities are going to be addressed in the new regime there is nothing to demonstrate that the new plan will deliver anything better than the wretched situation we have now. The record of SaHF and STP bode very badly for mega-schemes in NW London. 5. Digital primary care and Whole Systems Integrated Care (WSIC) Since our meeting with the NWL Accountable Officer and Communications Lead we have appreciated the opportunity to pursue some follow-up questions on the intentions behind the references in the papers to digital primary care and to the way in which personal data transferred to the WSIC database may be used. With respect to digital primary care we have been advised that this is a reference to the important role of Primary Care Networks over the next few years, more or less in the terms set out in the NHSE Long Term Plan. We are aware of the PCN arrangements in Brent and that formally this system only came into operation last month. In so far as it should mean the provision of extra Allied Heath Professional (AHP) staff to networks of geographically adjacent GP practices we welcome it as a contribution to the pressures these practices are facing. However we are aware that in Brent a number of PCNs consist of practices that are too far apart for patient convenience and that if and when extra staff (themselves a scarce commodity) become available tricky issues about how they are shared will arise. The culture of GP independence which has been a key feature of the NHS since Aneurin Bevan brought it into being in 1948 is not going to be overcome in a few months by the appointment of PCN clinical directors. As far as WSIC is concerned we in BPV have followed it closely since its inception. We do not believe that those patients whose data has been included are fully aware of what is there, not least if any interaction they may have had with Social Services is included. Moreover if fresh data is added the records must be identifiable by somebody. We will continue to press for transparency and dialogue on this issue. In fact we believe that this will be welcome to those operating the system. On related clinical matters we consider that many issues referred to for development in the Case for Change can and should be pursued irrespective of whether the 8-CCG merger goes ahead. Prime examples are the Integrated Care Partnerships under which there is joint commissioning by boroughs and CCGs for community services, continuing care and similar initiatives. Dr MC Patel spoke eloquently about these at the JOHSC meeting on 22 July, but was not able to contradict the Westminster councillor who pointed out that such arrangements could be taken forward now. 6. Conclusion Our conclusions are:

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• any re-organisation should be based on full disclosure of coherent plans, including a constitution and financial plan and that it would be risky and damaging to confidence to rush this through during the next few weeks;

• in spite of the engagement process to date the Case for Change has not been made and should not therefore proceed.

Brent Patient Voice 23rd August 2019 Contact: Robin Sharp CB, Chair, at robisharp@gmail.com .

Healthwatch Harrow Case for Change Feedback August 2020

Please see below the questions / comments in relation to the Case for Change for a single NWL London CCG – August 2020 from Healthwatch Harrow.

No. Reference Comment / question 1. General What is the Harrow Model for patient / resident engagement to

ensure that feedback on the local availability and quality of services influences future commissioning of services?

2. General Are there clear lines of accountability that will enable local people to challenge and influence decisions made at NWL CCG level about what health and care services are available to them in their local area?

3. General How does this model ensure there is Local influence – there will be approx. 250 practices covered with this – we need to ensure that the people of Harrow are heard and there is a patient input from Harrow. Would we lose power?

4.

General In what way are Brent, Harrow and Hillington being grouped together, e.g. page 1 - a shared CCG COO working across 2 or 3 boroughs. What work / decisions are part of this framework and how does this impact / feed into the Harrow Borough Committee (HBC)?

5. General What is the impact on all current stakeholder meetings, it is assumed these will change, have these been mapped out so there is clarity around the information, engagement, and flow?

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6. General What level of transparency will there be around budget allocation? We would like to see how and what level of duplication will be eradicated, and savings directed to front-line needs.

Will there be transparency about budgets between boroughs. Would a management level appear in the budgets?

7. General What protocols will be in place to address respective Boroughs sensitivities, priorities etc. to ensure there is fairness for all boroughs. Some boroughs may be more “needy” than other boroughs. How can we ensure that Harrow is not short-changed or loses out over funding or patients having to travel far to receive services.

8. General What communication strategies' and arrangements will be in place?

9. General How will Healthwatch and local authorities in each area retain

responsibility and power to use local patient experience to scrutinise and tackle poor performance or gaps in health services at a local level where those services are commissioned at a single NWLCCG level?

10. General PCN’s what is their role within this new framework and are they funded to do what is asked of them?

11. General How will the NWL CCG ensure that all local Healthwatch have the resources and support to fully represent local people’s views and experiences in discussions on health and care provision that are happening within Primary Care Networks and Integrated Care Partnerships at a local level, as well as being part of conversations at the NWL CCG level?

12. Page 5 Point 3 – if the aim is to ensure consistency in services across NWL, what happens if a borough has a different view to what the NWL CCG, do they have to follow what is agreed at NWL CCG.

13. Page 5 Point 5 - Whilst this this case for change relates to the NW London Collaboration of CCGs, it also refers to the Local Authority – when we are talking on page 5 about the patient voice are we also talking about the residents voice – including those who access social care services?

14. Page 5 Point 6 – “We will devolve decision making on delivery and integration of services to neighborhood and borough level” – what sort of timescales are we talking and will it be all boroughs at the same time on a borough by borough basis. Who decides when and based on what criteria?

15. Page 6 Borough GP member on the single CCG – how is this person selected/appointed?

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16. Page 6 & 7 Pay partner:

• What is the role of the lay partner at borough committee level and at the Single CCG level?

• Where will the 5 lay members be drawn from and who are they representing?

• What is the process of recruitment and selection?

17. Page 7 Single NWL CCG – this currently does not show HW engagement at this level? What model of engagement will there be at NWL level for Healthwatch?

18. Page 7 What is the rational for 1 Sessional GP being a member of the NWL CCG?

19. Page 7 Director of Public Health representative – for the 8 local authorities – what role will this be going forward with the changes in Public Health?

20. Page 8 Local residents voice: • Single NWL CCG – how do they hear the patients /

residents voice? It says through Engage-Participate-Involve-Collaborate. There has been no engagement with HW Harrow regarding this, how does this sit / support the Harrow Model for patient / resident engagement?

• EPIC – How established is this? How many people are engaged in the citizens panel? How is the information / intelligence captured here shared with the local Healthwatch’s? Does it capture borough intelligence?

21. Page 8 The Borough committee will include patient representation –

looking at the membership of the CCG Borough Committee – who is responsible for this at borough level? Links back to what is the Harrow Model for patient / resident engagement, HW Harrow are only funded to undertake targeted engagement, how do we pick up key intelligence from other sources e.g. HPPN, PALS etc?

22. Page 10 Single Out of Hospital Director – what is the process for selection and appointment to this role, who makes the decision as to who?

23. Page 10 How does the Local Authority Lead this sit within the borough leadership team – is there equity, as their structure is different?

Marie Pate, Operations Manager, Healthwatch Harrow/Enterprise Wellness

Marie.Pate@enterprisewellness.uk

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NWL CCG Merger – response from Healthwatch Ealing, Hounslow and Hammersmith and Fulham September 2020

Healthwatch Ealing (HWE), Healthwatch Hounslow (HWH) and Healthwatch Hammersmith and

Fulham welcome the opportunity to comment on the proposals to merge the eight CCGs which

make up North West London.

As a local Healthwatch our role is to ensure that local people are actively involved in shaping the

health and care services that they use, and that they have a say on how decisions about what

health and care services are available for them. We also monitor local provision and hold

commissioners and service providers to account for the quality of local publicly funded health and

care services.

This response is submitted under our statutory power to hold the NHS and the Local Council to

account.

Role of Borough Committee

The Case for Change document implies that the borough committee’s purpose is to implement

decisions made by the single CCG. If this is the case, that a decision has already been made, then

there is no opportunity for Healthwatch to influence this. Can any examples be worked through with

Healthwatch to demonstrate this in practice?

Membership of Single CCG

There is no obvious provision for Healthwatch’s voice to be heard at a regional level. Healthwatch

will be represented at borough committees (page 6), but the proposals do not indicate how that

voice will then be heard at a regional level. It may be the intention that they should be allocated

one of the lay member places, but our belief is that Healthwatch should be given its own voice to

reflect its independent status. This is of concern, taking into consideration that the CCG will be

responsible for developing policy and making decisions that borough committees will then be

responsible for implementing.

It also needs to be considered how many places Healthwatch representatives should be given at a

regional level as to allocate just one place for eight Healthwatch is unrealistic and unfeasible, and

we believe would be an attempt to diminish our role as the consumer champion for health and

social care services.

Failing to provide fair representation of all eight boroughs may lead to a repeat of

situations encountered in the past, namely that under the Shaping a Healthier Future consultation,

decisions were made that did not necessarily benefit a local population of one borough or another

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and were in stark conflict with the views of the local community. Has an example case or cases like

this been worked through?

Lay Membership of the Single CCG

We would also like to see clarification on the following points in relation to lay members:

• How will lay members be chosen?

• What remuneration will lay members receive?

• What role will lay members have in representing the public?

• Will these responsibilities rest with all lay members or just some?

• How will the public from each borough be represented?

Approval of Reports

It needs to be considered and agreed how Healthwatch reports will be handled under the merged

CCG. We would like to request that the CCG makes an official response to each report submitted

along with proposals to rectify any shortcomings.

Public Engagement with NWL CCG

The Case for Change document fails to outline how members of the public will be able to engage

with these meetings and what facilities or features will be put in place to encourage this. We

strongly believe that this needs to be addressed, as it has been stated as one of the commitments

to North West London (Page 5 - Patients … will continue to be involved in the single CCG and at

local level).

References to working with Healthwatch and the EPIC programme

EPIC is a new programme and has not been discussed in any detail with all the Healthwatch in

North West London; only one Healthwatch has been involved. There has been no proactive

outreach and communication about EPIC, and this is of great concern to us; it is telling of the

approach NWL have taken to date and the substantial changes that are needed in their working

relationship with Healthwatch.

The Case for Change document identifies that a best practice approach to patient and public

involvement is central to the approach and that ‘We are already working with Healthwatch and

local people to develop proposals for how this will work in practice’. This is simply not the case that

NWL are working with all Healthwatch on developing proposals and bearing in mind the diversity of

the eight boroughs, and the fact that the merger seeks to “reduce inequalities” as part of its

commitment, it is imperative that they do so.

Summary

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• We note the nature of this cost-cutting exercise and remain deeply concerned about the

reduction of local influence that it will entail.

• We are concerned about the influence and role of Healthwatch Ealing, Hounslow and

Hammersmith and Fulham within the merged and local arrangements.

• There is a need for NWL to engage with and work equally with ALL Healthwatch, and their

respective boroughs patients and public in the region. This does not currently happen and

will need urgently addressing within the new system. There must be equity,

acknowledgement and adjustments made to accommodate each of the local Healthwatch

and borough populations.

FROM CENTRAL AND NORTH WEST LONDON NHS FOUNDATION TRUST From: Claire Murdoch Chief Executive CNWL NHS Foundation Trust 350 Euston Road Regent’s Place, London NW1 3AX Tel: 020 3214 5760 Dear Jo Proposed merger of the eight North West London Clinical Commissioning Groups (CCGs) Thank you for your letter dated Wednesday 05 August 2020 regarding the above proposal as part of the North West London CCGs consultation. The purpose of this note is to set out the Trust’s views on the proposal. The Trust fully supports the merger of the current eight North West London CCGs into a single CCG in April 2021. We recognise the benefits and opportunities that come from a single CCG coterminous with the ICS footprint, supported by strong borough-based arrangements, with strong clinical input and local voice. We welcome the strong emphasis on borough partnership working at the different levels in the system. We believe this presents a clear opportunity for some of the functions and budgets currently held by CCGs to be delegated to providers, building on work already underway on the integration of physical and mental health. You will be aware of the recent progress in the borough of Hillingdon in which the Trust will be taking on a lead integrator role across Hillingdon Health and Care Partners. We are keen to explore similar arrangements in other boroughs. We also recognise the opportunity as commissioning becomes more streamlined and strategic in line with the Long-Term Plan (LTP), for provider-led collaboratives to enable providers and commissioners to integrate fully and transparently, and for these partnerships to start to pick up key responsibilities in relation to population health. These will play an important role in

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advancing equality of access and model fidelity across boroughs, delivering improved outcomes for our service users and addressing inequalities across local communities. In line with national policy, the Trust is leading or contributing to a number of provider collaboratives, including the North West London CAMHS Provider Collaborative, and from October leading the North London Eating Disorder Collaborative. These arrangements include delegated commissioning functions and budgets delivering demonstrable service and financial benefits. As you will know, work is also well underway on the development of a consistent core offer for mental health, learning disabilities and autism via the North West London Collaborative in partnership with West London Trust. We agree that the experience during the Covid-19 crisis, in which the NHS in North West London worked effectively across organisational boundaries and in partnership with local authorities and other organisations to ensure a co-ordinated response has only served to reinforce the direction of travel outlined above. There are some areas of the case for change and broader proposals, however, about which we do have concerns and would ask either for clarification or for changes to be made to the final proposals. Mental Health, Learning Disabilities & Autism (MHLDA) Programme Structure The MHLDA programme has a wide and complex remit, underpinned by the national commitment to meeting Mental Health Investment Standard (MHIS) and ensuring parity of esteem. There are a raft of LTP targets to meet. The phase 3 return includes detailed investment proformas, which is not the case for other programmes. There is, however, no parity between the structures proposed for the MHLDA and local care structure programmes. The resources proposed for the latter are double those for the former. We would ask for these resources to be looked at again and allocated more evenly across the two programme structures. Areas to strengthen in the case for change We believe the following areas would benefit from being strengthened as the CCG moves beyond the case for change stage: 1. Greater specificity on how the voice of service users, carers, and communities is a golden thread in local arrangements 2. How clinical (and multi-professional) leadership is maintained at a borough level 3. The role of (pan-ICS) provider collaboratives such as the NWL Collaborative in development between CNWL and West London Trust Resource allocation across NWL boroughs CNWL is committed to reducing health inequalities across NWL, recognising decades of varying underinvestment in boroughs across the system. It is our strong contention that this should not be based on disinvestment in individual boroughs, which would directly impact the availability and quality of services currently provided to patients and users with a disproportionate impact in Mental Health and Community Services. This approach does not align to the LTP ambition to redesign healthcare so that people get the right care at the right time in the optimal care setting, reducing hospitalisation and targeting our resources at some of the most vulnerable groups across our geography. Additionally, for mental health services there is clear national guidance that the MHIS principles should apply to current CCG footprints for the life of the LTP. Instead, we believe NWL should seek to

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tackle health inequalities through identifying best practice across the boroughs, both in terms of quality and efficiency, and set its ambition to target investment to replicate the optimum service offer to patients across the system considering their views and ideas about the care we provide. Executive structure The size of the Director of Nursing portfolio in the Integrated Care System (ICS) is substantial, both in terms of its remit (including governance and operational delivery) and of geography. Experience during the Covid-19 crisis has demonstrated that it has not always been feasible for a single directorate to co-ordinate effectively and that, in some cases, the quality oversight, assurance and delivery functions need to be separate. Our concern here is that these critical functions are at a risk of getting lost in such a broad directorate. I look forward to hearing from you on the above. If you have any queries or would like to discuss further then please let me know. Very best wishes. Claire Murdoch Chief Executive FROM: CENTRAL LONDON COMMUNITY HEALTHCARE NHS TRUST 9 September 2020 Dear Jo Proposed merger of the eight North West London Clinical Commissioning Groups Thank you for inviting us to feedback on the CCG merger proposals and the case for change, which we have now had the opportunity to consider; I am responding on behalf of our Chief Executive. CLCH is unequivocally supportive of the merger to a single NWL CCG and the direction of travel to the creation of an ICS with a single strategic commissioning body. As a Trust which provides services in 6 of the 8 NWL boroughs we would welcome the reduction in duplication and variation in commissioning that a single CCG will bring, which will reduce administrative burden and transactional costs across the system. The opportunity to move to a common framework and set of standards should serve to free up borough based partnerships to focus on delivering integrated care locally, whilst improving equity across NWL’s population. We wholly endorse the commitments as listed on slide 5 of the case for change and look forward to playing our part in supporting the delivery of those commitments, particularly at ICP level, through the proposed leadership arrangements of the “quartet”. We also support the financial principles as outlined. With respect to the proposed CCG Borough Committee, we wonder how this will interface effectively with the ICP and HWB, and whether there might be the risk of duplication between these groups. Is the intention that the chair of this group would be the same as the proposed GP CCG lead in the ICP group? If so, it is unclear how the voice of Primary Care providers would be represented, and perhaps the GP lead for the ICP should be selected from the relevant PCN Clinical Directors group.

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We support the concept of the local quartet in providing the leadership for each of the ICPs, but would only support the creation of a single out of hospital director role at a later stage once relationships within the partnership are fully established. We understand that the membership of the single CCG governing body is prescribed, but are unclear of the role of the “independent chair” as listed. The CCG borough based responsibilities seem clear, and we are of the view that the teams to deliver those functions could be consolidated under each of the COOs, at multi-borough level, to allow for resilience, consistency and value for money. We understand that a single operating model has been proposed for primary care commissioning and development, which we would support, but it will be important to have very close alignment between that function and the integration function locally to ensure that integration is effectively supported at neighbourhood/network level. We hope our comments are helpful and we look forward to working in partnership with the new CCG within the STP/ICS, which helps us improve the health and care outcomes for the whole population of NWL. Yours sincerely Charlie Sheldon Chief Nurse c.c Angela Greatley, Trust Chair Andrew Ridley, Chief Executive The Lonsdale Medical Group: Patient Participation Group 8 September 2020 TO: North West London, Collaboration of Clinical Commissioning Groups Dear Jo Ohlson, As chair of the Lonsdale Medical Group Patient Participation Group, thank you for giving us a chance to participate in the review of the proposed plans to merge North West London CCGs. We represent close to 24,000 patients in the newly combined practice and are doing all we can to support the team who are handling that challenge and the added challenges of the pandemic. We believe that there is little the we can say to influence the direction of travel of these plans, but we do have concerns that speeding ahead with this in the midst of a pandemic is foolhardy. We would, therefore, suggest that you proceed with caution. Brent already has suffered from a lack of resources, both historically and as a result of the impact of the pandemic. We feel that practices like Lonsdale Medical Group need all the support they can get in these difficult times. We remain concerned that the focus, which should be on patient care and safety at all times, will shift when there are so many more administrative tasks to fulfil with reduced staff numbers. The benefits of the CCG mergers have not been made clear. In sum, we would suggest this is delayed until the future trajectory of the pandemic is clearer. Sincerely, Deborah Unger, Chair, Patient Participation Group

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Lonsdale Medical Group cc. Keith Anderson, Robin Sharp, Sarah Tomlin, Victoria Secretan, PPG Dr. D. Dietch, Dr. A. Panagoulas, Dr. S. Read, Dr. L. David (Partners, LMG) Amanda Meehan, Practice Manager HAMMERSMITH AND FULHAM: SAVE OUR NHS

RESPONSE TO: The Case for Change – 2020 - NHS NW London Collaboration of CCGs

September 2020

Hammersmith and Fulham Save Our NHS (HAFSON) wishes to express its deep concern that the CCGs of NW London do not feel that the public voice needs to be heard in the deliberations on ‘The case for change for a single NW London CCG – August 2020’. As we have previously pointed out (and we are attaching our earlier 2019 submission), there are serious implications for patient-facing services in these proposals – not least when it is constantly reiterated that the purpose is to ‘reduce inequalities’.

It is inescapable that the new papers – whether the paper for public consumption or the apparently more privately circulated paper for local authorities – do not answer or clarify the key sets of questions and concerns submitted in August 2019. Indeed, it would seem that little has been done to progress issues since that time. While work on Covid-19 might have interrupted such work, it is extraordinary that at least for 6 months nothing was accomplished to answer the key issues raised not just by local people and campaigners but also by local authorities individually and by JHOSC.

The Importance of The Local

Because of initiatives taken at a very local level (essentially at a borough level), at least in parts of NW London, during the worst period to date of the covid crisis, there is some acknowledgement of the importance of the local in these papers. The real successes in containing the worst of the pandemic arose from very local initiatives and local actions. For example, we know from local reports, that the work done by H&F council with Imperial Healthcare Trust reduced the possible number of covid deaths in Borough care homes by initially closing care homes to new patients, by initiating a testing regime for both residents and staff and by providing appropriate PPE for staff in care homes. The speed of this activity came from a local authority able to work with local GPs and the local trust without having to go through cumbersome system-wide processes. This has been commented on by local GPs and at the PRG as one of several very important local initiatives – and was widely recognised as a success by national media.

We were also made aware of the CLCH initiative in H&F with the development of the Integrated Domiciliary Service (IDS) which came into play successfully without waiting for a system-wide direction during the crisis.

Despite recognition of the importance of the local and the ability of the local to take initiatives quickly, there is nothing in the paper as presented that gives any reassurance that such necessary local initiative can happen in a timely manner in future health emergencies should there be a cumbersome single system-wide CCG and associated structure. Larger systems, by their very nature, are simply slower to react to changing circumstances than smaller less complex bodies with immediate and localised knowledge.

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Equalities

At the outset of the public document you state: ‘Our vision for NW London Integrated Care Systems (ICS) is to reduce inequalities’. This ambition was foregrounded in the initial paper ‘Case for Change’ (2019). In our response to that paper we stated.

Additionally, a key rationale in the paper in support of the changes is the need to ‘reduce inequalities’, although little is provided about what this means in practice. The paper fails to instance which inequalities are being talked about, which specific groups are affected, where the inequalities occur etc. And therefore the paper can provide no clear strategies for dealing with inequalities. The single example mentioned is ‘frailty’. The implication is that some pathways work – others don’t. There is no clear analysis of what works, why, where and how. Or is this talk of equality a screen for a move to cutting provision to the lowest common denominator?

Now, fifteen months later, there is no greater definition of what the collaborative might see as inequalities or of any policy or practice developments as to how a single CCG might tackle these inequalities. Indeed there is no evidence that the collaborative has given any thought to which inequalities they wish to address nor have they provided any policy directions to address these inequalities. Among many others, Sir Michael Marmot has pointed out that inequalities in health provision and outcomes have been growing steadily in recent times (see http://www.instituteofhealthequity.org/resources-reports/marmot-review-10-years-on).

If the CCG is to address inequalities, the first step must be to identify what these inequalities are. In addition to any data held by health bodies across NW London (e.g. WISC data), what is needed is the detailed knowledge held by each local authority of its population ward by ward in terms of housing, social care needs, age structure, cultural/ethnic composition, income, unemployment etc – all the factors recognised as major determinants of health inequalities. Meaningful policies and strategies to deal with inequalities need to be based on granular knowledge of local communities and then to engage with the relevant local authorities and local communities.

This is not to preclude any focus on groups with protected characteristics – but there is a tendency for the CCG(s) to consider equalities only in terms of ‘protected characteristics’ when the evidence of inequalities is significantly more about poverty in terms of health.

At the JHOSC on 7 Sept 2020, the so-called pilot scheme presented by Dr M.C. Patel clearly has potential, not least for patients in the two wards concerned. However, it is hard to see how this is an argument in favour of a single CCG as the initiative is in fact a very localised initiative. And further, as a pilot it is inadequate as it has not comparators with other wards with different social profiles across NW London. With 130 wards across NW London it would be impossible to generalise from such a small pilot with a limited population base, however valuable that work would be. These initiatives do not require a single CCG.

We also note that reduction of inequalities is seen as a matter, apparently, of spreading thin resources more evenly across and within boroughs – surely a measure which will mean equalising down. This was clear at the JHOSC where two boroughs in particular will, over a period of time, lose resource. Both boroughs include significant areas of economic and social disadvantage.

And any reduction in inequalities is to take place over a period of 4 years! This is beyond cynicism in a context where growing poverty for large groups of people, often but not exclusively BAME people, have seen reduced standards of living and increasingly poor health outcomes in recent

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years. The effects of the covid pandemic have simply amplified this. It clear, across the UK, that levelling up does not happen without additional resource.

The Proposed Governing Body

The Governing Body seems remote and unrepresentative of the 2+ million residents of NW London. The most notable omission is that of local authority representatives. In our earlier submission we were concerned that the differing natures of the various local authorities could not be properly represented by a single LA person. It seems that the NHS now believes the answer to this is to remove entirely local authority representatives! This does not auger well for collaborative work with what you like to call local authority partners.

It is with some consternation that we note the absence of anybody dealing specifically with mental health. This beggars belief given a well-acknowledged and growing mental health crisis across the country and in our area – exacerbated by the covid crisis and by growing social and economic difficulties.

We also note that there will be 5 lay governors but no hint of how they are appointed or how they will relate to the public of 2+ million across NW London or how they will have knowledge of the local authority areas where residents live. The question of how they represent the diversity of people in NW London – ethnicity, gender, disability, health etc – is not even considered.

And Healthwatch has been dropped from the governing body whereas it has a statutory duty to hold NHS institutions to account – something that has happened and has been positively commented on by members of the public attending the collaborative in recent years.

Nothing is said about the accountability that is specific or structural of the governing body of the single CCG. Will there be meetings in public? And, if it is with present covid restrictions, will measures be taken so that meetings can be held virtually but allowing public interaction – something the collaborative AND local CCGs have so far entirely avoided. If meetings are in public, how will this be made possible given the wide geographical spread of NW London? Will the governing body be accountable in any way to scrutiny from local authorities – JHOSC and at the local level?

CCG Borough Teams/Borough Committees

We are somewhat confused as to whether the above are one and the same things as both terms are used in the papers and there is no clarification to explain them. We are making the assumption, perhaps erroneously, that they are the same.

First, a question about the composition of local teams. We note (p.6) that there is a single member of the local authority although it is not clear who this might be i.e. is it an elected member, the Public Health appointee, or another officer of the LA? This rather weights decision-making against the local authority. Indeed, throughout this paper, for all the claims to value the local and to recognise our local authority as partners, there is a complete failure to treat partnership as any sort of equal relationship with local authorities, which do have the merit of being elected to represent their local populations and which are therefore accountable in ways which the single CCG and local borough teams simply cannot be. All this, when LAs have considerable local knowledge; health and social care delivery obligations and accompanying financial obligations.

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Further, we note a lay member is mentioned. Is this one of the 5 lay members on the governing body? If so, this means the person may not be a local person. And if not, how will this person understand the NHS context in which they are working?

There is nothing about the responsibilities and powers of these bodies (see comments also below); and crucially nothing about how they will be financed or about whether they will have devolved financial powers and responsibilities.

What powers might a local body have to initiate and carry through delivery of services which they deem suitable and important for their local authority area, or will they simply be conduits between the local and the single CCG? The points made on p.6 are so elliptical that it is impossible to have any clear understanding of what the powers of these local bodies might be. Nor is it at all clear how or to whom they might be accountable. Will they be subject to local authority scrutiny?

We are very impressed at the opacity of the slide (p.11) which claims to differentiate the responsibilities to be undertaken by the CCG Borough team and by the single CCG at systems level. Is this a deliberate opacity or does the difficulty arise because this aspect of the structure has not yet been thought through. Certainly, it is not at all clear how both borough level teams and the single CCG can be equally responsible for the same things – this clearly needs to be spelt out!

Further, it is very obscure as to how these borough teams might work across borough boundaries as seems to be implied in this slide which talks of a COO working across 2 or 3 boroughs. Before proceeding with these proposals, we believe much clarification is needed. We were disturbed to hear, at the JHOSC, the accountable officer, Jo Ohlson, say that at this stage it was too complicated to say how local committees would work and how tri- or bi- borough issues might relate to local committees.

It seems that a major decision is to be made with major elements still unclear, even to the management of the collaborative!

Finance

In 1919 nearly all respondents raised key questions about finance. It was pointed out that there was no business plan underlying the paper. It was unclear who would lose or gain in what would clearly be a significant shake-out where at least part of the driving force was financial.

A year later, we are no wiser!

What, financially, is being kept back from local authorities and from the general public?

Both at a national and local level, these new structures are largely finance driven. Claims that it is values that count may well be meant sincerely, but values don’t pay for services.

Conclusion

Last year, A Case for Change failed dismally to make a case for change. HAFSON is deeply concerned that, more than a year later, very little seems to have changed. There is no clear rationale for such a huge change in organisation which will, despite claims, quite clearly impact on health delivery. We are deeply worried at the failure to even attempt to engage with, let alone consult, the public about what will have implications for patient-facing services.

Appendix: August 2019 NTRODUCTION

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This is H&FSON’s response to the various papers and discussions on ‘Commissioning reform in NW London: The case for change’.

We would like to voice our serious concern about the failure of the CCG Collaborative to engage appropriately with stakeholders, including the public, about this major reshaping of how health care is organised and delivered in NW London.

From the outset, the schedule of production of papers and of individual CCG governing body meetings has worked to exclude any meaningful questions being raised by the public and being answered in governing body meetings before decisions are to be made. Thus, the only H&F CCG governing body meeting to discuss the original paper took place on 11th June and the decision is to be made at the next H&F governing body meeting held in public. This means there is no time when the public might influence decisions or have their views seriously taken into account. To be clear, there will have been no meeting in public of the H&F CCG where public input or views could be taken into account.

It is worth noting that the date for submission of comments on the proposals has only been extended to August because of pressure from a variety of stakeholders who overwhelmingly expressed concern at the time scale being imposed.

This was linked to a strong critique of the initial paper as being ‘flimsy’, lacking in detail and without anything remotely approaching a business case. The subsequent paper, while it has some more detail, has not reassured most stakeholders that these proposals are sound and in the best health interests of the public of NW London.

In September, CCG Governing Boards are to be asked to agree to a single CCG for NW London to be in place by April 2020 (as the preferred option). This is BEFORE a detailed proposal has been drawn up and discussed with stakeholders, BEFORE GPs have a chance to vote on the proposed single CCG and BEFORE there is an acceptable and detailed business plan in place. This is simply unacceptable.

Our response is based on detailed reading of the various papers produced by the Collaborative, on attendance at the H&F and at the Collaborative CCG meetings, at the H&F scrutiny committee and Health and Wellbeing Board meetings and at the first JHOSC meeting. We have also been engaged in discussions more widely with councillors, other campaigners and stakeholders.

1. A SINGLE CCG

The largest commissioner to emerge will follow the merger of eight CCGs in North West London, covering 2.2 million people. (Health Service Journal, 23 July 2019)

The case for a single CCG is not clearly argued for. The advantages of moving from 8 CCGs working within a collaborative arrangement are not outlined. What, however, is clear, is that there is a major shift in power to the centre and thus a major democratic loss – in the collaborative, local CCGs have the right of veto of proposals that are seen to be detrimental to local needs.

What is clear is that the proposals are a major centralising of power and decision-making. The centre will have control of the total budget; will set health policy for 2.2m people; will set targets for each of the subordinate bodies; will set timetables; will monitor performance of lower bodies and, we surmise, may dispense with bodies which might fail or come into conflict with the central body.

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The papers, but particularly the second iteration, are replete with complex diagrams which fail to clarify relationships between the various components but do clearly reveal the fact that this is a complex but hierarchical structure with all key decisions entirely centralised.

A significant absence in the paper is any explanation of what the relationship would be between the single CCG and the proposed Integrated Care System. Will these exist side by side, will one be subordinate to the other, will they have different policy-making and financial control powers, will their staffing be independent etc? These are clearly key questions that need immediate clarification.

Similar questions arise in relation to the other lower level structures proposed in the second iteration of the paper – ‘place level’ organisations that seem to be a replica of local CCGs with undefined but significantly lesser powers; and integrated care partnerships which nationally seem to have varying structures and responsibilities.

In all this, there is little acknowledgement of the place of local authorities, voluntary bodies or the general public (i.e. patients and residents).

2. LOSS OF DEMOCRATIC ACCOUNTABILITY

It is unclear how a democratically elected local authority can assess the quality or suitability of health provision in their area if local CCGs are effectively abolished. The papers lack any mechanisms by which local authorities can make proposals for their residents at a formative stage to the mega CCG in the context of health policy being developed centrally.

Further, in the absence of clear protocols for the work/powers of local ‘place bodies’, it is difficult to see how scrutiny panels in democratically elected local authorities can meaningfully examine and/or object to important changes to local health provision which may include significant cuts to provision in their area.

Currently, CCGs across NW London hold approx. 40 meetings in public which stakeholders are able to attend and ask questions. Under the mega-CCG, it seems highly unlikely that this number of meetings will continue to be held. And if the pattern of 4 meetings plus AGM for a CCG is continued, any local authority area can expect to have a local meeting only once in 2 years! To attend meetings regularly will require significant travelling by members of the public and will result in more decisions being made outside the public view.

Further, we do not believe that the mega CCG, covering over 2.2m people, will be able to make appropriate decisions about health provision given the immense geographical spread, wide social and economic diversity including vast disparities of wealth, great ethnic and cultural diversity, disparity of health conditions and life spans. Local authorities have better and more up to date knowledge of these factors and are therefore better placed to be able to make the appropriate input into health decision-making for local populations.

Patient Reference Groups have been a valued way for local residents and stakeholder groups to feed in detailed information and to respond from their specific local knowledge bases to CCG proposals. The papers neglect to show how the scope and powers of PRGs will effectively feed into both local policy making and that of the mega CCG. Will they just become decorations to give an appearance of legitimacy?

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The draft NW London CCG Governing Body Arrangements are also a matter for concern. One assumes that the ‘clinical chairs’ are from each of the 8 boroughs – although it is not clear whether they will be elected/selected by local GPs or other clinicians or other bodies.

We note there are 4 lay members. Assuming these are appointed by the collaborative, it is not clear how they can represent the diversity of views across NW London.

There is more than one Healthwatch in NW London and they function quite differently. Why is not each Healthwatch body represented?

The loss of democratic accountability is significant in both the appointment of (non-voting?) positions from Public Health and Local Govt. First, Pubic Health is a local authority function now and how it will work will clearly relate to individual local authorities. Why should and how could a single representative speak for all 8 boroughs in NW London? This point is compounded by the mention of a single local government (co-opted) member. There are three significant issues of democracy here. The most obvious is, who is doing the co-opting? (Power lies with the co-opter!) Second, is the co-option of an officer or of an elected local councillor? Again, this has democratic implications. And finally, and perhaps most importantly, local councils are NOT all of the same political complexion. It is totally undemocratic to believe that a single local government ‘member’ can represent the varied views and interests of 2.2m people.

Perhaps the most innovative proposal is that the CCG will establish a ‘citizens panel’ which is to be representative of the local population. Sadly, no detail is given and in the limited discussions we have had and heard, it seems that such a panel will be no more than a banal focus group. This simply looks like a way of avoiding democratic involvement with local people and accountability to local public representatives.

3. PATIENT-FACING SERVICES

Although, on several occasions, the Chief Accountable Officer has publicly stated that ‘The Case for Change’ is merely a reorganisation of administration of NHS services across NW London, we note that at several important meetings Dr Patel from Brent CCG has led the support position by arguing vigorously that the patient experience will be much improved in the new system. He could not have been more clear that this really is about changing patient services. Changes to patient services require consultation, under NHS rules.

Additionally, a key rationale in the paper in support of the changes is the need to ‘reduce inequalities’, although little is provided about what this means in practice. The paper fails to instance which inequalities are being talked about, which specific groups are affected, where the inequalities occur etc. And therefore the paper can provide no clear strategies for dealing with inequalities. The single example mentioned is ‘frailty’. The implication is that some pathways work – others don’t. There is no clear analysis of what works, why, where and how. Or is this talk of equality a screen for a move to cutting provision to the lowest common denominator?

In H&F, to take one example – but it also applies outside our borough - we are already seeing cuts to services in out of hospital care. And the local CCG has told the H&F scrutiny committee that they would in future only commission those services that are statutory.

Does this mean that plans to ‘reduce inequalities’ will effectively be plans to reduce or cut services to the minimum statutory level across NW London. Dealing with significant variation is clearly about changing patient-facing services, and failing to present detailed analysis does not negate this.

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4. FINANCE

It is unprecedented that such a major reorganisation proposal could reach this stage – approx. one month before decisions are to be made – without sight of a business plan of any sort. These proposals cover 2.2m people and 8 local authorities yet there are no published financial papers/business case to underpin the proposed ‘Case for Change’.

How can stakeholders – the public, elected local authorities, GPs and other health professionals and bodies, the media – come to a rational judgment about whether these proposals are financially sound?

Given the uneven deficits across the NW London area, it seems unlikely that some local authority areas will not lose valued services in order to reduce deficits in other local authority areas. As stated in the Health Service Journal (23 July 2019):

One issue where concern is being raised in some areas, however, is the financial impact on areas whose CCG is in a relatively healthy position, as they merge with others deep in the red.

In north west London, local officials have raised concerns over the financial consequences of merging eight CCGs where performance is highly variable.

The combined system had an overall deficit of £57m in 2018-19 but Harrow CCG was £42m in the red while West London finished with a £17m surplus.

In a briefing, they said: “Creating a single CCG will raise fears that better funded areas are going to be levelled down, and there will be a loss of local accountability for budgetary decisions.

“We will need to be sensitive to these issues and ensure that good financial management across NW London is not seen as a punishment on some.”

Leaders in this area have said they are expecting regional guidance to ensure consistency over finance decisions. However, these are likely to be fairly informal recommendations.

The second iteration of the paper outlines what seems to be an increasingly complex structure with multiple layers of providers and decision-makers. No financial details are provided as to how these are to be funded and staffed and what the cost of the total structure and its parts would be. This is in the context of NHSE demanding that CCGs reduce administration costs by 20%. To claim that half of this has been saved through recruitment difficulties and a recruitment freeze, while still proposing to go ahead with this complex structure, without actual figures is asking those reading this paper to take simply too much on trust.

Like the Chief Accountable Officer, we welcome the dropping of the purchaser/provider split but it is difficult to see what advantage there will be for patients until we see the details of a new model and the actual figures. How will the new budgets match patient need?

Our worry about a clear business/financial plan is exacerbated by a recent, unpublished but widely circulated, paper on the NW London Financial Recovery Plan. The detail in this paper has huge patient-facing implications. This paper talks of ‘managing demand’ by

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• A 12k reduction in A&E attendance and 10k in non elective activity • A 3k reduction in elective care • A 38k reduction in outpatient attendances

In 19/20, the paper states that areas being scoped for implementation include 1 year temporary closure of Pembridge Unit, lengthening elective care waiting times to 6 months max, review of voluntary services etc. These are just examples from the paper, but what is clear is that much is already going on without any democratic scrutiny and that finance is becoming a key determinant of provision.

We fear that with a single mega CCG local stakeholders, including local authorities, will not catch sight of such finance-driven thinking until it is too late to influence decisions about health provision.

5. TEMPO

At all the meetings we have attended there was clear scepticism about the ability to move successfully to a single CCG by April 2020, even if this is seen as desirable. Stakeholders will have no time to look at finalised plans since decisions are to be made in September on the basis of revised plans drawn up after 24th August. This looks like a precipitous rush to force through a complex set of plans before stakeholders have a clear view of what is being proposed in any detail. This is exacerbated by the total absence of any business plan.

One final point. We understand that the plans need the approval of GPs – yet CCGs are to make the decision in their September meeting while GPs are not to be balloted until after the CCG decision and until after this decision goes to NHSE. How can this be acceptable?

From : The Hillingdon Hospitals NHS Foundation Trust

Dear Jo,

Re: Proposed merger of North West London CCGs

Thank you for your letter of 5th August seeking our views on the proposed CCG merger.

The Hillingdon Hospitals NHS Foundation Trust welcomes the proposed consolidation of commissioning in North West London, which can only strengthen our focus on addressing the challenges we face as a single NW London system. It will be important for partners across the NHS and in our local authorities to play a full part in making these new arrangements work. We will need to work together to ensure the needs of our local residents are met, including working as one organisation to tackle health inequalities and ensure equity of outcomes for all.

Yours sincerely,

Jason Seez

Acting Chief Executive

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From: Cllr Elizabeth Gaynor Lloyd

I submitted a response to the May 2019. "Case for Change" in August 2019. This is attached, and I have no reason to change the statement of concerns I set out then. I do, however, wish to add certain generic concerns as a result of the pandemic which has occurred, and the focus which has – in only too timely fashion – arisen as a result of Black Lives Matters focus on the inherent disadvantage suffered by BAME communities . This includes the COVID disproportionate effect, the research on which is only at inception.

As in the case of that August 2019 response, this email is written on a personal basis, not on behalf of Brent Patient Voice, which has submitted its own response to this August paper.

What has changed is that we are in a COVID world. The August 2020 paper makes not even a nod in the direction of the changes actually affecting our resident population as a result, or any focus on differential health results, including in the loss of "business as usual" in our local health providers. The only reference is to the learning of lessons from COVID, and a reference to the success of local initiatives in partnership as an example of what integration can achieve. Of course, there has been magnificent partner working. As a Councillor in Brent, I am very proud of the initiatives taken by my Council – relying, it is true, on the Government's exhortation to "spend what it takes" – which included the setting up of a COVID patient care home on 4th April, and the expenditure of literally millions on PPE for all our local care home providers at the end of March, regardless of the fact that those providers are private. Perhaps this is an example of a reference made in a paper about the previous version of integrated care presented to the Health and well-being board in July 2019, where the NHS wants to rely on the "flexibility of funding" available to local authorities.

This will not, however, be the vision of integrated care under the single CCG. Strategy and budgets come from the top. The only local authority representation will be a non-voting single public health representative. The only other reference is to the health and well-being committee, which is a committee of a local authority. Whilst good work, obviously, is done by those committees, at present they meet only 4 times a year, and quite what commissioning input they might have is hard to imagine. Individual Borough input will come from 1 GP per Borough (save in the case of the Borough where the chair comes from the Borough, when there will be an extra GP – apparently to ensure Borough representation!). There will be 5 lay members with no indication of how these will be recruited or represent the patient voice. Certainly the paper gives no detail of how the health and well-being board will work. Indeed, the paper gives no detail at all, certainly less than the May 2019 paper. We do learn, however, of a few more officers: Out of Hospital Borough director, shared CCG COO, working across 2 or 3 boroughs and the CCG Associate Director for each Borough.

Other than that, and a statement of vision, there is nothing in this paper, which could represent a case for change. However, my intention is only to comment on 2 aspects which are not covered at all: –

1 children and young persons – on a simple point, Brent has 23% of its resident population which is under 18. I am aware from an all too intimate knowledge of the contents of the database Whole systems Integrated Care that no children social care data is uploaded to that. So the business intelligence part of the ICS function will have a significant hole.

2 digital access - the vision of this paper is for the levelling out of health inequalities. Yet, papers such as Sir David Sloman's journey to a new health and care system and Matt Hancock's

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recent statement refer to "virtual by default" in terms of GP access and indeed secondary care. Digital access is simply not available to the poorest of the community, or, indeed, those "disabled" by language, age or simple digital illiteracy. Apparently 7 million throughout the country. The only way equality of access to a future health service substantially delivered by online services – which is the direction of travel – is that digital cheap or free broadband, and free devices are made available to the population, so that it becomes as much a right for the population as our water service – which is not free but at least cannot be cut off. This was not provided by the government in connection with the provision of education simply for children. How can we expected in the case of the health service, and how is it proposed in this case for change that this will be dealt with? Face-to-face must continue to be available for full clinical provision. There is already inequity in provision of health services because people do not have the communication skills, or the advocacy in face to face. Your search for equalities will be in illusory if you do not address the lack of digital access for the vast majority of our population.

Comments and Response from Ealing Save Our NHS on “The Case for Change for a Single NW London CCG” BACKGROUND This is the second “Case for Change” document from the NW London Collaboration of CCGs. The previous one titled “Commissioning Reform in North West London – the Case for Change” was produced in May 2019. Important issues were raised by Ealing Save Our NHS (ESON) in response to that document, but almost none have been addressed. Exactly how the Change will be made is still unclear and the Case is not made. Unfortunately, there is little doubt the top-down orders for yet another NHS re-organisation will be pushed through. No less than seven sections of the 2019 document concluded with lists of problems headed “What we still need to explore”. Overwhelmingly they all remain unexplored in the second document. We are therefore attaching the ESON response to the 2019 document as part of this consultation. The Case for Change is an attempt to apply the NHS England Long Term Plan to North West London. This Plan takes NHS organisation in a quite different direction to the 2012 Health and Social Care Act, requiring services to be controlled by Regional Integrated Care Systems (ICS) rather than CCGs. The document says “The NHS is moving away from a commissioning/provider split”. It means ICSs will have more rigid budgets and means a further move away from clinical to administrative/political control. Since there has been no legal change to the legal status of CCGs, they are to be merged into a single North West London CCG to enable a delegation of statutory power to a North West London ICS. Despite the talk of visions and consultations the key decisions have of course already been taken at a higher level. We, the public, along with the 8 CCGs, GPs and 8 local authorities are in fact being presented with a fait accompli. As the document itself admits “each ICS is expected to have a single CCG.” The monumental challenges of the Pandemic have been partly used as a justification for some of the decisions that were already under way. While some centralisation was needed for the pandemic, it also showed the importance of empowering local NHS staff to work as they know best, without interference and certainly without the sort of administrative centralisation proposed in the Case for Change.

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SHORTCOMINGS The proposed Changes are going in exactly the wrong direction – services being restructured to cut costs, increased contracting out to the profit-making sector, reduced clinical control and a huge undermining of accountability and transparency of this key public service. Being finance rather than clinically driven, the proposed changes don’t even appear to be thought through. Shockingly, the relationship between the two leading bodies of the ICS and single CCG is not explained. The difference if any between Borough Teams and Borough Committees is not explained. The Powers of the Borough Teams or Committees are not explained. The proposed financial responsibilities and divisions between the ICS a new Borough teams or organisations is not explained. INEQUALITIES “Centralisation” of services locally and nationally has generally led to a centralisation away from the poorer communities. There has also been a breakup of holistic provisions along with contracting out of services. The poorer you are, the more disadvantaged you are, the less educated and articulate and the less able bodied, the harder it has become to access services. The ongoing pandemic has highlighted the frighteningly higher death rate among minority and poorer communities. The second Case for Change Document refers to these issues at the very start saying “Our vision for NW London Integrated Care System (ICS) is to reduce inequalities” but ESON fears that inequalities may instead increase. Ongoing undermining of Ealing Hospital, which services the predominantly minority and needy community of Southall shows how little the move to centralisation has taken account of local needs. Many people can’t afford to travel for hours by bus to Northwick Park Hospital, can’t deal with online services and will be squeezed out for a variety of similar reasons. Unfortunately, the inequalities referred to in that opening statement are not even referred to in the rest of document! The only inequality that comes up is a difference in spending per head between local authority areas. Apart from that, there is a single reference to equalities as a responsibility allocated to Borough teams and for some reason bracketed with ‘engagement’ - perhaps because it’s seen as a PR issue. MENTAL HEALTH AND SOCIAL CARE Mental Health and Social Care are widely regarded as the Cinderella’s of our health and care systems. The exclusion of local authorities from the ‘Case for Change’ re-organisation proposals presage a reinforcement of the division between social care and health. Unless Local Authorities are involved in the ongoing strategic discussion, social care can’t become further integrated. Even at the Borough level it’s proposed that an ‘Out of Hospital Director’ would pull together GPs, community health and mental health – but not social care. Just how unintegrated is that? For the NW London Regional CCG governance there is to be no mental health representation. Nor are the disastrous levels of mental health support addressed in the Case for Change. Earlier suggestions that already overworked GPs might somehow do more seem to have faded away leaving the document with nothing to say.

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LACK OF PUBLIC ACCOUNTABILITY Our experience of attending CCG meetings is that they have been led by managers and, if anything, have been an additional burden on GPs. It seems unlikely the merged CCG will be different. As an example, right across England the CCGs are all dutifully voting to abolish themselves and merge. This obviously doesn’t bode well for the next stage and illustrates a somewhat Stalinist version of democratic decision making. ESON would of course rather have this current consultation than no consultation at all, but like everyone else we are aware the decisions have already been made. This also gives us no confidence that future processes will be transparent. Indeed, the authors of the Case for Change document are themselves both informal non-statutory bodies - the NHS NWL London Collaboration of CCGs and the NHS NWL Health and Care Partnership. Yet it is they who are in charge and are managing with dubious legitimacy or accountability. There is still no indication whether the ICS meetings will be open to the public. That is where the key decisions will be made. In our view the elected local authorities are being pretty much frozen out. CCGs at least geographically shadowed local authorities who are at least rooted in local communities, are elected and have some accountability. But in the Case for Change the presence on the merged CCG of a single officer from all 8 boroughs is a fig leaf. It’s not clear what power the Borough teams would have, other than implementing decisions from the Single CCG / ICS. Will they be expected to carry the can for tight budgets with which to replace reduced Hospital services? Will they be open to any public scrutiny? The concern is that, rather than operating transparently, members of the public may be appointed as a cover for ‘engagement’. In our experience Healthwatch is not a vehicle for public scrutiny. It has shown no propensity to review or criticise NHS policies, rather it involves volunteers to conduct surveys at the behest of the authorities. EPIC appears to be an NHS NWL selected group of residents who may be approached when the ICS wants to introduce a new policy or change an existing one. Both of these bodies appear to be acting as focus groups on behalf of the NHS management. While this may be useful, it’s along way from any accountability or transparency for publicly funded services, especially when the role of local authorities is to be hugely reduced. We also note that there will be 5 lay governors but no hint of how they are appointed. To whom will this large group of appointees be responsible? Will they just be friends, trusted colleagues or perhaps appointees from the profit-making sector? The intentions behind this large influential group are not revealed, which gives us another cause for concern. IN CONCLUSION While the latest Case for Change document talks about levelling up Primary Care it provides no data or explanation of how that might be achieved other than reducing finance for hospital care. There is nothing on how to fill existing Primary Care vacancies or training on new responsibilities. There is no explanation on how to deal with the hugely increased waiting lists for hospital care and at the same time reducing the hospital budget.

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It’s hard not to draw the conclusion that this document is unfit for purpose, purporting as it does to lay out plans for multi-billion-pound re-structuring of vital services. Important issues are not dealt with as if this latest reorganisation has not been seriously though through or planned. Oliver New Chair, Ealing Save Our NHS 11 September 2020 from August 2019: Ealing Save our NHS Comments on the NHS North West London Collaboration of CCGs Document “Commissioning Reform in North West London, the Case for Change” SUMMARY The ‘Case for Change’ document proposes far ranging organisational plans, the content of which is quite undeveloped or even non-existent. There is a clear intention, however, to introduce rigid budgets which would inevitably lead to patients being denied treatment. A confidential NHS document recently passed to Ealing Save Our NHS reveals that North West London NHS had a cumulative deficit (i.e. underfunding) of £324 million by 2018/19. A central response to this in the document is apparently to “stem growth of activity”. In other words, to cut existing health services. We believe this is the background to the “Case for Change” and the main reason we find it to be unsupportable. AN INBUILT LACK OF CLARITY The Forward to the Case for Change document starts thus: “This Case for Change document is written in response to the NHS long term plan…. The long term plan raises other issues: how a NW London integrated care system would operate; how integrated care partnerships (ICPs) would develop at a more local level and the development of primary care networks.” Unfortunately in our view, the document doesn’t live up to this challenge as it fails to explain just how the Integrated Care System (ICS) would work, nor how the proposed Eight ICPs would work. It is also vague about the development of Primary Care Networks. The introduction continues: “This document focusses on the first of those issues- a proposed change that would see NW London moving from eight CCGs to a single CCG.” So even at the start it’s unclear whether we are talking about integrated care partnerships or about CCGs. We believe this ambiguity reflects the fact that decisions have yet to be made. The Case for Change also says: “We want to eliminate the administrative burden that comes from running eight statutory organisations”. But they are statutory organisations, so how can they be replaced? Even merging them into a single CCG is legally dubious. The proposed solution seems to be keeping a CCG or CCGs and running a whole new structure of ICS and ICPs alongside, which obviously increases the administrative burden. This lack of clarity is repeated throughout the whole document – a document, which claims to lay the framework for the NHS in a fifth of London with a budget of around £5 billion pounds. Ealing Save Our NHS shares the view already expressed by other organisations that the document cannot be supported.

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THE LEGACY OF SHAPING A HEALTHIER FUTURE AND ITS SUSTAINABILITY AND TRANSFORMATION PLAN (STP) If ever there was an example of officials ignoring the nakedness of the Emperor, it was the doomed Shaping a Healthier Future Plan for North West London, which, along with the STP, is to be replaced by a ‘Case for Change’. Surely before NHS bosses embark on yet another re-organisation, they must make some public assessment of what’s gone wrong so far. They can’t pretend it didn’t happen! Every re-organisation necessarily impedes front line staff from settling down to the job. It moves experienced people around, demoralises many and frequently empowers the managers at the expense of clinical staff. If there is no balance sheet of the disastrous SaHF, with its huge waste of money and time, how can we have any confidence in new proposals? Some of the same people, who wasted possibly £200 million worth of NHS money in North West London on SaHF, have now put their name to the Case for Change! Are we honestly supposed to pretend the last seven years of attempts to apply SaHF never happened? Are we still to pretend the Emperor was clothed? Many mothers in Ealing are distraught at the loss of Maternity and Paediatric services in Ealing Hospital – yet these awful closures of important services are claimed as somehow being “successes” for SaHF. Meanwhile, even after the official demise of SaHF, Ealing Hospital has continued to have services removed and there is clearly no strategic view of its future. It seems as though North West London senior managers are content to allow our local hospital to drift while they address their own organisational structures. Ealing Save Our NHS firmly believes this would not be allowed to happen to a hospital based, not in Southall, but in an affluent part of London. Until the focus is on the needs of the communities, especially the neediest communities, local people are unlikely to support yet another re-organisation. We do of course welcome moves to cut spending on administration: “Maintaining eight separate statutory bodies is difficult to justify when there is so much pressure on health spending, and each statutory body costs an average of about £680k to run.” What the ‘Case for Change’ annual £680k figure for running each CCGs refers to is a mystery because data from the latest NHS NWL Annual Reports of the 8 CCGS reveals total ‘workforce/employee benefits’ of over £80 million. There is of course no mention of the millions of NHS money given to outside management consultants for the failed ‘Shaping a Healthier Future’ plans. This amounted to £76 million between 2009 and 2017, at which point SaHF stopped publishing the figures. Is this just to be shrugged off? THE CASE FOR CHANGE PROPOSALS “We want to … move towards greater integration with the eight local authorities in NW London. We believe doing so will enable us all to achieve more for our residents in improving health and care services within the budgets we have.” This statement and others, though typically vague on detail, sets alarm bells ringing for more than one reason. There are huge differences between local authorities and NHS services, in that local authorities are elected and accountable to the public. If decisions are taken jointly in committees with unelected NHS staff appointed centrally, this accountability would effectively be lost. There is no commitment in the ‘Case for Change’ that the ICP meetings of local authorities and NHS managers would even be held in public, like the CCGs, let alone any suggestion of accountability.

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The other fundamental difference between the NHS and Local authority provided social care is that NHS services are free. It has often been pointed out that a person with dementia is faced with losing all their property including their house as they have to pay for social care, whereas the identical person with cancer would receive free treatment from the NHS. There are no assurances that combining budgets would not take us towards more care being charged for. Even more concerning is the mention of services provided ‘within the budgets we have’. This is just one of several references to fixed capitated budgets not based on patient need. For some time, it has been suggested that the underfunding of the NHS has been partly motivated by a philosophy of some in Government that more NHS services should be paid for as part of a deliberate ‘shrinking of the state’. The proposition of the Long Term Plan to merge NHS and social care budgets does nothing to dispel that fear. The proposed Integrated Care Partnerships appear to be motivated by centralised budget cuts. The proposed ‘Partnership’ would seem to be one of junior partners being overseen, at least in part, by a North West London strategic body (the ICS), in turn overseen by NHS London, NHS England and the Health Minister. Exactly how will it work? The document doesn’t say, presumably because they don’t know. The only clarity is that budgets would be restricted and consequently cuts enforced. One code for this is “move away from payment by results”. Apart from introduction of that key centralised financial straitjacket, it seems most other things are still vague for the grass roots level, presumably because: “The operating model to determine functions which continue at local level will be developed over the summer as part of the engagement process. We need to develop further the framework for ICP development and encourage those who are furthest ahead to make progress.”

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Despite the inability to develop plans in key areas, the ‘Case for Change’ aks us to endorse drastic new organisational plans. In summary there would be an Integrated Care System (ICS) Board, a Clinical Commissioning Group (CCG) Governing Body, an STP Partnership Board, 8 Place (Borough) Teams’, ‘Local Committees’’, 8 Integrated Care Partnerships (ICPs) and 47 Primary Care Networks (PCNs) management teams. All centrally controlled with fixed budgets for a huge area with massive variations of problems. Will there be separate plans and separate budgets or a single plan and separate budgets or a single plan and a single budget? Answer – not decided. It’s no wonder that elected Councillors for local Boroughs have a wide range of concerns which included inadequate time to assimilate the changes for a 1 April 2020 start date, financial risks, budget organisation, how it will actually work in practice, cuts to services, no business case and staffing uncertainties. So little has been worked out or decided - this is a senior NHS management demanding a free hand to make sweeping changes. CENTRALLY RESTRICTED BUDGETS WOULD REPLACE PATIENT NEED “A move to a single CCG will also support the move away from the payment by results system towards capitated outcome-based budgeting, support consistency and equity in our methods for engagement, and simplify system wide financial planning.” “At the end of financial year 2018/19 the eight CCGs in NW London had collectively overspent their budgets by £56.7m – we aim to manage our spending within our budgets.” “Over 30% of patients in acute hospitals do not need to be in an acute setting and should be cared for in more appropriate places.” Put these three extracts from the ‘Case for Change’ together and a frightening picture emerges. Already the LNWUH Trust was retrospectively refused funding for A&E patients, simply because numbers had exceeded an anticipated target. Having been denied funding in an unprecedented manner, Trusts are told they are ‘in deficit’ and should not ‘be rewarded for the so-called overperformance of vital services. This is quite patently not clinically driven policy but cuts driven policy. The new system would mean that patients would inevitably be denied treatment. ‘NHS NWL has stated publicly that as these are just organisational changes and will not impact care services, no formal public consultation will be needed. However, as fixed priced budgets seem to be a central part of the reform commissioning package this would certainly impact on patient services by reducing, or at worst eliminating, some care services. Given this, surely the public must be formally and transparently consulted about these major changes.

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ACCOUNTABILITY REPLACED BY ‘ENGAGEMENT’ We have already made reference to the possible undermining of the current accountability of local authorities through merging social care into ICPs. The refusal to examine the SaHF collapse highlights a cavalier attitude to accountability. If eye-watering sums of money can be wasted, thousands of staff demoralised and services cut in a failed project, how can the very same people expect support for a new project? The Case for Change document has no proposals for public accountability. Accountability is one thing – engagement another. It’s well known that for all its strengths, the NHS has always suffered from a democratic deficit relative to many other public services. Currently the 8 CCGs do at least meet in public and are borough based and subject to scrutiny by local authorities. But a year ago the CCGs were collectively all given a new boss and expected to integrate their policies. The fig leaf of them being independent and clinically led was thus removed at a stroke! Would the proposed ICPs (however they are constituted) meet in public? We are not told. The single CCG would do so, but a single CCG covering the whole of North West London would be remote from all local communities and of interest only to a dedicated minority and then only if they had the time and ability to travel across London. Furthermore, this single CCG would be subject to the decisions of the ICS, made presumably behind closed doors. In a nod to the tax-paying public and patients, the ‘Case for Change’ proposes establishment of a huge focus group called a “citizens’ panel” to be managed no doubt by the public relations/engagement team. Of course focus groups have their place, but they are a tool for senior management and should not be confused with public accountability. It’s hard to imagine that the poorest from our communities would have a strong voice in this focus group. Likewise Healthwatch. The Case for Change states that “Healthwatch has always been represented in our entire governance structure and will continue to be so. Their active participation has enabled effective engagement across NW London, regular patient involvement in project development and implementation.” During the seven years of huge public opposition to the Shaping a Healthier Future our local Healthwatch, the ‘official’ vehicle for public participation, barely even mentioned SaHF, let alone questioned this disastrous project in any way. Instead it focussed mainly on patient surveys requested by the CCG. So in our view although Healthwatch no doubt has a useful purpose, it must be recognised as a wing of the health authorities and cannot be seen as representing the broader views of the public. IN CONCLUSION A team from Ealing Save Our NHS recently had the opportunity of a short meeting with the Accountable Officer and the opportunity to share our concerns. Helpful as this was in some respects, we were of the view that the ‘Case for Change’ was still extremely undeveloped. It became clear that proposals are deliberately kept fluid in many respects. For example there is no clarity on the functioning of the CCG in relation to boroughs, let alone how the ICPs would work. Furthermore some hitherto existing categories such as what constituted an NHS District General Hospital are to be disregarded in favour of more fluidity. This reads like a free hand for the centre and a loss of clinical decision making in favour of centrally ordered rigid budgets.

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A recent update provided for the North West London local authorities Joint Health Overview and Scrutiny Committee (JHOSC) failed to substantially address any of this detail, apart from lists of commissioning and management areas of responsibility. It’s therefore the strong view of Ealing Save Our NHS that to push all this through in the next few months as proposed would in our view be irresponsible. NHS NWL has as yet failed to produce even a draft NHS NWL Long Term Plan. Clearly it would be putting the cart before the horse to introduce underdeveloped organisational changes before having an approved regional. Long Term Plan to service the care needs of 2.2 million residents, let alone rushing it through uncompleted. Finally, it’s our belief that the rigid budget system underlying the Case for Change would inevitably lead to a loss of services to patients. Those with money might be able to purchase these lost services, but others certainly could not, further undermining the principle of Health Services for all. 4 August 2019

From: Hounslow and Richmond Community Healthcare NHS Trust

Dear Jo

Proposed merger of the eight North West London Clinical Commissioning Groups

Thank you for proving an opportunity to express our views on the proposal to merge the eight North West London CCGs: Brent, Central London, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow and West London.

The trust supports the move to a single CCG in line with the expectation in the NHS Long Term Plan and the alignment of the CCG with the proposed NWL ICS.

We fully support the commitments outlined in slide 5 and welcome the desire to remove duplication, increase standardisation and enable a more equitable distribution of resources. However, we would like greater recognition of the role of community services as a partner with primary care in the delivery of integrated care and the importance of the borough, population-based focus for the delivery of care.

Slides 6-9 clearly articulate the CCG borough focus but lack the detail of the structure proposed to support this. However, we have been provided with the Hounslow structure and will comment on that through the local partnership group. The share of activity between the single CCG and its borough committees is also clear, although how this will be delivered in practice needs clarification.

Slide 10 on Borough-based partnerships appears out of place in the CCG case for change as it relates to borough-based provider collaboratives. We are fully in support of borough-based alliances. Our experience is that the local health and care alliance in Hounslow works well with all partners, including the local authority, and is evolving as relationships are strengthened. The suggestion that there should be a standard model for the management of these partnerships (single out of hospital director) seems premature without exploring further the potential

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opportunities afforded by moving to a more blended commissioner/provider model across health and care. We would welcome the opportunity to discuss this further.

Yours sincerely

Patricia Wright

Chief Executive

From: Imperial College Healthcare NHS Trust

Dear Karen & Jo

Thank you for the opportunity to comment on your proposal to merge the eight North West London CCGs. We are very supportive of your overall plan and can see significant benefits to a single CCG being able to contribute to strategic decision-making at a sector level. As your letter and accompanying case for change outlines the key will be how, in tandem, we find the right mechanisms to build trust and relationships at a local community and borough level, so that we deliver care that really matters to our patients and local citizens. In reading through the proposal six areas came up that we thought were worthy of comment: Commissioning for outcomes. We see the move to one CCG as a strong opportunity to evolve how our commissioning function moves beyond issues of demand and capacity to be truly based on need. This is crucial to tackling the health inequalities that we know are deeply inherent within our sector. Commissioning and contracting needs to be based on the delivery of defined outcomes that will best meet that need, rather than solely focusing on processes. Broad provider collaborations then need to be given the space to work with patients, citizens and local communities to co-produce the new models of care that will best deliver these outcomes. Consideration also needs to be made with how this function will interface with NHS England specialist commissioning, such that services funded through both commissioning pathways can plan and deliver services that provide an outstanding user experience. Understanding local need. We support the idea of borough based partnerships as we see these as key to how our integrated care system will understand local need, as well as being able to deliver care that understands the context of the local communities. As has been demonstrated within the COVID-19 pandemic there needs to be strong leadership within these partnerships from the local authority director of public health and team. This could be brought out more in your proposal. Out of hospital. We are concerned that the description of borough based partnerships (slide 10 of case for change) misses a key partner by excluding acute and specialist hospital providers. Through many years of development of innovative integrated care work in a number of specialties, and in a number of geographical ‘places’, we have built deep relationships with local authorities, local citizen and community groups, GP practices and more recently PCNs, community and local mental health providers and third sector organisations. These are the relationships that are at the heart of improving outcomes and reducing inequalities, and we are very committed to playing an active part in this. In addition we see our responsibility to develop as a key ‘anchor’ partner with the local communities around each of our hospitals, working together to improve issues around employment, economic regeneration and environmental sustainability, all of which are key determinants of health and well-being. The way this is currently described risks the delivery of truly integrated care.

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Co-production. Although we were pleased to see a slide (8) in the case for change on involving local residents in the work of the single CCG we would strongly encourage a much bolder vision for involvement and engagement. The current proposal takes too much of a traditional approach to listening to feedback and representation, at a time where the most innovative healthcare systems in the world are learning the benefits of true co-production with their local citizens and communities. We need to significantly change the delivery of our services to be much more user-focused, and repurposing resource to build capability and capacity in co-production skills and leadership will be essential to doing this. Research, innovation & education. Although the new single CCG is clearly not the commissioner of research, innovation and education activities, we feel that the proposal misses a key chance to describe how the CCG would utilise the opportunities that our depth of research, innovation and education capability in north west London can bring to transforming services, bringing in new treatments, involving patients in research and evaluating impact. The changes you are proposing are a key opportunity for us to bring the benefits of our longstanding investments in clinical research and education much closer to the population we serve. Inequalities. We are very pleased to see equity of access mentioned in the fourth of your commitments to north west London, and believe that it is good starting point for commissioners and providers to use to begin to address some of the key issues of equity. However, access is only the entry-point to the issue and we would welcome a stronger focus on commissioning measures that will genuinely tackle the variations in outcomes that are at the heart of many health inequalities. An example of this would be increasing investment in some of the simple measures (for example, seeing a dentist before 12 months of age; supervised brushing in nursery schools; pre-school education) that the evidence shows reduce harm (such as dental extractions in children). We currently spend nothing on the former and over £2m on the latter, and the harm is disproportionately in children who live in poverty. We hope that these comments are helpful and very much look forward to working with you as we continue to build genuinely integrated care. Best wishes Dr Bob Klaber Director of Strategy, Research and Innovation On behalf of Professor Tim Orchard, CEO

From; Chelsea and Westminster NHS Foundation Trust

Dear Jo,

Re: Proposed merger of North West London CCGs

I am writing to express our strong support for the proposed merger of the eight North West London CCGs. As we have discussed many times, we need to consolidate the transactional function of commissioning, while ensuring we focus on addressing the inequalities that are all too apparent in our local populations. It will be important to ensure that the provision and delivery of care in each borough is informed by the health and care needs of the people who live there and that we work in ever closer partnership with our local health and care partners to achieve this.

Yours sincerely,

Lesley Watts

Chief Executive

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From: Barbara Bendenek

Dear Jo,

Thank you for the opportunity to share my views on the merger of the 8 NWL CCGs. Please accept my apologies for the lateness of my response.

It is clear that the move to one CCG will happen. Some London collaborations of CCGs have already done so and NWL has supported that direction of travel. Covid19 has emphasised the benefits of the 8 current CCGs working together and there are many NHS services which are better delivered at scale. The creation of one CCG can provide a saving on administrative costs.

There are many reasons why this is a good idea, but there remain a number of problem areas. The two that concern me most and that fall into the areas I know most about are:

Role of local services

I have participated in a number of discussions about the move to one CCG over the last year. What causes serious concerns is that the questions about the relationship between the one CCG and local NHS services (and the borough councils) has never been clearly laid out. While the one CCG is presented as intending to be based on the think global act local principle, there has not been any clear presentation of how the services in the boroughs will interface with the one CCG. It feels a bit like the system operate on the basis that decisions will be made in NWL and the local teams will have to implement decisions over which they had little influence

At the last ICS Local Care Board (28.08.20) I asked how the local services and the single CCG would work together. The answer was “the ICP and PCN governance group has still to be set up. It will look at NWL and PCNs and where the decision making and delivery sit.”

I have asked the same questions about the role and influence of local services at Hounslow CCG Governing Body meetings when you were present, and the answer has been “it is still work in progress”

I do not understand how existing local services such as GP federations (or consortia), PCNs, and CCG local commissioning teams can support a move to a single CCG when their role in it has not been clarified. Not to mention the relationship with community health trusts, local council services and all the other providers.

This feels to me like “divide and rule”. In all the discussions and documents I have seen, the plan seems to be PCNs having input into what is decided in NWL. But PCNs are small (there are 7 practices in the Brentford and Isleworth PCN) and there are many of them each operating (to some extent at least) in their own way. I do not see how a multiplicity of small PCN can have any effective influence.

And where do the Integrated Care Partnerships fit into all of this? Especially since none is very mature, and some are notably immature. It feels like they are key in making the one CCG system work in a way which is responsive to local needs and capacity.

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I hope that some of this has progressed since I was last present at discussions.

Proper involvement of patients and public

Since the start of the pandemic a number of key committees involving patients and stakeholders stopped meeting (Integrated Lay Partners Group; The Hounslow Integrated Care Project team has been disbanded and there is now patient involvement in the oversight at a senior level in the planning for one CCG nor post Covid medical care; The Hounslow Health and Wellbeing Board – which is where we are told stakeholder oversight will take place). Other local and NWL meetings with patient representation have just started meeting again – and it is clear than a lot of changes have happened in the interim. This is understandable because the pandemic threat was very serious. But it does make clear that patient involvement is seen as an extra rather than essential.

There are many Hounslow CCG and Hounslow Council post Covid19 working groups. I have tried to get information about how many of these groups have patient/resident members and have utterly failed to get any response. NWL and Hounslow seem to be right back to doing to patients rather than doing with them. There are huge changes coming, because of financial problems, Covid19 and the move to one CCG. It makes sense to work with the people who are, and will be, using the services.

Just like the issue of how local stakeholders can have influence in the one CCG, there is no clear pathway for local patients and public to be involved in an effective way.

EPIC is a good idea – but it is a broad and wide-ranging programme which feels far away from local patient knowledge and experience.

In Hounslow we have effective network PPGs, but we are very concerned that there is no mechanism for our knowledge and experience to contribute to the decisions made by the one CCG. Nor have I seen any discussion about how that will happen. I would, however, like to thank the Hounslow CCG Governing body has invited the Network PPG leads to attend the Governing Body meetings and Seminars. We really appreciate the support that Annabel Crowe and Clive Chalk give us.

I hope this is useful – and thank you again,

Barbara Benedek

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