… with budgets which are “aligned” rather than “pooled.” Here’s a translation
21st March 2018
By Graham Smith
Cornwall Council’s plans to take over the National Health Service remain in place, although somewhat slowed, following the publication of a report to be considered by the authority’s 10-member cabinet next week. Instead of launching a new organisation on 1st April, the council now wants to “start a mobilisation phase” which could still result in all strategic health commissioning decisions moving to County Hall.
Although the original ambition for a “single place, single plan, single budget” Accountable Care System has been shelved, the council still hopes its Health & Wellbeing Board will make progress towards a single, strategic commissioner with “aligned” budgets. Such a plan was not included in the six options previously considered and has led some to describe it as “Option 7.”
The Health & Wellbeing Board is chaired by council leader Adam Paynter, rather than chief executive Kate Kennally, who continues to chair the Sustainability and Transformation Plan board. However, one of the tasks of the Board, before September, is to appoint a “suitably qualified and experienced joint commissioning post.” Ms Kennally had previously been identified as the lead officer for this role, despite the concerns of Cornwall’s doctors and nurses that she lacks clinical experience or judgement.
The preference of a council Inquiry Panel was to set up an ACS in the guise of Option 6, which called for full merging of budgets. The preference of the NHS Kernow Clinical Commission Group is for Option 2, which is to use existing statutory mechanisms on a sector-by-sector basis, known as Section 75 Agreements.
The CCG is now keen to expand the use of Section 75 Agreements beyond “delayed discharge” from acute hospitals and to encourage similar joint approaches in mental health. The CCG is also deeply suspicious of the political “Devolution” ambitions of County Hall.
There are divisions within the council’s cabinet over whether its approach now is closer to Option 2 or Option 6. The only thing which is completely clear is that any official, or councillor, who uses the words “Accountable Care” now risks severe reprimand, as both County Hall and NHS chiefs struggle to find a language they can agree on.
The CCG’s governing board has agreed to move towards Option 6 but wants first to fully explore the potential of Option 2. This puts the board slightly at odds with its own chairman, Dr Iain Chorlton, who is an enthusiast for Option 6.
Conservative Cornwall councillor Andy Virr, who chaired the Inquiry Panel and recommended Option 6, now believes the council’s Liberal Democrat leadership has surrendered to “far Left wing protestors” and is fudging the issue of merged budgets.
In an email to all councillors, Mr Virr said: “The panel was very clear that joined up commissioning meant that budgets should be combined and not just aligned. We accepted that this was something the council and health organisations would want to work towards over the next couple of years. However, just ‘aligning’ budgets was not proper joined up working and would lead to silo working and off handing of responsibility.
“This is an important moment for health and social care in our county. We need to grasp this opportunity to deliver a real long lasting improvement to health and social care in Cornwall. We need to rise above the ‘political’ noise and study the facts and do the right thing.”
Follow the money: Kate Kennally’s ambition to bring about fundamental structural change is still on the agenda
The difference between “aligned” budgets and “pooled” budgets is now being dissected and scrutinised with officials unsure whether anything will actually change on 1st April. Ms Kennally had previously been keen to launch a “shadow” Accountable Care System on that date, with the ambition of becoming a fully-functioning ACS or ACO next year.
“The start of the mobilisation phase” is still identified as next month. By June, the council and NHS Kernow are intended to have jointly funded a “Senior Responsible Officer” for joint commissioning. A final, detailed business case is still due by September. All of this still sounds remarkably like the original ACS proposal which Mr Virr fears has now been abandoned.
A Judicial Review due for trial at Leeds High Court on 24thApril is designed to test the legality of single, fixed budgets. Many councillors believe it would be sensible to postpone a decision until after that hearing. A second Judicial Review is still awaiting a trial date to determine the legality of Accountable Care Systems or Organisations without Parliamentary scrutiny and legislation.
The question of historic NHS debt is also to be answered by the September deadline. NHS Kernow, and the Royal Cornwall Hospital Trust, are thought to have accumulated debts totalling £100 million – but as this is due simply to the NHS internal market and budgetary re-charges, based on a Treasury formula which fails to recognise Cornwall’s unusually high health demands, many regard the debt as a largely theoretical construct.
A summary of the current business plan says:
There will be an independently chaired System Assurance Group, which is a system-wide forum to hold the Commissioning and Provider system leads to account for the delivery of the system’s strategic priorities.
- Reporting into this group will be an Integrated Strategic Commissioning (ISC) Joint Committee and a Transition Integrated Care Partnership (ICP) Board.
- The ISC Joint Committee Board will include all four commissioning organisations and be responsible for the commissioning of all CIOS health, care and well-being services
- The transition ICP board will include all CIOS statutory health and care provider organisations together with Primary Care and will ensure prioritisation and implementation of a whole system plan to ensure a coordinated approach to developing place based delivery of care, holding partners to account to manage and mitigate risks to support the delivery of the commissioned quality and performance service outcomes within the agreed financial envelope.
- The transition ICP board will also set the agenda for and oversee the work plans of the planned care board and A&E delivery board which will report into the transition ICP board.