Partnership Board questions and answers

View or download questions submitted to our Partnership Board, along with the responses:

Response to questions from members of the public, West Yorkshire and Harrogate Health and Care Partnership; 7 September 2021

Question 1

I would like to preface my question with a request that it is discussed by Board members in this meeting and not left to ICS managers to respond to. The lack of Board discussion of questions from the public is a real weakness. We bring questions here for all the Board members to consider - but under the current process this doesn’t happen. As a result, our questions are like pebbles that just skim across the surface of the meeting and have no effect on it.

At a Public Participation meeting with ICS managers on 17.3.21, referred to in the Minutes of 1st June 2021 Board Meeting as “positive”, Ck999 asked for the contact details of the 4 coopted members of the public on the ICS Board, so we could ask them to take up our questions in the meeting. We also said we need to know what their remit, powers and duties are (if any). None of this has happened.

So: Please will Board members discuss and comment on the fact that Rob Webster’s Chief Exec Report does not mention the recent Centre for Policy studies think tank analysis of integrated care systems, which uses West Yorkshire and Harrogate ICS as a case study, and recommends that:

“the Government should: Drop from the Health and Care Bill legislation to put ICSs on a statutory footing. The evidence to date suggests that there is no clear link between integration and improved outcomes... Before charging on down this road, we need much better evidence that the ICS model is the right one to adopt.”

In particular, please will Board members discuss and comment on these findings from the Centre for Policy Studies, that specifically refer to West Yorkshire and Harrogate ICS:

The Centre for Policy Studies report notes some positive evidence in terms of delayed transfers of care in the West Yorkshire and Harrogate ICS-

“but...there was a worrying and perhaps related rise in emergency readmissions...to hospital [which] had risen to 14.4% by 2019-20, overtaking the national average...Overall, there was no evidence of significant performance improvements. And again, there had been a significant increase in healthcare bureaucracy, with a 20% increase in managerial staff since 2016...

The establishment of the WYHHCP seems to have led to a degree of productivity decline, with greater inputs yielding no overall improvement in outcomes –even on an optimistic reading – in a region that has been cited as proving the effectiveness of the NHS England led approach.”

While

“The gap between West Yorkshire and England in terms of cancer mortality rates did not close in any significant way from when the STP was set up.”

And

“On average, respiratory disease mortality was 0.4% lower in West Yorkshire in the three years from the establishment of the STP in 2016 compared to the three years beforehand. However, the gap between West Yorkshire and England only closed marginally in West Yorkshire’s favor in 2017 and 2018, with the gap then opening up again in 2019.”

There is more analysis of other key health outcomes for West Yorkshire and Harrogate Integrated Care System that basically show no evidence of improvement since the STP was set up in 2016.

In terms of workforce,

“ The NHS workforce in West Yorkshire and Harrogate increased by 6.5% under the STP and ICS to reach 2,290/100,000 population in the region. This rise was 40% greater than seen nationally” - but “the proportion of clinically qualified workers declined from 52% when the STP was set up to under 50% under the WYHHCP.”

This is because:

• "There was a 10% increase in senior managers from March 2016 to March 2020, while the support and infrastructure workforces grew by 16% and 19% respectively.
• The clinically qualified workforce [only] grew up 6.5%”

If the 4 coopted members of the public on the Board would like to get in touch with Calderdale and Kirklees 999 Call for the NHS, you can email us on changingmorethanlightbulbs@gmail.com

Response to Question 1 - summary of response and discussion by Board members

The Chief Executive noted that the reason that his report did not mention the recent think tank analysis of NHS integration was that the analysis had been published after the papers for the Partnership Board had been circulated.

Although the findings would need to be considered, he noted that the think tank report provided only a partial analysis of the work of the ICS and its priority outcomes. For example, it did not cover the key issues on today’s Partnership Board agenda, such as progress in tackling health inequalities for Black, Asian and minority ethnic communities and colleagues and the important contribution to the health and care system of the voluntary, community and social enterprise (VCSE) sector.

Some of the outcomes from priority work by the Partnership were noted, including the additional 6,700 people with hypertension being supported as a result of the Healthy Hearts programme, and the 53,000 new carers identified across the area.

It was noted that there that no re-organisation or restructuring had taken place within the ICS and that the Partnership brought together organisations to work collaboratively on shared objectives.

The increase in the workforce in West Yorkshire was a positive indicator. This included significant growth in staff providing support to clinical staff over the last 5 years, including healthcare support staff and technicians. COVID had meant that additional staff had been needed to address estates issues.

The Chair of the Partnership noted that a priority for the Partnership was to make progress on delivery of the outcomes reflected in its 10 big ambitions, which were covered in a later item on the agenda. He welcomed that contact had been made with the Partnership Board co-opted members about how questions were dealt with by the Board.

Board members further considered the question about the outcomes achieved by the Partnership under the Chief Executive’s report. The reduction in stillbirths and maternal mortality in more deprived communities was noted. Board members highlighted the work of the Partnership on the wider health and care agenda in areas such as early intervention, supporting homeless people and responding to the pandemic. Board members noted that case studies highlighting the difference our Partnership is making were available on the website. Recent progress in increasing diversity in recruitment from Black, Asian and minority ethnic communities was also highlighted under that agenda item.

Response to questions from members of the public, West Yorkshire and Harrogate Health and Care Partnership; 1 June 2021

Question 1

UK statistics suggest that 50% of those admitted to hospital with covid-19 have troublesome symptoms three months later, with underlying respiratory, cardiac, renal, endocrine and immunological pathology. The Office for National Statistics estimates that 1.1 million people are living with long covid in the UK. Nationally it appears that despite government pledges, long covid clinics are often unavailable, lack specialist medical supervision or specialist multidisciplinary teams and have long waiting lists. It is welcome that a specialist service is being set up in Leeds for children, however, as a group they are far less affected than adults. What is the estimated number of patients in West Yorkshire suffering from long covid? What steps are being taken to ensure that cases are systematically recorded in primary care computerised medical records so that need is accurately documented? How much funding has been made available from government for clinics in West Yorkshire to manage patients with long covid? What is the current situation with respect to location of functioning clinics, numbers and composition of staffing, and waiting times for referrals?

Question 1: Response

The Partnership recognises the important issues relating to Long COVID that the question raises. Nationally, around 1 in 7 people with COVID are still experiencing symptoms after 12 weeks and this currently adds up to 600,000 people.

To support long COVID assessment, we have received about £1m from NHS England. This is primarily being distributed to our places, together with the Leeds Hub for children across West Yorkshire and Harrogate. We expect further funding to be made available for long COVID treatment and rehabilitation, although we have not received confirmation of the funding this point.

We are continuing to work as a WY&H system and across our places to better understand the needs of people with long COVID and provide the appropriate assessment, treatment and rehabilitation services. In the period 5th April -5th July 2021, it is estimated that 655 referrals were made to post-COVID-19 assessment clinics in West Yorkshire. The ICS does not hold information on the number of long COVIC patients being treated in primary care.

A number of steps have been taken to support systematic recording in primary care. These steps include webinars for primary care staff, training on the coding of patients and support for case-finding. CCGs are also overseeing the implementation of a National Direct Enhanced Service for Long Covid in General Practice which aims to improve detection, recording and referral of Long Covid Patients. These steps are designed to ensure that all patients can access the appropriate support in line with NICE guidelines on managing the long-term effects of COVID-19 . In West Yorkshire, clinics are provided in each of our places as follows:

Bradford and Airedale – Bradford Acute Teaching Hospitals Trust.

Calderdale – Calderdale and Huddersfield Foundation Trust

Kirklees – Locala Health and Wellbeing

Leeds – Leeds Teaching Hospitals Trust

Wakefield – Mid Yorkshire Hospitals Trust

Clinics are operated by multidisciplinary teams which typically include respiratory medical staff and specialist nurses, physiotherapists, occupational therapists, dieticians and psychologists.

The ICS does not hold comprehensive data on waiting times for an initial clinical assessment in West Yorkshire. At 5th July 2021, estimated waiting times were as follows:

Approx. 60% of patients were waiting less than 42 days, with 40% waiting 0-6 days

Approx. 40% of patients were waiting more than 42 days, with 13% waiting 98+ days

Question 2

For legitimate reasons, the public are concerned about the increasing influence of the private sector in the NHS, the Centre for Health in the Public Interest estimating that 18% of total funding now finds its way to private companies. The chair of the ICS Governance Working Group has told us that it is unlikely that private providers would accept seats on the board of the ICS given the risk sharing that this would involve. However, over the last year the government preference has clearly been to bypass NHS and Public Health structures in favour of massive contracts with the private sector, at huge cost to the taxpayer. The Bath and Somerset Partnership Board already has Virgin Care as a member, and has welcomed the recent NHS white paper. Can the Partnership Board reassure the public of West Yorkshire that private providers will not be included in the membership of the ICS boards due to the major conflicts of interest this would entail?

Question 2: Response

The Partnership does not currently envisage that private providers will be included in the membership of ICS Boards, although we will clearly have to ensure that our arrangements meet the requirements of the legislation and statutory guidance, once published.

The Partnership anticipates that public sector and voluntary, community and social enterprise providers will continue to provide the vast majority of services across our area. We will continue to ensure that conflicts of interests that arise in relation to any type of provider are managed robustly and transparently.

Question 3

Provider collaboration:

The proposed legislation introduces a duty for providers to collaborate to deliver the 'triple aim' of better health and wellbeing, better care and sustainable use of NHS resources. There are already good examples of collaboratives, where acute trusts or mental health service providers come together within their own sector. Whilst this is important for developing and delivering more efficient & effective services by sharing good practice and reducing variation, there is a risk that this perpetuates silo working if this horizontal collaboration remains the main focus. At place level the biggest opportunity to make a positive impact will be as a result of vertical collaboration across sectors, bringing together a range of different service providers and stakeholders. How will the ICS ensure that all providers are held to account for collaborating at place level to deliver optimal services and pathways that are truly integrated from a patient perspective?

Question 3: Response

The Partnership strongly agrees that the collaboration of providers at both system and place level is critical. The Integrated Care Partnerships (ICPs) in each of our places are partnership of all local health and care stakeholders and providers including the voluntary, community and social enterprise sector. There are already good examples of this, for example the Mental Health Alliance in Wakefield.

A key part of our Integrated Care Partnership (ICP) development work, is to support places to take on the delegation and accountability for integrated care system functions at a local level so they can effectively join up care and reduce health inequalities. The ICP development framework sets out ‘what good looks like’ in relation to provider collaboration and how providers work together to support the delivery of more integrated care.

Question 4

Role of NED/Lay Members:

CCG Lay Members have played an important dual role in CCGs over many years:

As non-executive directors (NEDs) they provide independent leadership, advice, expertise and constructive challenge; and

As patient representatives they ensure the interests of patients are at the heart of discussion & decisions at all times, with a commitment to improving outcomes, tackling health inequalities & delivering the best value for money for the taxpayer.

The proposed legislation provides flexibility for ICSs to develop their own accountability arrangements to suit local circumstances. What arrangements are being considered by the ICS for independent NED and patient voice representation for:

The ICS Board

The ICS Health & Care Partnership

Place level Integrated Care Partnerships

Question 4: Response

The Partnership agrees strongly that Non-Executive Directors, Lay and co-opted members play an important role dual role in providing independent challenge and in ensuring that citizen voice is heard. Independent members play an important role in our current system-level arrangements such as the Partnership Board and the Joint Committee of CCGs and we see them playing an equally important role in our new arrangements.

CCG Lay members have played an important role in CCGs and we are committed to ensuring effective independent challenge in our new place arrangements. We are setting out ‘what good looks like’ in our ICP development framework and the arrangements will be enshrined in our ICS constitution.

We are committed to ensuring that there is strong citizen voice that represents the diversity of our communities. We have commissioned an independent review of our public involvement arrangements and will be using the recommendations from this to develop and improve further.

Question 5

Re: Tackling Health inequalities progress report/Operational planning 2021/22 report

What does the ICS Board think are the most urgent steps that need to be taken now to reduce the continuing disproportionate impact of C19 on low income and BAME neighbourhoods and individuals?

Question 5: Response

One of the main priorities in reducing the impact of COVID 19 on low income and BAME neighbourhoods and individuals is to improve vaccination uptake for these groups. The paper on Black, Asian and minority ethnic update talks about the continuation of the WY&H Health Inequalities COVID-19 Vaccination Group to ensure that targeted approaches to reducing inequalities continue to influence vaccine rollout, including example of targeted work by voluntary and community sector organisations with the Gypsy and traveller community. The primary care networks across our places are working really hard to improve the vaccination uptake with initiatives such as vaccinations in faith centres and mosques, drop-in clinics, working with VCS partners and women only sessions with good success.

Question 6

Why does the Tackling Health Inequalities Progress Report omit any discussion of the very serious health inequalities impact of Covid 19, apart from a brief mention of vaccination? Particularly since the Operational Planning 2021/2 Report (para 18) points out “NHS services can only be re-introduced when test, trace and isolate capacity and infrastructure in place, especially for our most at-risk communities including those who are ethnic minorities, those who are the poorest, those with pre-existing conditions and those where the intersectionality issue plays out to maximise disadvantage.” And it will be critical to learn from what has happened and how to do better.

Question 6: Response

Tackling health inequalities and improving population health is in the fabric of our Partnership and every programme has these ambitions built in to their priorities, work plan and approach. The agenda items on inequalities today are updates on two specific pieces of work and are not a comprehensive review of the ICS work on inequalities.

Differences in social position and social status that are usually described together as socio-economic inequalities play a huge role in unfair, unjust and avoidable differences in health outcomes between communities. The debate on these differences is a debate of what sort of society we want to be and discussions must happen in all forums including policy, ethics and politics.

The ICS is fully committed to reducing inequalities in the 2.7 million people living in West Yorkshire and Harrogate, as evident in our ten big ambitions. The ICS acknowledges that no single organisation can do it alone and the real work in tackling inequalities must happen in places and communities hence a strong emphasis on community empowerment and partnership working along a social gradient. The ICS is adding value through facilitating the provision of insight and intelligence, increasing capacity and capability of the system in tackling inequalities. Some of these initiatives are covered in today’s agenda item on the Health Inequalities Academy.

Question 7

What does the ICS Board now think of its response to my question at the ICS Board meeting on 30 March 2020: Is tackling socio-economic health inequalities part of emergency preparedness plans for Covid19? This was the ICS Board’s response:

“The NHS in West Yorkshire and Harrogate, and Public Health England (PHE) are well prepared for outbreaks of new infectious diseases. The NHS has put in place measures to ensure the safety of all patients and NHS staff while also ensuring services are available to the public as normal. NHS 111 has an online coronavirus service that can tell people if they need medical help and advice on what to do. This information is being shared widely across all communication channels and public services, and beyond.” How does the ICS Board now rate that answer?

Question 7: Response

The Partnership’s response to your question of 3^rd March 2020 reflected the national and WY&H understanding of COVID 19 at the time. Since then, partners across our system have worked together collaboratively to tackle the disproportionate impact of COVID on our communities.

Question 8

Operational planning 2021/22 report (para 23) - How is the ICS going to implement this NHS Planning priority: “building on what we have learned during the pandemic to transform the delivery of services”?

Particularly since - as the Doctors for the NHS Evidence to the Health and Social Care Committee of the House of Commons points out:

“The White Paper makes many references to learning from the experiences of the pandemic, but a systematic and open review of the pandemic response has not yet taken place, so how can we be sure that the appropriate lessons have been learned.”

Question 8: Response

The Partnership’s approach to planning is set out in detail in the report on today’s agenda. Partners have learned a huge amount from the pandemic in relation to access to and delivery of services and we are building this learning into our transformation plans. For example, in primary care, telephone appointments have increased threefold during the pandemic. We will be seeking to ‘lock in’ changes such as these, making sure that they do not have a detrimental impact on health inequalities.

In Bradford and Craven, a COVID Scientific Advisory Group has been established, linking health and care partners with the university. This has provided an important new perspective on how we can improve population health and we will be seeking to build on this approach more widely across our system.

Question 9

Re: Response to White Paper: developing governance arrangements/ Response to White Paper- update and next steps

This is a question in 3 parts, about:

The ICS NHS Body’s duty to compel providers to comply with the requirement for the system to deliver a balanced budget and meet the 3rd Triple Aim.

Whether/how the ICS would make sure there are appropriate clinical checks on these ICS financial duties.

How the ICS would provide accountability and transparency in its use of the opaque and de-regulated contracting methods of the Provider Selection Regime.

The White Paper 5.12 says the ICS NHS Body will have a new duty “to compel providers to have regard to the system financial objectives [set by NHS England] so both providers and ICS NHS Bodies are mutually invested in achieving financial control at system level.” This is reflected in Developing Governance arrangements para 4, place based arrangement: “ICSs will decide how they align their allocation functions with place...There will be a duty placed on the ICS NHS Board to meet system financial objectives. ”

Question 9a

How is WYH ICS planning to carry out this duty of compulsion on place- based Integrated Care Partnerships?

Question 9a: Response

It is important to be clear about what the White Paper states in terms of compulsion. The White Paper suggests that NHS ICS bodies will have the duty to compel providers to ‘have regard to’ system financial objectives, so that both providers and NHS ICS bodies are mutually invested in achieving financial control at system level.

The notion of ‘having regard to’ system financial performance and control already exists for us within our partnership. Our agreed Memorandum of Understanding which all partners have signed up to is clear that we will work together to live within our means at organisational, place and system level. We do this already across our NHS revenue allocations and capital allocations, and have done this successfully over the last two years.

In terms of compulsion in relation to what happens in place and in organisations, the White Paper states that NHS providers will retain their current organisational financial statutory duties, and the ICS NHS body will not have the power to direct providers.So, as now, we will work to our shared ambitions, supported by an agreed set of principles and behaviours.How this is done will be set out in our governance arrangements, and item 21 on today’s agenda sets out the approach being taken to the development of these arrangements.Partnership Board members will be invited to comment further on this work at that point.

Question 9b

As well as that new duty, the ICS is also required to meet the third Triple Aim (initially defined as ““reducing the per capita cost of health care” by the American Institute for Healthcare Improvement that first came up with the “Triple Aim”.) The White Paper 6.18 says “ICSs will ... need to ensure they have appropriate clinical advice when making decisions [about NHS Spend and performance].” What system is the ICS putting in place to make sure that there are appropriate clinical checks on the ICS duty to compel providers to deliver ICS financial balance and meet the third Triple Aim duty, if these financial limitations would risk patient safety and/or access to treatment?

Question 9b: Response

Our Partnership is strongly committed to clinical and professional leadership and has agreed a set of principles to support this. One of these principles is that strategic priorities and work plans will be developed collectively, with multi-professional clinical involvement. Clinical and professional leadership will be an integral part of planning, priority setting and decision making at both place and system level. Clinicians will therefore play an important role in ensuring that there are effective and appropriate checks on key issues such as access to services and patient safety.

Question 9c

Developing governance arrangements, para 9. How is the ICS Board going to “ensure that our arrangements continue to align with the principles of good public sector governance, including accountability and transparency”, when the Provider Selection Regime’s deregulated contracting methods are fantastically opaque, seem designed to meet the interests of private and third sector providers not patients, and risk the kind of corruption that has occurred with government Covid-19 related contracts awarded under emergency regulations?

For example, the Provider Selection Regime proposal for “simplified” Any Qualified Provider lists for GP referrals to elective care proposes that the statutory Integrated Care System NHS Body Boards will be able to pre-select companies to put on the Any Qualified Providers list, without any procurement process. All the selectors will have to do is “demonstrate the providers meet the stated service conditions”. (7.7-7.9 NHS Provider Selection Regime Consultation document February 2021). These AQP companies can then register their services on the Electronic Referral System list. Is the ICS Board happy that patients have to be “demonstrably” damaged or failed before the ICS can take a company off the Electronic Referral System list?

Question 9c: Response

The Partnership strongly supports accountability and transparency in public procurement. Our response to the consultation document on the provider selection regime argued that decision making processes must be public and there must be scrutiny of the arrangements.

The consultation document sets out a range of measures for ensuring this, including publishing both contracting intentions and awards of contract and publishing a summary of contracts in the annual report.The ICS will of course comply with all requirements set out in the legislation.We may introduce additional measures if we feel that these are necessary to enhance accountability and transparency.

Response to written questions from members of the public, West Yorkshire and Harrogate Health and Care Partnership; 1 June 2021

Question 1

Chief Executive’s update

What is the population data referred to in Para 11 of Rob Webster’s Update? What platform is it held on, and who is the data controller?

What measures are being taken to deal with physical contraints on the delivery of routine services? (para 40, Rob Webster’s Update).

Does this include WY hospitals subcontracting to “insourcing” businesses such as Totally Ltd, in order to clear the Covid-19-caused waiting lists backlog? If so, which insourcing companies will WYH ICS and WYAAT be, or are, considering subcontracting to for the purpose of elective recovery?

Did NHS England/Improvement approve the Integrated Care System’s bid for £1.2m for a proposed virtual elective care hub? If so, how will this contribute to clearing the waiting lists? If not, why not?

Question 1: Response

Population data for long COVID is held locally in our places. The ICS does not hold information about the platforms on which is held or the data controller arrangements.

Trusts are doing everything they can do to organise services in ways that minimise the impact of COVID on delivery, for example by creating “COVID Secure” sites (eg Dewsbury, Chapel Allerton) and using the independent sector. However, there are still constraints due to social distancing requirements and the physical layout of sites that reduce capacity compared to before the pandemic.

Physical space remains a challenge. The West Yorkshire Association of Acute Trusts Elective Co-ordination Group is looking at mutual aid opportunities to utilise fallow weekend theatre space and reviewing different uses for facilities. Staffing remains a challenge due to some areas having high sickness and also difficulty with staffing additional lists at weekends. Staff recovery and mental health awareness are rightly high on Trust’s agendas.

Individual trusts are responsible for determining any requirements for sub-contracting. The ICS is not responsible for the decisions that individual trusts make and does not hold this information.

NHSEI provided funding of £271,947 for a “virtual elective hub”. The funding was used to provide capacity to share data, understand system level waits and ensure equity of access.

Question 2

Operational planning 2021/22 report

(para 23) How is the ICS going to implement these NHS Planning priorities?

expanding primary care capacity to improve access and local health outcomes and address health inequalities;

transforming community and urgent and emergency care to prevent inappropriate admissions to hospital, improve flow and reduce length of stay;

Response to question 2

Our general practices are already reporting delivering appointments equivalent to or more than pre-pandemic levels. However, we recognise that there is local variation in terms of patient experience and many patients are still experiencing difficulties with accessing care in a timely manner. Our West Yorkshire Primary Care Strategy sets the direction of travel for Primary Care, defining our primary care plan, visions and aims across the current primary and community care landscape for West Yorkshire.

Restoring and increasing access to primary care services- Getting practice appointment levels to appropriate pre-pandemic levels

Our WY approach and plan will target support to areas where access is proving more challenging including areas of greater inequalities. Our WY primary care programme will resource support to develop a local Access Improvement plan including a Deep Dive approach – working with Practices/PCN with wider access challenges. The Deep Dive will:

Harness insight and intelligence around access needs, preferences, barriers, patient experiences and inequalities
Use data and intelligence from national and local surveys and engagement events including the national Healthwatch report.

Outcomes

Key themes and lessons learnt will be analysed and shared to inform future access developments including;

WY Access Improvement Plan with agreed improved patent experience outcomes.
Improved patient awareness of how to access routine and urgent care – a described consistent route into care and a consistent offer for patients
Access models developed and designed around population needs, ensuring that local access models provide a genuine mix of appropriate digital and face to face consultations
Build on the work with Harnessing the Power Communities to enable and release resource to support PCNs in more effectively signposting patients.

We are also working with wider primary care including Community Pharmacy on the GP Community Pharmacy Consultation Service - supporting improved resilience in General Practice and ensuring patients are seen by the most appropriate clinician as timely as possible.

Maximising clinically appropriate dental activity

Access to NHS dental care is more challenging in some parts of WY. Further work will be prioritised in collaboration with regional dental commissioning and local PH colleagues to draw together plans that demonstrate an understanding of dental activity impacts on health inequalities with plans to improve access and outcomes for communities at most risk.

A group has been formed to fully understand capacity in West Yorkshire and flexibilities that can be maximised to improve access to care and tackle health inequalities.

Plans will be developed with clear actions that can be taken at system and place level to support access with a particular focus on health inequalities. Plans will deliver an improvement in average length of stay with a particular focus on stays of more than 14 and 21 days.

The ICS has a senior leadership team in place for Discharge. Four areas have been agreed to view discharge below; these will inform our priority areas:

People’s experience and outcomes
Safety and quality and timeliness
Operational system efficiency

System working and workforce

In addition, A&E Delivery Boards are well established across the ICS. The boards have the remit for system flow through the UEC pathway with a consistent focus on discharge flow to reduce length of stay, community capacity to support safer transfer of care and improve outcomes by maintaining a ‘Home First’ approach.

Work is underway in the 5 places to develop further the 2-hour crisis response service as per the national ambitions in the planning guidance. West Yorkshire also hosts the Kirklees UCR accelerator, which is working towards delivery of the standard early by October 2021.

We continue to progress the work already underway through the NHS 111 First and Same Day Emergency Care programmes

Significant progress has been made in implementing the NHS111 First approach during 2020/21 and continues with all Places and UEC providers working collaboratively together to implement through the WY wide UEC Programme Board. All systems are developing Same Day Emergency Care Services (SDEC) 7 days a week 12 hours a day and working on direct pathways to manage flow in emergency departments.

We will roll out the Emergency Care Data Set (ECDS) to all services

Urgent and emergency services are working towards daily ECDS submissions by October 2021 to deliver a single and consistent data set. This will provide greater insight into the delivery of patient care, identifying variance and supporting new ways of working.

Question 3

Para 25

Where are Calderdale’s and Kirklees’ place draft plans that were submitted on 28 April 2021?

Who prepared these plans, following what process?

Where is the aggregated WYH version of the plans, that was submitted to NHSE/I on 6 May?

Did WY JHOSC have sight of these plans?

Response to question 3

Draft plans for individual places have not been published as stand-alone documents. They have contributed to the development of an aggregate West Yorkshire ICS-level plan, the final version of which was submitted to NHS England on 3 June.

Draft place plans were developed by CCGs, Trusts, Councils and other partners working together.

Operational plans are subject to formal assurance by NHS England and NHS Improvement. They have not been shared with WY JHOSC.

Question 4

What is the membership of the Future Design and Transition Group Ditto the Governance Working Group. Are their agendas, papers and minutes publicly accessible?

Response to question 4

The Future Design and Transition Group is made up of the Chief Officers of the Clinical Commissioning Groups and senior system leaders representing our Partnership sectors.

The Governance Working Group is Chaired by Tim Ryley, Accountable Officer for Leeds CCG and is comprised of more junior staff. It is working on the technical detail of our governance arrangements and also includes representatives from across our partnership.

These are internal working groups and their agendas, papers and minutes are not publicly available. Both groups are advising the Partnership Board on matters relating to the establishment of the statutory ICS. Partnership Board meetings take place in public.

Question 5

Is/are the Future Design and Transition Group and/or the Governance Working Group ruling out the possibility that either or both boards, and any Joint Committees, may include private/third sector companies?

Response to question 5

The Partnership does not currently envisage that private providers will be included in the membership of ICS Boards at system or place level. However, we will have to ensure that our arrangements meet the requirements of the legislation and statutory guidance, once published.

Question 6

Developing governance arrangements para 4, place based arrangement:

would current risk/reward sharing capitated budgets for primary care networks continue, as in the Calderdale Cares prospectus?

would the aligned incentives contract with CHFT continue?

What ICS employees would work at place level under Integrated Care Partnership agreements?

Response to question 6

Detailed decisions about finance and staffing under the new statutory arrangements have yet to be made. Our intention is that the vast majority of ICS employees will continue to work at place level under the new arrangements and that decisions about financial matters in place will continue to be made at that level.

Question 7

The report ‘White Paper- update and next steps’ Para 13 refers to ICS operating model portfolios that include strategy and partnerships, planning and system improvement and corporate services”. To develop these or any other ICS Operating Model portfolios, is the ICS already contracting with, or planning to contract with, any companies (or NHS organisations) that are listed on the Health Systems Support Framework?

Response to question 7

The ICS is not already contracting with, or planning to contract with, any companies (or NHS organisations) that are listed on the Health Systems Support Framework.

Response to questions from members of the public, West Yorkshire and Harrogate Health and Care Partnership; 2 March 2021

Question 1

We appreciate that The West Yorkshire Partnership has raised a flag for accountability and striven to retain CCGs but would like to know how the Board thinks it can avoid being steamrollered by the legislation, stem the loss of accountability and uphold the primacy of place based planning in reality, not just in rhetoric? Only at place is there some accountability to the electorate and the intimate, local knowledge and networks needed to make a decent fist of tackling health inequalities.

Question 1: Response

Place will continue to be the primary unit of planning and collaboration across our system, with the statutory ICS working to support our places to integrate services, reduce health inequalities and improve outcomes.

Under the White Paper, place-based arrangements between local authorities, the NHS and providers of health and care will be left to local organisations to decide and we will build arrangements that maintain clear leadership and accountability at place level. This will continue to include the central involvement of Health and Well Being Boards. In addition, we expect significant devolution of functions and resources to place-based committees to enable joint decision-making with local government. This is anticipated in the legislation and is expected to be available to us.

We are absolutely committed to this model of working, and do not believe that the legislation proposed in the White Paper will preclude us from working in this way.

Question 2

We would also like to know how the Board thinks the planned legislation will give Adult Social Care a greater voice in NHS planning and allocation? Although another tier of organisation has been added to the proposed structure, it seems to have been relegated seats in the upper balcony while health and a few representatives from Local Government get seats in the front stalls.

Question 2: Response

The White Paper sets out a number or measures for strengthening the role of social care, including representation in ICS governance structures and a new duty to collaborate. For example the statutory ICS Board includes proposed requirements to have local authority representation, unlike the current CCG governing bodies.

In West Yorkshire and Harrogate, social care already has a strong role in all of our partnership arrangements and is seen as an equal partner in delivering health and care improvement. This will continue under the new arrangements.

We recognise that the arrangements at place level are key to this, and will ensure that this is built in to our thinking.

Question 3:

Given the White paper is suggesting that ICS will have more control over procurement, we would like to know:

What is the Board going to do to avoid the loss of oversight, transparency and accountability which has characterised recent Government contracting and resulted in a poorly performing test and trace system and significant waste on PPE provision by firms whose main qualification seems to have been having friends or cronies in Government?

What efforts are going to be made to use public providers and avoid private firms taking money out of the public purse to pass on to their shareholders?

How can the Board avoid strategic planning being skewed by private companies whose primary responsibility is to their owners and shareholders if, as suggested, they are given seats and thereby power and influence on the proposed Health and Care Partnership Boards?

Question 3: Response

NHS England has issued a consultation document on the proposed new provider selection regime. This covers the checks and balances that will apply and arrangements for ensuring transparency and accountability. We support the need for such measures. The Partnership will be responding to that consultation paper and will publish its response. (Attached at Annex 1)

The current requirement to go out to competitive tender has been widely criticised as creating unnecessary complexity and costs for commissioners and providers and acting as a barrier to health and care integration. It has also been criticised by many for enabling and accelerating the “privatisation” of NHS services.

The WY&H Partnership broadly welcomes the proposals to give commissioners more flexibility and only go out to tender when there are demonstrable benefits. It is of course vital that in making decisions, commissioners act in the best interests of patients, taxpayers and the local population.

Question 4:

Given the White paper also seems to be taking initial, small steps towards making Social Care a handmaiden to Health in one integrated system, with the focus on facilitating hospital discharges and reducing the use of expensive secondary care, we would like to know if the Board will resist this direction of travel? We fear that such a move will reverse the decades’ long struggle of the disabled people’s movement to stop Social Care being seen through a medical lens rather than situating it firmly in the development of inclusive societies and independent living.

Question 4: Response

Social care is focused on supporting people. In doing so, the best care works with people and other partners. This is reflected in the White Paper, which recognises the need for inclusive partnerships that reach beyond health and social care and focus on population health and reducing health inequalities. It also emphasises the importance of close partnership working between the NHS and local authorities at neighbourhood, place and system level.

These partnerships are at the centre of how we work in West Yorkshire and Harrogate across health and social care and we see them as key to our success so far. We will carry on with our approach of local authorities (including public health, housing and other key services, as well as social care) being equal partners with the NHS in delivering health and wellbeing improvements.

Response to questions from members of the public, West Yorkshire and Harrogate Health and Care Partnership; 1st December 2020

Question 1:

The WY&H BAME independent review meeting on 2nd September 2020 agreed that overseas charging regulations as an element of the hostile environment “would be explored further as part of the review and that the findings would be included in the review”. While welcoming the breadth of the review as a whole and the many recommendations made, I can find only limited references to refugees and asylum seekers, with a single sentence referring to charging: “it is essential that we keep in view overseas visitor charging . . . in terms of health inequalities”. Are there perhaps findings that I have missed or that have not been included in the review, or were there no findings to report? In any case, will the Partnership Board now commit to collect data on the scale of charging across its geographical footprint and any negative effects on both patient health (for example by surveying clinicians experience) as well as on applications for settled status? Will it also encourage NHS trusts to take steps to become more migrant friendly as set out by Medact? (section 6.2, https://www.medact.org/2019/resources/briefings/patients-not-passports/)

Question 1: Response

The Partnership is pleased that you had the opportunity to meet with Professor Dame Donna Kinnair and colleagues from the BAME review team on 12th November 2020, where this was discussed.

The Review explored many areas and when agreeing the final recommendations and subsequent action plan the Panel wanted to ensure that we maximised the opportunities in our reach to create the largest impact. The recommendations are high level and as highlighted in the report this is a live plan. As a result it will evolve over time and can also be flexed. The Partnership wants to assure you that we will continue to bear the issues that you have highlighted in mind, particularly the issue of migrant friendly hospitals. This will be addressed by the recommendation which refers to anti-racism campaigns and creating a more welcome environment for those working in our organisations as well as those receiving care from us. Health inequalities for migrant populations will be considered throughout the action plan as an area of focus.

To ensure a continued focus on the BAME Review, the Partnership Board at its meeting on 1st December 2020 agreed that progress on the action plan should be a standing item on its agenda for future meetings.

Question 2:

Screening experts have raised many concerns about the mass testing for coronavirus in Liverpool, not least the overstated accuracy of the tests involved, the possibility of false negatives giving false reassurance, the possibility of false positives identifying people who are not actually an infective risk to others and don’t require isolation or contact tracing, and the recent scientific evidence that asymptomatic carriers may be at low risk of spreading infection. Will the WY&HPB encourage its members to insist on seeing a full scientific analysis of the results of the so called Liverpool ‘pilot study’ before making a decision to endorse roll out of mass testing in their own areas, bearing in mind a full cost benefit analysis may argue against such a programme?

Question 2: Response

The West Yorkshire Councils have been given the opportunity to express an interest in Community Testing linked to being in tier 3 of Covid-19 restrictions. They are working together to develop a consistent approach, learning from the initial lessons from the mass testing pilots in Liverpool and Stoke on Trent as well as from extensive local experience of managing the pandemic so far.

The West Yorkshire Councils have identified the following principles that will inform the scale up of rapid testing:

The roll out will be sequenced to target the groups that have the greatest chance of halting the virus transmission.
Testing will be integrated with local contact tracing to identify people that may have been exposed to the virus (contacts) and with support to enable people to isolate for the required period
The roll out must not impact negatively on the delivery of the Covid-19 vaccination programme
Due to the limited sensitivity (high false negatives) of the test, it should not be used in any circumstances where there is a risk that it will increase infection.
It should not be used a as an alternative to the ‘gold standard’ PCR test as a ‘gateway’ to high risk activities or where there is a high risk that vulnerable people could be infected
Lateral flow tests (LFT) should deliver additionality to the existing testing programme, providing testing to those that would otherwise not be eligible to be tested
Roll out of LFT should be ‘co-produced’ with the relevant setting / community / group to maximise accessibility and appropriateness for the target group and use capacity within settings
LFT will be voluntary and will not be a requirement for access to certain services

All West Yorkshire Councils submitted an expression of interest on Monday 30th November and the expressions of interests are informed by these principles.

Question 3:

We are now anticipating a mass roll out of vaccination when comprehensive coverage of the population will be necessary for maximum benefit. It is essential that the NHS, local government and public health teams have charge of the immunisation programme, with NHS England and Public Health England providing leadership to ensure local delivery. Appropriate funding must be made available for staff recruitment, training and messaging. To repeat the mistakes of national test and trace (and NHS 111 giving faulty covid advice) using low paid, poorly trained staff employed by private firms could only be another disaster. Will the WY&HPB insist that its plans for place level multi-agency teams to deliver immunization include that these are publicly provided in order to win the trust of the people and optimise the chance of success?

Question 3: Response

The Covid-19 vaccination programme will be delivered by the NHS, working together with local authorities, voluntary and community sector partners and local government organisations across West Yorkshire and Harrogate.

Detailed planning is underway at national, regional and local levels, building on the expertise and strong track record the NHS already has in delivering immunisations like the annual flu vaccination programme. As with the flu vaccination, primary care will play a key role in delivering the vaccinations and the aim is to provide these in a range of NHS locations and new dedicated vaccination centres, which will be managed by the local NHS, general practices and community pharmacies.

The NHS will also be responsible for all the staff delivering the vaccine, all of who will be fully trained to the standards required by Public Health England, who are responsible for all vaccination training.

Question 4:

In general, why are WYH ICS responses to public questions consistently so rubbish? (I include ICS responses to questions at WYH JHOSC meetings, as well as at ICS Board meetings). The main ways in which ICS responses are rubbish are:

not providing the requested information

using straw man arguments

questionable truthfulness

platitudes

For clarification, there are examples of most of these types of responses at the bottom of these questions. So, in particular:

Why do you not provide facts, when facts are requested?

Why do you not give evidence to show the validity of assumptions, when policy issues are being questioned?

Why do you make assertions that don’t stand up to fact-based scrutiny?

Will you attempt in future to show respect for the public by answering our questions with the facts and evidence requested, rather than treating public questions as a tick box exercise that allows you to claim you are engaging with the public? (This is how regular questioners see your responses, in frequent complaints to each other.)

In future, please will you ask people with operational knowledge of the issues we are asking about to answer the questions? (I appreciate they are busy, but if the ICS doesn’t have time and resources to answer the public’s questions it would be better to say so, and not invite questions.)

Examples of ICS rubbish responses

As an example of the ICS failing to provide the requested information, at the 30th Sept WY JHOSC I requested information about the Integrated Care System’s work to build up the capacity of NHS labs to analyse Pillar 1 Covid19 tests. The ICS response was obfuscatory. It didn’t provide the requested information. I have since re-submitted the questions to Martin Barkley, CEO for Mid-Yorkshire Hospitals NHS Trust, who has led the ICS and Local Resilience Forum programme to build up capacity for COVID testing in West Yorkshire. He should surely be in possession of the facts. Wakefield CCG emailed back that they are treating this as an FOI request. They have not yet sent a reply.

The ICS has used straw man arguments to avoid answering a question. eg At the December 2019 ICS Board meeting, I asked the ICS to recognise that a salutogenic Local Industrial Strategy could not include the pursuit of economic growth, because economic growth is not a sustainable or salutogenic objective. So far no one has found a way to decarbonise economic activity, so “clean growth” – one of the government’s “challenges” that the Local Industrial Strategy commits to “making a contribution to meeting”- is a contradiction in terms. The ICS replied “The Leeds City Region Local Enterprise Partnership has made it clear throughout the development of the Local Industrial Strategy that it is not about growth ‘at any cost’ and the principles of inclusive growth and clean growth are embedded throughout the draft strategy.” (That’s the straw man argument – did we say the Local Industrial Strategy was about growth ‘at any cost’? No, we didn’t. And the reply avoided acknowledging the contradictions in the 'clean growth' concept.)

Sometimes the truthfulness of the ICS’s replies seems questionable, eg At the 1st September 2020 ICS Board meeting, in response to a question about the West Yorkshire & Harrogate Clinical Forum’s Ethical Framework, the ICS replied “...our response to the pandemic in West Yorkshire and Harrogate has meant that we have been able to provide care to the standard expected.” To which we can only say, it cannot be truthfully said that the Integrated Care System has been able to provide care to the standard expected during the pandemic - unless the standard you expected was pretty dire. Because:

Almost all elective hospital care stalled during the initial months of the pandemic

Many people found themselves unable to ask GPs for advice and referrals.

Many hastily-discharged patients died in care homes.

There is a backlog of cancer patients who didn’t get seen.

The ‘excess death’ rate rocketed, beyond the numbers of people dying of Covid-19.

NHS England/Improvement sent out the directive on the Phase 3 Covid-19 response, instructing Sustainability and Transformation Partnerships and Integrated Care Systems to restore routine NHS services.

The Clinical Forum recognised the “inaccessibility of usual treatment pathways and consequent impact on wider population health due to the reconfiguration of hospital care to focus very heavily on providing capacity for treatment of COVID-19”.

Question 4: Response

Thank you for your feedback to the Partnership Board. We are concerned that you feel the answers to your questions were not as you would expect. The Partnership takes public involvement and participation seriously and works hard to ensure we are open and transparent in all our communications. Given how we have worked together in the past we hope we can move forward positively. We look forward to meeting with you at your earliest convenience to discuss further.

As discussed via email, your feedback has been shared with the independent review of public questions carried out by Healthwatch. We are sorry that this was not made clear at the Partnership Board meeting under the ‘public questions’ item and instead covered later in the agenda. Please be assured we have noted your comments and thank you for your feedback.

All responses to public questions are based on the best information and evidence available to us at the time. To ensure that our responses are accurate, we always consult colleagues with operational knowledge of the issues. Albeit we are working in exceptional circumstances, we continue to take all public questions seriously so please do continue to send them.

In relation to the specific examples that you have cited:

a) Pillar 1 lab capacity As this is now being dealt with via the Freedom of Information process it would seem most appropriate to await a formal response via that route.

b) Local industrial strategy: In our response we set out how the draft strategy was based on principles of inclusive and clean growth and highlighted the City Region’s agenda to respond to the climate emergency, including the aim to be UK’s first zero-carbon city region by 2038.

c) Ethical framework: COVID-19 has placed exceptional demands on health and care systems across the world. The collaborative response of partners in West Yorkshire and Harrogate has enabled us to respond effectively to those challenges as we continue to stabilise and reset services. Our Clinical Forum has developed a a framework to suppport our response, which you can read here.

Question 5

5.1. What increased capacity at NHS Labs has the HCP/LRF programme created

Question 5.1 Response

The local NHS laboratories have worked closely with colleagues regionally and nationally as part of the COVID-19 Testing Cell, established at the start of the pandemic to secure equipment, reagents and consumables to perform COVID-19 testing in our NHS laboratories in the region. Each Network (in our case, West Yorkshire and Harrogate) appointed a ‘Pathology Incident Director’ as a link point with the national Testing Cell.

At the start of the pandemic, only the Public Health England (PHE) laboratory at Leeds General Infirmary had the equipment and supplies to undertake a very small amount of COVID testing (approximately 100 tests/day). By late Spring, all our acute hospital trusts had the equipment, reagents and consumables to perform Pillar 1 COVID testing from their laboratories. In line with the national request, the NHS laboratories in our Network have had capacity and supplies to perform 3,000 tests/day on our ‘high throughput’ equipment since October 2020.

5.2. Did this include any increase in the number of PCR machines?

Question 5.2 response

Yes. Additional PCR platforms were secured for a number of NHS laboratories to create additional testing capacity.

5.3. If so, in which NHS Lab?

Question 5.3 response

Additional platforms were secured to support testing at Airedale General Hospital, Bradford Royal Infirmary, Calderdale Royal Hospital, Harrogate District Hospital, Leeds General Infirmary and Pinderfields General Hospital.

5.4. I understand that Pinderfields microbiology lab was refused funding last year to carry out PCR testing, but was given some money to procure a PCR machine due to COVID-19. Has this machine arrived? And if so, has it been used for pillar 1 test analysis, pillar 2, or both?

Question 5.4 response

The Pinderfields Microbiology Laboratory has not been refused funding.Indeed we bought a second PCR testing machine which became operational at the very beginning of May 2020. This new machine, along with the existing Panther machine provide Pillar 1 PCR testing at a capacity of 900 a day

5.5. Also with regard to any other increase in West Yorkshire NHS Lab capacity, has this been/is this being used for pillar 1, pillar 2, or both?

Question 5.5 response

Hospital based pathology laboratories primarily provide Pillar 1 testing. The PHE Virology Laboratory at Leeds General Infirmary has undertaken some testing that would have otherwise been undertaken in Pillar 2 for short period, when capacity in Pillar 2 has been limited. Pillar 2 testing is undertaken to the best of my knowledge predominantly by the Lighthouse Laboratories.

5.6. If no pillar 2 tests are being analysed in West Yorkshire NHS Labs, do they all go to Lighthouse Labs for analysis? If not where do they go?

Question 5.6 response

As above – other than some short-term support to Pillar 2 by the PHE Laboratory in Leeds, Pillar 2 tests are analysed by Lighthouse Laboratories.

5.7. Does the Health and Care Partnerships COVID-19 reset require any change to plans for pathology lab cuts and centralisation across West Yorkshire and Harrogate

Question 5.7 response

There are no ‘cuts’ to pathology services planned. The pre-existing strategy for some routine pathology services for primary and secondary care to be delivered more at scale than what exists at the moment with more or less each hospital doing its own urgent and inpatient laboratory work, will continue. Nevertheless we need to re-visit the plans of what functionality an acute hospital laboratory will need in the light of the experience we have gained during this COVID19 pandemic.At the present time though no such discussions have taken place, only a recognition that they need to.

Response to questions from members of the public, West Yorkshire and Harrogate Health and Care Partnership; 1 September 2020

Question 1:

The West Yorkshire & Harrogate Clinical Forum's Ethical Framework states that: "community care is facing limited resource in the sense of inaccessibility of usual treatment pathways and consequent impact on wider population health due to the reconfiguration of hospital care to focus very heavily on providing capacity for treatment of COVID-19."

a) Which community care treatment pathways are inaccessible as a result of the reconfiguration of hospital care for Covid-19? For how long are they likely to remain inaccessible?

b) With reference to these specific community care pathways, what care, if any, will be available for patients who are deemed unfit for usual treatment pathways, on the basis of utilitarian ethics? Please answer pathway by pathway.

c) With reference to these specific community care pathways, what percentage of patients are likely to be deemed fit for and given the usual treatments? Please answer pathway by pathway.

d) What are the likely clinical consequences for patients who are refused the usual treatments in these specific community care pathways? Please answer pathway by pathway.

Question 1: Response

The Partnership developed its Ethical Framework at a time when the extent of the impact of the pandemic was unclear. It was important as a health and care partnership that we provided a framework to help staff to make the best decisions around care for our patients and the people who use our services. The Framework supports our wider aim of ensuring that we can continue to deliver the best possible care to people who most need it, even under the most difficult circumstances.

Unfortunately, the experience of some other healthcare systems across the world in responding to COVID is that sufficient resources are not always available to meet exceptional peaks in demand for healthcare. The utilitarian principles have not been required as our response to the pandemic in West Yorkshire and Harrogate has meant that we have been able to provide care to the standard expected. Our aim as a Partnership is to continue to do everything within our power to ensure that we avoid the circumstances when we would need to employ utilitarian principles.

It is not the role of the Partnership to determine the detail of specific community care pathways in each of our places. The Ethical Framework sets out broad principles to be applied in managing demand and capacity for services. How those principles are applied to specific community care pathways is a matter for local places to decide, in line with the health and care needs of their local populations.

Question 2:

The West Yorkshire & Harrogate Clinical Forum's Ethical Framework also states, "There is also the potential for resource limitations if a surge of infections impacts on critical care availability."

a) Where does this ethical framework for Covid19 critical care sit with the NICE guidelines?(Covid-19 rapid guideline: Critical Care in Adults, last update as far as I know 27 March 2020.)

b) And where does the Harrogate Nightingale Hospital fit in? Wasn’t that set up in order to significantly increase the number of critical care beds?

The West Yorks and Harrogate ICS has told us: The NHS Nightingale Hospital Yorkshire and the Humber is part of a wider national response to the Covid-19 pandemic and is an insurance policy for our region. The Nightingale Hospital remains on standby to provide additional critical care beds in our region should our existing hospital critical care provision reach capacity in the event of a second wave of covid-19 over the coming weeks and months. So why does the Ethical Framework identify “the potential for resource limitations if a surge of infections impacts on critical care availability”? Isn’t the “insurance policy” Nightingale hospital enough? If not, what further resources would be needed to provide critical care for all who need it, on the basis of the NHS ethics of equality of access?

Question 2: Response

We believe that our Ethical Framework is entirely consistent with current NICE guidelines. Both have as their aim the provision of the best possible care for patients, taking into account their individual needs and circumstances.

Our previous response reflects the current position in relation to NHS Nightingale Yorkshire and the Humber. The Nightingale Hospital remains on standby to provide additional critical care beds in our region should our existing hospital critical care provision reach capacity. Unfortunately, we cannot rule out the possibility that a future surge of infections may impact on the total availability of critical care. Our Ethical Framework provides guidance on how we can provide the best possible patient care in such a situation.

Question 3:

CK999 has already asked West Yorkshire and Harrogate Integrated Care System about the effects on WYH ICS’s ability to respond to the Covid-19 Pandemic, of decade-long cuts to NHS funding, hospital beds and clinical staff – including ICU beds and staff, and the government’s failure to promptly authorise and direct widespread testing and tracing, from the start of the pandemic. Your answers were evasive.

Did the West Yorkshire & Harrogate Clinical Forum consider whether it would be more ethical to demand adequate resources to meet patients’ needs, rather than having recourse to utilitarian “ethics” of weighing up one patient’s claim on scarce resources against another’s? If not, why not? And if so, why did they reject this course of action?

Question 3: Response

The Partnership does not see this as an ‘either/or’ issue. We believe that we have a responsibility to both make the case for adequate resources and at the same time to put in place contingency plans to deal with exceptional circumstances.

The Partnership, and the individual organisations of which it is comprised, have a strong track record of advocating at national level for funding to meet the health and care needs of our population. This has led to significant additional investment in WY&H and we will continue to advocate on behalf of our population. However, we know from the experience of other healthcare systems across the world that sufficient resources may not always be available to meet unprecedented demands for healthcare. We consider that it is our responsibility as a Partnership to ensure that we have a framework in place to guide decision making even in the most difficult circumstances.

Question 4:

And where does this Ethical Framework sit in relation to the proposed virtual elective care hub for West Yorkshire?

a) Has NHS England/Improvement approved the Integrated Care System's bid for £1.2m for this virtual elective care hub?

b) We understand that if the funding is approved, this data crunching IT centre will trawl through planned operations waiting lists and determine who are priority patients and where in West Yorkshire NHS and private hospitals capacity exists for planned care operations at a given time. It will then direct patients accordingly.

c) Clinical prioritisation of patients

d) “would primarily include surgery for cancer, high priority non-cancer diagnoses, and those who are ‘long waiters’”. “A clinical panel will be convened, if necessary, to support patient prioritisation at WY&H level. Will the clinical panel be using the utilitarian ethical framework?

e) And is this just a backup for computer algorithms that say yes or no to patients’ getting planned care? What ethical considerations have been programmed into the algorithms?

Question 4: Response

We have not heard whether the bid for funding for a virtual elective hub has been successful. We do not currently know what the timescales are for hearing about the outcome of this bid.

The purpose of the virtual hub, if created, would be to support collaboration between organisations to make sure that patients across West Yorkshire and Harrogate receive the interventions and or care required according to clinical priority and need. There is no plan to use algorithms to determine clinical priority. Our Ethical Framework provides guidance on how we can provide the best possible patient care should a need for prioritisation occur.

Question 5:

I wish to register that it is plain from all the evidence that COVID-19 is being used by the government with the complicity of the various ‘authorities’ to further the long-standing agenda of underfunding, rationing, privatisation and alignment of our NHS towards a US- style health system.

It is not difficult for anyone who has troubled to look even just below the surface that COVID- 19 is seen by the government as a golden opportunity to ‘press on’ under cover of the ‘Response to COVID’ mantra.

Unfortunately, we do not have medical personnel in positions of power or influence or even an effective opposition in parliament to 'call out’ what is plainly happening for anyone with eyes to see.

Ironically, COVID-19, whilst uncovering the lie that there is not enough money, has at the same time provided another cover for what is actually political choice.

The talk of ‘utilitarianism’ in the ‘Ethical Framework for WY & H Health and Care Partnership’ it seems is the latest framing in the litany of lies.

I send this only to register that as one small voice along with many others there is a group across this country who recognise the tragedy of what is happening to our NHS (along with much else). Unfortunately, the juggernaut will continue to roll because of the cowardice or greed or both of those in positions of power and influence in the context of a population starved of proper in-depth truthful debate in the media.

It would be good to receive a reply but I doubt I will receive one. Apologies for the strident tone, but what else do we have to try and resist the dismantling of our NHS.

Question 5: Response

The Partnership would strongly contend that it is not complicit in furthering the ‘underfunding, rationing, privatisation and alignment of our NHS towards a US-style health system’ which your statement alleges.

Whist the Partnership has welcomed potential legislative changes designed to enable greater collaboration and integration and place less emphasis on competition, it must operate to the best of its ability within the current policy context. Our aim, as set out our five year plan, is to deliver the best possible health and care across our area. Rather than dismantling the NHS, or delivering a ‘US-style health system’, the whole rationale behind the Partnership is to integrate the health and care system across WY&H so that it better meets people’s health and care needs. The Partnership does not aim to privatise the NHS.

The vast majority of services across the Partnership are delivered by staff from the NHS, local authorities, the wider public sector and the voluntary and community sector. Any work with the private sector is procured in accordance with public sector procurement regulations.

The Partnership would also strongly contend that it does not lack clinical personnel in positions of power or influence. The Partnership Board is comprised of many clinicians from across primary and secondary care partners. The Partnership’s Clinical Forum is a key part of our governance arrangements and is comprised almost entirely of clinicians.

The Forum has led the development of much important Partnership work, including the Ethical Framework which you reference.

Question 6:

What people, bodies, institutions and/or companies make up the West Yorkshire Clinical Forum?

Question 6: Response

The purpose of the Clinical Forum is to provide clinical leadership, advice and challenge for the work of the Partnership. It is made up of clinicians from across our Partnership. The current list of members is attached.

Question 7:

It seems to me that the new plans in the ethical framework appear to offer a 'Waitrose Stye NHS, a Cheap as chips, buyer-beware Market Style NHS or a Foodbank style NHS. i) Who or what is going to decide " access to the most appropriate treatment for them, given a reasonable chance of the treatment succeeding." ii) Who or what is going to evaluate " reasonable chance" and how does that square with the emphasis on addressing the health inequalities of the BAME group.

The Ethical Framework says "If a resource is limited or inaccessible, a patient who will gain more benefit and is more likely to benefit from that resource should be prioritised to receive it; a patient who is less likely to benefit from the resource should be given the best care possible that is more readily available".

i. Who or what is going to decide whether a resource is limited, when in actual fact all resources are limited due to chronic underfunding and redirection of funding there is, to for-profit provision? For example, the STP plans cut hospitals and hospital beds, now beds are being secured in for-profit provision as a mandate.

ii. Around the time of the passage of the Health and Social Care Bill through the House of Lords, a Baroness was reported as saying that unemployed people should not receive treatment on the NHS. Will the criteria used to decide who gets what treatment be a) listed in words b) be discussed by a panel who do not know the patient, c) an algorithm?

iii. How are the 'chances of success' going to be weighed up against the future life chances of an individual either getting the treatment, or not even getting a chance to have it, when all physiologies are different and really no one knows how an individual body will respond to an intervention?

iv. The mention of a Utilitarian Approach seems to me to signal the death of the National Health Service. Will Councillors and others on the West Yorkshire and Harrogate Health and Care Partnership Board, campaign and lobby strongly, for the concept of a utilitarian approach (which it seems to me is as great a change as the 'Enclosures' in the 18th Century which lead to thousands having no control over their own lives and being forced into cities,) to be never needed. Why is it acceptable in the 21st Century to contemplate 'fully, calmly and rationally' the unthinkable? Will Councillors and others campaign and lobby strongly to prevent a Utilitarian Approach in a stronger way than just changing its name, or just accept what comes?

Question 7: Response

The Framework supports our wider aim of ensuring that we can continue to deliver the best possible care to people who most need it, even under the most difficult circumstances. It supports, but does not replace, decision-making by individual clinicians.

Responsibility for ensuring that patients have access to the most appropriate treatment will remain, as now, with individual clinicians. These decisions will continue to be made within the context of available resources.

Unfortunately, the experience of some other healthcare systems across the world in responding to COVID is that sufficient resources are not always available to meet exceptional peaks in demand for healthcare. Our aim as a Partnership is to continue to do everything within our power to ensure that we avoid the circumstances when we would need to employ utilitarian principles.

Question 8:

With reference to the Paper Supporting our BAME Staff and Communities: How will the work of the WY&H BAME Network help with decisions for 'scarce resources' in real live situations, e.g. 2 people with severe Covid-19 in hospital, with similar prognoses and of similar age but only one supply of oxygen, when one is BAME and has to return to an overcrowded and damp residence, and the other has to return to a spouse with a warm dry home?

Question 8: Response

The WY&H BAME Network has set up a COVID Research and Health Inequalities Group which has a targeted focus on reducing the gaps in health outcomes that have become apparent during the pandemic. This group is working with the WY&H Health Inequalities Network to further understand local data and insight and identify racial inequalities which impact on population health. The Group will provide evidence to the wider WY&H BAME independent review into the impact of COVID-19 on health inequalities and support for BAME communities and staff, which will be published in Autumn 2020.

Question 9:

With reference to item 26/20: While Public Health England has effectively been abolished and moved into a new organisation with a central role in dealing with pandemics, it is stated that: “Our public health teams and colleagues continue to work closely with us on all other aspects of work undertaken by PHE, including screening, vaccination, intelligence and health improvement”. Does the Board consider that there are staff and resources available to continue these aspects of PHE work at the same level as before the reorganisation, and if so, is this an interim arrangement or does the Board see these functions previously carried out by PHE being taken over longterm by local authorities with appropriate funding?

Question 9: Response

Public Health England is in a period of transition towards the full establishment of its successor organisation in Spring 2021. The Partnership believes that sufficient staff and resources are in place to enable the continuation of PHE’s work during this period. The Secretary of State has established an advisory board to develop a long term plan for the new organisation. The advisory board includes specialist input from PHE.

Question 10:

The update from the Chief Executive states that the number of people testing positive for coronavirus in Yorkshire and Humber is amongst the highest in England. There have been outbreaks in food processing plants in Cleckheaton and Bramley while nationally, the Food Standards Authority is investigating approximately 40 outbreaks in food factories. In meat packing plants, infection has been attributed to cramped working conditions, background noise (which leads to shouting), and poor ventilation. Similar compound risk situations might occur in other crowded, noisy, indoor environments, such as pubs, live music venues, gyms and schools.

The German meat processing plant outbreak in which 1500 workers were infected was investigated very thoroughly, including with genetic finger printing of the virus isolated. This showed the outbreak was a super-spreader event in the plant and not related to spread in the community. Transmission of the virus occurred indoors over distances of 8 metres and more. Such outbreaks have demonstrated that current precautions for controlling spread of infection in workplaces is inadequate, and airborne transmission a much more significant problem than previously thought. UK experts have been calling for urgent recognition of the key role of ventilation in work places in preventing COVD-19. How is the Board raising the importance of airborne viral transmission, with a focus on effective ventilation to reduce risk of further outbreaks?

Question 10: Response

Each of our WY&H places has published an Outbreak Control Plan setting out how local partners will work together to reduce the transmission of COVID-19, prevent and manage outbreaks. These Outbreak Control Plans bring together well-established public health expertise, specialist health infection protection skills and environmental health functions.

Where we have identified workplace outbreaks in West Yorkshire and Harrogate, we have shared the learning in ‘real time’ across our health and care system through our established networks. In addition, our Partnership Test and Test Programme Board, which includes the Directors of Public Health from each of our places, meets weekly and ensures that we have a comprehensive picture of prevention and outbreak control activity across the area.

Experience in the UK and worldwide indicates that a range of factors may be involved in workplace outbreaks. These include workplace-specific factors such as the environment, background noise, temperature and ventilation as well as other factors such as car-sharing and staff behaviours during meal and smoking breaks.

The factors associated with airborne transmission are complex and new evidence is emerging continually. The Chief Medical Officer provides weekly updates to Directors of Public Health on this and other evidence relating to the transmission of COVID-19 and the learning is used to inform delivery of Outbreak Control Plans

Question 11:

With respect to item 28/20 I was pleased to read that the Partnership Board has commissioned an independent review into the impact of COVID-19 on health inequalities and support needed for BAME communities and staff, to be chaired by Professor Dame Donna Kinnair.

One of the areas of focus is “to identify opportunities to work as a system to improve outcomes for specific services and specific ethnic groups”.

I would like to ask the Board if this will include investigating the damaging effect of so called overseas visitor charging, which deters many migrants with unsettled status from seeking health care for fear of information being passed on to the Home Office. The negative impact on health of the ‘hostile environment’ has recently been well documented in a report by Doctors of the World

View the report here

In addition, during the COVID-19 pandemic it is essential for the health of the wider community that migrants, through fear of jeopardising their applications for settled status, are not deterred from engaging with contact tracing services and are given necessary support if asked to self-isolate. It is also regrettable to see that the counter-fraud teams in some Trusts have identified overseas visitors trapped in the UK during the pandemic because of government imposed travel restrictions, as a group likely to try and defraud the NHS and requiring particular vigilance. This is not likely to send out a message of support to BAME communities suffering disproportionately from coronavirus.

I would like to receive assurance from the Board that the issue of harm done by implementing overseas charging regulations will be considered as part of this review.

Question 11: Response

As indicated verbally at the Partnership Board meeting on 1st September, we escalated this issue to the WY&H BAME independent review meeting on 2nd September. At that meeting, it was noted that whilst the overseas charging regulations are national government policy, their implementation may contribute to creating a ‘hostile environment’ for migrants. At the meeting it was agreed that this issue would be explored further as part of the review and that the findings would be included in the review report, due to be published in Autumn 2020.

Response to questions from members of the public, West Yorkshire and Harrogate Health and Care Partnership; 2 June 2020

Question 1:

The WY&H Partnership Board is asked to note the direct and indirect impacts of COVID-19 on different population groups and support an approach to “stabilisation and reset” that:·acknowledges that the impact of COVID-19 has been variable across the system and we need to adapt our response to reflect this; embeds a preventative approach across partnership priority programmes; and takes the opportunity to adapt as a system prioritising interventions to population groups disproportionately affected by health inequalities.

There is no mention in this paper, of the effect of mandatory pushing of untested patients away from hospital wards and into Care Homes for rehabilitation, even though Care Home staff had undergone no extra training in infection control or had access to Personal Protection equipment for themselves or the other patients because there was not the time or the availability. Can we be assured that the so called 'stabilisation and reset proposals' are going to be real services for real people in real situations to help their actual lives, carried on by others who are getting a fair wage for a fair days work, rather than a digital offer which will merely siphon money into company coffers and tax havens?

I see reference to voluntary and community sector who play a key role supporting vulnerable groups; BUT charities are 'charity' and 'community sector' rely on volunteers who are likely to become scarcer as the retirement age rises.

Question 1: Response

The stabilisation and reset work will focus on ensuring that the right services will be in place for people locally. The way these will be provided will depend on the circumstances. There will be cases where digital solutions work well for people who receive services, and in these cases we want to ensure that they are maintained. We are working closely with Healthwatch partners to ensure that the views of communities are reflected in this.

At place level, local authority and NHS colleagues are working to ensure that care home staff have the right support and access to Personal Protective Equipment and testing. This is reflected in the local Care Sector Resilience Plans.

Question 2:

What power does West Yorks Combined Authority and WYH HCP have to prevent McJobs?

West Yorkshire Devolution and Economic Recovery

Item 20/20 Recommendations and next steps It is recommended that he WY&H Partnership Board:·notes the content of the paper including the current position in relation to devolution and the priorities of the West Yorkshire Economic Recovery Board;·further develops place based conversations across health and care about the importance of economic development and inclusive growth; and considers best practice from each place and shares this widely, in particular how best to tackle existing and emerging health and economic inequalities post COVID-19

If I see a new huge ugly warehouse and new build houses constructed on agricultural land, while less than a mile away a brownfield site is being reclaimed for agriculture in the short term, then housing in the longer term, I have to wonder what is going on?

Question 2: Response

The West Yorkshire Recovery Board, as part of the vision it has set, is focussed on growing a more inclusive economy with less inequality, with a recovery that delivers good work and a decent standard of living. The products and programmes it goes on to develop will seek to support and drive these improvements.

Similarly, the West Yorkshire Combined Authority and Leeds City Region LEP support the creation of good private sector jobs and ensuring economic growth leads to opportunities for all as key priorities for building a more inclusive and productive West Yorkshire economy.

These themes are central to the policies, strategies and interventions that continue to be developed. For example, the emerging Local Industrial Strategy identifies skills development, addressing barriers to well-paid employment, and access to high quality careers, education and training services as critical to achieving this. We continue to work with Government, partners and stakeholders to deliver on this ambition.

Question 3:

Will the conversations across place based 'health and care' be underpinned by any sort of ethical structure? Or is the all-important ethos to be US style, money and expediency!

I cannot see 'ethics' at work in some education commissioning and procurement. Nor do I see it in the race to digitalise NHS records and commission Covid tracing functions to companies with track records in fraud and terrorist surveillance. The reality of the companies' previous performance is not a political statement, but a statement of fact.

Whether fraud and terrorist surveillance is ethical, is a subject for debate.

Question 4:

If an ethical structure is to be used to underpin the 'conversations', where will it be published and who, which bodies/interests/organisations will be involved in producing it?

Questions 3 & 4: Response

Keeping people safe, improving outcomes and tackling inequalities is at the heart of everything we do. This applies to all of our stabilisation and reset work right across the Partnership.

Note: Since the Partnership Board met in June 2020, the Partnership has published its ethical framework.

Question 5:

Are you able to tell me how and when face to face appointments with GPs at surgeries within the Partnership area will be available again following the Coronavirus lockdown? Will it be different in different places? Who will decide? Also, my own GP surgery in Cleckheaton has disabled online bookings of appointments, but substituted a new online 'Request help from surgery' service through Engage Health UK. Will we always be obliged to go through this before being able to get a face to face appointment? Who owns the data collected on patients by Engage Health UK and what do they do with it?

Question 5: Response

Face to face appointments with GPs have not ceased, however in the interest of both patient and staff safety, face to face appointments are limited to consultations only when it is clinically necessary and appropriate.

National Standing Operating Procedures are in place for all General Practice Services. The Standing Operating procedure strongly advises all Practices to adopt remote triage as a default for delivering care and treatment when necessary and appropriate based on clinical judgement. In practice, this means GP practices using telephone, video and online consultation technology. In accordance with NHS England & Improvement guidance, GP practices have been strongly encouraged to disable on-line booking of appointments so that patients can be appropriately risk assessed to ensure patient and staff safety. As the virus becomes more controlled General Practice will over time begin to open up direct appointment booking and even more digital options to enable greater choice and improved access for patients. Patient data is managed under strict Information Governance protocols and can only be shared in accordance with General Data Protection Regulations.

At the beginning of the COVID-19 pandemic, Cleckheaton Group Practice (along with many other GP surgeries) either disabled or amended access to on-line appointment booking in line with a new Standard Operating Procedure (SOP) directed by NHS England & Improvement. This SOP requested that practices adopted a ‘total triage’ model where all patients would be remotely assessed initially to determine the need for a face to face appointment. This included using remote consultations wherever possible either via telephone, video or online access. Temporarily disabling on-line appointment booking ensured that patients who may have been exhibiting COVID symptoms did not inadvertently attend the practice in person, potentially spreading the infection to other patients and practice staff. The practice fully intends to reverse this change at a point in time that meets with national guidance.

Response to questions from members of the public, West Yorkshire and Harrogate Health and Care Partnership; 3 March 2020

Question 1:

(Strategic Direction)

(Improving Population Health programme - strategic direction and objectives for action) Please will Board members consider my questions when it comes to providing feedback on the priority areas?

Since all the Health and Wellbeing Boards have carried out Joint Strategic Needs Assessments, what’s the point of “partnership efforts to understand the causes of poor health”? Surely those causes are already widely known?

Question 1: Response

We build on the learning from the Joint Strategic Needs Assessments in each place to understand the causes of poor health at a system level. We add to the Joint Strategic Needs Assessments with system level intelligence, working with partners such as Public Health England to improve our understanding of population health at a system level.

Question 2:

In deciding that the American asset-based approach is key to the success of the Programme, what evidence, if any, for its appropriateness did the Improving Population Health Programme Board consider?

Question 3:

If they did consider evidence, when and how did they do this, when formulating their strategic approach?

Question 4:

Specifically: Did they consider the evidence base for the asset-based interventions to be used by Primary Care Networks? If so, what evidence did they review? Did it include the Health Foundation’s briefing, Understanding Primary Care Networks? This says:

“... the evidence for the impact of some of these [PCN] roles is not always clear – – for example, for social prescribing link workers (and for social prescribing interventions more broadly)...

Ultimately, the success of social prescribing is contingent on the availability of services within communities to effectively address identified needs. Of the link workers who responded to a small NALW survey in 2019, 74% identified ‘a lack of resources and/or funding in the community and difficulty in accessing resources in the community/council’ as the most challenging aspect of their role.”

Question 5:

Given this evidence of widespread lack of resources and/or funding in the community, have they considered that an asset-based approach could actually increase inequalities? Did they take into account the study in the Journal of Community Practice: Neoliberalism with a Community Face? A Critical Analysis of Asset-BasedCommunity Development in Scotland?

This identified that:

“Asset-based approaches could potentially advantage the already influential and cohesive communities...The potential for the asset-based approach to not only sideline the issue of inequalities, but to also increase them, is, we argue, the most significant issue raised by our study and one which is to some extent absent from the key literature in this area.”

Question 6:

Did the Improving Population Health programme Board and/or the Health Inequalities Network consider further evidence, eg from the Health Foundation’s briefing,

Understanding Primary Care Networks, that

“aspects of the way PCNs are currently designed risk exacerbating existing inequalities in the provision of primary care,”- and so “risk negating efforts to tackle health inequalities”?

This is despite the inclusion of a PCN service specification on Tackling Neighbourhood Inequalities from April 2021.

For example, the Health Foundation’s briefing says that,

“The Carr-Hill formula – used to weight funding for GP practices – has been criticised for not sufficiently taking the effects of deprivation into account...As a result, the weighted component of per capita funding for PCNs is based on a formula that may systematically under-fund practices with the most need.”

I can’t see anything that rectifies this in the NHSE/BMA 6th Feb 2020 Update to the GP contract agreement 2020/21 - 2023/24, although if there is I’m happy to be set right.

Question 7:

Did they consider evidence that the assets agenda, through a relentless focus on the positive, may marginalize discussions of significant structural and economic inequalities and undermine collective oppositional action to address these problems - when it is these that are really the cause of poor health among poor people and that need solving? For example, the work of Barbara Ehrenreich (2010),Lynne Friedli (2011) and Kevin Harris (2011)?

Reponses to Questions 2 – 7 on the Asset Based Approach for the Improving Population Health

Our asset based approach for the programme comes from an understanding that we should move towards a model that focuses on the capabilities of an individual rather than their deficits. Assets can be described as the collective resources which individuals and communities have at their disposal, which protect against negative health outcomes and promote health status. In better understanding what motivates and interests people we can help them to live healthier and happier lives. This applies also to the assets in a community and the assets within our wider workforce.

Asset based approaches emphasise the need to redress the balance between meeting needs and nurturing the strengths and resources of people and communities. Asset based approaches are not a replacement for investing in service improvement or attempting to address the structural causes of health inequalities.

The approach we are taking is widely recognised. It is informed by evidence from multiple sources including:

Public Health England (2015) “A guide to community-centred approaches for health and wellbeing”
Kings Fund (2019) “A citizen led approach to health and care lessons from the Wigan Deal”
Kings Fund (2013) “Strong communities, wellbeing and resilience”
Social Care Institute for Excellence (2018) “Integrated Care Research and Practice – Asset Based Places”
The Health Foundation (2015) “Head, hands and heart: Asset-based approaches in health care. A review of the conceptual evidence and case studies of asset-based approaches in health, care and wellbeing”
“What makes us healthy? The asset approach in practice: evidence, action, evaluation”

Our approach is much broader than Primary Care Networks. We have set out an approach but we will not prescribe specific interventions to be used by specific primary care networks. We recognise the need to work with communities to understand the wider services that exist for social prescribers to refer into and to understand the gap in community provision.

Question 8:

Have they reviewed any evidence of how people living in poor communities are likely to respond to being the priority target for diagnostic cancer tests and individual behaviour change schemes aimed at reducing high levels of illnesses strongly associated with poverty and deprivation, such as COPD, heart problems etc?

Question 8: Response

We will be engaging with local communities on approaches to address inequalities in the coming year to test perceptions on this in West Yorkshire and Harrogate.

Question 9:

Have they reviewed any evidence about how public spending cuts and increasingly precarious employment have disproportionately worsened the health of people living in poor communities, or considered the value of concerted lobbying of government to reverse these damaging policies?

Question 9: Response

We are actively feeding in learning from the Marmot Report 2020 into the work of the Improving Population Health Programme. This report highlights how the gap in health has grown between wealthy and deprived areas.

View the report here.

Question 10:

Since the Improving Population Health Programme seems to depend largely on the work of new Primary Care Network staff, did the Board or relevant Networks consider evidence that it’s not at all clear how realistic the Primary Care Network workforce plan is? The Health Foundation briefing Understanding PCNs said:

“NHS England is confident that 20,000 additional allied health professionals will be available in time, but there are no data available in the public domain to allow us to model or verify these projections. NHS England has not stated how many of each type of professional is expected, but the scale of the increases required will be large. In September 2018, there were only 55 physiotherapists, 99 physician associates and 428 paramedics working in general practice in England.”

(This info is from NHS Digital. General practice workforce, final 30 September 2018, experimental statistics. 2018.) Available here

Question 12:

If they did consider this evidence, what are they doing about it?

Question 13:

Do you have any information about the test bed cluster for the PCN specification on Tackling Neighbourhood Inequalities Specification (which seems not to exist yet)?

Response to Questions 10-13 (Links with Primary Care Networks)

Primary Care Networks (PCNs) are one mechanism through which we can target efforts to Improve Population Health. Our programme considers partners wider than PCNs including; our acute and mental health hospital trusts, the voluntary and community sector and the neighbourhoods that people living in West Yorkshire and Harrogate identify with.

We are aware of the workforce challenges in Primary Care that can disproportionately affect our most disadvantaged areas. We are working with the Primary and Community Care Programme to take action to address this including specific posts for newly qualified GPs in areas ranked most deprived and a support programme for GPs and PCNs operating in our most deprived communities. This work will be delivered through Health Education England and FairHealth https://fairhealth.org.uk/trailblazer/ , based on learning from the Deep End GP work in Glasgow.

We don’t have any additional information about the test bed cluster for the PCN specification for Tackling Neighbourhood Inequalities. We have expressed an interest with the NHS England Health Inequalities team in supporting the development of this specification in addition to being involved in the development of other Health Inequalities approaches targeted towards Integrated Care Systems.

Question 14:

When are the Calderdale PCNs Population Health Management workshops going to happen? Will Patient Participation Group members be able to take part

Response to Question 14

A date has not yet been set for Calderdale’s Population Health Management workshop. In the Wakefield Population Health Management workshop patient participants were present and we will recommend the same for the workshops in all places.

Question 15:

In relation to the Improving Population Health Management programme’s planned contribution to the grandiose aim of becoming “a global leader in responding to climate emergency through increased mitigation, investment and culture change throughout our system” - I would just like to say that the Integrated Care System’s written response to my comments about the Local Industrial Strategy at the December Board meeting completely missed the point: that economic growth is incompatible with climate change reduction/mitigation and the related goal of protecting biodiversity. The ICS response did this by creating a straw man argument, defending the Local Industrial Strategy against a charge I never made: that it is about pursuing growth at any cost. Please in future will you respond to what people say, not what you want to spin us as having said?

Response to Question 15:

Your comments are noted.

Question 16: Objectives for action

What analytical capacity does the Integrated Care System need to undertake Population Health Management? Is the ICS procuring support for developing this from any organisations on the Health Systems Support Framework? Is the Imperial College Health Partners /Yorkshire and Humber Academic Health Science Network’s Population Health Management Programme responsible for developing this analytical capacity?

Response to Question 16:

We are working with existing analysts working across the partnership, in roles in clinical commissioning groups, hospital trusts and local authorities, to undertake population health management. We are also working with Public Health England to undertake an audit of our capacity within the system to help understand future training needs for our analytical workforce.

Imperial Health Partners and Yorkshire and Humber Academic Health Science Network are providing workshops in each place to provide an introduction to Population Health Management but they are not responsible for developing capacity within the system.

Question 17:

On the subject of Data analytics, I would like to query the ICS response to my question to the 3rd Dec 2019 Board meeting about who really benefits from the Local Industrial Strategy’s focus on Artificial Intelligence and Data. The ICS said it is unable to comment on speculation about the impact of potential future trade deals with the US. I find that quite unbelievable, given the emphasis on dealing with the likely consequences of Brexit that I know local NHS organisations have been forced to make.

Response to Question 17:

The Improving Population Health Programme is unable to comment on this question.

Question 18:

One of the objectives for action is to work with the Local Enterprise Partnership and the West Yorkshire Violence Reduction Unit to explore how to share intelligence that impacts on the determinants of health, and another is to Work jointly with the Violence Reduction Unit to pilot a school and community programme aimed at reducing Serious Youth Violence (in particular crime using a weapon) in targeted areas across WY&H.

By searching online for the Violence Reduction Unit, I found it’s a home office- funded initiative to bring together the police, local government and health and community leaders to tackle violent crime by understanding its root causes. But surely there is already widespread knowledge of the factors that have led to increased violent crime, particularly among children and young people? Such as the destruction of youth services, rampant childhood poverty and all it entails, and the huge cuts to police budgets? As well as the cuts and privatisation of the probation service?

So isn’t this evading the reality that violent crime, particularly among children and young people, is a problem resulting from ideologically-driven austerity policies? And, just like the asset-based approach to Improving Population Health, doesn’t this approach risk marginalizing discussions of significant structural and economic inequalities and undermine collective oppositional action to address these problems?

Wouldn’t the Integrated Care System be better off pointing out to the government that it is the cause of the problems it’s paying the Police, local government and health and community leaders to solve?

Response to Question 18:

The West Yorkshire and Harrogate Improving Population Health Programme and West Yorkshire Violence Reduction Unit (VRU) are working in partnership to embed a Public Health approach to reducing serious violent crime.

A Public Health approach is working at both a population and individual level to understand the characteristics, behaviours and potential protective factors of populations to prevent serious violent crime whilst considering the impact and relationship between the determinants of health (including austerity, housing, education and employment) and health inequalities.

We are building on the evidence that has been developed nationally, particularly the success that has been seen with the VRU in Scotland, we are using the three questions developed in the Scottish model and applying them through our partnership working:

The added value of working in partnership with the VRU is the ability to ensure that the health and care system are embedded in the partnership which has traditionally been led via the police and Community Safety Partnerships.

Serious violence cannot be tackled in isolation. It must be observed and addressed through the identification and grouping of preventable multiple risk factors and underlying determinants that cause violence. Violence prevention is every body’s business and must be tackled at a system level and must also be incorporated within a range of broader partner strategies and policies as the risk and protective factors for violence are experienced across different life stages.

We have already begun to see the success of our partnership with developments in A&E departments, linking the VRU agenda to the Health and Housing work stream and developing a public health approach to evaluation that all commissioned projects will undertake. At the recent launch of the VRU, West Yorkshire was acknowledged as one of the VRUs that are clearly demonstrating their commitment to a public health approach, not just addressing the enforcement and consequences of violent crime but evidencing commitment to tackling the root causes of serious violent crime.

Question 19

Is tackling socio-economic health inequalities part of emergency preparedness plans for Covid19?

A 2011 study of “Socio-economic disparities in mortality due to pandemic influenza in England” (Int J Public Health (2012) 57:745–750 DOI 10.1007/s00038-012-0337-1 ) found that:

“People in the most deprived quintile of England’s population had an age and sex- standardised mortality rate three times that experienced by the least deprived quintile (RR = 3.1, 95% CI 2.2–4.4). Mortality was also higher in urban areas than in rural areas (RR = 1.7, 95% CI 1.2–2.3). “

In preparing for a possible pandemic, is there going to be rationing of access to critical care? I have read recently of a “3 wise men” approach, doctors deciding who should get access, linking to ethical guidance published in relation to pandemic flu a decade or so ago – minimising harm, fairness etc.

There are potential health inequality implications:

There could be socioeconomic patterns in terms of exposure and the practicality of taking personal steps to reduce exposure.

Patients in poorer areas will have more difficulty in self-isolating – many will be carers themselves, families will be more at risk

it’s hard to imagine patients with a handful of co-morbidities getting to the top of the priority list for access to critical care – and co-morbidities are more prevalent in poorer areas

There could be a wide range of measures to reduce the health inequality impact:

The payment of something akin to a winter fuel payment to all those on low income, just to give this vulnerable group a little financial flexibility and opportunity to reduce their risk of exposure to the virus; and to cope with the financial penalties of self-isolation if necessary.

Carers need additional support, but on the other hand domiciliary care workers risk spreading infection (and are at risk themselves). More money is better than nothing, but extra support staff should be recruited asap.

Coronavirus assessment hubs should be easily accessible to deprived communities. Protocols for treatment or admission to hospital need to be open and transparent, and assessed for any potential inequality

I’m struggling with the access to critical care issue – hard to think of anything practicable other than the “3 wise men/women” approach, as the issues are too complex.

Later on, access to vaccines may become an issue if they are in short supply. We don’t need to wait, equitable access procedures can be developed in advance.

Are any of these - or other - measures being carried out to ensure that people in poor/deprived communities have equal access to covid19 care?

Response to Question 19:

The NHS in West Yorkshire and Harrogate, and Public Health England (PHE) are well prepared for outbreaks of new infectious diseases. The NHS has put in place measures to ensure the safety of all patients and NHS staff while also ensuring services are available to the public as normal.

NHS 111 has an online coronavirus service that can tell people if they need medical help and advice on what to do. This information is being shared widely across all communication channels and public services, and beyond.

Question 20: (Improving Planned Care Programme)

The Secretary of State for Health and Social Care has recently called for an end to rogue rationing decisions that deviate from national guidance. He cited the example of IVF saying “Why should 3 cycles of IVF be allowed in some parts of the country while some parts offer none? A local part of the NHS deciding it’s OK not to offer IVF, with no accountability – it’s absurd and it’s unacceptable in a national service”.

NHS Airedale, Wharfedale and Craven CCG, NHS Bradford City CCG, NHS Bradford District CCG, Calderdale CCG, Greater Huddersfield CCG, Harrogate and Rural District CCG, Leeds CCG, North Kirklees CCG and Wakefield CCG all offer only 1 IVF cycle. After the last Partnership Board I was told in writing that all policies are in line with NICE guidance. Will the Board commit to this being the case across the Planned Care Programme?

Response to Question 20:

The West Yorkshire and Harrogate CCGs have not delegated responsibility for fertility services to the WY&H Joint Committee. These will continue to be locally agreed commissioning decisions, and neither the Joint Committee nor the Partnership can comment on them. For those commissioning polices that have been delegated to the Joint Committee, we would refer to our response to the questions that you asked at the Partnership Board in December:

"... the commissioning policies and clinical thresholds that have been developed across WY&H have been led by clinicians from across the area and have been based on evidence and best practice guidance... To date all of the policies have been in line with NICE guidance where it is available, and any proposals to deviate from NICE guidance are most likely to be as a result of evidence published subsequent to the latest NICE guidance"

Question 21:

NHSE 17 Evidence Based Interventions (17 EBI)

I do not share the board’s confidence in NHSE’s 17 EBI and would ask the board to agree that these should be reviewed more critically. Statutory guidance from NHSE has been implemented across West Yorkshire and Harrogate CCGs, but it is important to re-iterate that while NICE were involved in the consultation process, it did not endorse the subsequent guidance that requires economic levers to implement NHSE recommendations. You stated in a reply to my previous question to the board that the 17EBI programme was developed in collaboration with NICE. I took up this point with NICE and received the following written reply:

“This work was undertaken by NHS England rather than NICE. It would be inappropriate for us to comment on the validity of this work and the subsequent published guidance.” Removal of benign skin lesions was one of the major targets for reducing activity under the 17EBI programme, despite there being no evidence base. The unforeseen consequences were recently highlighted in a newspaper article https://www.theguardian.com/society/2020/feb/11/revealed-beautician-procedures- leaving-customers-burned-and-scarred

Patients are simply turning to alternative sources of treatment. Rogue beauticians are leaving customers burnt and scarred when removing moles and lesions, as well as missing potential signs of skin cancer. Dozens of patients a month are complaining about their treatment by beauty therapists, hairdressers and nail technicians who have removed blemishes from their skin; staff with no medical training are performing potentially dangerous, invasive procedures. A leading cosmetic doctor has described the situation as horrific. Would the board agree that this should prompt a review of current commissioning in this area?

In relation to other category 2 interventions, taking the example of breast reduction surgery, the NHSE website used to state: “Some CCGs do not fund breast reduction surgery at all, and others fund it selectively if you fulfil certain criteria”.

Will the board undertake to look at provision of all category 2 interventions and make sure that they are being offered to patients who do fulfil the NHSE indications?

Response to Question 21:

The NHS England Evidence Based Interventions programme has responsibility for reviewing the criteria for each policy. Within the WY&H Planned Care Programme (formerly Elective Care and Standardisation of Commissioning Policies programme) we have set a three year review period for the policies. Policies are reviewed prior to this when significant clinical evidence is published which indicates the policy should be reviewed sooner. This is not the case for the 17 policies within the Evidence Based Interventions. As part of the ongoing implementation and assurance of the Evidence Based Interventions policy all CCGs within WY&H are working with their commissioned providers of care to ensure that interventions are being carried out in line with the policy.

The NHS does not routinely fund interventions that are for cosmetic reasons. People with skin lesions that present a risk to health and well-being or which interfere with function are already able to access NHS funded treatment within the criteria outlined in the NHS England Evidence Based Interventions policy. People seeking surgery for cosmetic reasons should ensure their practitioner is appropriately qualified and insured, and do so at their own risk.

Question 22: Cataract surgery

The West Yorkshire and Harrogate Elective Care and Standardisation of Commissioning policies has developed a clinical pathway for cataract surgery. I am pleased to say that this does follow NICE guidance. Cataract surgery is the most common operation performed by the NHS, but increasing numbers of patients are having the procedure formed in the private sector and paid for by the NHS. Figures over the last 5 years show for West Yorkshire a fall in cataract operations in the NHS from around 15,000 to 14,000, and an increase from around 1,000 to 11,000 in the private sector. This striking trend will have negative effects on staff training and future recruitment for the NHS. The Ian Paterson and Michael Walsh cases have also raised serious concerns about the business models of private hospitals, their avoidance of scrutiny, and some serious safety concerns including who is responsible when things go wrong, as the surgeons are not direct employees. Does the board know who is in fact responsible when things go wrong with NHS patients who have been sent to the private sector for surgery? Will the board look are reversing this trend and building NHS capacity?

Response to Question 22:

With increasing demand for healthcare interventions and increasing complexity of the interventions available, the demand placed on the NHS estate and resources is considerable. Capital funding for estate growth and development is limited, although the WY&H Partnership has been extremely successful in securing national funding for development. When available this funding is used for specific projects which address clinical care in areas where the estate and/or resources are in need of modernisation or where there is inadequate provision to meet the health needs of the population.

Provision of NHS funded cataract surgery is sufficient to meet the demands of the WY&H population and so it would be inappropriate to invest funding into the development of additional capacity when there are other clinical specialties with greater need.

All Independent Sector providers of NHS funded services are required to have full insurance for all their interventions, and this is checked by the CCG on award of a contract to provide services. Surgeons also have their own medical professional indemnity cover which is checked by the Independent Sector providers for whom they work. The liability for any harm experienced by a patient receiving NHS funded care in an Independent Sector provider remains with the provider of the care.

Question 23:

Does the Partnership require NHS providers to put in place support programmes for their own staff facing obesity and/or smoking issues, as one more way of encouraging the wider population in the West Yorkshire and Harrogate area to address obesity and smoking problems?”

Response to Question 23:

(Note: The partners within the WY&H Health and Care Partnership do not “require” each other to do things. They work together and each play their own parts in actions they agree to take together.)

In responding to your question during the meeting, colleagues gave assurance that NHS providers had in place a wide range of initiatives to address obesity and smoking amongst their staff and also to support their wider health and wellbeing. We undertook to provide examples of these initiatives after the meeting.

I hope that you will understand that in view of the priority that the NHS is giving to responding to COVID-19, providing a full response to your enquiry is likely to take a little longer than usual. Please accept my apologies for any delay – I will be in touch again as soon as I am able.