Lancashire and South Cumbria ICS has produced a Business Case for addressing chronic weaknesses in delivery of Individual Patient Activity – which reaches in to social care.

But the document does not appear on the ICS website, and makes almost no reference to local government at all, raising the question of whether it is even being discussed by councils.

It can be found tucked away in the papers of the eight CCGs within the area, and is remarkable as a paper for a number of reasons, not least the fact that an Integrated Care System seems to require a 60-page document to make the case for spending an extra £770,000 per year (an increase of 0.35% on a £200m-plus budget) to address serious and long-standing gaps and delays in care.

Modest ambition

From the outset the ambition is modest to say the least – to do what many people might have thought NHS Commissioners were there to do from the beginning:

“This business case sets-out an ambition to transform the way we work, supporting individuals presenting with health and social care needs to access the most appropriate care.”

It goes on to admit that this has not been the case at least since 2013:

“The JCCCG has acknowledged that the current level of Individual Patient Activity services provided across Lancashire and South Cumbria (with the exception of Blackpool) is providing standards of care that fall well below an acceptable standard and should be of concern to all CCG Governing Bodies.”

However it clearly has not been a concern to 7 of the 8 CCGs, who have been falling short for years (the exception is Blackpool, where CCGs chiefs have worked with the council):

“A 2018 independent review highlighted 7 specific thematic areas where sustained improvement was required. The thematic review highlighted key failings in the governance arrangements, poor leadership within both commissioning and operational delivery, fragmented services leading to poor patient experience and poor delivery against National standards.”

However the analysis of this problem highlights not only significant under-funding, but also flaws which campaigners warned were inherent in the 2012 Health and Social Care Act, which came into force (and established CCGs) in 2013:

“The current commissioning & operational delivery model is highly fragmented, delivered by multiple commissioners and providers leading to poor system leadership, a lack of appropriate commercial due diligence, and an unstable and unsustainable delivery model resulting in a poor quality & underperforming service.”

The solution is effectively to unpick the divisions created by a patchwork of CCGs:

“The business case proposes to replace the fragmented multiagency approach with a single Lancashire & South Cumbria IPA business unit bringing together the economies of scale of a strategic hub together with 5 place based delivery team. All financial, commercial and operational responsibilities will be delegated to the business unit.

“…The current multiprovider delivery model will be replaced by a single operational management structure”

Among the worst performers

The Business Case goes on to make clear that while IPA performance is “variable”, “the region is one of the worst performing in the country against a wide range of indicators.”

More of this is explained on page 16, which addresses incomplete referrals (referrals for CHC assessment which have not been assessed within 28 days):

“For CHC incomplete referrals Healthier Lancashire and South Cumbria is the second worst STP/ICS in the country …. As a system Lancashire and South Cumbria have over 90% of the incomplete referrals in the North of England and almost 56% nationally.”

The explanation again underlines the dysfunctional system created by the 2012 legislation which scrapped Primary Care Trusts:

“In Lancashire and South Cumbria as at January 2020 there are approximately 3,800 reviews outstanding of which over 2,800 are overdue. … The overdue review issue issues date back to 2013 when approximately 2000 overdue reviews were transferred to MLCSU [Midlands & Lancashire Commissioning Support Unit] from Primary Care Trusts without commensurate resource to address.” (p17-18)

To make matters worse there are enormous variations across the eight CCGs in numbers of patients deemed eligible for Continuing Health Care and Funded Nursing Care:

“For standard CHC there is a 150% variance in eligibility rates across the region from the highest to the lowest. Just three CCGs are below the England average. For FNC eligibility there is a 193% variance in eligibility rates across the region from the highest to the lowest. All but two CCGs are below the England average.”

Continuing to wield a sledgehammer to crack an exceedingly small nut, the Business Case on page 43 labours the point, explaining the need for this minimal increase in spending to partially remedy the failure of 7 of the 8 CCGs to deliver an adequate service:

“This business case sets out the rationale for the transformation of IPA across Lancashire and South Cumbria. The case for change and proposed new model of care provides a compelling argument for the proposed changes.

“Approval and mobilisation of the business case will require an additional recurrent investment of £796k from April 2020. This is a pragmatic response to the challenge of both improving and sustaining performance in the next financial years and also moving towards an end to end service.”

Partial solution

But £796,000 is only part way to solving the problem, which requires investment of an additional £2-£4 million. This is 1-2% of spending on top of the current £200m IPA budget – but only a microscopic percentage of the £3.5 billion budget of the new ICS.

But rather than spend that small amount to solve the problem, health chiefs have opted to tackle only part of it:

“Every benchmark the programme has looked at indicates that the service across the rest of Lancashire and South Cumbria is under resourced. It is also acknowledged that the system does not have an extra £2m to £4m readily available.

Consequently, the pragmatic approach suggested to recurrent investment is that in 2020/21 an additional £796k targeted at critical performance improvement and working differently should be made.”

The Business Case is therefore revealing. It shows that far from offering bold and innovative moves to address long-standing weaknesses and failures in services for some of the region’s most vulnerable people, the new ICS is setting off by agonising over piecemeal and penny-pinching “pragmatic” measures that will leave inequalities in place and subject patients to poor services for years to come.

 

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John Lister
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