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					                                                                                      Agenda Item 6

                  Children & Young People’s Strategic Partnership Board
                        Monday 1st November, 5.30-7.30pm, Civic Suite, Catford

     AGENDA



No.                              Item                         Time         Action/Info/Discussion/
                                                                                 Agreement

1     Apologies                                              5:30pm

2     Minutes of the last Meeting – 19 July 2010                      Agreement

3     Matters Arising

4     Comprehensive Spending Review (AD/WT)                  5.40pm   Discussion
      Briefing report

5     JCG Savings Work: update on current position (CG/WT)   6.00pm   Information and discussion
      Presentation and update on JCG efficiencies work

6     UHL reconfiguration (TH)                               6.20pm   Discussion and agreement


7     Call back from previous meetings:                      6.40pm   Discussion and agreement
      Teenage Pregnancy (CG)

8     LSCB Report, inc Child Protection Review – Interim     6.55pm   Information and discussion
      Report (MS/IS)

9     Performance Briefing                                   7.10pm   Agreement


10    AOB/Date of Next Meeting                               7.25pm
      Details of the next meeting:
                  th
      Monday 17 January 2011, 5.30-7.30pm
      Civic Suite, Catford


      Information Items:
           Health White Paper Consultation
 Children & Young People’s Strategic Partnership Board


 CYPSPB ACTION SUMMARY (arising from meeting held on 19th July 2010)

ITEM           ACTION TO BE TAKEN                   MEMBERS       OUTCOME/CURRENT
                                                    RESPONSIBLE   POSITION
                                                    FOR ACTION

4. CYPP        The board noted the impact budget WT               On forward plan
Review         savings will have on some actions,
               and requested that the actions in
               the CYPP review be monitored by
               the board in future meetings.

5. JCG           A single service across the                     Training is not being
Efficiencies       partnership for training                       pursued as an area for
Savings        An update of progress to come to                   JCG savings. Cross
               next meeting.                    IS                authority work is being
                                                                  managed corporately.


                 Universal under 5s
                 Early Intervention
                 Complex Needs
               The board agreed for work to WT                    On agenda
               continue.

                 Maximising the use of school’s
                   budgets and DSG                                Discussions with schools
               Consultation and further work with AD              is in progress
               schools will continue in this area
               during the Autumn term.


7. LSCB        The Annual report will go through    MS            Included in agenda item
               the LSCB board, and Chief Officers                 11
               Group. Feedback from this will
               come back to the board.




                                                                                      2
              Children and Young People’s Strategic Partnership Board

Minutes of meeting held on 19th July 2010 at 5.30pm in Civic Suite, Lewisham High Street,
London

Present:
Alan Docksey                Head of Resources
Barrie Neal                 Head of Corporate Policy & Governance (LBL)
Christine French            Service Manager (Performance) (LBL)
Christine Grice             Head of Education, Access & Support
David Smart                 Chief Inspector (MET)
Fergus Grant                External Relations Manager, (JCP)
Geeta Subramaniam           Head of Crime Reduction Service (LBL)
Jane Shepherd               Director of Community Health Services
Johann Williams             St Andrews Community Centre
Magda Moorey                Chair of Professional Executive Committee (PCT)
Marion Saunders             Independent Chair (LSCB)
Martin Howie                Director (VAL)
Helen Klier (Cllr)          Cabinet Member for CYP (Chair)
Ruth Holden                 Chair Secondary consultative
Sue Tipler                  Head of Standards and Achievement (LBL)
Warwick Tomsett             Head of Commissioning, Strategy & Performance (LBL)

Also Present:
Andrea Tibble               Probation
Catherine Bunten            Policy Officer (LBL)
Jo Fletcher                 CAMHS
Max Krafchik                Service Manager (Strategy & Policy) (LBL)
Rachael Turner              Joint Commissioner (LBL)

Apologies:
Chris Threlfall             Head of Education Development
Claire Champion             Director of Operations and Nursing (UHL)
Danny Ruta                  Joint Director of Public Health
Dith Banbury                Vice Principal – Lewisham College
Donal O’Sullivan            Consultant in Public Health Medicine
Frankie Sulke               Executive Director for CYP (LBL)
Gill Galliano               Chief Executive PCT
Irene Cleaver               Chair of Primary Schools Consultative
Paul Calaminus              Service Director (CAMHS)
Pauline Kennedy             Assistant Director, Children’s Society
Sara Robinson               Probation Service
Tim Higginson               Chief Executive (UHL)




                                                                                       3
Item              Minutes                                                               Action

1. Apologies      As noted.

2. Minutes of     Minutes of the 26th April 2010 meeting were accepted as a
the last          true record.
meeting.

3. Matters
Arising

4. Children and   WT presented the CYPP review to the board.
Young People’s    The review has been circulated to members, and is a useful
Plan (CYPP)       reference tool to track progress against our priorities.
Review
                  Future challenges will include the Child Poverty strategy and
                  action plan. All LAs have a statutory duty to produce a needs
                  assessment (work on this has started) and a strategy, which
                  in Lewisham will be incorporated into the CYPP with any
                  additional items noted in the CYPP review.

                  The CYPP review records progress and actions as at April
                  2010.
                  The board noted the impact budget savings will have on
                  some actions, and requested that the actions in the CYPP
                  review be monitored by the board in future meetings.     WT

5. Joint          Following agreement from the board in January 2010, JCG
Commissioning     have taken forward work in 5 areas of potential partnership
Group (JCG)       savings.
Efficiencies
Savings             A single service across the partnership for training

                  Single Site Venue – this option has proved unfeasible due to
                  unavailability of a site large enough to house all programmes
                  and complexity of delivery.

                  Due to the different training management structures
                  operating across the partnership (specifically not having a
                  set budget for a locality and/or for CYP training), it is difficult
                  for many partners to identify specific funds for multi agency
                  training delivery.

                  Work has also been underway on a LBL approach across
                  Children’s Services, and with neighbouring boroughs.

                  Whilst acknowledging a longer term preference for option 4,
                  the board commended the work done and wished LBL well in
                  pursuing its cross authority approach. Opportunities for the
                  CYP partnership may be reviewed in the light of effective
                  implementation of the LBL cross authority approach. Further
                  work to continue to explore the feasibility of a multi agency
                                                                                                 4
              service and of partner agencies joining the LBL corporate
              work. An update will come to next meeting.                IS

                Universal under 5s
                Early Intervention
                Complex Needs

              The work in these three areas is ongoing, and the board
              were updated on progress.

              The aim is to create and redirect efficiencies from the
              universal level, reshape services at the targeted level, and
              over a period of three years, to meet complex needs earlier.

              Significant savings opportunities can be identified through
              this work.

              The board noted the need to incorporate new Government
              policy with respect of Children’s Centres and SEN Green
              Paper, and that consultation with the wider community will be
              required if services are to be reshaped.

              The board agreed for work to continue.

                 Maximising the use of school’s budgets and DSG
              Work has focussed on the services that schools purchase
              from the Local Authority and the scope available to adjust the
              charges.

              Consultation and further work with schools will continue in
              this area during the Autumn term.

6. LAC        IS presented the board with a report on LAC performance,
performance   focussing on issues of placement stability

              In order to tackle the high levels of placement moves, a
              panel is being established which all applications for moves
              will go through to be agreed (except in emergency cases).
              This will incorporate the work coming out of the JCG
              efficiencies described above.

              This will not only give more scrutiny of moves, but also
              enable us to explore the themes for placement moves.
              Additionally, Care UK are recruiting foster carers on behalf of
              Lewisham to increase local placements and reduce costs.

              Work has also been done following the disappointing
              achievement results for LAC in education, and will continue
              around the arrangements and governance of a virtual school.

              Lewisham, like many boroughs since Baby P, has also
              experienced a rise in the number of LAC, increasing the
              pressures on services.

                                                                                5
                 There is also a link with the work being done in JCG
                 regarding early intervention aiming to reduce the number of
                 children entering the LAC system.


7. LSCB          MS presented the LSCB draft annual report to the Board.

                 The following issues for the LSCB were noted:

                 Identifying appropriate performance indicators for the
                 partnership to demonstrate outcomes.

                 A need for an increased focus on the 13-16 age group (wider
                 than teenage pregnancy focus).

                 Need for greater resources to achieve targets in the action
                 plan. Partners will receive requests for increased resources
                 to the LSCB.

                 MS noted that a lot has been achieved and this is a reflection
                 of the engagement of partners and the wide skills base
                 available in the LSCB.

                 The Annual report will go through the LSCB board, and Chief       MS
                 Officers Group. Feedback from this will come back to the
                 board.

8. Performance   Highlighted issues from the dashboard data:
Management
and Dashboard    DfE “Tell Us” survey will not take place, the 5 indicators this
Data             was feeding will therefore not be updated. NI115 (substance
                 misuse) is also one of Lewisham’s LAA targets.

                 Appendix c, pg134 shows Ofsted information on
                 performance profile. Our secondary schools have fallen from
                 85% as good or better to 64%

                 SCPs – 3 out of 3 are good or better

                 WT informed the board that Rushey Green Children’s Centre
                 has an Ofsted inspection this week, and that partnership
                 support was essential.

                    Being Healthy – page 6
                 Immunisations and MMR varies by quarter. NHS London
                 target is 90%, Lewisham is at 74%

                 NI112 – Teenage Conception shows an improvement in first
                 quarter of 2009, with 59 conceptions – 63.2% (previous year
                 75.3%)

                 Obesity and HWMP data is expected in Autumn term.


                                                                                        6
                  Staying Safe – page 9
                NI64 – Child protection plans lasting 2 or more years.
                Lewisham in lowest quartile.

                NI60 Core Assessments completed in timescale
                Despite the actual rate of completion rising, the increase in
                core assessments shows a negative impact on this NI.


                  Enjoy and Achieve – page 13
                Improvements seen in early years foundation stage, where
                we have closed the gap for the 4th successive year

                Key Stage 1, from provisional information from teacher
                assessment shows a drop in writing and maths, Key Stage 2
                shows improvements.

                Steady progress is being made in tackling secondary school
                absence


                  Making a Positive Contribution – page 16
                Youth offending remains a high priority, including the
                breakdown within the target.


                  Economic Wellbeing – page 18
                Concerns at level 2 and 3 achievement at age 19, with
                respect to gap between those who do, and don’t have free
                school meals.

11. AOB/Date of Details of the next meeting:
Next Meeting    Date: Monday 1st November 2010
                Time: 5:30 – 7:30 pm
                Venue: Civic Suite




                                                                                7
                                                                                                Agenda Item 4




                                                          Comprehensive Spending Review: Briefing
                                                                              November 1st 2010


1.        Purpose of Report
1.1       The purpose of this paper is to draw together the key points of the Spending Review to provide the
          Children and Young People’s Strategic Partnership Board with a briefing about the initial messages
          from the speech. There will be further announcements and more detail to follow and we will continue to
          conduct detailed analysis and issue briefings where relevant on the impact of the review on the
          Partnership.

2.        Background
2.1       On 22nd June, the Chancellor, George Osborne, delivered his emergency budget. The Budget set out
          the overall level of public spending for the four years from 2011/12 to 2014/15. The 2010 Spending
          Review is a Treasury-led process to allocate resources across all government departments, according
          to the Government's priorities. It will set departmental expenditure limits (DEL) It is then up to
          departments to decide how best to manage and distribute this spending within their areas of
          responsibility.

          The 2010 Spending Review will cover the four years from 2011/12 to 2014/15.
               th
          On 20 October 2010 the Chancellor, George Osborne made a speech and presented the Spending
          Review to Parliament. Overall the Chancellor announce there will be cuts of 19% to government
          spending, below the 25% expected.


3.        Departmental Messages
3.1       Education (DfE):
         Revenue expenditure by DfE will rise each year, from a baseline of £50.8bn to £53.9bn in 2014-15.
         Capital expenditure will be reduced by 60% from baseline £7.6bn to £3.4bn by 2014-15.
         Overall resource savings in DfE’s non-schools budget of 12 per cent in real terms by 2014-15.
         33% reduction in real terms by 2012-15 from the DfE’s administrative budget

          Sure Start and Early Years
         Sure Start will be refocused on its original purpose of improving the life chances of disadvantaged
          children and targeting early intervention on families who need the most support
         Sure Start services will be maintained in cash terms including new investment in 4,200 Sure Start
          health visitors
         Extending 15 hours a week of early years education and care to all disadvantaged two year olds from
          2012-13.
         Reforms to encourage more community providers to enter the market, including through payment by
          results. The introduction of an early years single funding formula will also “make the market more fair
          and equitable.”

          Schools
         There will be a real terms increase in the 5-16s school budget of 0.1% in each year of the spending
          review. Including a £2.5bn pupil premium, an assumed efficiency of £1b and a freeze on pay.
         Underlying per pupil funding will be maintained in cash terms and so allowing for demographic growth.
         £15.8bn of capital funding for new schools, rebuilding or refurbishing but some existing BSF projects
          will be subject to reductions of 40%.
         Funding for specialist schools, including for High Performing Specialist Schools (HPSS), will be
          mainstreamed from April 2011. This funding, approximately £450 million for 2010-11, is not being

                                                                                                                    8
                                                                                                  Agenda Item 4

         removed from the schools system and will continue to be routed to schools through the Dedicated
          Schools Grant
         School sport funding will no longer be ring-fenced and the Department will not continue to provide ring-
          fenced funding for school sport partnerships. The Department is ending the requirements of the
          previous Government's PE and Sport Strategy.

          Further and Higher education
         The Government will continue with plans to raise the participation age to 18 by 2015
         The support currently provided by Education Maintenance Allowances (EMAs) will be focused on the
          most disadvantaged children.
         The Further Education resource budget will be reduced by 25%
         Colleges will benefit from:
              o reduced bureaucracy by simplifying funding arrangements to a single source;
              o streamlining Arms Length Bodies; and
              o abolishing central targets.
         Train to Gain will be ended

3.2       Health (DH)
         DH budget growth of 0.1% per year.
         An additional £1 billion a year for social care through the NHS, as part of an overall £2 billion a year of
          additional funding to support social care by 2014-15.
         The Government will pay and tender for more services by results, rather than be the default provider of
          services including community health services and children’s centres.
         The commitment to fund 4,200 new health visitors was confirmed in the Spending Review. The level of
          funding will be announced in due course.

3.3       Transport (DfT)
         DfT budget cut by 5% per year.
         £30 billion investment into transport projects over 4 years.
         Funding to enable Crossrail to go ahead, and to support £6 billion of capital expenditure by Transport
          for London (TfL) to maintain and upgrade the London Underground network.
         Increases to the cap on regulated rail fares to three per cent above RPI for three years from 2012.
         Protection of the statutory entitlement for concessionary bus travel.

3.4       Communities and Local Government (CLG)
          Communities
         150,000 new affordable homes over the Spending Review period accompanied by major reforms.
         Reforming the planning system and introducing a New Homes Bonus to support economic growth and
          increase housing supply.
         Reforming the council housing finance system so local authorities have greater control over their own
          finances, and can reinvest to meet local housing need.

          Local Government
         LG budget cut by 7.1% per year.
         Funding in all four years of the Spending Review to enable local authorities to freeze their council tax in
          11-12.
         Greater personalisation and increasing delivery through the voluntary and community sector.
         Ring fencing of all revenue grants will end from 2011-12, except simplified school grants and a new
          public health grant
         The number of separate core grants will be radically reduced from over 90 to less than 10
              The nine grants are:
                  o      Early intervention (likely to include current grants for Teenage Pregnancy, substance
                       and alcohol abuse, young people at risk of becoming NEET, and elements of Sure Start)
                  o      DSG
                  o      Learning Disabilities
                  o      Public Health grant from 2013 -14
                  o      New Homes Bonus
                  o      Council tax freeze grant
                  o      Housing benefit and Council tax benefit admin grant
                  o      PFI grant
                  o      Preventing Homelessness grant
                                                                                                                    9
                                                                                                  Agenda Item 4

         The first community budgets will be run in 16 local areas (including Lewisham) from April 2011 for
          families with complex needs. These will pool departmental budgets for local public service
          partnerships.
         More than £4 billion of revenue grants will be rolled into formula grant. This includes the £114.05m
          funding previously received from DfE (which will reduce to £66.34m by 2014-15) for the following:
                   o     LSC Staff transfer (baseline £50m – reducing to £34.6m in 2014 -15)
                   o     Services for Children in Care (£54.8m reducing to £28.2 in 2014-15)
                   o     Child Death review process (£7.7m reducing to 3.5m in 2014 -15);
                   o     The contribution from DoH to the “Personal Social Services” portion of the formula grant
                       appears to include money previously allocated to CAHMS
         Local authorities and their partners will be able to cease reporting any of the 4,700 Local Area
          Agreement targets, and those that are kept will not be monitored by Government
         £200 million of capitalisation in 2011-12 will be made available to local authorities to help support local
          authorities that undertake organisational restructuring

3.5       Work and Pensions (DWP)
         DWP budget growth by 0.6% per year.
         This includes £2 billion over the next four years for the Universal Credit, which will replace means
          tested working age benefits.
         The percentage of childcare costs that parents can claim through the childcare element of the Working
          Tax Credit will be reduced from 80 per cent to its previous level of 70 per cent, saving £385m by
          2014/15.
         Couples with children will also have to work for at least 24 hours a week between them, rather than the
          current 16 hours, to be eligible for the Working Tax Credit.
         Child benefit to be removed from families with a higher rate tax payer, but will not be scrapped for
          children aged 16 and above and the child element of the Child Tax Credit will increase over the next
          two years - by £30 in 2011 and by £50 in 2012 - to protect low-income families from the cuts in the
          welfare system. .
         Overall resource savings of 26 per cent in real terms on DWP’s core budget by 2014-15, through
          greater use of digital services for processing benefits.
         Reducing spending on Council Tax Benefits by 10 per cent and localising it.
         Raising the State Pension Age for men and women to 66 as a gradual increase from 2018 to April
          2020.
         Uprating the basic State Pension by a triple guarantee of earnings, prices or 2.5 per cent, whichever is
          highest, and preserving key benefits for older people including Winter Fuel Payments.

3.6       Cabinet Office
         Overall budget growth of 28%.
         This includes a transition fund of £100 million to support voluntary and community sector organisations.
         Funding to support the Big Society including pilots for National Citizen Service.
         The Government will resource and implement the AV referendum and Boundary Review, as set out in
          the Coalition Agreement.

3.7       Remaining Departments
           Department:                                    Cut:
           Business, Innovation and Skills                BIS budget cut by 7.1% per year.
                                                          Relative protection for science and key elements of
                                                          adult skills funding.
                                                          Increasing funding by £250 million a year by 2014-15 on
                                                          new adult apprenticeships.

           Culture, Media and Sport                       Budget cut by 6% per year.
                                                          Maintaining free entry to museums and galleries.
                                                          The TV licence fee will be frozen until 2016-17.
           Energy and Climate Change                      Budget cut by 5% per year.
                                                          Up to £1 billion of investment to create commercial scale
                                                          carbon capture and storage (CCS) demonstration
                                                          plants.
                                                          £1 billion of funding to capitalise a UK wide Green
                                                          Investment Bank.
           Environment, Food and Rural Affairs            Budget cut by 8% per year
                                                                                                                   10
                                                                                                Agenda Item 4
        Her Majesty’s Treasury                          Overall resource savings of 33%.
        HMRC                                            Overall resource savings of 15 per cent.
        Home Office                                     Home office budget cut by 6% per year with Police
                                                        budget cut by 4% per year.
        Justice                                         Budget cut by 6% per year


4. 0   Key Figures

                                                   Planned      Cumulative        Planned        Cumulative
                                                   Revenue      Real Growth       Capital        Real Growth
                                                    Budget       (Revenue)        Budget          (Capital)
                                                   2010-11                        2010-11
                                                                      %                                %
                                                   £ billion                      £ billion
        Education                                       50.8              -3.4            7.6                -60
        NHS (Health)                                    98.7               1.3            5.1                -17
        Transport                                         5.1              -21            7.7                -11
        CLG Communities                                   2.2              -51            6.8                -74
        CLG Local Government                            28.5               -27            0.0                  0
        Business, Innovation and Skills                 16.7               -25            1.8                -52
        Home Office                                       9.3              -23            0.8                -49
        Justice                                           8.3              -23            0.6                -50
        Energy and Climate Change                         1.2              -18            1.7                 41
        Environment, Food and Rural Affairs               2.3              -29            0.6                -34
        Culture, Media and Sport                          1.4              -24            0.2                -32
        Work and Pensions                                 6.8              2.3            0.2               -5.5
        HM Revenue and Customs                            3.5              -15            0.2                -44
        HM Treasury                                       0.2              -33            0.0                  0
        Cabinet Office                                    0.3               28            0.0                  0


5.0    Key Themes

5.1    Public Service Reform
       The Government will pay and tender for more services rather than be the default provider (this
       includes children’s centres and mental health). The Government will also look to set specific service
       areas that should be delivered by non-state providers including voluntary groups (includes youth
       services) and introduce new rights for communities to run services, own assets and for public service
       workers to form cooperatives.

       The Government will direct around £470 million over the Spending Review period to support capacity
       building in the voluntary and community sector, including an endowment fund to assist local voluntary
       and community organisations. The Government will provide funds to pilot the National Citizen Service
       and establish a Transition Fund of £100 million to provide short term support for voluntary sector
       organisations providing public services. The Big Society Bank will bring in private sector funding in
       addition to receiving all funding available to England from dormant accounts.

5.2    Welfare
       A single universal credit will be introduced over the next two Parliaments. £2b of resources committed
       over the CSR period to make this happen.
       The Introduction to Work Programme will be led by the voluntary and private sector
       Universal benefits: higher rate tax payers will no longer receive child benefit, and child benefit for those
       who are eligible will continue to end of full time education.
       Funding for 150,000 new affordable homes over the Spending Review period accompanied by major
       reforms in housing benefit and social housing.

5.3    Social Care, early intervention and family intervention



                                                                                                                11
                                                                                               Agenda Item 4
      The use of personal budgets will be extended across many services included SEN and support for
      children with disabilities. The Government will introduce a new and simplified early intervention grant –
      not ringfenced - of £2billion by 2014 -15.
      The Spending Review also announces a new national campaign to support and help turn around the
      lives of families with multiple problems. The campaign will be underpinned by local Community
      Budgets focused on family intervention. These will pool departmental budgets for local public service
      partnerships to work together more effectively. Councils and their partners will have greater flexibility to
      work across boundaries in health, policing, worklessness and child poverty. Lewisham is one of the
      pilot sites. DfE has confirmed that these budgets will be funded from the early intervention grant.

5.4   Child Poverty
      The Government will use some of the savings from withdrawing Child Benefit from families with a
      higher rate taxpayer to fund significant above indexation increases in the Child Tax Credit. This is
      better targeted on low income families, worth £30 in 2011-12 and £50 in 2012-13, and “will ensure the
      Spending Review will have no measurable impact on child poverty in the next two years”
      The Government’s longer term strategy for tackling child poverty will be set out by the end of March
      2011, and will take into account the conclusions of the Frank Field review. The Government will
      publish its first child poverty strategy before the end of March 2011.




                                                                                                               12
                                                                                                                        Agenda Item 7




                                                                                                         Teenage Pregnancy Report
                                                                                                                November 1st 2010


RECENT TEENAGE PREGNANCY DATA

                                              Since March 2008, the rolling average has been on a downward trend, see Figure 1.
                                              Current rolling quarterly average is the lowest since Q2 of 2001
                                              This is the first occurrence of two low successive quarters at the beginning of the year
                                              These figures show Lewisham has the 5th highest reduction in London against 1998 baseline
                                               and has the 3rd highest rate in London (after Lambeth and Southwark)
                                              Subsequent soft intelligence from UHL suggests a lower number of births to teenage girls

                                      90




                                      80




                                      70
  Under 18 conception rate per 1000




                                      60




                                      50




                                      40




                                      30




                                      20

                                                                                      Quarterly rate

                                      10

                                                                                      Rolling average

                                       0
                                           March
                                                   June



                                                                       March
                                                                 Dec
                                                          Sept



                                                                               June




                                                   2008                2009

                                             Quarter & Year

Figure 1: Quarterly Rates in Lewisham Q1 2008 - Q2 2009, ONS



DEVELOPMENT OF DATA TOOL

                                              Performance Team have developed a Data Tool of named young people in Years 9-13 using
                                               May 2010 school census and includes:
                                                  o Free school meals (FSM)
                                                  o Low attainment (English or Maths at KS2 or KS3 under expected levels 4 and 5)
                                                  o Exclusions (permanent and fixed)
                                                  o Absence (at least one absence, authorised or unauthorised)

                                                                                                                                     13
                                                                                Agenda Item 7

           o Child Protection and LAC (currently or previously)
      Further refinement is needed to ensure thresholds are relevant and to include other data
      The data sets relate to the teenage pregnancy risk factors which have been promoted
       nationally to aid targeted work



EARLY INTERVENTION APPROACH
The information gathered in the Data Tool will be used to target prevention work in 4 ways: 1:1
support and raising aspirations of young people, Speakeasy program for parents and information
sharing.

1) 1:1 SUPPORT

The Teenage Pregnancy Team will provide intensive 1:1 support to young people identified by the
Data Tool and referrals from professionals.

Teenage Pregnancy Team Structure

      Recent transfer from Youth Service (June) provided extra capacity – 1 full-time Keywork
       Coordinator and 17 sessional workers joining the 3 other full-time staff
      Experienced in working with very vulnerable young people
      All trained in sexual health, confidentiality, condom distribution, sex and the law, STIs,
       contraception and local/national services
      Further training planned to enable team to undertake termination/miscarriage follow-up,
       support to victims and perpetrators of sexual bullying and domestic violence
      Team are able to provide 1:1 support to 100 young people in 12-month period based on
       previous caseloads



                             Kate Parsley
                            TP Coordinator




     Maureen
      Barber
     Keywork
    Coordinator
                                    Nicolette              Emma Corker
                                   Lawrence                     SRE
                                   Inclusions               Coordinator
                                    Advisor                (out of school)




      X17
   Keyworkers


Figure 2: Organisational Chart of Teenage Pregnancy Team


                                                                                              14
                                                                                    Agenda Item 7

The Team are currently working with a case load of 33 young people aged 11-18, the majority of
whom are aged 14-16, whereby 86% are female.




.
Figure 3: Age of young people in current caseload



The package of support provided by the Teenage Pregnancy Team will always include :
    Relationships, self-esteem and emotional wellbeing
    Choosing and continuing with contraception including condom use
    Education, employment and training
    Home life

Support may involve accompanying individuals to sexual health clinics to obtain long-acting
reversible contraception (LARC) and establishing motivation for particular behaviours. The team are
very flexible whereby the gender of the worker, length of intervention, frequency and length of
meetings and times support is provided is negotiated between staff and the young person. It is
expected that the majority of young people would be seen for a period of at least 6-months. The team
will also be monitoring the development of the caseload and following-up each individual after they
complete their programme to show the achievements being made as a result of the support.



Case Studies

The following case studies are from the last 18 months and provide examples of the needs of clients
that the Teenage Pregnancy Team work with and the outcomes following the support provided:

Female, aged 16
 She was referred by the Connexions PA on duty, she was emotional and crying and disclosed
   various issues including having had over 50 sexual partners, a previous miscarriage, a bad
   relationship with her mother at home and no aspirations when school ended.
 She was supported intensively for 6-months which focussed on improving her relationships with
   family and friends, providing mediation between her and her mother, making a referral to
   counselling and accompanying her to a sexual health clinic for LARC fitting.
 Outcomes: the client restored the relationship with her mother, worked in retail for 1 year and has
   just started NVQ Level 3 in Health & Social Care at Bromley College, has an improved
   relationship with peers and has had long-term partners since.

                                                                                                  15
                                                                                  Agenda Item 7

Female, aged 17
 She was referred by an alternative education provider following a miscarriage, she was in a
   destructive relationship and her mother had recently thrown her out of the home.
 She was provided with short-term support over 2-months which focused on relationships with
   family and the police, a referral was made for counselling following her miscarriage and the
   breakdown in relationship with her mother, she was supported with reassessing her negative
   relationship, accompanied to a clinic for a LARC fitting, helped with re-housing, supported to
   access crisis loan and benefits when she was housed in a hostel
 Outcomes – she is living independently, she has stayed in education and is no longer in a
   destructive relationship

Female, aged 16
 She was referred by a LAC social worker when she was 15 as she was not engaged in education
   and was about to become sexually active
 She has been provided with intensive support for the past 4-months, which has focused on
   delaying sex, self-esteem and relationships and the worker has engaged with her school, the
   education department and alternative education providers to maintain her education.
 Current Progress – she is about to finish Year 11 with qualifications, she is very happy in her
   foster placement, she is engaging in safer sexual behaviour, applying for college and gaining
   independent living skills

Female, aged 14
 She self-referred into the service following 1.5 years of being out of education,. Her mother has
   mental health issues and has taken her back and forth to Jamaica since Year 8 and she was
   mentioned at the Girls and Gangs Forum regarding an incident and potentially being pregnant..
   During the girls only summer scheme she started exhibiting inappropriate sexualised behaviour
   and was desperate for a boyfriend
 She has been supported for 4-months so far which has focussed on raising her self-esteem, self-
   identity and confidence, reducing naivety and neediness with males and other peers, improving
   her relationship with mother and contraception
 Current Progress – she now has a social worker, she is making progress by getting back into
   education and some of her attitudes have improved

Female, aged 17
 She was referred via Girls and Gangs Forum by her boyfriend’s resettlement officer, she had a
   previous miscarriage, was out of school and she had not left home for 1 year following risk of
   gang related violence
 So far she has been supported very intensively in her home for 5-months focusing on her fear of
   violence, her use of contraception and a potential subsequent pregnancy, her self-
   esteem/motivation and aspiration, she has been accompanied to SHIP and the police and is now
   housed outside Lewisham.
 Current Progress – she is engaging with Connexions re: her housing and the Youth MARAC
   around her fear of violence, she is more confident and motivated about relationship with
   boyfriend, she is using contraception having decided against another pregnancy and is looking
   for a job


Evidence base

Young women with 5 or more risk factors have a 31`% probability of becoming a mother under 20,
compared with 1% to those without. Young men with 5 risk factors have a 23% probability of
becoming a young father under 23, compared to 2% without.

In the last 18 months, 52 vulnerable young women have been supported to reduce teenage
conception and only two clients have conceived since engaging with the service. This equates to a
96% success rate.
                                                                                                16
                                                                                       Agenda Item 7

Stoke-on-Trent have implemented early intervention work whereby they have 6 full-time workers,
who have engaged 8,000 young people in targeted SRE in schools and the community and provided
360 young people with 1:1 support. Between 2007 and 2008 Stoke’s conception rates reduced by
14% compared to the England reduction of 3.2% for that same time.


2) RAISING ASPIRATIONS AND SELF-ESTEEM
GOALS Training is a package of support to raise aspirations and self-esteem in vulnerable young
people, often used by Youth Offending services which have had 83% re-engagement in education
from NEET clients. The programme can be OCN accredited at Level 1 or 2 depending upon
participation and it involves group exercises, individual tasks, discussions and memorable activities
all following a motivational approach. There are 4 GOALS trained staff within IYSS and this
programme will be offered to all participants.


3) SPEAKEASY: SUPPORT FOR PARENTS
Speakeasy is a course developed by the FPA which prepares parents to discuss puberty, sexual
health and relationships with their children. Research from DoH in 2000 showed a third of mothers
and two thirds of fathers had told their children ‘not a lot’ or ‘nothing’ about SRE. Last autumn, in the
workshop which followed the Angie Le Mar play “Do you know where your daughter is?” many
parents were unaware of the frequency of sexual bullying in schools and lacked confidence in
discussing SRE with their children.

The Speakeasy programme increases confidence, reduces anxiety and embarrassment and
supports parents to challenge myths and misconceptions they have about the subject. There are 12
staff in Lewisham trained to provide Speakeasy Training and parents whose children are engaged in
1:1 support will be offered the course. The programme will also be linked to the Pastoral Support
Plan being developed for Crossways Academy and particular schools and agencies e.g. Sedgehill
and Youth Offending Service will be targeted.


4) INFORMATION SHARING
Schools and youth provisions will be contacted to inform them that pupils or clients have been
identified as at risk or early pregnancy. This gives the Teenage Pregnancy Team an opportunity to
highlight the opportunities available e.g. training and resources and increase the wrap-around
support being provided to the young people.




                                                                                                      17
                                                                                                         Agenda Item 8




                                     LSCB Report, including interim report on Child Protection Review
                                                                                   November 1st 2010


1.    Purpose of Report
1.1   To provide the Partnership Board with an update in respect of the work of the LSCB
      and a summary of the first part of the Munroe Review of Child Protection.

2.    The LSCB Annual Conference
2.1   The LSCB annual conference was held at Lewisham Hospital on 8th October. The title
      was ‘The three ages of vulnerability: working with vulnerable children and
      young people ’. The conference was designed to provide learning in relation to three
      periods of development 0-5 years old, 5-12 years old and 12-18 years old. A range of
      workshops covering e-safety, private fostering, substance misuse, sexual health and
      theraplay was also provided Keynote speakers presented on attachment, the
      recognition of physical abuse and recent research on working with adolescents. Two
      young people in care presented their views on the positive and negative aspects of
      living in care, supported by Lewisham’s mentoring co-ordinator.

2.2   A large number of people (154) from across the partnership applied for places and
      managers were asked to nominate representatives in order to ensure all agencies
      could be represented. 101 people attended.


                                                Attendance breakdown

                                                      YOS
                                                                                     CAMHS
                                                       3% CAMHS
                                            SLaM
                                                                                     CYP
                                             3%            7%
                                 School
                                                                                     Early Years
                                  10%
                                                                                     Education
                         Probation
`        Private / Vol
                            1%
                                                                        CYP
                                                                        23%
                                                                                     Housing
              2%                                                                     LBL Other
                         Other
                          2%                                                         Lewisham Hospital
                                                                                     Lewisham PCT
                  Lewisham PCT
                       17%                                                           Other
                                                                       Early Years   Private / Vol
                                                                          11%        Probation
                         Lewisham Hospital                      Education            School
                               10%                                 5%
                                                                                     SLaM
                                          LBL Other      Housing                     YOS
                                             2%            4%



3.    Safeguarding in relation to Faith and the Voluntary & Community Sector
3.1   Safeguarding continues to be an important area among the above groups. Faith
      groups are now contacting the LSCB for information on training and safeguarding
      policies (a template is now available on the LSCB website). London Safeguarding
      Board has recently launched a Pan-London Safeguarding Children Culture & Faith
      Project which aims to promote a step-change in safeguarding children living in
                                                                                     18
                                                                                 Agenda Item 8

      minority ethnic, culture or faith communities. To support this London authorities have
      been asked to run consultation focus groups among this sector to obtain their views
      on improving safeguarding among these groups. In Lewisham we are planning to
      hold our focus group in January. The project will run for 18 months. Voluntary Action
      Lewisham has also been working to raise safeguarding standards within the voluntary
      sector using Safe Network material, consisting of a range of safeguarding templates
      designed to help increase their knowledge and understanding of safeguarding. The
      LSCB will provide safeguarding training to support this.

4.    LSCB Induction programme
4.1   Forty two people attended the first LSCB induction session on 11th October. The
      induction will be held four times a year and is designed to ensure that all new staff
      working with children and families are made aware of the LSCB, its roles and
      responsibilities, key priority areas, the importance of early intervention and inter-
      agency working, SCRs and ways the LSCB can support them. The feedback was very
      positive.

5.     LSCB Training Audit
5.1    The LSCB’s training programme has recently been audited by external auditors. The
       purpose was to ensure an effective programme is in place to enable practitioners to
       effectively safeguard children. The programme received the highest grade of
       ‘Substantial Assurance’ that targets have been met or exceeded within a robust
       framework of controls.
 Level Effectiveness System
6.     Stop it Now!
6.1    Work with the Lucy Faithful Foundation has led to arrangements for the free delivery
       of seminars for parents at two of our children’s centres to raise awareness of sexual
       abuse. The initiative is called 'Lets start talking' and aims to raise awareness of the
       everyday steps parents can take to prevent child sexual abuse. It covers warning
       signs of abusive behaviour, action to protect children and how talking can help
       prevent abuse. A session for practitioners will be delivered in December. The trainer
       presented an e-safety workshop at our conference which was well received and is in
       agreement to providing e-safety sessions for parents.

7.    LSCB funding
7.1   The LSCB budget has been seriously depleted due to the recent serious case
      reviews. There is now concern that the current contribution to the LSCB is insufficient
      to support its work. Lewisham Hospital and SLAM have made a single contribution
      this year which has helped, but this will remain an ongoing concern unless
      contributions increase.

7.2   Like all services the LSCB is looking at ways of reducing its overheads while
      remaining focused on its core functions of quality assurance, monitoring and training.
      During 2011/12 we plan to reduce our training costs by using four internal trainers to
      deliver eight training sessions previously delivered by external trainers. We are also
      working with our neighbouring LSCBs (Bexley, Bromley and Greenwich) to negotiate
      a reduction in fees from a group of external trainers delivering the same training in all
      four authorities. In addition the four authorities are exploring the possibility of training
      2 SCR chairs from each authority to chair each others SCRs to avoid the high costs of
      using independent chairs. We are also discussing developing a peer audits system
      across the authorities.

                                                                                               19
                                                                                  Agenda Item 8


                     A summary of the Munro Review of Child Protection
                                  Part one: a systems analysis

On 1st October Professor Eileen Munro set out her initial analysis on the review into social
work in England. The review was informed by a call for evidence that ran throughout July
this year. Over 450 individuals and organisations submitted more than 1000 pieces of
evidence to the review. Responses were received from those with a wide variety of expertise
including social workers, children, young people, families, LAs, health professionals, the
police, and lawyers.

In the review Professor Munro looks at early intervention by highlighting that Social workers
are only one of the many groups who work with children. She states that ‘while
professionals in universal services cannot and should not replace the function of social work,
they need to be able to understand and think professionally about the children, young people
and families they are working with’. The report focuses on issues such as:

         developing a greater range of expertise in Early Years settings and other
          universal services in support of vulnerable children, young people and families
         the types of changes required in universal services to tackle the rise in referrals
          to children’s social work services.

It is clear that Professor Munro is not only examining the role of social work and social
workers but how other professionals that work with children can help to identify and support
children who may not need protection but do need additional support to improve their well
being.

Having made that clear the review moves on to its main focus and central strand, which is
improving frontline practice. Professor Munro’s findings suggests that this is target driven,
children and young people continue to have frequent changes of social worker, do not find
help quickly available and feel their wishes and feelings often go unheard. The report looks
at why previous reforms, while well meaning have not led to improvements and only served
to get in the way of social workers spending time with vulnerable children and families.

Issues of uncertainty is also reported to be a key feature in child protection work. Munro
states that identifying cases of abuse or neglect is an uncertain process in a system which is
over-bureaucratised.

Professor Munro said:

        I want to be clear from the start that there are no simple quick-fix solutions to improving
        the child protection system. A key question for the review is why the well-intentioned
        reforms of the past haven’t worked. Piecemeal changes have resulted in a system
        where social workers are more focused on complying with procedures. This is taking
        them away from spending time with children and families and limiting their ability to
        make informed judgments.

        Professionals should rightly take responsibility when things go wrong but they need
        more freedom to make decisions, more support and understanding, and less
        prescription and censure. Too often social workers are either criticised for breaking up

                                                                                                20
                                                                                                        Agenda Item 8

        families or for missing a case of abuse. But the system they work in is built around
        predicting a parent’s ability to look after their child, which is never certain.

        We need a system that constantly looks to do things better. Any solution must prioritise
        meeting the needs of children.

The problems identified by Professor Munro in the report include

        professionals too focused on complying with rules and regulations and so spending
         less time assessing children’s needs
        a target-driven culture meaning social workers are unable to exercise their
         professional judgement
        too much emphasis on identifying families and not enough attention to putting
         children’s needs first
        serious case reviews concentrating only on errors when things have gone wrong,
         rather than looking at good practice and continually reflecting on what could be done
         better
        concerns about the impact of delays in the family courts on the welfare of children.
        professionals becoming demoralised over time as organisations fail to recognise the
         emotional impact of the work they do and the support they need.

Professor Munro wants to improve the serious case review (SCR) process so that lessons
learned can be put into practice more effectively. The Government has published two recent
research reports on SCRs, which have fed into Professor Munro’s review.

The research shows that:

        SCRs highlight important issues but there is a greater emphasis on getting the report
         right rather than learning the lessons
        SCRs should look at good practice and not just when things go wrong
        there is confusion and debate about what leads to an SCR as professionals are
         overwhelmed and struggle to make good decisions.

The final report is due in April 2011, with an interim report in January. These will focus more
on recommendations for change.


-----------------------------------------------------------------------------------------------------




                                                                                                                  21
                                                                        Information Item




       The London Borough of Lewisham and NHS Lewisham response to Equity and
                                                Excellence: Liberating the NHS
                                                            November 1st 2010



1.    Introduction

1.1   The London Borough of Lewisham and NHS Lewisham welcome the opportunity to
      respond to the proposals outlined in Equity and Excellence: Liberating the NHS and
      its four consultation documents: Local democratic legitimacy in health;
      Commissioning for patients; Transparency in outcomes – a framework for the NHS;
      and Regulating healthcare providers.

1.2   Lewisham has strong local partnership arrangements and a long history of close
      collaborative working between the health sector and the local authority. Lewisham’s
      joint commissioning arrangements were recognised in the recent Total Place pilots as
      being some of the most advanced in the country.

1.3   The White Paper’s proposals will result in changed roles for Lewisham’s health
      services, the Council and local communities in the provision of services and the
      delivery of improved health outcomes. This response is a joint response from the
      Lewisham Council and NHS Lewisham.

1.4   This document provides responses to the questions raised in each consultation
      paper.

1.5   This response attaches at Appendix A the specific contributions made by members of
      Lewisham’s Healthier Communities Select Committee.


2.    Summary

2.1   Lewisham is committed to improving health outcomes locally and will ensure that it
      responds positively to changes in the structure and delivery of healthcare. However,
      Lewisham would want to be satisfied that any new arrangements are robust and do
      not lead to a loss of local focus. Lewisham hopes that central Government will
      recognise the strength of existing local arrangements in implementing the White
                                                                                       22
                                                                           Information Item

      Paper proposals and provide the flexibility to build on what is already in place and
      delivering successfully. Further more detailed information on the viability and cost of
      implementing these proposals would also be welcomed .

2.2   Lewisham is a diverse borough and therefore would emphasise the importance of
      ensuring that these proposals do not disadvantage any citizen or community. A full
      Equalities Impact Assessment of the national proposals should complement and
      support local Equalities Impact Assessments so that any potential negative impacts
      can be clearly identified and appropriate action taken in response.

3.    Local Democratic legitimacy in health

3.1   HealthWatch

1. Should local HealthWatch have a formal role in seeking patients’ views on
whether local providers and commissioners of NHS services are taking
account of the NHS Constitution?
2. Should local HealthWatch take on the wider role outlined above, with
responsibility for complaints advocacy and supporting individuals to exercise
choice and control?
3. What needs to be done to enable local authorities to be the most effective
commissioners of local HealthWatch?

3.1.1 Lewisham is committed to the extension of choice and control across health and
      social care services and to the effective resolution of complaints. While Lewisham
      would welcome the additional support that could be provided in both these areas by a
      local HealthWatch and the Government’s commitment to match any additional role
      with funding, further detail is required as to the expected capacity of HealthWatch to
      undertake these new roles while retaining the community engagement activity that
      has characterised the existing Local Involvement Networks (LINks).

3.1.2 To act as an effective consumer champion, local HealthWatch will require the
      capacity and capability to represent diverse and potentially conflicting views of
      patients, service users and the wider public. In Lewisham, LINks have been
      successful in developing a broad network of partners and undertaking outreach
      activity. However, a local HealthWatch would need to be able to complement this
      activity by ensuring that the intelligence and information gathered is robust,
      representative and able to effectively inform strategic actions and commissioning
      decisions. This will require more than strategic representation on appropriate boards
      and will need significant support and investment by partners locally. Members of
      Lewisham LINk have voiced their concerns about having the infrastructure and
      capability to assume these new roles. Further consideration should be given by

                                                                                          23
                                                                            Information Item

      Government as to the specific support and training that HealthWatch members might
      require.

3.1.3 The consultation paper does not clarify whether the advocacy and casework role
      being proposed for local HealthWatch will cover both health and social care services
      or just the former. Clarity is also required on how the Patient Advice and Liaison
      Service will be delivered. Lewisham would support a system which covers both
      health and social care but would also note the potential volume of activity this would
      represent and the scope of funding and resources available to support this effectively.
      In addition, Lewisham would not want to see anything that negated the value of the
      considerable advocacy contribution already made by the third sector in this borough.

3.1.4 Given the record levels of complaints about NHS and community health services
      reported by the NHS Information Centre - a 13.4 per cent rise over the last year, from
      89,139 to 101,077, and the biggest year-on-year increase since 1997/98 – Lewisham
      would welcome clarification on whether a local HealthWatch could act as the sole
      mechanism for managing and resolving formal complaints in line with statutory
      requirements whilst continuing to carry out its other proposed functions.

3.1.5 Further clarity is also required as to how HealthWatch will be able to align its
      proposed advocacy and complaints role on an individual, case-by-case basis while
      also retaining its capacity to work with local partner organisations to develop strategic
      plans and commissioning intentions. Similar issues could arise in terms of local
      HealthWatch’s independent connection with the Care Quality Commission, given that
      the consultation paper also suggests that HealthWatch be part of the proposed Health
      and Wellbeing boards and therefore potentially involved in decision-making for the
      local health and social care economy.

3.1.6 Many local authorities have a good track-record in supporting community engagement
      and citizen participation. It should be feasible to use the capacity of well established
      forums and consultation schemes to add breadth to the proposed role and reach of
      the local HealthWatch. Local authorities will need flexibility to make use of the
      mechanisms already available to them to build the capacity of HealthWatch and
      therefore arrangements should not be too prescriptive.

3.2   Integrated working

4. What more, if anything, could and should the Department do to free up the
use of flexibilities to support integrated working?
5. What further freedoms and flexibilities would support and incentivise
integrated working?



                                                                                            24
                                                                             Information Item

3.2.1 Nationally, Lewisham is one of the leading local authorities in establishing integrated
      working arrangements with the NHS. Like many authorities, Lewisham already has a
      jointly appointed Director of Public Health. However, since April 2010, in Lewisham, a
      section 75 agreement has aligned PCT and council budgets for adult health and
      social care services, with the Council as the lead commissioner. Joint commissioning
      arrangements are also in place in terms of children’s services. The result is that many
      services in Lewisham are now commissioned jointly, making flexible use of both
      health and social care resources in adults and across the Children’s Trust
      Partnership. This results in services that are better value for money and that
      effectively employ the intelligence and expertise available from both organisations
      and other partners.

3.2.2 The Department of Health may want to consider flexibilities where commissioning
      budgets are currently aligned rather than pooled. At present, aligned budgets still
      retain separate limitations from both the NHS and the Local Authority regarding how
      these resources can be allocated. For example, the local authority cannot place a
      service user in a facility that is part of an independent hospital group. These
      limitations obviate against the efficiencies and flexibilities that joint commissioning is
      supposed to realise.

3.2.3 In addition, the Department may wish to consider arrangements to facilitate the
      transition of staff and their associated costs, most notably pensions between NHS
      and local authorities.

3.2.4     Lewisham recognises that a new partnership needs to be developed with GP
        consortia in relation to joint commissioning. It would be potentially damaging to lose
        some of the effective economies of scale that have already been achieved in joint
        commissioning at the borough level.

3.3     Health and Wellbeing boards

6. Should responsibility for local authorities to support joint working on health
and wellbeing be underpinned by statutory powers?
7. Do you agree with the proposal to create a statutory health and wellbeing
board or should it be left to local authorities to decide how to take forward
joint working arrangements?
8. Do you agree that the proposed health and wellbeing board should have the
main functions described above?
9. Is there a need for further support to the proposed health and wellbeing
boards in carrying out aspects of these functions, for example, information on
best practice in undertaking joint strategic needs assessments?
10. If a health and wellbeing board was created, how do you see the proposals
fitting with the current duty to cooperate through children’s trusts?
                                                                                             25
                                                                            Information Item

3.3.1 Lewisham agrees that statutory powers should underpin local authorities’
      responsibility to support joint working on health and wellbeing.

3.3.2 Strong partnership arrangements exist in Lewisham for the governance of health and
      social care. Lewisham’s Adult Strategic Partnership Board and Children and Young
      People’s Strategic Partnership Board bring together partners from the public, private
      and voluntary sectors to develop the strategic direction and monitor progress towards
      improved health outcomes and reduced health inequalities. These boards currently
      fulfil many of the roles and responsibilities proposed for the Health and Wellbeing
      Boards. They have overseen the development of Lewisham’s joint commissioning
      arrangements and taken the lead on the development of the Joint Strategic Needs
      Assessment. Commissioning groups reporting to these two boards ensure that similar
      collaboration takes place in developing commissioning plans. Safeguarding is
      currently managed by an Adult Safeguarding Board and a Children’s Safeguarding
      Board, both of which share the same independent chairperson, but operate according
      to separate processes to reflect different legislative requirements

3.3.3 There are strong arguments in favour of retaining Children’s Trust arrangements,
      particularly arrangements that allow a greater focus on the wider issues considered
      through such arrangements, for example education, attainment and economic well
      being. The strength of these existing structures is their ability to consider local need
      from different perspectives and thereby develop holistic solutions at a local level.

3.3.4 Lewisham recognises that the introduction of a health and wellbeing board has the
      potential to strengthen local governance in terms of coordinating public health activity,
      managing specific health and wellbeing interventions and co-ordinating activity to
      tackle health inequalities. Such a board would also provide the local authority and its
      partners in the community with a formal means through which the Council and its
      partners work with and support GP commissioning consortia and the NHS
      Commissioning Board. .

3.3.5 Lewisham supports the emphasis that the White Paper places on public health and
      the importance of aligning public health responsibilities with the duties of local
      authorities. The greater role envisaged for local authorities in public health promotion
      should sustain our strong partnership working across health, social care and
      children’s services. Lewisham requires more information from the Public Health
      White Paper on the extent of the public health remit and budget and how this will
      interact with the wider determinants of health, including housing, early years support,
      transport, leisure and recreation and social care.

3.3.6 Further clarity is required as to the relationship of the Health and Wellbeing Board to
      existing robust partnership arrangements and decision-making functions within local
      authorities and, while they remain in existence, Primary Care Trusts. Lewisham is a
                                                                                            26
                                                                           Information Item
       mayoral authority and therefore further consideration would be required at a local
       level as to how an executive Health and Wellbeing Board with decision-making
       responsibilities would interact with existing governance structures. Similarly, further
       clarity would be required as to how Executive Directors in the PCT with statutory
       responsibility and decision-making power over the allocation of PCT resources would
       continue to exercise these functions.

3.3.7 Lewisham recognises the value of a board that provides support for the strategic
      management of health and social care at a local level and takes responsibility for the
      wider health inequalities agenda. However, the Government will want to ensure
      there is sufficient flexibility available to build on effective local arrangements. As an
      example, the introduction of a Health and Wellbeing Board would need to recognise
      the significant variations in both client group and practices that exist between Local
      Safeguarding Children’s Boards and Adult Safeguarding Boards. Bringing both of
      these functions under the remit of a single board would not necessarily dispose of the
      need to run two separate processes, involving different partner organisations.

11. How should local health and wellbeing boards operate where there are
arrangements in place to work across local authority areas, for example,
building on the work done in Greater Manchester or in London with the link to
the Mayor?
12. Do you agree with our proposals for membership requirements described
above?

3.3.8 Lewisham welcomes the opportunity to engage in further discussion as to how any
      new governance arrangements will work, particularly where shared priorities across
      health, social care and children’s services may help achieve efficiencies and deliver
      greater choice for service users. However, it is difficult to comment at this stage on
      the arrangements as individual governance structures across London boroughs will
      need to be considered. It is important to recognise the purpose and value that
      different local governance arrangements make towards addressing local need. The
      principle here is that decisions are made at the appropriate level and can be
      influenced by those communities that might be most affected by those decisions.

3.3.9 The proposed membership of the Health and Wellbeing Board recognises the breadth
      of partners that is required to ensure that health and social care commissioning
      effectively responds to local needs. The involvement of local voluntary and community
      organisations and LINks at strategic partnership boards is current practice in
      Lewisham and has proved to be an effective means of ensuring broad and robust
      discussions on health and social care developments. As detailed in section 3.3.5 and
      later in 3.4.2, further clarification is required as to the capacity and delegated authority
      in which board members attend and make decisions at the Health and Wellbeing
      Board.


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3.4    Overview and Scrutiny
13. What support might commissioners and local authorities need to empower
them to resolve disputes locally, when they arise?
14. Do you agree that the scrutiny and referral function of the current health
OSC should be subsumed within the health and wellbeing board (if boards are
created)?
15 How best can we ensure that arrangements for scrutiny and referral
maximise local resolution of disputes and minimise escalation to the national
level?
16. What arrangements should the local authority put in place to ensure that
there is effective scrutiny of the health and wellbeing board’s functions? To
what extent should this be prescribed?

3.4.1 In Lewisham, the Healthier Communities Select Committee has made a real
      difference in championing the public interest and challenging health providers to
      deliver better health services. It has led on specific activity to identify local health
      improvement issues, most notably conducting Men’s and Women’s Health Reviews.
3.4.2 Lewisham is a Mayoral authority and Overview and Scrutiny undertakes an important
      role in scrutinising and calling in decisions approved by the Mayor. The scrutiny of
      health services must be transparent and have a strong element of democratically
      accountable oversight, independent of the health or social care service, in order to
      ensure it is responsive to local need. Lewisham supports the impetus provided in
      some areas for a greater degree of joined-up working through a Health and Wellbeing
      Board. However, this function is not compatible with scrutinising health and social
      care decisions through the same body. Further clarity is needed on how the
      principles of overview and scrutiny can be retained.

3.4.3 Lewisham would support proposals for partnership boards to be able to call witnesses
      and to agree upon proposals and the overall strategic direction of health and
      wellbeing in the borough. However, it is important that the principles of scrutiny are
      secured, and that arrangements are in place to ensure that scrutiny is seen to be, and
      is in practice, separate from those making the decisions.

3.4.4 Within Lewisham, any change to the role of scrutiny will require constitutional change
      and agreement by the Council.

4.    Commissioning for Patients

4.1   Scope of GP Commissioning

1. In what practical ways can the NHS Commissioning Board most
effectively engage GP consortia in influencing the commissioning of
national and regional specialised services and the commissioning of
maternity services?
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4.1.1 The current commissioning of regional specialised services in London is coordinated
      via a Specialist Commissioning Team. This team is outside of the influence of
      individual PCTs. Lewisham suggests that future commissioning undertaken by the
      NHS Commissioning Board could be influenced by having a small panel of GPs on
      the contracting team for each area, to ensure that the services commissioned are
      those required/needed.

2. How can the NHS Commissioning Board and GP consortia best work
together to ensure effective commissioning of low volume services?


4.1.2 There is a requirement for the continuation of current risk-sharing arrangements, and
      these need to be transparent to GP consortia.

3. Are there any services currently commissioned as regional specialised
services that could potentially be commissioned in the future by GP
consortia?


4.1.3 Within the current portfolio of services there are several services that in time could be
      commissioned by consortia. As the consortia move towards commissioning via
      clinical pathways, not individual treatments that will make this process easier. For
      example, in a locally commissioned maternity pathway, the specialist NICU/PICU
      service could also potentially be commissioned locally by consortia as part of this
      pathway.

4. How can other primary care contractors most effectively be involved in
commissioning services to which they refer patients, e.g. the role of primary
care dentists in commissioning hospital and specialist dental services and the
role of primary ophthalmic providers in commissioning hospital eye services?

4.1.4 The model of managed clinical networks or clinical pathway re-design groups could
      provide an effective way of managing scarce finite budgets, re-designing clinical
      pathways across primary and secondary care and improving quality and productivity.
      Such networks could be led by the NHS Commissioning board and membership
      would include primary and secondary care clinicians, public health, and lay
      representation.

4.2   Duties and responsibilities of GP consortia and the relationship between
      consortia and individual GP practices




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5. How can GP consortia most effectively take responsibility for improving
the quality of the primary care provided by their constituent practices?
6. What arrangements will support the most effective relationship between
the NHS Commissioning Board and GP consortia in relation to monitoring
and managing primary care performance?
7. What safeguards are likely to be most effective in ensuring
transparency and fairness in commissioning services from primary care
and in promoting patient choice?


4.2.1 Lewisham proposes that improvements to the universal quality of primary care will
      require an agreed, possibly nationally-held, definition of what constitutes Tier 0 and
      Tier 1. If a practice is not able to consistently deliver Tier 0, this calls into question
      whether it is viable as a practice. For Tier 1 and above, obligatory participation in peer
      review should offer weaker practices the chance to remodel care to patients.
      Practices that repeatedly fall outside of expected performance levels should be
      required to work with the consortia to provide core services, with an appropriate
      payment mechanism from the poor quality practice to the practice(s) that deliver the
      service to patients. The Local Medical Committee (LMC) has a critical role in working
      with primary care commissioning organisations and the consortia to tackle repeatedly
      poor performance. If peer support does not achieve the desired improvement, then
      contractual means should be used.

4.2.2 Lewisham feels that the most effective arrangements in relation to monitoring and
      managing primary care will be based upon explicit definitions of the role of both GP
      consortia and NHS Commissioning Board as well as clarity as to the degree of
      performance variation that can be dealt with through peer review. There should be
      similar clarity about when contractual remedial mechanisms would kick in and with
      what consequence. This would require a set of nationally agreed performance
      indicators that takes account of patient mobility deprivation and BME in order to
      calculate variation bands, e.g. -2 Standard deviations below local average could
      trigger contractual action.

4.2.3 In relation to safeguards to ensure transparency and fairness in commissioning
      decisions, Lewisham proposes that business plans for the procurement of primary
      care services should be subject to the same business scrutiny as other services,
      using business planning processes. Once the commissioning plans have been agreed
      the procurement of these services could be shared at a supra-consortia level from a
      procurement unit – removing the likelihood of conflicts of interests influencing
      decisions and ensuring robust contracting processes.




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4.3       The role of the NHS Commissioning Board

8. How can the NHS Commissioning Board develop effective relationships
with GP consortia, so that the national framework of quality standards,
model contracts, tariffs, and commissioning networks best supports local
commissioning?
9. Are there other activities that could be undertaken by the NHS
Commissioning Board to support efficient and effective local
commissioning?


4.3.1 The NHS Commissioning Board will need to work with GP consortia to develop
      standards, contracts and tariffs that reflect local commissioning. This could be
      undertaken by using certain consortia as early implementers/pilots for certain aspects
      such as the development of integrated pathway tariffs in conjunction with a GP
      consortia working with an integrated acute/community provider. This process would
      allow GPs to influence the tariffs and pathway standards. In addition to this, GPs will
      need to be involved in the development of the contract frameworks. Lewisham
      suggests that there will need to be an overarching framework that enables many
      aspects of the contract to be left to local determination and negotiation, so as to
      realise the benefits of local expertise and local identification of need.

4.3.2 The NHS Commissioning Board may wish to engage the population in a wider,
      potentially national, debate as to what the NHS is to provide in the future, in light of
      the increasingly restrained financial climate. At present, local areas hoping to
      undertake more efficient and effective commissioning are all individually trying to
      negotiate issues such as the removal of ‘clinically ineffective procedures’, and this
      process could be assisted or further informed by national decisions.

4.4       Establishment of GP consortia

10. What features should be considered essential for the governance of GP
consortia?

4.4.1 Lewisham considers the following features to be essential to the good governance of
      GP consortia:

         Role of the accountable officer – it will not be sufficient to appoint a non-GP
          accountable officer who can be removed if the consortium overspends, leaving GP
          members free to continue practising as before. At least one accountable officer
          should be a GP and there should be some notion of collective accountability of the
          directors of the consortium;


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      Leadership of the consortia – The learning from Professional Executive Committees
       has been that effective leadership cannot be based purely on being voted on by peers
       – members had to have some core competencies to equip them to be strategic
       commissioners. GP consortia Directors should be required to demonstrate their
       abilities against an agreed framework. There could be a mechanism for
       demonstrating that prospective consortia leaders can display these competencies,
       and from this group there should then be transparent arrangements for the election of
       GP consortia leaders. Voting should be in proportion to list size, with a lower
       threshold to ensure all practices can have influence.

      Primary care performance – there needs to be a mechanism for suspending a GP
       member of the consortium from participating if and for as long as the practice has
       been issued with breach of contract notifications or where there are capability
       proceedings with an individual GP. The suspension should last until such time as a
       recovery plan is agreed with the primary care contracting organisation or until
       recovery has been achieved.

      The methodology for agreeing progress towards “fair share” budgets needs to be
       revisited – both within PCT areas and between PCT areas. This could include a
       gradual redistribution of resource until such time as all consortia allocations are on
       target – this will create major challenges to over-targeted areas and should therefore
       be addressed over a longer timescale. We should not avoid addressing this, however
       hard. Judgements on the effectiveness of commissioning needs to be separated,
       however, from changes that are related to change in budget allocation.

      Health and Wellbeing Board – At present the proposed arrangements for a local
       health and well being board puts a duty on consortia and the local authority to take
       account of each other’s perspective without spelling out how potential tensions in
       commissioning plans might be overcome. Health and Wellbeing Board should be
       able to make decisions in the interests of the local population, but consortia should
       have power to refer to the Secretary of State as a final arbiter.

11. How far should GP consortia have flexibility to include some practices
that are not part of a geographically discrete area?
12. Should there be a minimum and/or maximum population size for GP
consortia?


4.4.2 Lewisham would support consortia arrangements that are coterminous with the local
      authority boundary, as it should lead to more effective local joint working. However,
      where consortia cross borough boundaries or where a consortium joins with another
      to commission larger contracts or specialist services, it would be appropriate for
      agreement to be sought between the separate Health and Wellbeing boards involved

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       as to which would take responsibility for overseeing the commissioning plans. It
       would not be an efficient use of resources to have GP consortia reporting to more
       than one board.

4.4.3 If ‘insurance’ risk is pooled by risk-sharing with other consortia, and if economies of
      scale for some commissioning functions, such as financial and clinical governance
      and compliance, accounting etc., can be achieved by practices or consortia buying in
      such services from external providers, then the optimum size for a GP consortium
      should be determined by clinical quality and patient choice considerations. As vertical
      integration of clinical services continues to develop, and managed clinical pathways
      mature, for example through primary, community and secondary care integration, the
      optimum size for a consortium looking to improve care pathways may be around
      50,000 -100,000 patients. Having consortia of this size means that patients will
      realistically be able to choose between 2-3 integrated healthcare organisations within
      their local area; patient choice will eventually shift from choice of hospital to choice of
      managed care provider.

4.5    Freedoms, controls and accountabilities

13. How can GP consortia best be supported in developing their own
capacity and capability in commissioning?


4.5.1 PCTs and local authorities should be charged with responsibility for supporting GP
      consortia to develop their own capacity and capability in commissioning. This would
      ensure that GP consortia had the best advice and skills currently available from those
      people already doing the work. This could be done by:
    Transferring knowledge and skills – PCTs and local authorities assisting GP consortia
      and transferring the skills required
    Clarifying the skills required by GP consortia to carry out their commissioning
      responsibilities
    Assessing the skills available within GP consortia
    Identifying where any gaps in skills can be filled

14. What support will GP consortia need to access and evaluate external
providers of commissioning support?

4.5.2 GP consortia will want to satisfy themselves that all potential providers of
      commissioning support have sufficient competencies and robust safeguards in terms
      of financial management, risk assessment, clinical governance etc. Lewisham would
      suggest that the NHS Commissioning Board could provide some kind of advisory
      service for GP Consortia and a standard set of tendering and evaluation resources /
      templates.

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15. Are these the right criteria for an effective system of financial risk
management? What support will GP consortia need to help them manage risk?

4.5.3 The criteria described in the paper are the right criteria, but there needs to a strong
      emphasis on financial control within the consortia. It will be easier for consortia to
      accept risk-pooling locally in regard to insurance risk but acceptance of a general ‘top
      slice’ to a national/regional Board would be more difficult. An important element of
      managing risk is the capacity to forward plan, often in circumstances of some
      uncertainty, e.g. rising demand, resource availability, incidences of disease or trauma.
      It is therefore an important feature of management at the local level, that a forward
      plan identifies the primary objectives for commissioning, the needs and the available
      resources. An important feature of this plan is identifying the elements of risk to be
      managed and the contingencies for mitigating against those risks. An important
      element of any governance structure will be to provide support and guidance on these
      forward planning activities and to monitor action in support of the plan.

4.5.4 Management of financial risk could be assisted by improvements in the current
      contracts that allow more flexibility with regard to penalties of a substantial nature,
      e.g. failure to deliver accurate, timely information should incur significant penalties
      that can be removed, not just withheld, until the information is received. Data
      availability is the easiest way to understand and take action to minimise risk.
      Stronger emphasis support should also be available re: coding issues. In addition
      there should be requirements to move towards best practice/upper quartile levels of
      performance with non compliance being penalised for both providers/consortia.

16. What safeguards are likely to be most effective in demonstrating
transparency and fairness in investment decisions and in promoting choice
and competition?

4.5.5 In addition to the standard safeguards and processes that ensure transparency and
      fairness in commissioning, such as separating the agreement of commissioning plans
      from procurement processes, Lewisham supports the proposals set out in Regulating
      Healthcare providers for Monitor to oversee issues of competition.

17. What are the key elements that you would expect to see reflected in a
commissioning outcomes framework?

4.5.6 Most of the outcome measures are reflected in Transparency in outcomes – a
      framework for the NHS. However, many of the indicators, especially in the
      effectiveness measures, are in need of further development or replacement. Although
      the indicators are broadly suitable for long term strategic planning, they would need to
      be broken down to measure inequality and don’t allow current progress in delivering
      outcomes to be assessed and therefore transparently communicated to residents.
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      Providing this, more current, assessment of progress will be important to allow
      commissioners, residents and the local authority to effectively judge progress in
      meeting the planned outcomes.

18. Should some part of GP practice income be linked to the outcomes
that the practice achieves as part of its wider commissioning consortium?

4.5.7 Lewisham agrees with the proposal to link income to outcomes and would suggest
      that the more direct this link and the larger the potential reward the more likely that
      outcomes will improve. The outcomes should be health outcomes and quality of
      service outcomes, and should include health inequalities outcomes, particularly those
      where primary care can make a significant contribution, such as smoking cessation,
      blood pressure, cholesterol and diabetes control.



19. What arrangements will best ensure that GP consortia operate in ways that
are consistent with promoting equality and reducing avoidable inequalities in
health?

4.5.8 At a local level, the principles of addressing inequalities need to be firmly set in the
      governance arrangements and commissioning plans which should be based on a
      good understanding of local need, gaps and priorities. This will be further enhanced
      by the statutory responsibilities placed upon GP consortia and the local wellbeing and
      health inequalities strategy.

4.6   Partnership

20. How can GP consortia and the NHS Commissioning Board best
involve patients in making commissioning decisions that are built on
patient insight?

4.6.1 Lewisham strongly supports the inclusion of patient experience feedback as a key
      part of the business planning / decision-making process for GP consortia. This should
      be in addition to consulting with former and current service users. Elected
      representatives play a key role in representing the views of local residents and
      communities and should continue to have the ability to inform and influence local
      discussions around changes to services

21. How can GP consortia best work alongside community partners
(including seldom heard groups) to ensure that commissioning decisions
are equitable, and reflect public voice and local priorities?




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4.6.2 There is a currently a strong relationship in Lewisham between statutory
      organisations and voluntary and community groups. This provides a secure
      foundation on which the GP consortia could build. This includes both formal and
      informal relationships that focus on engagement, involvement and delivery.
      Commissioning decisions will need to be based on robust needs assessments which
      have gone through a process of validation with local people. Commissioning priorities
      will need to be clear and transparent and therefore suitable for communication to local
      residents.

22. How can we build on and strengthen existing systems of engagement
such as local HealthWatch and GP practices’ Patient Participation
Groups?

4.6.3 Our local LINk, together with GP and PCT commissioners, has developed a system of
      reporting as part of formal quality meetings with our main providers. A quarterly
      composite report captures information provided through all comments, complaints and
      consultations etc. Lewisham intends to continue to strengthen these mechanisms.
      Practices have had variable success with recruiting to and maintaining patient
      participation groups and there is a need to build on the experience of those practices
      which have been successful. The PCT, GP and acute service redesign pathway
      groups have recruited a patient panel to support the process of service redesign,
      prioritising sections of care pathways and utilising patient experience. Lewisham
      would want to continue this good practice in the future.

23. What action needs to be taken to ensure that no-one is disadvantaged by
the proposals, and how do you think they can promote equality of opportunity
and outcome for all patients and, where appropriate, staff?

4.6.4 Perhaps the most important action is for the Department of Health and all affected
      statutory organisations to undertake an equality impact assessment on any proposed
      changes. In Lewisham, action at a local level needs to build upon existing
      frameworks for the evaluation of impact assessments. These tools need to be
      available to all partners involved in the commissioning and delivery of health, social
      care and children’s services.

24. How can GP practices begin to make stronger links with local
authorities and identify how best to prepare to work together on the
issues identified above?

4.6.5 GPs in Lewisham have already started to forge links with the local authority and have
      indicated a willingness to work in partnership. There is existing representation on
      both children’s and adults’ commissioning boards. The addition of a local authority
      representative on the revised Professional Executive Committee should help
      strengthen these links.
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25. Where can we learn from current best practice in relation to joint working
and partnership, for instance in relation to Care Trusts, Children’s Trusts and
pooled budgets? What aspects of current practice will need to be preserved in
the transition to the new arrangements?

4.6.6 Nationally, Lewisham is one of the leading authorities in terms of partnership working.
      The Total Place pilot earlier this year identified that Lewisham had more robust
      structures in place than many other authorities. The overarching section 75
      agreement will allow for further development of partnership working and create further
      opportunities for pooled budgets. For many areas of commissioning, services are
      commissioned jointly using both health and social care resources for adults, and from
      across the Children’s Trust Partnership for children and young people. Clearly there
      are advantages in continuing to commission these services jointly as this ensures
      best use of resources and allows for clear pathways with holistic responses for
      patients and service users.

4.6.7 Lewisham’s mature Children’s Trust partnership arrangements have developed and
      are managed through the Children and Young People Strategic Partnership Board
      (CYPSPB). The Board uses a robust performance management framework that
      helps to ensure all partners are committed to delivering the priorities within the
      Children and Young People’s Plan. Commissioning for children and young people is
      based on a shared commitment that all money within Lewisham’s Children’s Trust is
      children’s money. Through joint-commissioning, Lewisham has been able to secure
      maximum impact with the collective resources available within the Trust and has
      succeeded in implementing integrated services and management arrangements.
      Lewisham would support proposals for the structure and delivery of healthcare that
      both strengthen local flexibility to achieve integrated services and avoid the potential
      risks of fragmented service delivery.

5.    Transparency in outcomes

5.1   Principles and structure

1. Do you agree with the key principles which will underpin the development of the
NHS Outcomes Framework
2. Are there any other principles which should be considered?

3. How can we ensure that the NHS Outcomes Framework will deliver more equitable
outcomes and contribute to a reduction in health inequalities?

4. How can we ensure that where outcomes require integrated care across the NHS,
public health and/or social care services, this happens?



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5.1.1 Lewisham broadly supports the principles that underpin the development of the NHS
      Outcomes Framework. Lewisham welcomes the recognition that many outcomes
      require strong partnership work and that performance frameworks and specifically
      those that cut across both health and social care, and more broadly children’s
      services, need to be developed and aligned as closely as possible.

5.1.2 As evidenced through Lewisham’s Total Place pilot, successful integrated care is
      supported through a shared understanding of outcomes, priorities and effective
      interventions. By establishing the parameters for activity and performance, the
      outcomes framework has a key role to play in promoting integrated care. Lewisham
      would recommend that the development of the outcome frameworks for both social
      care and public health is aligned as closely as possible to the NHS outcomes
      framework. This would ensure that partnership activity can concentrate on joint
      responses to issues and avoid the need for each member of that partnership to
      manage their own separate suite of outcomes and indicators. For example, the
      inclusion of more explicit references to health promotion and the role of prevention in
      the NHS outcomes framework would recognise the wider lifestyle factors that affect
      both clinical and patient reported outcome measures and provide the basis for more
      effective joint-activity.

5.1.3 A full Equalities Impact Assessment will need to be carried out an all aspects of the
      outcomes framework to ensure that it is able to identify variations in outcomes by
      equalities groups. All indicators will need to be able to be disaggregated by equality
      strands to support the current equalities framework and to allow commissioners to
      fully understand the factors underpinning health inequalities.

5.2   Domain structure

5. Do you agree with the five domains that are proposed as making up the NHS
Outcomes Framework?

6. Do they appropriately cover the range of healthcare outcomes that the NHS is
responsible for delivering to patients?

7. Does the proposed structure of the NHS Outcomes Framework under each domain
seem sensible?

5.2.1 Lewisham broadly agrees with the five domains and the proposed structure of the
      framework underneath each domain. In light of the financial pressures that are likely
      to be experienced across public agencies, Government may wish to consider whether
      a ‘use of resources’ measure/assessment could be introduced into this framework as
      a domain. This would allow effective financial/resource management and appropriate
      governance arrangements to be recognised as key contributory factors to improved
      clinical and patient outcomes.

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5.2.2 It is difficult to comment fully on the practical application of the framework without
      further detail as to how the information to populate the framework will be gathered
      and the different spatial levels that will be used to disaggregate and analyse the data,
      i.e. will it be available at a borough basis, a GP consortium basis etc.

5.2.3 Lewisham      suggests     that   the   outcomes    framework      should   include
      references/indicators related to immunisation and screening programmes as one of
      the most widely used tools to avoid contraction of many serious illnesses, and thus
      reduce mortality rates.

5.3     Domain 1: Preventing people from dying prematurely

5.3.1 Consideration will need to be given as to the language used for the outcomes and
      related indicators.    Terms such as ‘Mortality amenable to Healthcare’ and
      ‘Misadventures to patients during surgical and medical care’ may lead to confusion if
      presented alongside other, more user friendly, patient reported outcome measures.
      Further consideration should also be given as to how the outcomes framework
      supports the choice elements of the White Paper.

5.3.2    Domains 1 and 2 will need to be closely interlinked to ensure that issues around
        quality of life are considered in terms of their effect upon premature mortality. See
        point 5.4.1

5.4     Domain 2: Enhancing quality of life for people with long-term conditions

5.4.1 As proposed, the NHS outcomes framework doesn’t specify any indicators that
      directly measure quality of life after a healthcare intervention. For many common
      serious conditions, quality of life is as important a consideration as the clinical
      outcomes. For example, a third of people having a stroke die within 10 days, a third
      recover within a month, but a third survive with significant health problems such as
      paralysis and cognitive impairment. This could be measured either through a Patient
      Reported Outcome Measure (PROM) or a measure of how many years of good
      quality life are experienced after the episode.

5.4.2 When defining the ‘generic PROMs’ in the outcome indicator set, it will be important to
      ensure that long term conditions (LTCs) that are rare in the general population but
      which disproportionately affect certain groups are captured so that the results can be
      locally analysed and inform the commissioning of local services. For example, a
      higher proportion of Lewisham’s population has sickle cell anaemia than the national
      average and this will require appropriate service levels.




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5.4.3 Indicators measuring the numbers of patients with mental health problems and
      numbers of patients with learning difficulties in settled accommodation should be
      included and expanded to cover ages 18+.

5.4.4 Lewisham’s strong voluntary and community sector makes significant contributions to
      improved local outcomes. The Government may wish to consider how the outcomes
      framework can recognise such contributions in specific areas, for example in
      improving the quality of life for people with long term conditions, particularly at the
      beginning and end of the care pathway.

5.5   Domain 3: Helping people to recover from episodes of ill health of following
      injury

5.5.1 With the exception of National Indicator 125, the proposed indicators for Domain 3 are
      health-specific and do not recognise the contribution of other partner agencies in
      improving these outcomes, for example local authorities’ reablement services.
      Government will need to ensure that social care outcomes in this area are closely
      aligned or that the outcomes are shared to avoid duplication of activity and the
      accompanying inefficiencies.

5.6   Domain 4: Ensuring people have a positive experience of care

5.6.1 Lewisham suggests that an additional improvement area should be included to
      capture people’s experience of preventative care.

5.6.2 PROMs only focus on surgical procedures; they may also need to consider non-
      surgical episodes of care, e.g. after pneumonia or stroke etc, and after non-admitted
      episodes of care, e.g. treatment by GP.

5.7   Domain 5: Treating and caring for people in a safe environment and protecting
      them from avoidable harm

5.7.1 Lewisham proposes that the quality measures for this domain should specifically
      include staff opinion of safety (e.g. using the content from the existing NHS staff
      survey on staff safety) and information governance (e.g. protection of personal data).

5.7.2 To ensure more integrated activity at a local level, Lewisham suggests that this
      domain should also cover the extensive safeguarding work carried out by the NHS
      and local authorities in social care across services for adults and children.

5.8   Additional consultation questions

31. Is there any other issue you feel has been missed on which you would like to
express a view?


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5.8.1 Previously, when performance frameworks have changed, those indicators that had
      reached a certain standard of reliability and comparative usefulness were arranged
      under the Existing Commitments section of the NHS Performance Framework.
      Lewisham suggests that current indicators should be maintained in a similar way,
      thereby providing a wealth of health information going back several years.

5.9   Possible outcome indicators

32. What are the strengths and weaknesses of any of the potential outcome indicators
listed in Annex A with which you are familiar?
33. Are other practical and valid outcome indicators available which would better
support the five domains?
5.9.1 The collection method of some PROMs and other indicators will need to be
       considered carefully. Some forms of survey may be discriminatory and provide
       skewed, inaccurate results. For example, a written questionnaire will provide more
       complete data from people who can read and write English and potentially present
       incomplete data on more vulnerable and hard-to-reach groups who do not.

30. How can the NHS Outcomes Framework best support the NHS to deliver best
value for money?
5.9.2 See section 5.2.1 regarding the Lewisham’s suggestion for ‘Use of Resources’ to be
      considered as part of the NHS outcomes framework.

6.    Regulating healthcare providers

6.1   Lewisham broadly supports proposals to extend the freedom for foundation trusts to
      self-determine appropriate configuration and constitutional arrangements and the
      flexibility to develop additional capabilities and services in response to need and
      demand, within an appropriate framework of governance and financial control.

6.2   Further clarity is required regarding the role nationally of the Care Quality
      Commission on the quality of Foundation Trust services and their governance (such
      as approving Foundation Trust proposed changes to constitutions), as well as more
      locally of GP consortia as stakeholder governors of Foundation Trusts and/or in their
      commissioning role. It is interesting to note the number of Foundation Trusts with
      conditions on their licenses via the Care Quality Commission. Lewisham understands
      that Lewisham Healthcare NHS Trust will be responding to this consultation directly.




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Appendix A: Healthier Communities Select Committee formal response to
Equity and Excellence: Liberating the NHS

Background

The Constitution of Lewisham Council devolves all statutory powers in relation to the
overview and scrutiny of the provision of service by, and performance of, health bodies
providing services for local people to the Healthier Communities Select Committee. These
functions include all powers given to the Councils Overview and Scrutiny Committee by the
Health and Social Care Act 2001, NHS Act 2006, Local Government and Public Involvement
in Health Act 2007 and regulations made under that legislation.

The Constitution also devolves all of the Council’s Overview and Scrutiny functions in
relation to social services provided for those 19 years old or older including, but not limited
to, services provided under the Local Authority Social Services Act 1970, National
Assistance Act 1948, Mental Health Act 1983, NHS and Community Care Act 1990, Health
Act 1999, Health and Social Care act 2001, NHS Act 2006.

As a group of 10 locally elected councillors with the responsibilities outlined above, the
Healthier Communities Select Committee is uniquely placed to make an informed response
to the Department of Health consultation. Its broad focus across health and social care
service and performance in Lewisham ensures members of the Committee have a
comprehensive overview of the functionality of the current NHS structure, and the interaction
between the local NHS, national NHS, Local Authority and local LINk.

At its meeting on the 2nd of September 2010, the Healthier Communities Select Committee
considered the proposals outlined in Equity and Excellence: Liberating the NHS and its four
consultation documents: Local democratic legitimacy in health; Commissioning for patients;
Transparency in outcomes – a framework for the NHS; and Regulating healthcare providers.
To support the development of an informed response, the Committee took evidence from:

•      GPs representing Lewisham’s Local Medical Committee (LMC) and the Lewisham
       Primary Care Federation.
•      The Lewisham LINk Executive
•      The representative of the Chief Executive of NHS Lewisham
•      The Executive Director of Community Services in Lewisham
•      A representative of University Hospital Lewisham

The Committee also considered a report (appended to this response) that provided summary
information about the impact the involvement of a scrutiny committee, with suitable officer
support, has had on health and social care services in Lewisham in recent years.

Response

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Firstly, the Committee wishes to note that it believes that the major cost and disruption
caused by substantial structural changes to the NHS during a period of economic constraint
is not the most appropriate way to proceed.

Secondly, the Committee notes that the White Paper is published in the context of the
Coalition Agreement, but some aspects of the Agreement do not appear in the White Paper,
and that implementation of some White Paper proposals may be influenced by the Spending
Review expected from the Treasury in October 2010.

The Committee has chosen not to respond to every question from all 4 consultation papers,
but rather to focus on the questions for which it considers it has evidence to support a
response, and on which it considers it is best placed to respond with regard to relevance to
the people of Lewisham. The responses to the questions are recorded below.

Local democratic legitimacy in health

Do you agree with the proposal to create a statutory health and wellbeing
board or should it be left to local authorities to decide how to take forward
joint working arrangements? (Q7)

Do you agree that the proposed health and well being board should have the
main functions describe in paragraph 30? (Q8)

Do you agree that the scrutiny and referral function of the current health OSC
should be subsumed within the health and wellbeing board (if boards are
created) (Q14)

What arrangements should the local authority put in place to ensure that there
is effective scrutiny of the health and wellbeing board’s functions? To what
extent should this be prescribed? (Q16)

In considering all questions in relation to the potential role of a Health and Well Being Board
and the removal of statutory powers from OSCs, the Committee strongly feels that for
accountability and true democratic legitimacy there must continue to be a separation of
powers between executive decision makers and the scrutiny function, and that a separate
scrutiny function should continue to be required even if a health and wellbeing board is
introduced.

In the local democratic legitimacy in health paper the following is stated in relation to the
proposed role of the health and wellbeing board:




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       35. We anticipate that the health and wellbeing boards would have a lead role   in
determining the strategy and allocation of any local application of place- based budgets for
health

       39. The board would include both the relevant GP consortia and representation
from the NHS Commissioning Board (where relevant issues are being discussed)

       40. In addition to the strategic role, at a practical level, health and wellbeing
       boards could agree joint NHS and social care commissioning of specific services,
for example mental health services, including prevention, or agree the allocation and
strategy for place-based budgets on cross-cutting health           issues. The precise role of
place-based budgets should be a decision for the           health and wellbeing board in light of
local priorities.

       43. If a health and wellbeing board was created within a local authority, it would
have a key new role in promoting joint working, with the aim of making       commissioning
plans across the NHS, public health and social care coherent,          responsive and
integrated. It would be able to exercise strategic oversight of health and care services. It
would be better equipped to scrutinise these services locally. To avoid duplication, we
propose that the statutory functions      of the OSC would transfer to the health and
wellbeing board.

It appears to the Committee that the health and wellbeing board would be tasked with
making decisions on strategy and allocation of local place-based budgets and would include
representatives from commissioning bodies. To provide such a board with statutory scrutiny
functions appears to go against the stated principles of accountability and legitimacy, as it
would be tasking the same board with both making commissioning and funding decisions,
and then scrutinising those decisions.

The paper goes on to state, at paragraph 50, that “a formal health scrutiny function will
continue to be important within the local authority, and the local authority will need to assure
itself that it has a process in place to adequately scrutinise the functioning of the health and
wellbeing board”. The Committee notes the disparity in contained within the proposals and
feels that the point raised in paragraph 50 should be noted and the formal scrutiny function
with statutory powers retained.

The Committee further feels that primary legislation should continue to allow local Overview
and Scrutiny Committees, such as the Healthier Communities Select Committee, to hold
statutory scrutiny powers, including a method of veto on commissioning plans. The
Committee feel that in regard to newly created GP Consortia, there should also be a formal
system of accountability through Overview and Scrutiny.



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                                                                              Information Item

Specifically in relation to question 7, the Committee believes that, in line with the stated aim
to give more power to patients and local communities, each locality should decide on how to
take forward joint working arrangements.

Should local Health Watch take on the wider role outlined in paragraph 17, with
responsibility for complaints advocacy and supporting individuals to exercise
choice and control?(Q2)

What action needs to be taken to ensure that no-one is disadvantaged by the
proposals and how do you think they can promote equality of opportunity for
all patient, the public and, where appropriate, staff? (Q17)

The Committee is concerned that the time and other resources that have been spend on
building an awareness of Lewisham LINk and its role in increasing local involvement in local
health services would be wasted should it be rebranded as “Healthwatch”. The Committee is
also concerned that the role of complaints handling is a substantial task that could detract
from the core function of patient and public involvement above and beyond formal
complaints.

The Committee feels that it is important that where budget deficits are held by Primary Care
Trusts, these deficits should not transfer to the newly established GP commissioning bodies.

Transparency in outcomes

How can we ensure that the NHS Outcomes Framework will deliver more
equitable outcomes and contribute to a reduction in health inequalities? (Q3)

The Committee cautions that not all outcomes are easily measurable, and that some
appropriate measures of process can provide a useful proxy indicator for service providers
and commissioners in the interim, and therefore careful consideration should be given as to
what indicators and performance measures are to be kept and which are to be discontinued.

Regulating health care providers

Do you believe that the Government should remove the cap on private income
of foundation trusts? If not, why and on what practical basis would such
control operate (Q1)
What changes should be made to legislation to make it easier for foundation
trusts to merge with or acquire another foundation trust or NHS trust. Should
they also be able to de-merge? (Q4)
What action needs to be taken to ensure that no-one is disadvantaged by the
proposals, and how do you think they can promote equality of opportunity and
outcome for all patients, the public, and where appropriate staff? (Q21)
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The Committee do not believe that the Government should remove the cap on the private
income of foundation trusts.

The Committee feel that in principle Foundation Trusts should be able to de-merge.

The Committee have concerns about the possibility that Foundation Trusts would leave the
‘NHS family’ and the subsequent impact this could have on matter such as superannuation
schemes.

The Committee would welcome the establishment of co-operative and mutual models as part
of future provision of health services.




                                             )




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