Our Healthier South East London
Consolidated Strategy
Draft v2.0
August 2015
Section
Executive Summary
Purpose of the document
Introduction to south east London
Introduction to the Our Healthier South East London Strategy and the
approach taken to developing it
Stakeholder communications and engagement
The case for change
Vision for the future of health and care in south east London
Proposed model(s) of care: Delivering better care for our populations
Community Base Care
Planned Care
Maternity
Children & Young People
Urgent Emergency Care Model
Cancer
Benefits/ outcomes of achieving our vision
Financial impact and affordability
What is needed to deliver our vision?
Infrastructure & Estates Supporting Strategy
Workforce Supporting Strategy
Information Management and Technology Supporting Strategy
Risks and challenges
Delivering the strategy
Appendices
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Page
3
35
38
41
45
54
62
65
Ver.
Date
Record of Change
Change Author
1.0
19 June
2015
•
Version agreed by CCB and
circulated to governing bodies
Dan Moore,
Programme
team
1.1
3 August
2015
•
Revised public health data and
references
Updated with PPAG Reading
Group comments submitted
22062015)
Jonny Halls,
Programme
team
Updated care model slices to
reflect papers submitted to CEG.
Care models have been revised
following care summit and
stakeholder feedback
Revised options appraisal
process added
Amendments to programme
outcomes
Updated programme plan
Jonny Halls /
Dan Moore,
Programme
team
•
1.2
11 August
2015
136
149
154
•
•
•
•
2.0
169
172
179
20 August
2015
Approved by CCB members and
published on website
Dan Moore,
Programme
team
Draft in progress |
2
Draft in progress |
3
Executive
Summary
Overview
This executive summary provides an overview of the Our Healthier South East London Commissioning Consolidated Strategy. It will summarise and
provide key highlights from the programme.
This section provides:
1. Introduction and Purpose
2. Introduction to south east London
3. Introduction to the Our Healthier South East London Strategy and the approach taken to developing it
4. Stakeholder Communications and Engagement
5. The case for change
6. Vision for the future of health and care services in south east London
7. The strategy proposed model(s) of care: Delivering better care for our south east London populations
8. The approach to identifying the outcomes the strategy aims to achieve
9. Financial impact and affordability
10. What is needed to deliver our vision for south east London
11. Risks and Challenges
12. Delivering the strategy and next steps
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress |
4
Executive
Summary
Introduction
Purpose of this document
•
•
This document brings together the context of the south east London health
and social care economy and details the potential initiatives that could be
implemented to have transformational impact.
•
Every CCG in the country is required to produce a strategy. In south east
London, commissioners want to make sure that the strategy reflects local
needs and aspirations. The first draft of the south east London strategy
was sent to NHS England for review on 20 June 2014. This was a national
deadline. The strategy runs for five years, so it is very much a work in
progress. Through local and wider clinical and public engagement,
potential ways to improve services have been identified, but considerable
further work and engagement on the thinking and implementation of these
plans is now taking place.
•
This version has developed significantly since June 2014 and brings
together the proposed initiatives and their potential impact. It remains a
work in progress and is under review by a wide range of stakeholders.
In south east London, we have some very good health services. People
are living longer and many people are healthier. But we also have some
services that could be better. We have services that people find hard to
access and some people do not get the help they need to keep
themselves and their families well. We also have wide variation in life
expectancy and too many people die early from preventable diseases.
•
Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark CCGs,
with NHS England as co-commissioner, are working in partnership with
local authorities, local providers, patient and public voices (PPVs) and
other key stakeholders to define a five-year strategy for health and
integrated care services across south east London.
•
The strategy complements and builds on local work and has a particular
focus on those areas where improvement can only be delivered by
collective action or where there is added value from working together. It
seeks to respond to local needs and aspirations, to improve the health of
people in south east London, to reduce health inequalities and to deliver a
health care system which is clinically and financially sustainable. The
approach is commissioner led and clinically driven, and informed by wide
engagement with local communities, patients and the public.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress |
5
Executive
Summary
Introduction to south east London
•
•
•
This commissioning strategy focuses on six NHS Clinical Commissioning
Groups in south east London covering a population of approximately 1.8
million people:
—
Bexley CCG
—
Bromley CCG
—
Greenwich CCG
—
Lambeth CCG
—
Lewisham CCG
—
Southwark CCG
•
Each of these CCGs works in partnership with a number of organisations
and providers. In particular the key providers which the CCGs have
worked with to develop the strategy are:
—
King's College Hospital NHS Foundation Trust
—
Guy's and St Thomas' NHS Foundation Trust
—
Lewisham and Greenwich NHS Trust
—
Dartford and Gravesham NHS Trust
—
South London and Maudsley NHS Foundation Trust
—
Oxleas NHS Foundation Trust
—
Bromley Healthcare Community Interest Company
To develop the best possible care models and interventions for the
strategy it is important to understand the current health of the population
of south east London. To do this a model called the ‘Christmas tree’ was
used.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
The segmentation model summarises the population segments which are
detailed below: You can view the diagram on page 40.
—
Approximately 16% of people in south east London are in the “health
and wellbeing group”, i.e. are healthy and well.
—
Approximately 49% of people in south east London are experiencing
inequalities or putting their health at risk. For example this could be
people who drink too much or don’t take enough exercise or are living
in poverty.
—
Approximately 25% of people in south east London are in the early
stages of long term conditions. For example, a long term condition
could be, diabetes, poor mental health or high blood pressure.
—
Approximately 9% of people in south east London are living with 3 or
more long term conditions.
—
Approximately 1% of people in south east London are approaching or
at the end of their life.
•
Through understanding our population better the strategy is able to focus
on developing care models and innovations that best address the needs of
the people in south east London. A key component of this is to develop a
strong foundation of Community Based Care to support people to live
healthier lives and reduce the number of people exposed to risk factors
either by birth or behaviour.
•
A central part of the vison for the strategy is to be able to provide person
centred care in a proactive and integrated way. In order to do this Local
Care Networks are being developed across south east London. These
Local Care Networks will deliver community based care to local
populations through patient focused, proactive, accessible, coordinated
services and through making every contact count. Further detail of Local
Care Networks are provided in the following slides and on pages 66
onwards.
Draft in progress |
6
Executive
Summary
Introduction to the Our Healthier South East London Strategy
and the approach taken to developing the strategy
•
•
This programme is led by the six NHS Clinical Commissioning Groups in
the south east London with commissioners from NHS England (London),
working in close partnership with local authorities, local providers of care
and other partners.
Aligning our Strategy with London and National Policy Agendas
•
They have identified six priorities for improvement to deliver better care
for the south east London population. These are being researched and
developed by Clinical Leadership Groups focussing on:
—
Community based care
—
Planned care
—
Urgent and emergency care
—
Maternity
—
Children and young people
—
Cancer
•
The groups are formed from clinicians, commissioners, social care leads
and other experts, Healthwatch representatives and other patient and
public voices from across south east London.
•
Each of these groups has developed a model of care which forms part of
the integrated whole system model described on page 14. Each Clinical
Leadership Group is developing a number of interventions and assessing
the impacts of these interventions in terms of delivering improved quality,
better and less variable outcomes for people across south east London
and that they provide value for money and support a sustainable whole
system health and care economy.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
We know that a 'one size fits all' model will not work for the NHS, which is
why we are responding to local needs. However, we have taken the
insight, evidence and direction provided by London and national policy
agendas and embedded this into our design. This includes the:
—
NHS Five Year Forward view
—
Better Health for London
South east London leads are represented across the 13 London
Transformation Programmes and our work is enabled by the learning from
others and our collaborative work on a "once-for-London” basis, where
appropriate.
Principles and governance
•
In addition, as part of implementing and developing the strategy, the
programme follows a number of principles which have been reflected in the
governance and delivery structure. This structure entails the five key
governance elements of the programme :
—
Senior joint forum for strategic direction and decision making
(equivalent to a Programme Board) – the Clinical Commissioning
Board
—
Collaborative forum for partnership working – the South East London
Partnership Group
—
Clinical forum to guide design work – the Clinical Executive Group
—
Delivery focused forum to manage design and implementation
activities – the Implementation Executive Group.
—
Collective forum for patients and public voices to contribute to shaping
the strategy’s content – Public and Patient Advisory Group
Draft in progress |
7
Executive
Summary
Stakeholder Communications and Engagement is a core
part of the strategy development process
•
Our approach to developing the strategy has been strongly focused
around communicating and engaging and working in partnership with our
stakeholders.
•
Commissioners continue to design and develop the strategy with
partners, patients, local people and key stakeholders, with thinking and
planning being developed and amended through the engagement
process.
•
•
•
The strategy is clinically-led and developed, with over 300 clinicians,
nurses, allied health professionals, social care staff, commissioners and
others developing ideas through the six Clinical Leadership Groups. Each
Clinical Leadership Groups includes Patient and Public Voices and
Healthwatch representatives to make sure that these voices are heard at
all points in the development of the strategy.
In addition to ensuring that patient and public voices feed directly into the
Clinical Leadership Groups and supporting work streams, commissioners
have been engaging widely from the beginning by building on existing
local borough-level work.
A series of deliberative events were held in June 2014, December 2014
and February 2015 looking at people’s current experiences of care and
particularly at the more recent events, how people’s experiences might be
enhanced in the future by these new models of care. Capturing feedback
from engagement activities is systematic and transparent. All
contributions are recorded and fed back into the strategy via programme
managers - ensuring that local views influence strategy development.
Examples of feedback and how it is being used are published via ‘You
Said, We Did’ reports which are published on the website as well as the
full reports of deliberative events and other activity.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
Engagement and communication is led by Clinical Commissioning Groups
via the Communications and Engagement Steering Group which has met
at least monthly since May 2014. The group consists of Clinical
Commissioning Groups Communications and Engagement leads. Leads
from NHS providers and local councils have also been invited to attend.
•
Engagement at local level and through local channels is on-going. This
was primarily focused on the case for change during 2014, with a wider
focus on the whole system model and emerging ideas in the spring of
2015. This included gathering patient stories and using materials
developed by engagement partners, the Innovation Unit, Local
engagement on the Issues Paper commenced in May 2015.
•
A variety of methods have, and will be, used to gather the views of a broad
spectrum of patients and the public. Activities will include:
—
borough level deliberative events
—
focus groups with specific communities
—
utilising the existing mechanisms and opportunities identified through
our Clinical Commissioning Groups’ engagement colleagues.
Draft in progress |
8
Executive
Summary
There is a strong case for changing the way current health
and care services are provided in south east London
•
This strategy identifies that outcomes in south east London are not as
good as they should be: The longer we leave these problems, the worse
they will get. We therefore recognise that we all need to change what we
do and how we do it. The case for change has identified and investigated
these problems, helping to target our aims. Nine key issues have been
identified as detailed below:
Too many people live with preventable ill health or die too early
•
3,603 people died prematurely across south east London in 2013[1], with
four of our boroughs having higher rates of premature death than England
and London.
The outcomes from care in our health services vary significantly and
high quality care is not available all the time
•
Too often, the quality of care that patients receive and the outcome of
their treatment depend on when and where they access health services.
Patients tell us that their care is not joined up between different services
•
The social care system is under increasing pressure
•
Our services are often not set up to detect problems soon enough,
meaning that people with long term conditions or mental illness often
have to be admitted to hospital in crisis.
People’s experience of care is very variable and can be much better
•
While patients are very happy with some services, surveys tell us that
their experience of the NHS is inconsistent and that they do not always
receive the care they want.
Many Local Authorities are facing unprecedented pressures due to growing
demand in some areas, with increasing numbers of older residents,
residents living much longer with complex care and health needs and
increased mental health needs. New laws and duties are also leading to
additional implications and uncertainty for councils.
The money to pay for the NHS is limited and need is continually
increasing
•
We don’t always treat people early enough to have the best results
•
Patients and carers find it frustrating to have to continually provide the
same information to different people. This is because different parts of the
NHS do not always communicate effectively with each other or with social
services
NHS funding currently increases in line with inflation each year. However,
the costs of providing care are rising much faster because the NHS is now
treating more people with more complex conditions than ever before and
the costs of care often grow faster than consumer inflation
It is taxpayers’ money and we have a responsibility to spend it wisely
•
We know that by providing services in a different way, it is possible to
improve outcomes, to help people to live healthier lives, to deliver services
which are consistently of high quality and get more for our money
[1] Source: HSCIC Indicator Portal, under 75 mortality for all causes in 2013
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress |
9
Executive
Summary
Vision for the future of health and care services in south east London
•
To solve the problems outlined in the case for change, we have developed a collective vision for south east London. In south east London we spend £2.3billion
in the NHS. Over the next five years we aim to achieve much better outcomes than we do now by:
—
Supporting people to be more in control of their health and have a greater say in their own care
—
Helping people to live independently and know what to do when things go wrong
—
Helping communities to support one another
—
Making sure primary care services are consistently excellent and have an increased focus on prevention
—
Reducing variation in healthcare outcomes and addressing inequalities by raising the standards in our health services to match the best
—
Developing joined up care so that people receive the support they need when they need it
—
Delivering services that meet the same high quality standards whenever and wherever care is provided
—
Spending our money wisely, to deliver better outcomes and avoid waste.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 10
Executive
Summary
The strategy proposes model(s) of care: to deliver better
care for our south east London populations
Care Model Design
•
To develop the initiatives to focus on these aims, the Clinical
Commissioning Groups and NHS England – London region have created
the six Clinical Leadership Groups to devise better care for our
population.
•
Each of these groups has developed a model of care which forms part of
the integrated whole system model described on page 13. Each Clinical
Leadership Group is developing a number of interventions and assessing
the impacts of these interventions in terms of delivering improved quality,
better and less variable outcomes for people across south east London
and that they provide value for money and support a sustainable whole
system health and care economy .
Local Care Networks
•
Local Care Networks are the centrepiece of the strategy and sit within
Community Based Care.
•
The Community Based Care Clinical Leadership Group aims to support
people to live healthier lives and reduce the number of people exposed to
risk factors either by birth or behaviour. For people with long term
conditions, Community Based Care will take a rehabilitative/ re-ablement
approach, supporting people to manage their own health positively,
prevent deterioration wherever possible and reduce risks on these
people. For those people with complex long term conditions or who are in
the last year of life, support will be available to enable them to continue to
lead as full and active life as possible.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
Community based care will be delivered through Local Care Networks. The
services available will be proactive, accessible, coordinated and provide
continuity; with a flexible, holistic approach to ensure every contact counts.
This will be primary care delivered to geographically coherent populations,
at scale, whilst still encouraging self-reliance.
•
24 local care networks are being developed to support whole populations
across south east London. This will be a universal service covering the
whole population ‘cradle to grave’. A local care network will involve
primary, community and social care colleagues working together and
drawing on others from across the health, social care and the voluntary
sector to provide proactive patient centred care. Services will be delivered
in ways that respond to the varied needs and characteristics of our
communities.
Clinical Leadership Group initiatives
•
In addition to the Local Care Networks, each Clinical Leadership Group
proposes further initiatives. These are summarised in the following slides.
Draft in progress | 11
Executive
Summary
The Community Based Care Target Model
The strategy sets out an agreed target model for local care networks that will deliver community based care. It is intended that each Local Care Network across
south east London delivers the target model. However, the target model will have to be tailored to the local community that it serves.
Integrated Single System Leadership and Management
‘The Core’ (as a minimum all
LCNs should encompass)
Serving geographically
coherent populations
between 50,000 – 130,000
•
•
•
•
•
Southwark
Greenwich
Bexley
Lambeth
Lewisham
•
•
•
•
•
Leadership team
All general practices working at
scale (federated with single IT
system and leadership)
All community pharmacies
Voluntary and community sector
Community nursing for adults and
children
Social care
Community Mental Health Teams
Community therapy
Community based diagnostics
Patient and carer engagement
groups
Working with…
•
•
•
•
•
•
Bromley
•
•
•
•
•
•
•
Strong and confident communities
Accessible hospital outpatient
treatment clinics and acute oncology
(urgent and emergency and cancer
care)
Specialist opinion (not face to face)
and clear specialist service pathways
Pathways to Multi Disciplinary Teams
Integrated 111, London Ambulance
Service and Out of Hours system
(interface with Urgent care centres
co-located with emergency
department model)
Housing, education and other council
services
Community based midwifery teams
Private and voluntary sector e.g. care
homes and domiciliary care
Cancer services
Children’s integrated community team
and short stay units
Rapid response services
Carers
And there will be others..
To deliver…
•
•
•
•
•
•
•
•
•
•
Support for patients to manage their own
health (Asset Mapping, Social Prescribing,
education, community champions etc
Prevention – Obesity, Alcohol and Smoking
Improved Core general practice access
plus 8-8, 365
Improved call and recall systems for
screening and early identification and
management of long term conditions
Reduction in gap between recorded and
expected prevalence in long term
conditions
Support for vulnerable people in the
community including those in care homes
and domiciliary care
Reduction in variation (level up) primary
care management of long term conditions
Reablement – Admissions avoidance and
effective discharge
Multi Disciplinary Team configuration –
main long term conditions groups (incl.
mental health) and Frail elderly
End of Life Care
Integrated Pathways of care
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 12
Executive
Summary
Community Based Care delivered by Local Care Networks
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 13
Executive
Summary
Our integrated whole system model
Community Based Care delivered by Local Care Networks is the foundation of the integrated whole system model that has been developed for south east London.
This diagram provides an overview of the whole system model, incorporating initiatives from all 6 Clinical Leadership Groups.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 14
Executive
Summary
Planned care model
Key Features of the model
Standardisation
1
Reducing variation across the planned care pathway
from referral practice to discharge through the
co-development of high level standards.
Diagnostics
2
•
•
•
•
Enhance patient management by GPs
Rapid access to diagnostics for GP’s
Evidence based standardised Clinical pathways
Shared results across the system supported by
integrated IT systems
Elective Care Centres
3
Provider collaboration to create centres of excellence
for high volume specialities that drive up quality of
service provision and improve outcomes for patients
• Orthopaedic (hips and knees)
• Ophthalmology
Pathway Review
4
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
•
•
•
Urology
Neurosurgery
Nephrology
Gynaecology
Draft in progress | 15
Executive
Summary
Maternity model
Key Features of the model
1
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Primary prevention and targeted wellness programmes
within the Local Care Network (LCN)
2
Assessment of pregnancy risk at or before 10 weeks to
assign the most appropriate midwife team from the outset:
a)
LCN community based midwife teams for low risk
b)
Specialist condition focused teams for high risk
c)
On-going communication with primary care and other
community based services
3
Midwife Led Continuity of Care and support:
a) Every women has a named midwife providing
continuity and co-ordination of care developing individual
care plans and reflecting individual needs
b) Continuous assessment of risk throughout pregnancy
c) Facilitating easy access to specialist care when
required
4
Culture of birthing units to encourage straightforward birth
and improve the experience for low risk women
5
Achieving the London Quality Standards and supporting
improvement in the quality of service, safety, outcomes
and satisfaction.
6
Better co-ordination through postnatal and neonatal
phases to improve mother and baby flows and experience
7
Smooth handover to LCN with continuing advice and
support on healthy choices.
Draft in progress | 16
Executive
Summary
Children and Young People model
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Key features of the model
1
Primary prevention and wellness
• Within the local care network, focusing on the well child.
• In the context of the family setting, looking after the child or
young person’s physical, social, emotional and mental well
being.
2
Children’s integrated community team delivering:
• A range of proactive services for children with more complex
needs
• Early intervention for acute illness and supported early
discharge
• Management of short-term conditions
• Signposting and navigation through the system
3
Extended GP hours
• For general practice from 8 to 8
• With closer links to short stay paediatric units and
emergency departments, to enable better co-ordination and
to help prevent unnecessary hospital admissions
• To be delivered via the Community Based Care model .
4
Short stay paediatric units
• Co-located with an ED
• Designed to ensure that children and young people are
returned to the community as quickly as possible and
unnecessary hospital stays are avoided
• With close links with the Children’s Integrated Community
Team
5
Planned care pathways
• With referral advice and guidance tools
• Specialist advice and support back into the community
6
Supported transition to adult services
Organised by Local Care Networks and Children’s Integrated
Community Teams
Draft in progress | 17
Executive
Summary
Urgent and emergency care model
Key Features of the model
Achieving the London Quality Standards in all areas:
• Acute medicine
• Emergency general surgery
• Emergency departments
• Critical care
• Fractured neck of femur
Meeting the Facilities Specification for:
• Urgent care centres (UCC)
• Emergency centres (EC)
• Emergency centres with Specialist Services (ECSS)
• U&EC system
1
Improving access in Primary Care, in hours and out of hours, to unscheduled care.
GPs, Urgent Care Centres (UCCs) and Emergency Departments (ED) functioning in a closely
linked co-ordinated way; responsive community care, including specialist response teams, will
prevent un-necessary hospital admissions with easy access to specialist advice for GPs as an
alternative to ED referral
1. 8am – 8pm 7 days a week
2. Standalone Urgent Care Centres with the same standards
3. Community based rapid access teams including a home ward.
2
Specialist advice and referral
4. Access to specialist advice
5. Access to a specialist response clinic
3
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Improved 111 capability and LAS onward referral
6. London Ambulance Service will be able to redirect to appropriate services, such as the
rapid access team, home ward or hospital based specialist clinics and excel in navigating
patients to the right part of the system
7. 111 are able to give advice, provide internal triage and coordinate onward referral to other
parts of the system other than the ED
4
An enhanced single “front door” to the Emergency Department.
8. Bringing together UCCs and the ED in a single governance structure and providing expert
streaming across all sites
5
Emergency Department interface with Mental Health services
9. This will also allow for earlier identification of MH cases (including Dementia) reducing
length of stay and enabling quicker streaming to specialities for mental health patients by
having Psychiatric Liaison nurse (PLNs) and Triage joint assessments.
10. Quicker interface with specialist services like drug and alcohol
11. Quicker interface with under 18 mental health liaison teams
Draft in progress | 18
Executive
Summary
Cancer model
Key Features of the model
Primary prevention: Best delivered in the Local Care Network
Early detection
1
•
•
•
•
Increased screening rates to national benchmark through targeted engagement
Diagnostics: Pilot project – serious but unspecific symptoms pathway
Promotion of early diagnosis and equal access to treatment for all people, focus
on individuals who shared one or more of the nine protected characteristics e.g.
older people, individuals with mental health needs and/or a learning disability.
Professional development for all staff within Primary Care
Treatment and Transition
2
Provider collaboration to create networked centres of excellence:
• Non complex cancer treatments and support closer to home
• Access to appropriate information and support for patients and carers
• Acute Oncology Services – networked and supported by integrated IT
• Consistently meet the access time scales on our cancer services
• Routine use of the recovery package
Living with and Beyond Cancer; Cancer as a long term condition
3
•
•
•
•
•
•
•
Stratified pathways of care
Support for people living with the adverse consequences of cancer treatments
Comprehensive support for carers
Psychological support for people living with Cancer
Inclusion of Cancer as a criteria for referral to exercise/physical activity on
prescription schemes
Support to return to work, study or volunteering
Routine use of the recovery package
End of Life: Best Delivered in the Local Care Network
4
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
•
•
Ensure a dignified death irrespective of setting
Ensure consistent use of coordinate my care
Advance Care planning
Draft in progress | 19
Executive
Summary
Approach to identifying the outcomes the strategy aims to
achieve
•
The primary aim of delivering the Our Healthier South East London
strategy and vision is to develop ways to improve the health and care
outcomes for south east London communities and people. A framework
which sets out measures to monitor the impact of the strategy and
interventions on outcomes has been developed through engaging with
our partners across health and care providers, Public Health, clinicians
and public and patients. This framework sets out the measures that
demonstrate the effectiveness of the strategy in achieving the outcomes
allowing us to quantify the strategy’s impact.
Focusing on the achievement of outcomes
•
By implementing the strategy and its care models the aim is to reduce the
variability in outcomes we see today as outlined in the case for change
and to improve the overall health and care outcomes for people across
south east London.
Structure of the framework
•
The framework is made up of the following core elements:
—
—
—
Domains: The high-level grouping or classification of outcomes that
are measuring similar things. There are a number of existing
outcome frameworks which were reviewed and based on those
frameworks, four ‘domains’ that are common across them were
selected.
Outcomes: The overall impact of the strategy on the health and
well-being of our populations and individuals in south east London
Indicators: The measures selected to demonstrate the achievement
of the outcome. These are as outcome focused as possible but in
some cases a process/structure measure has been used as a proxy.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Eight outcomes have been identified
•
Preventing people from dying prematurely and enabling them to live longer
and healthier lives
•
Reducing differences in life expectancy and healthy life expectancy
between communities
•
People are independent, in control of their health, and able to access
personalised care to suit their needs
•
Health and care services enable people to live a good quality of life with
their long term condition
•
Treatment is effective and delivers the best results for patients and service
users
•
Delivering the right care, at right place, at the right time along the whole
cycle of care
•
Commitment to people having a positive experience of care
•
Caring for people in a safe environment and protecting them from
avoidable harm
Indicators
•
There are a number of indicators that have been identified and these are
still undergoing review from stakeholders and Public Health
Draft in progress | 20
Executive
Summary
•
•
•
NHS funding currently increases in line with inflation each year. However,
the costs of providing care are rising much faster because the NHS is
now treating more people with more complex conditions than ever before
and the costs of care often grow faster than consumer inflation.
The NHS Five Year Forward View outlines a £30 billion financial
challenge nationally by 2020/21. Consistent with this, in the absence of
action, the scale of the affordability challenge in south east London is
forecast to grow to over £1 billion by 2019/20. The graph to the right and
the table below demonstrate how this challenge grows over this period.
Local authorities, who are responsible for social care services, are also
looking to save over 30% of their current expenditure over the next 3-4
years. Therefore we need to get better value for money for all that is done
in the NHS and social care services. We need to get the best possible
outcomes for patients and make the most of resources that are under
increasing pressure. This means we need a more integrated approach
between different services.
System wide income/expenditure (£
millions)
The NHS faces a growing affordability challenge
5,900
5,903
5,400
4,900
4,812
4,400
Expenditure (Do Nothing)
Revenue
3,900
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
Absolute challenge
Annual challenge
Percentage challenge
Over the period from 2014/15 to 2019/20, the south
east London expenditure (without efficiencies) will
grow by just over £1 billion more than the projected
budget of £4.8 billion. This is comparable with the
£30 billion national challenge set out in NHS
England’s Five Year Forward View.
On average, the south east London healthcare
system will need to make efficiencies of £218m each
year (from a budget which will grow to £4.8bn)
between 2014/15 and 2019/20.
On average, the south east London healthcare
system will need to make efficiencies of 4.2% each
year between 2014/15 and 2019/20.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
An estimated annual breakdown is shown below.
An estimated breakdown is shown below.
14/15
15/16
16/17
17/18
18/19
19/20
14/15
15/16
16/17
17/18
18/19
19/20
£251m
£228m
£154m
£162m
£141m
£156m
6.0%
5.3%
3.4%
3.5%
3.0%
3.2%
NB: The financial data contained within the following slides may be subject to change
following discussions with providers and CCGs with respect to the modelling (see note
on p. 206).
Draft in progress | 21
Executive
Summary
Financial impact
and affordability
Closing the affordability challenge
System wide income/expenditure (£ millions)
•
The graphs on this page demonstrates how the benefits from the
programme can be combined with savings within individual organisations
to close a substantial amount of the £1.1 billion affordability challenge.
The benefits shown are as follows:
1.
Programme gross benefit.
2.
Provider efficiencies at 2.5%: The provider finance leads feel that
a 2.5% CIP may be reasonable in addition to efficiencies generated
through the programme.
5,900
5,903
5,672
5,400
5,078
4,900
4,812
•
It is important to note that both of these savings are presented
gross of investment requirements (which total £90 million in the
programme central case). It is expected that these investment
requirements will, at least in part, be satisfied through additional funding
requested through the Five Year Forward View and committed by the
Government. Taking south east London’s proportionate share of the £8
billion committed would imply that £248 million is available for this
purpose.
•
The central case assumes the £231 million gross benefit with 40%
investment (the high case and low case are 30% investment and 50%
investment respectively).
•
The resultant position is a £266 million affordability challenge for
the South East London health care economy.
Expenditure (Do Nothing)
4,400
Expenditure (Strategy)
Expenditure (Residual)
3,900
2013/14
Revenue
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
NB: Profiling of benefits shown above may significantly change as implementation
plans are developed.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 22
Executive
Summary
Initial estimate of acute bed requirement
• Using historical NHS bed occupancy data for the acute providers
and our projections of bed demand considering demographic/nondemographic growth assumptions we have estimated the bed
gaps/increases show in the table below.
• We have modelled the impact of the strategy on overnight bed days
to be a net reduction of 140,000 and a net increase in day case bed
days of 25,000. This translates directly to a number of beds using
various occupancy rates as shown in the table below.
• This only relates to acute beds and we would expect a proportion
of this activity to be provided within community beds. Also note that
the ‘do nothing’ position does not reflect any potential reductions
associated with QIPP delivery post 2014/15 plans or Better Care
Fund related non-elective admission reductions.
Baseline bed days/beds
2013/14
Growth (2019/20)***
Gross change
(2019/20)
Net change
(2019/20)
1,178,000
198,000
(339,000)
(140,000)
Overnight beds (current occupancy rates*)
3,571
601
(1,015)
(414)
Overnight beds (85% occupancy rates)
3,571
861
(1,092)
(231)
181,000
30,000
(5,000)
25,000
Day case beds (current occupancy rates*)
595
99
(15)
84
Day case beds (68% occupancy rates)
595
254
(19)
235
Overnight bed days
Overnight
Day case bed days
Day case
Total bed days
Total
Strategic impacts bed days/beds
1,359,000
228,000
(343,000)
(115,000)
Total beds (current occupancy rates*)
4,166
700
(1,030)
(330)
Total beds (revised occupancy rates****)
4,166
1,115
(1,111)
4
* Bed occupancy source: Bed occupancy for the year estimated using the average of KH03 quarterly returns from NHS England for Q4 2013/14 – Q3 2014/15.
(GSTT: 81%, KCHT: 94%, LGT: 94%, DGT: 95%, weighted average: 90.5%).
** These figures have been fixed at current occupancy levels and 2013/14 activity.
*** These figures relate to a level of increased demand as shown above and an additional number of beds due to requiring lower occupancy levels.
**** The total revised occupancy rates are blended across the inpatient overnight bed and day case bed rates shown earlier in the table.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 23
Executive
Summary
Summary of where we have reached in developing the strategy
The aims of the consolidated strategy are to make a difference to the health and
well-being outcomes of the people and communities in south east London and to
create a sustainable health and care system as a foundation for the future.
To date, the consolidated strategy brings together the case for change, the care
models and their anticipated impacts on outcomes for the people and
communities in south east London. This is combined with an assessment of the
potential impact these models may have on how people use services and the
extent to which it will support the future financial sustainability of the system.
people to only visit hospital when they really need to
•
Pathways and professionals will be more integrated
•
Productivity is expected to increase and there will be greater efficiency in the
south east London system
•
The plan will be for bed occupancy to meet the national guidance (which is not
the case now) which will improve safety, quality and efficiency
Recent programme updates include;
Taking into consideration growth assumptions over the next 5 years, and not
changing our clinical models of care would mean that too many people would
continue to be admitted to hospital where better Community Based Care models
could provide improved outcomes. We have calculated the increase in bed
capacity that would be needed across south east London to respond to the rise in
population and aging population using our current approaches to delivering care.
The projected demand would increase so much that the number of beds needed
would be enough to fill a new hospital site and this is not possible or
affordable. Applying the initial impact of the strategy’s care models work on the
projected demand levels for hospital beds, shows that by implementing the care
models in the strategy, we would reduce the need for additional hospital beds by
providing an alternative high quality model of care that is focussed on improved
outcomes for the population we serve.
•
The whole system affordability gap has been defined
•
The Clinical Leadership Groups design guides are being finalised and
potential impacts of the care models reviewed
•
Supporting strategies of Estates, Workforce and IT continue to be developed
•
Ensuring that progress and plans for the London Quality Standards are
embedded into the strategy and exploring options on how they can be
achieved
This is because,
•
Further developing the supporting strategies of Workforce, IM&T and Estates
•
The care models are focused on prevention and early intervention and
keeping people healthy. Therefore keeping people out of hospital
•
Refining the indictors for the Outcomes to make sure the best possible ones
have been selected so we can measure the benefits or not of the strategy
•
Community Based Care is the foundation of the whole system and is intended
to keep people closer to home, treating them in the community and enabling
•
Engagement on the options appraisal methodology
•
Ongoing communications and engagement
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Whilst the strategy programme has progressed a long way to achieve its aim,
there is still much work to do
Further work is required on
Draft in progress | 24
Executive
Summary
How will we deliver the strategy?
Part of the Clinical Leadership Groups work is to develop the plans to deliver
the care models. In addition, three supporting strategies are being developed
to support the overall delivery of the care models and changes at a whole
system level.
Infrastructure & Estates
•
The Estates Supporting Strategy is an essential element of the strategy
programme to support the delivery of our new models of care in a way
which ensures they deliver the outcomes we aim to achieve. We must
understand the capacity of our capital assets, estates and facilities across
south east London to utilise, reduce or develop these in the most
appropriate way to meet the needs of our population.
•
There is a clear synergy between the south east London need to
reconsider estates and the national and London wide direction of travel.
‘The five year forward view sets out an integrated agenda and new care
models over the next five years. In addition, Better Health for London
outlines the evidence base for re-evaluating the utilisation and value of
NHS estate in London.’ (The Healthy London Partnership Estates
Programme). Therefore, our Estates Supporting Strategy has made clear
links with the work being delivered at a London wide level by the ‘Our
Healthy London Partnership - Estates Programme’ being led by London
CCGs and NHS England.
•
The Estates Supporting Strategy aims to address specific requirements
that provide additional support to facilitate delivery of the strategy, building
upon London wide programme delivery where the time scales allow. The
estates strategy will be built into the delivery programmes for all models of
care as appropriate and financial impacts further detailed within the
Financial modelling. The three stages of the Estates Supporting Strategy is
are as follows:
The three supporting strategies are
•
Infrastructure & Estates
•
Workforce
•
Information Management and Technology
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
—
Understanding the baseline
—
Understanding the requirement
—
Addressing the gap
Draft in progress | 25
Executive
Summary
Workforce
•
The workforce supporting strategy will need to clearly articulate how the
workforce is going to deliver what south east London needs. This will
include new ways of working (i.e. flexibility, rotations, different staff groups
doing different tasks to today, team work and collaboration) and different
working locations (i.e. more staff working in the community as opposed to
acute settings).
•
For this purpose the programme has so far established:
Better Health for London, the Five Year Forward View and Our Healthier
South East London have all identified the need to focus on:
•
Developing a workforce capable of delivering the new models of care.
•
Identifying the actions needed to move and motivate the workforce to its
new roles in empowering patients and promoting their independence,
making every contact count; and fostering an environment where
colleagues engage with each other rather than refer and hand-over.
•
Understanding what patients will need to realise their own potential, and
for workers to challenge the old ways and accept new ways as we plan
for an effective and sustainable workforce.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
—
A baseline of the current workforce
—
A methodology to define characteristics of the required new workforce
These will support the next steps which will take the workforce where it
needs to be in the future. These steps include:
—
Articulating the workforce strategy
—
Reaching out to the workforce
Draft in progress | 26
Executive
Summary
Information Management & Technology (IM&T)
•
•
Information and IT will be a key enabler for the strategy. Specifically, it
can support staff in new ways of working and empower patients to be
active participants in their care.
Key considerations for understanding the IM&T requirements to support
the strategy and any gaps are:
—
—
—
—
National and London initiatives and policies: There are a number of
National and local initiatives and policies that may support the
implementation of the strategy.
CCG IM&T strategies: Each CCG has its own IM&T strategy and
implementation plans, which have been reviewed and initial
assessments made to determine support for the strategy.
Identifying uniformities at a south east London level so there are
consistent ways of working. For example, adopting the same data
quality standards, and staff identification processes for who should
be viewing/editing data and design principles…
Key ways in which interoperability will support the delivery of the vision and
care models in the consolidated strategy are:
Care Quality
•
Improves the quality of patient care by providing access to complete,
accurate, timely information in one location.
•
Provides visibility into the “whole” patient by sharing basic medical
information across a patient’s care providers
Care Efficiency
•
Patient Safety
•
Makes life-saving information available 24-hours-a-day for clinical decision
support
•
Our findings so far indicate that primary key requirements of
interoperability between GP systems and primary and secondary care are
planned and/or being implemented at various speeds. All CCGs are
moving to GP systems that will enable sharing of records across GP
practises supporting Local Care Networks and will be interoperable with
acute
•
To various extents CCGs have plans in place to align with some of the key
IT/Digital guidance in the 5YFP IT/Digital, London Transformation
Programme, 2020 Personalised Health and Care and Implementing these
guidelines would meet many of the strategy requirements.
•
However, additional transformation initiatives that may require agreement
and funding at a south east London level have not been explored or agreed
at this stage.
Gaps and any investment costs: Understanding where these are not
currently accounted for in CCG and or provider plans, and are
needed to implement the strategy.
A primary requirement to enable the strategy is for health and care systems
across south east London to be interoperable
Why is interoperability Important?
Interoperability is important because it will enable south east London health
information systems and professionals to work together within and across
organizational boundaries in order to more effectively deliver healthcare to
people and communities.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Saves time previously used to look for information, i.e. lab results, or
repeat tests that have already been performed in another care setting
Draft in progress | 27
Executive
Summary
There are risks to delivering the Strategy which are closely monitored and assessed for impact
The following high level risks have been identified to the implementation of the strategy. This list will be reviewed regularly through the Clinical
Executive Group, Implementation Executive Group and Clinical Commissioning Board.
Title
Risk
Impact
1. Information
Systems
•
Lack of integrated or interoperable
information systems undermines
ability to integrate services across
the health system in south east
London
•
Possible duplication of system, process •
or information, resulting in poorer patient •
experience, poor quality of services
across integrated pathways and
additional cost
2. Workforce
Capability
•
Existing workforce skills or
capability to deliver new models of
care
•
New models of care may not be
implemented
Services may not be delivered safely
Patient satisfaction
Staff satisfaction issues
Quality and effectiveness of care
•
•
•
•
Mitigations
•
•
•
IM&T supporting strategy workstream established.
Utilising existing integration initiatives across SEL to
support strategy
Workforce supporting strategy workstream established
Work in hand to identify gaps between capabilities
required to deliver new models of care and those
available in current workforce
Key characteristics and skills being identified for
training purposes
3. Delivery
Timeframe
•
It may be challenging to complete
•
required activities and assurances in
time to go to consultation, if
required, in December, particularly
as a result of needing to engage
patients and service users in the
process
Delay to programme implementation for •
those elements which might require
formal consultation or loss of support
from partners and stakeholders for some
or all of the strategy
On-going dialogue with NHSE to agree assurance
process and detailed communications and
engagement plan to test critical path
4. Delivery
Timeframe
•
Insufficient time for good processes
in terms of governance, decision
making and ownership
•
The strategy and associated documents •
are not owned by all stakeholders
across SEL
We will maintain four key activities: intensive
engagement with partners and stakeholders; ensuring
NHS England is engaged; careful mapping of
governance and decision making; and meeting with
NHSE by mid-June to review the approach
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 28
Executive
Summary
Title
Risk
Impact
Mitigations
5. Clinical
Leadership
Group Impact
Analysis
•
Modelling: Finance and Activity
•
The impact analysis does not fully close
the identified affordability gap but does
make significant progress towards doing
so. It is not yet clear if this is sufficient
•
6. Financial
•
sustainability of
health system
New service models do not deliver
reduced demand for hospital care or
hospital capacity does not reduce in
line with demand
•
Potential increased system costs through •
duplication of services
System may not be sustainable
7. Patient / Public •
Resistance to
Change
If partners and stakeholders are not
sufficiently engaged throughout the
development of the five year strategy
– or if the case for change is not
sufficiently convincing - any proposed
service change could be subject to
significant local opposition
•
•
•
•
•
Further engagement required
Possible legal challenge
Delays to implementation of changes
leading to increased cost and delay
Need to amend strategy in response to
concerns
•
•
•
•
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Explore and incorporate additional QIPP and CIP
opportunities and continue to explore options with
NHSE
Making sure there is clinical input into the design
of care models and that they have sufficient
impact on activity
Engagement activities will be undertaken with a
broad range of partners and stakeholders
throughout the development and implementation
of the strategy
Dedicated communications and engagement
enabling workstream to coordinate these
activities
Patient and Public voices in all key groups to help
shape strategy
Strategy reflects input from partners and
stakeholders
Draft in progress | 29
Executive
Summary
Delivering the strategy and next steps
•
A number of interventions have been defined and agreed and now the
strategy programme must start to consider how these will be
implemented and delivered.
•
For most interventions implementation planning can commence
immediately. There are some interventions where care model delivery
options need to be considered. These interventions will have to undergo a
robust options appraisal process.
•
It is proposed that the filtering of options will occur through two gateways of
assessment against criteria; hurdle criteria and evaluation criteria (the
diagram on the following page provides an overview of the methodology).
•
The criteria against which the options will be assessed will be agreed
before commencing the appraisal. Moreover, the likelihood of optimal
implementation of options is increased by gathering wide ranging
stakeholder contribution to the formation and specificity of criteria.
•
Although some interventions do not in their own right require a detailed
options appraisal (those that start implementation planning), the result of
implementing those interventions could impact on the appraisal of other
interventions because they will lead to shifts in settings of care and
volumes of activity. As a result, it is important to consider the scope of a
detailed options appraisal and how to account for whole system changes
within the appraisal of individual interventions.
•
.
Implementation planning
•
The development and implementation of the strategy has involved
consideration of options for care model design from the outset.
•
This is an iterative process which reviews the range of interventions to
produce best outcomes for south east London.
•
It considers ways to formulate the care models to produce these best
outcomes based on a range of qualitative and quantitative evidence.
Implementing some of the interventions will require consideration of care
model delivery options and these will either be implemented at a local
level or at a south east London level.
Options appraisal process
•
This approach aims to identify the best way or way(s) of delivering the
overarching strategy and realise its full benefits. It filters the many
potential options for how the system can be implemented and is designed
to identify options that are recommended for further work.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 30
Executive
Summary
Process for appraising options
•
In order to identify the best way or way(s) of delivering the overarching
strategy, an options appraisal process is required to realise its full benefits.
This focuses on those options which may lead to significant service
change. This approach filters the many potential options for how the
system can be implemented and is designed to identify options that are
recommended for further work
•
It is proposed that the filtering of options will occur through two gateways of
assessment against criteria; hurdle criteria and evaluation criteria (the
diagram on the following page provides an overview of the methodology).
•
The criteria against which the options will be assessed should be agreed
before commencing the appraisal. Moreover, the likelihood of optimal
implementation of options is increased by gathering wide ranging
stakeholder contribution to the formation and specificity of criteria.
•
Although some interventions do not in their own right require a detailed
options appraisal, the result of implementing those interventions could
impact on the appraisal of other interventions because they will lead to
shifts in settings of care and volumes of activity. As a result, it is important
to consider the scope of a detailed options appraisal and how to account for
whole system changes within the appraisal of individual interventions.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 31
Executive
Summary
Options for appraisal methodology
13 July – 28 Aug
28 Aug – 12 Sept
Develop scope and supporting
information
Identify areas where there are options
for service delivery and reconfiguration
may be required. A number of inputs
will be used (strategy impacts, LQS
Provider baseline and planning
assumptions including cost of
implementation) In a partnership
approach develop principles for
agreeing service level options
12 Oct – 19 Oct
Develop service level
options
Working groups will be
formed to develop service
areas/CLGs options using
the agreed principles
.
Consolidate options at a
whole system level
Consideration of the options in
the context of the whole
system. This will consider the
consequences and
interdependencies of the
service level options from a
whole system perspective,
eliminating options against
agreed criteria.
19 Oct – 3 Nov
3 Nov – 7 Dec
Non-Financial Appraisal
The whole system options
identified proceed to the
appraisal process.
Financial appraisal and
Consolidation
The initial short list of options
proceed to a financial appraisal.
A short-list of options will be
developed by conducting a
non-financial option appraisal.
This will determine the final short
list of options that may require
consultation
Evaluation criteria for the
next stage will be developed
and agreed.
Develop scope
•
•
Clinical models
LQS baseline
Supporting information
•
•
•
•
•
•
Finance and Activity
Estate and service
baseline
Design principles
Strategy outcomes
Provider baselines
Initial specialty level
breakdown
Develop
options
on
agreed
service
area
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Appraisal
of service
specific
options
Consolidate service
level options into
whole system options
Appraisal of whole
system options (Nonfinancial)
Appraisal of whole
system options
(Financial)
Short list
of options
Draft in progress | 32
Delivering the
strategy
High level programme plan
The high level plan on the next page shows at high level the next stages of the plan for implementation, option appraisal and consultation if required. It is
ambitious and dependent on partners and key stakeholders continuing to engage with and support the work as it develops. This timeline has been tested
with provider organisations and other stakeholders.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 33
Full Strategy Section
Page No.
Purpose of the document
35
Introduction to south east London
38
Introduction to the Our Healthier South East London Strategy and the approach taken to
developing it
41
Stakeholder communications and engagement
45
Case for change
54
Vision for the future of health and care in south east London
62
Proposed model(s) of care: Delivering better care for our populations
65
Benefits/ outcomes of achieving our vision
136
Financial impact and affordability
149
What is needed to deliver our vision?
155
Risks and Challenges
179
Delivering the strategy
172
Appendices
179
Draft in progress | 34
Draft in progress | 35
Purpose of the
document
Introduction
Purpose of this document
•
•
It brings together the context of the south east London health and social
care economy and details the potential initiatives that could be
implemented to have transformational impact.
•
Every CCG in the country is required to produce a strategy. In south east
London, commissioners want to make sure that the strategy reflects local
needs and aspirations. The first draft of the south east London strategy
document was sent to NHS England for review on 20 June 2014. This was
a national deadline. The strategy runs for five years, so it is very much a
work in progress. Through local and wider clinical and public engagement,
potential ways to improve services have been identified, but considerable
further work and engagement on the thinking and implementation of these
plans is now taking place.
•
This version has developed significantly since June 2014 and brings
together the proposed initiatives and their potential impact, but it remains a
work in progress and is under review by a wide range of stakeholders.
In south east London, we have some very good health services. People
are living longer and many people are healthier. But we also have some
services that could be better. We have services that people find hard to
access and some people do not get the help they need to keep
themselves and their families well. We also have wide varieties in life
expectancy and too many people die early from preventable diseases.
•
Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark CCGs,
working with NHS England as co-commissioner, are working in
partnership with local authorities, local providers and other key
stakeholders to define a five-year strategy for health and integrated care
services across south east London.
•
The strategy complements and builds on local work and has a particular
focus on those areas where improvement can only be delivered by
collective action or where there is added value from working together. It
seeks to respond to local needs and aspirations, to improve the health of
people in south east London, to reduce health inequalities and to deliver a
health care system which is clinically and financially sustainable. The
approach is commissioner led and clinically driven, and informed by wide
engagement with local communities, patients and the public.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 36
Purpose of the
document
Overview
This document sets out:
1. Introduction to south east London
2. Introduction to the Our Healthier South East London Strategy and the approach taken to developing it
3. Stakeholder Communications and Engagement
4. The case for change
5. Vision for the future of health and care services in south east London
6. The strategy proposed model(s) of care: Delivering better care for our south east London populations
7. Benefits/outcomes of achieving our vision
8. Financial impact and affordability
9. What is needed to deliver our vision?
10. Risks and Challenges
11. Delivering the strategy
12. Appendices
This document steps through each of the above sections. Firstly providing context and an overview of the programme, before detailing the reasons for the strategy
and the initiatives developed to support this.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 37
Draft in progress | 38
Introduction to
south east
London
Overview of the NHS in south east London
There are a number of organisations across south east London who commission
and deliver health services. These are summarised below:
Commissioning organisations
There are 6 Clinical Commissioning Groups in south east London. These
organisation are co-terminus with London Boroughs and commission the
majority of services people receive. The CCGs are:
•
NHS Greenwich CCG: 265,995 (in 2014) and is made up of 44 local GP
practices
•
NHS Bexley CCG: services 238,446 (in 2014)
•
NHS Bromley CCG: Services 320,460 (in 2014) and is made up of 47 local
GP practices.
•
NHS Southwark CCG: Services 302,290 (in 2014) and is made up of 44
local GP practices.
•
NHS Lambeth CCG: Services 317,738 (in 2014) and is made up of 47
local GP practices.
•
NHS Lewisham CCG: Services 289,794 (in 2014) and is made up of 44
local GP practices
•
South London and Maudsley NHS Foundation Trust (Mental Health)
•
Oxleas NHS Foundation trust (Mental Health)
In addition to the organisations set out above people in south east London
receive care from a number of other organisations including NHS trusts located
in other areas, community health providers and third sector organisations.
Main acute and mental health providers
There are a number of provider organisations located in and delivering health
services in south east London. These include:
•
King's College Hospital NHS Foundation Trust
•
Guy's and St Thomas' NHS Foundation Trust
•
Lewisham and Greenwich NHS Trust
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 39
Introduction to
south east
London
Population of south east London
•
For south east London, we have used a segmentation model to
understand the population:
—
Public Health have developed a model of the south east London
population based on the use of the Kernow Model of population
demographics developed in Cornwall and a well evidenced Scottish
model of long term conditions prevalence.
—
The south east London population has been segmented here to
show those people living healthy lives, those with risks of developing
long term conditions and those who are living with long term
conditions. These segments of the population are demonstrated,
based on their size, as the segmentation model .
—
—
Community Based Care (CBC) aims to support people to live
healthier lives and reduce the number of people exposed to risk
factors either by birth or behaviour. For people with a long term
condition Community Based Care will take a rehabilitative/ reablement approach supporting people to manage their own health
positively , prevent deterioration wherever possible and reduce risks
on these people. For those people with complex long term conditions
or who are in the last year of life, support will be available to enable
them to continue to lead as full and active life as possible.
Community Based Care will be delivered through Local Care
Networks. The services available will be proactive, accessible,
coordinated and provide continuity; with a flexible, holistic approach
to ensure every contact counts. This will be primary care delivered to
geographically coherent populations, at scale, whilst still
encouraging self-reliance.
Costs
EoL
Early
(1%)
stages
18,000 residents
of LTC
3+
LTC
(25%)
(9%)
153,000
residents
Early stages
of LTC
(25%)
445,000 residents
People experiencing
inequalities or putting
their health at risk
(49%)
870,000 residents
Health and
wellbeing group
(16%)
276,000 residents
People with multiple complex needs where standard
services are not effective who need personalised care
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 40
Draft in progress | 41
Introduction to the Our Healthier
South East London Strategy and
the approach taken to developing it
Overview of the programme
•
Our Healthier South East London is a five year commissioning strategy
which aims to improve health, reduce health inequalities and ensure all
health services in south east London meet safety and quality standards
consistently whilst being sustainable in the longer term.
•
The way health services are delivered needs to change in order to meet
the emerging needs of an ageing population in which many more people
live with long term conditions. This means that more resources must be
directed towards services based in the community, keeping people out of
hospital unless they really need to be there.
•
Commissioners have already made progress on improving care outside
hospital in south east London, and the strategy aims to build on that by
delivering better integrated care outside hospital, meaning less care
delivered in hospitals and more in the community.
•
•
The programme is being shaped by six Clinical Leadership Groups (one for
each of the priorities above). Each of these groups includes clinicians,
commissioners, social care leads and other experts, Healthwatch
representatives and other patient and public voices from across south east
London.
•
Each of these groups has developed a model of care which forms part of
the integrated whole system model described on page 64. Each Clinical
Leadership Group has developed a number of interventions and assessed
the impacts of these interventions in terms of delivering improved quality,
better and less variable outcomes for people across south east London
and that they provide value for money and support a sustainable whole
system health and are economy
NHS Five Year Forward View and Better Health for London
•
We know that a 'one size fits all' model will not work for the NHS, which is
why we are responding to local needs. Our vision for the future is also in
line with the NHS Five Year Forward view and the aspirations and
recommendations of the London Health Commission.(Better Health for
London)
•
The NHS Five Year Forward View starts the move towards a different
NHS, recognising the challenges and outlining potential solutions to the big
questions facing health and care services in England.
•
The London Health Commission (now known as Better Health for London)
in November 2014 reported ten aspirations for the capital, with the main
aim of making London the healthiest major city in the world. The report
made a series of recommendations, including measures to tackle
childhood obesity, encouraging healthier lives, better support for people
with mental illness, improving GP access and more community support for
people with long term conditions.
For this purpose, six priorities for local healthcare have therefore been
identified for improvement. These are:
—
Community based care
—
Planned care
—
Urgent and emergency care
—
Maternity
—
Children and young people
—
Cancer
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 42
Introduction to the Our Healthier
South East London Strategy and
the approach taken to developing it
Programme Principles
•
For the purposes of identifying and implementing this strategy, the
Commissioning Strategy Programme approach has been based on the
following principles, which have additionally been reflected in the
governance and delivery structure:
—
Being based on local needs and aspirations, listening to local voices
and building on work at borough level, whilst taking into account
national and London policies
—
Focusing on improving health outcomes and reducing inequalities
—
Employing a strong partnership approach, led by NHS
commissioners and involving closely a wide range of local partners,
including patients and communities, local authorities and NHS
partners, to build agreement on priorities, strategic goals and
outcomes
—
Creating solid foundations by ensuring all stakeholders have a
common understanding of the scale of the challenge and then a
shared vision and ambition for the next five years
—
Being open and transparent throughout the process, from
identification of need, to implementation of the strategy
—
Engaging broadly, building on existing borough-level work with wider
engagement activity to complement this as appropriate
—
Working with the Health and Wellbeing Board in each borough.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Programme governance structure
•
The Commissioning Strategy Programme governance has been designed
to sit within the existing governance and decision making structures of the
CCGs and NHSE. It also provides new formal forums to undertake the five
key governance elements of the programme:
—
Senior joint forum for strategic direction and decision making
(equivalent to a Programme Board) – the Clinical Commissioning
Board
—
Collaborative forum for partnership working – the South East London
Partnership Group
—
Clinical forum to guide design work – the Clinical Executive Group
—
Delivery focused forum to manage design and implementation
activities – the Implementation Executive Group.
—
Collective forum for the patients to contribute to shaping the strategy’s
content – Public and Patient Advisory Group
•
These functions are supported by a programme management structure to
support clinical design and implementation activities.
•
The Clinical Commissioning Board provides the link between programme
governance and business as usual governance within commissioning
bodies: NHS England governance for direct commissioning and the CCG
Governing Bodies.
•
The Clinical Commissioning Board currently reports via the existing Clinical
Strategy Committee to the CCG Governing Bodies, who are responsible
for making formal decisions in public relating to the proposed
Commissioning Strategy. The CCGs have now proposed to establish a
committee in common for Strategic Decision Making for collaborative
decision making on strategic issues. This arrangement also provides the
link, through existing local arrangements, to the Health and Wellbeing
Boards to ensure alignment with their strategies and obtain agreement for
the Better Care Plans.
Draft in progress | 43
Introduction to the Our Healthier
South East London Strategy and
the approach taken to developing it
Overview of the programme
The diagram below summarises the governance structure for the five year commissioning strategy. However, it should be noted that a Committee in Common is
currently being proposed as an additional decision making body.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 44
Draft in progress | 45
Stakeholder
Communications and
Engagement
South east London providers and partners
•
•
Working on behalf of the six CCGs and NHS England, the programme
engages and works in partnership with a wide range of stakeholders and
organisations.
•
Providers
—
Across south east London the six CCGs work with seven main
providers as demonstrated on slide 31. These are:
—
King's College Hospital NHS Foundation Trust - a local and
specialised acute hospital
—
Guy's and St Thomas' NHS Foundation Trust - local and specialised
acute hospital focusing on residents of Lambeth and Southwark
—
Lewisham and Greenwich NHS Trust – a local acute hospital with
some specialised acute services and community care services
—
Dartford and Gravesham NHS Trust – a local acute trust
—
South London and Maudsley NHS Foundation Trust – a mental
health trust focusing on residents of Lambeth, Lewisham and
Southwark
—
Oxleas NHS Foundation Trust – a mental health trust focusing on
residents of Bexley, Bromley and Greenwich
—
Bromley Healthcare Community Interest Company
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
•
In addition to the six acute providers there are also:
—
GP practices
—
Voluntary and third sector organisations
—
Local authority social care services
—
England and London wide partners
The CCGs also work closely with NHS organisations in London and across
England These organisations include:
—
London Ambulance Service
—
Department of Health
—
NHS England
—
Neighbouring CCGs
—
NHS South East Commissioning Support Unit
—
Public Health England
—
Local authority partners
The CCGs have strong partnerships with local authorities to take into
account the various health and wellbeing groups that operate within local
authorities.
Draft in progress | 46
Stakeholder
Communications and
Engagement
Overview and approach
•
Our approach to developing the strategy has been strongly focused
around communicating and engaging and working in partnership with our
stakeholders.
•
Commissioners continue to design and develop the strategy with
partners, patients, local people and key stakeholders, with thinking and
planning being developed and amended through the engagement
process.
•
•
•
The strategy is clinically-led and developed, with over 300 clinicians,
nurses, allied health professionals, social care staff, commissioners and
others developing ideas through the six Clinical Leadership Groups.
These Clinical Leadership Groups also include Patient and Public Voices
and Healthwatch representatives to ensure that a patient voice is heard at
all points in the development of the strategy.
In addition to ensuring that patient and public voices feed directly into the
Clinical Leadership Groups and supporting work streams, commissioners
have been engaging widely from the beginning by building on existing
local borough-level work.
A series of deliberative events were held in June 2014, December 2014
and February 2015 looking at peoples current experiences of care and
particularly at the more recent events, how peoples experiences might be
enhanced in the future by these new models of care. Capturing feedback
from engagement activities is systematic and transparent. All
contributions are recorded and fed back into the strategy via programme
managers - ensuring that local views influence strategy development.
Examples of feedback and how it is being used are published via ‘You
Said, We Did’ reports which are published on the website as well as the
full reports of deliberative events and other activity.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
Engagement and communication is led by CCGs via the Communications
and Engagement Steering Group which has met at least monthly since
May 2014. The group consists of CCG Communications and Engagement
leads. Leads from NHS providers and local councils have also been invited
to attend.
•
Engagement at local level and through local channels is on-going. This
was primarily focused on the case for change during 2014, with a wider
focus on the whole system model and emerging ideas in the spring of
2015. This included gathering patient stories and using materials
developed by engagement partners Innovation Unit, Local engagement on
the Issues Paper commenced in May 2015.
•
A variety of methods have, and will be, used to gather the views of a broad
spectrum of patients and the public. Activities will include:
—
borough level deliberative events
—
focus groups with specific communities
—
utilising the existing mechanisms and opportunities identified through
our Clinical Commissioning Groups’ engagement colleagues.
Draft in progress | 47
Stakeholder
Communications and
Engagement
Direct involvement of patient and public voices
Patient and public voices (PPVs) and Patient and Public Advisory Group
(PPAG)
•
Patient and public voices have been involved in the Clinical Leadership
Groups since June 2014. Each of the Clinical Leadership Groups has at
least three patient and public voices and one Healthwatch representative,
who are supported by the Patient and Public Voice Project Manager and
the Programme Manager in each area.
•
The PPVs come together in a Patient and Public Advisory Group (PPAG)
forum for peer support and to strengthen public and patient voices across
the strategy, which meets every 6-8 weeks. The PPAG enables members
to explore a range of issues not covered within the individual Clinical
Leadership Groups; review key draft documents from the south east
London commissioning strategy programme, advising on clarity of
message and the development of plain English versions; and contribute
to engagement plans and activities, complementing the advisory role of
the South East London Stakeholder Reference Group.
•
The PPAG has undertaken a number of ‘deep dive’ sessions into each of
the Clinical Leadership Groups, the workforce supporting strategy, whole
systems model and whole systems outcomes enabling members to
contribute to all the areas of the programme. The PPAG has also
reviewed the first Equalities Impact Assessment and identified priority
areas for the next Equalities Analysis.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
PPAG has formed a reading group to review public facing documents to
ensure that the language is suitable for the public to understand. This has
included the Case for Change summary for the programme; website; the
Issues Paper; and newsletters. Changes were made to all of these
documents following feedback from the Reading Group, including the
addition of questions to the Frequently Asked Questions (FAQ) list;
changes to terminology; reordering of contents; use of simpler English; and
addition of information.
•
The Patient and Public Advisory Group members themselves suggested
that we should not rely wholly on the Reading Group. We have therefore
committed to ensuring that key materials will be sent to the external Plain
English campaign to be kite-marked with their ‘plain English’ mark,
although this will depend on timescales and other practical considerations.
•
Members of PPAG have been involved in discussions to shape the short
film to introduce ‘Our Healthier South East London’ and have been
included in the film itself. They have also been involved in the procurement
of: external support for the programme and for workforce development.
Draft in progress | 48
Stakeholder
Communications and
Engagement
Wider engagement
Early engagement activities and feedback - Case for Change for south
east London
•
•
The early public engagement on the strategy focused on testing the draft
case for change via CCG engagement routes. The Case for Change was
developed by local clinicians, social care and public health professionals.
It looked at the most important health issues for people in south east
London. It is based on local needs and aspirations and builds on work
carried out already at borough level, while also taking into account
national and London-wide policies.
Dedicated engagement events:
•
Wider testing of the work of the Clinical Leadership Groups and the
overall shaping of the strategy has also been carried out to further test
developing ideas. These have included:
•
Two south east London-wide engagement events involving more than
100 invited representatives of voluntary and public stakeholder groups,
the public and patients
The events were led by clinicians, social care professionals and CCG
commissioning leads. Rich feedback was provided and participants
welcomed the overall direction of the strategy. Detailed feedback was
gathered and used directly to shape strategy development and
engagement.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
—
Participants agreed with most of what they had seen of the draft
strategy. A need for more detail on some of the aims was expressed,
with helpful suggestions for additional focus areas
—
Participants broadly agreed the case for change reflected their
experiences.
—
Participants broadly agreed with the strategy’s clinical themes which
they explored. However it was felt that there is a need for further detail
and more focus on certain elements. Additional helpful suggestions
were made.
•
Participatory workshops (December 2014 and February 2015)
Four workshops were held across south east London - for the boroughs of
Lambeth and Southwark; Bromley; Bexley; and the boroughs of Greenwich
and Lewisham. 110 people participated across the four workshops.
•
The aims of the workshops were to:
Deliberative events (June 2014)
•
The headline reports from these meetings are available at
http://www.ourhealthiersel.nhs.uk/Feedback. Key messages and
comments included:
—
Familiarise people with the purpose and main messages of the
strategy
—
Listen to people’s experiences and thoughts about current services
—
Gather feedback on behalf of the programme team to be fed into the
further development of the strategy
Draft in progress | 49
Stakeholder
Communications and
Engagement
•
The events were led by CCG chief officers and the programme team. A
number of members of the programme’s Public and Patient Advisory
Group attended. Detailed feedback was gathered and four overarching
themes connected all the comments:
—
Person-centred care: people talked about the importance of building
relationships of trust with health and care professionals, of getting
support that takes account of their wider health and social needs, of
feeling listened to and respected
—
Seamless and continuous care: people talked of the lack of
coordination between services and the need for better ways of
sharing information about patients and connecting provision, so that
patients do not have to knock on multiple doors to get the right help,
or indeed fall into gaps between services
—
The importance of support networks in the community: being
connected to networks of support in the community makes a vital
difference on people’s health, quality of life and how much they need
to rely on formal health and care services
—
The need for better information and signposting: people recognised
that there is a wealth of services, which are perhaps not being used
to their full potential because of lack of clarity on what is available
and how to access it, from alternative options to ambulance and
A&E, to support services in the community.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
All of this feedback has been shared with the programme and the Clinical
Leadership Groups to consider as part of the development of the plans.
•
Reports on these are available including format, agenda and responses
and can be found in Appendix C
Market research:
•
An independently-run telephone survey with a representative sample of
local populations to gain deeper insight into local people’s views on priority
areas for the strategy’s Clinical Leadership Groups was carried out in July
and August 2014. This was supplemented with more in-depth face-to-face
surveys with groups of people with those protected characteristics for
which it would not be realistic to obtain a statistically valid sample through
the telephone survey. These individuals were contacted via local
community groups and surveyed in July and August 2014 via in-depth
interviews by an independent research company.
•
This research fed into the development of the programme’s Clinical
Leadership Groups to consider as part of the development of the strategy
and the emerging clinical models.
•
A report on findings can be found in Appendix C.
Draft in progress | 50
Stakeholder
Communications and
Engagement
Community research
•
A number of drop-in sessions were held during November and December
2014 with the aim of talking to people in different groups about their
experiences of care, to provide richer insights to support the work that
Clinical Leadership Groups are doing to design new models of care. The
sessions focused on maternity, children and young people, urgent care
and Local Care Networks.
—
5 November 2014 - Community research with new or expectant
parents. Drop-in session at Northend Children’s Centre, Bexley
—
6 November 2014 - Community research with new or expectant
parents. Drop-in session at St Augustine’s Children’s Centre, Bexley
—
11 November 2014 - Community research with people with cancer –
a drop-in session at Greater London Support Group (part of Prostate
Cancer Support Federation), Lambeth
—
13 November 2014 - Community research with families, children and
young people. Drop-in session at Kaleidoscope, Lewisham
—
25 November - Community research with people with cancer – a
drop-in session at St Christopher’s Hospice, Bromley
—
29 November 2014 - Community research with families, children and
young people. Drop-in session at Lewisham paediatric A&E
—
8 December 2014 - Community research with people with cancer.
Drop-in session at Waterloo Action Centre, Lambeth
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
Altogether 59 people and families were involved in this research,
representing a range of backgrounds.
•
The key insights about what excellent services look and feel like and what
outcomes are most valued have been used as part of the Care Design
Guides produced by the Clinical Leadership Groups, which set out
proposed models and interventions. The research also led to the
development of a set of case studies showing current patient journeys and
key points where the future journey will improve the health and the
experience of patients. These case studies are being used in on-going
engagement work and have been used to bring the abstract ideas to life.
In-depth case study research
•
Alongside the drop-in sessions, a number of detailed case studies were
produced to be used by Clinical Leadership Groups to explore what their
planned models might mean for patients; and for further engagement
research. The case studies and engagement materials have been tested
with patients through local engagement events in March and April 2015.
•
Details on the case studies can be found in Appendix C
Draft in progress | 51
Stakeholder
Communications and
Engagement
“You said, we did” reports
Communications
•
•
As part of the programme, ‘You Said, We Did’ reports are produced that
summarise our engagement work and include samples of the feedback
that we have received along with our responses to the feedback. All
feedback and responses to the programme are logged centrally and
shared with the appropriate groups for action and response. Some
specific examples are below:
Local Care Networks: more person-centred care and focusing on
keeping well
•
You said:
—
“People who live alone are much less likely to come forward for
screening, so campaigns should be targeted at them”
—
“There should be more proactive care to stop greater needs arising
down the line. This doesn’t need to be provided by a highly-paid
professional, they could be a volunteer.”
—
•
“I found I ended up having to coordinate medical staff, and I think
this was particularly hard as I have other health conditions as well as
cancer.”
Regular communications with programme stakeholders is fundamental to
ensuring that there is an awareness and understanding of the strategy.
This includes:
—
Monthly updates to Governing Bodies
—
Updates to Health and Well Being Boards at programme milestones
—
Monthly public-facing updates, shared via CCGs and the programme
website
—
Weekly emails to CCGs and members of the programme groups
—
Programme website, www.ourhealthiersel.nhs.uk launched October
2014
—
Twitter stream launched May 2015
—
Working with CCGs to ensure patients and residents know initiatives
currently underway
We did:
—
A key element of the Local Care Networks is to support people to
live healthier lives. There will be a greater focus on prevention as
well as advice and treatment. Local Care Networks will draw on a
range of specialists, service providers and community groups
including those in the voluntary sector to help people stay well
and/or manage their conditions. Care navigators will help ensure
care is co-ordinated with the patient at the centre. Targeted wellness
programmes are a key part of this (and specifically for cancer),
which will take into account current research on what campaigns are
most effective and how to target people .
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 52
Stakeholder
Communications and
Engagement
Accessible materials
Equalities analysis
•
•
In order to ensure that our strategy is informed by the diverse population in
south east London and to enable us to fully understand the potential impact
on communities with protected characteristics (as well as complying with
the Equalities act 2010) we have, and will, conduct equalities analyses
throughout the programme.
•
An initial equalities impact assessment was carried out at the beginning of
the programme. Building on this, the programme has commissioned a
second equalities analysis to be conducted in June 2015 and to influence
the focus of pre-consultation engagement work (if consultation goes
ahead).
We are committed to ensuring that our public facing documents are
understandable. As such we work with the PPAG reading group to shape
and improve all public facing documents. Their input has enabled us to
produce a number of materials in plain English, such as a summary of the
strategy and the case for change (August 2014); Issues Paper and
summary Issues Paper (March 2015); and Easy Read versions of the
Issues Paper.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 53
Draft in progress | 54
The case for
Change
Outline of the case for change: Why we are developing the
strategy
•
•
Our health outcomes in south east London are not as good as they
should be.
—
Too many people live with preventable ill health or die too early
—
The outcomes from care in our health services vary significantly and
high quality care is not available all the time
—
We don’t always treat people early enough to have the best results
—
People’s experience of care is very variable and can be much better
—
Patients tell us that their care is not joined up between different
services
—
The social care system is under increasing pressure
—
The money to pay for the NHS is limited and need is continually
increasing
—
It is taxpayers’ money and we have a responsibility to spend it well
—
South east London’s acute, community and mental health providers
face a similar and interrelated set of challenges and drivers
The longer we leave these problems, the worse they will get. There is a
need to change what we do and how we do it. The rest of this section
describes the above points in more detail and sets out our case for
change in south east London.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
The full case for change is available on our website
www.ourhealthiersel.nhs.uk It is currently being updated to include the
latest figures and supporting information.
Too many people live with preventable ill health or die too early
•
In south east London premature death and differences in life expectancy
are both significant issues. There is a difference in life expectancy between
the most and least deprived wards of 8.7 years for women and 9.3 years
for men. When it comes to healthy life expectancy – by which we mean,
people living in good health – that difference increases to 18 years gap.
3,603 people died prematurely across south east London in 2013,[1] with
four of our boroughs having higher rates of premature death than England
and London. The biggest causes of early death are heart disease, cancer
and respiratory diseases.
•
While the mortality rates for these illnesses have decreased significantly in
our area in recent years, they are still considerably higher than the London
average. To address this problem, we need to improve the health of people
who live in south east London.
•
From a UK wide perspective, the health of our population is poor and
worse than comparable countries. The UK is ranked 10th out 11 countries
for people living health lives. Our poor health is a major factor in generating
the demand for care which is putting the NHS and social care under such
well publicised pressure. People are living longer than ever before, but this
means many more people are also living with long term conditions such as
diabetes, high blood pressure and mental illnesses.
[1] Source: HSCIC Indicator Portal, under 75 mortality for all causes in 2013.
Draft in progress | 55
The case for
Change
•
•
•
The diagram opposite breaks the population into five broad groups;
people known to be nearing the end of life (1%), people with three or
more long term conditions (9%), people in the early stages of a long term
condition (25%), people experiencing inequalities or putting their health at
risk (49%) and people who are healthy and well (16%). The higher up the
“tree” the more money is spent on that group.
The major causes of “health inequalities” between people in south east
London and elsewhere in the UK are smoking, excess alcohol and drug
use, not enough exercise and obesity, and poor mental health.
Our aim is to help people move towards the “trunk” and into the healthy
and well group. To do this we must support the 49% of the population
who are affected by inequalities and who are at risk of developing long
term conditions due to inequalities or lifestyle factors.
•
The outcomes from care in our health services vary significantly and high
quality care is not available all the time.
•
Too often, the quality of care that patients receive and the outcome of
their treatment depend on when and where they access health services.
For example, we do not always provide the recommended level of cover
by senior doctors in services dealing with emergency care, maternity or
children. People taken ill at weekends or in the evenings are less likely to
see a senior doctor in hospital.
Costs
EoL
Early
(1%)
stages
18,000 residents
of LTC
3+
LTC
(25%)
(9%)
153,000
residents
Early stages
of LTC
(25%)
445,000 residents
People experiencing
inequalities or putting
their health at risk
(49%)
870,000 residents
Health and
wellbeing group
(16%)
276,000 residents
People with multiple complex needs where standard
services are not effective who need personalised care
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 56
The case for
Change
We don’t always treat people early enough to have the best results
Patients tell us that their care is not joined up between different services
•
Our services are often not set up to detect problems soon enough,
meaning that people with long term conditions or mental illness often
have to be admitted to hospital in crisis. Earlier diagnosis and support
could have helped them to get better sooner or prevented their illness
becoming so serious.
•
•
In this respect, we are not putting enough emphasis or resources into
services based in the community, to prevent people becoming ill or
encourage them to take responsibilities in managing their own health.
Patients and carers find it frustrating to have to continually provide the
same information to different people. This is because different parts of the
NHS do not always communicate effectively with each other or with social
services. This results in patients with complex conditions often being
passed from one service to another. In particular, patients sometimes stay
longer in hospital because joined up arrangements for their care in the
community on and after discharge have not been put in place.
People’s experience of care is very variable and can be much better
•
While patients are very happy with some services, surveys tell us that
their experience of the NHS is inconsistent and that they do not always
receive the care they want. Patient satisfaction in south east London is
generally low compared to national benchmarks. Four of our boroughs
scored in the bottom 25% for patient satisfaction in hospital care and
three of four trusts were in the bottom 25% for the ‘Friends and Family
Test’, which tests whether patients would recommend the trust to friends
and family.
•
Therefore it is crucial that we provide consistent, high quality services for
everyone in south east London.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 57
The case for
Change
The social care system is under increasing pressure
•
Many local authorities face unprecedented pressures on their resources
and in some instances are looking to save over 30% of their current
expenditure over the next 3-4 years.
•
Demand in services is growing in some areas with increasing numbers of
older residents, residents living much longer with complex care and
health needs, increased mental health service demand alongside the
continued need to support those with lifelong health and care needs to
live as independently and as full a life as possible.
•
Council investment is increasingly focused on statutory provision, thus
reducing any ability to work creatively with universal and preventative
services. In due course, this could have further significant impacts on
demand for health and care services.
•
Added to this, requirements on social care providers continue to increase
(examples include minimum wage increases and statutory holiday
increases) without increases in funding - yet the level of complexity that
we expect these organisations to support continues to rise. If we are to
provide high quality community based care, we need to further develop
and value this workforce.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
The implementation of the Care Act 2014 places new duties on local
authorities and partners to promote wellbeing and prevention within
communities to help reduce or delay the need for care. From April 2016,
there will be a cap on individual contributions to the cost of their care.
Although welcome, this focus comes without any certainty on the costs
associated with these new duties, nor of the increased demands from
people who use services and their carers.
•
Furthermore, developing implications of case law with regard to the Mental
Capacity Act and Deprivation of Liberty Safeguards (DoLS) are adding
significant new duties and pressures on adult social care, putting additional
pressures on care homes and hospitals to ensure that people are not
illegally deprived of their liberty. A focus on care at home can best reduce
the trauma of change for those with impaired capacity and consequently
help reduce the need for DoLS assessments.
Draft in progress | 58
The case for
Change
•
•
•
NHS funding currently increases in line with inflation each year. However,
the costs of providing care are rising much faster because the NHS is
now treating more people with more complex conditions than ever before
and the costs of care often grow faster than consumer inflation.
The NHS Five Year Forward View outlines a £30 billion financial
challenge nationally by 2020/21. Consistent with this, in the absence of
action, the scale of the affordability challenge in south east London is
forecast to grow to £1 billion by 2019/20. The graph to the right and the
table below demonstrate how this challenge grows over this period.
Local authorities, who are responsible for social care services, are also
looking to save over 30% of their current expenditure over the next 3-4
years. Therefore we need to get better value for money for all that is done
in the NHS and social care services. We need to get the best possible
outcomes for patients and make the most of resources that are under
increasing pressure. This means we need a more integrated approach
between different services.
System wide income/expenditure (£
millions)
The NHS faces a growing affordability challenge
5,900
5,903
5,400
4,900
4,812
4,400
Expenditure (Do Nothing)
Revenue
3,900
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
Absolute challenge
Annual challenge
Percentage challenge
Over the period from 2014/15 to 2019/20, the south
east London expenditure (without efficiencies) will
grow by just over £1 billion more than the projected
budget of £5 billion. This is comparable with the £30
billion national challenge set out in NHS England’s
Five Year Forward View.
On average, the south east London healthcare
system will need to make efficiencies of £218m each
year (from a budget which will grow to £4.8bn)
between 2014/15 and 2019/20.
On average, the south east London healthcare
system will need to make efficiencies of 4.2% each
year between 2014/15 and 2019/20.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
An estimated annual breakdown is shown below.
An estimated breakdown is shown below.
14/15
15/16
16/17
17/18
18/19
19/20
14/15
15/16
16/17
17/18
18/19
19/20
£251m
£228m
£154m
£162m
£141m
£156m
6.0%
5.3%
3.4%
3.5%
3.0%
3.2%
Draft in progress | 59
The case for
Change
It is taxpayers’ money and we have a responsibility to
spend it well
•
We know that by providing services in a different way, it is
•
possible to improve outcomes, to help people to live healthier lives, to
deliver services which are consistently of high quality and get more for
our money.
•
As an example, changes have been made in the acute treatment of
stroke, major trauma and heart attacks in London: services are now
provided in a small number of specialist centres rather than in every
hospital and this has transformed outcomes. More people now survive
strokes, major trauma injuries and heart attacks in London than ever
before. In bypassing their local hospitals to these centres, the care they
receive is much better. These changes have also saved money for the
NHS so we know that such cost effective changes are possible. A study
showed that the changes to stroke services saved 12% more lives
(around 400 lives a year) and £811 per patient, in spite of the costs of
setting up the new system.
•
Nationally 16 million people attend A&E each year, but 40% needed no
treatment or could have been managed by their GP. This adds
unnecessary costs to the system and create delays in planned hospital
care. Additionally there are problems of access to GP appointments
which can put added pressure on the system; in producing meaningful
discharge and care plans; and in producing better outcomes after surgery
and cancer treatments. Changes are needed to reduce unnecessary
costs in order to get more value for the limited money available to the
NHS.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 60
The case for
Change
South east London’s acute, community and mental health providers
face a similar and interrelated set of challenges and drivers
•
A number of drivers and issues are shaping the strategic context for
provider organisations in south east London. The key issues and drivers
for providers include the following:
—
A constrained financial environment
—
The implications of regulatory changes and recent key
recommendations in relation to safety, quality and patient care
(including the Francis Report, the Berwick Report, recommendations
as a result of Winterbourne View, the Urgent and Emergency Care
review, and the Future Hospitals Commission)
—
Uncertainty in the system about the long term provider landscape
and future patient flows
—
Local service integration including primary care and integrated
community care
—
Emergency centre designation
—
Specialist service consolidation / designation in line with the national
strategic direction
—
New workforce models in response to the need for ambulatory
upskilling and staff shortages within the existing workforce
—
Information Management and Technology, which will be a key
enabler of change for providers, but will also demand time and
investment.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
In addition, London’s ambulance services are facing increasing and
changing needs for care. Some of the key factors affecting the service
include:
—
Increasing demand, whereby over the last three years there have
been significant changes in the health needs and expectations of
Londoners, with a total increase in incidents of 5% between 2011 and
2013.
—
Changing profile of demand by illness, including an 11% increase in
alcohol related calls between 2011 and 2013; a 19% increase in chest
pain related calls between 2011 and 2013; and an 11% increase in
dyspnoea calls between 2011 and 2013
—
Diversion between demand growth and level of funding
—
Changing patient needs including those on an ageing population, high
and increasing diversity of population, increasing issues as a result of
population not registered with a GP, and the need to address the
symptoms of mental illness
—
Utilisation of staff significantly above the rest of the country.
Draft in progress | 61
Draft in progress | 62
Vision for the future of
health and care services
in south east London
Vision for the case for change
•
To solve the problems outlined in the case for change, we have developed a collective vision for south east London. In south east London we spend £2.3billion
in the NHS. Over the next five years we aim to achieve much better outcomes than we do now by:
—
Supporting people to be more in control of their health and have a greater say in their own care
—
Helping people to live independently and know what to do when things go wrong
—
Helping communities to support one another
—
Making sure primary care services are consistently excellent and have an increased focus on prevention
—
Reducing variation in healthcare outcomes and addressing inequalities by raising the standards in our health services to match the best
—
Developing joined up care so that people receive the support they need when they need it
—
Delivering services that meet the same high quality standards whenever and wherever care is provided
—
Spending our money wisely, to deliver better outcomes and avoid waste.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 63
Vision for the future of
health and care services
in south east London
Our integrated whole system model
Community Based Care delivered by Local Care Networks is the foundation of the integrated whole system model that has been developed for south
east London. This diagram provides an overview of the whole system model, incorporating initiatives from all 6 Clinical Leadership Groups.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 64
Draft in progress | 65
Proposed model(s) of care:
Delivering better care for our
south east London populations
Introduction to the care models
Purpose
•
•
This section provides an overview of how these interventions have been
developed through engagement with wider stakeholders and the public.
•
We then provide an overview of the Community Based Care model
followed by more detail on the remaining Clinical Leadership Groups.
•
Each of the CLGs provides a high level summary of the Clinical Leadership
Group’s proposed interventions. This is followed by more detailed
information on each individual intervention for the care model. This
provides:
•
To develop the initiatives to focus on these aims, the Clinical
Commissioning Groups and NHS England – London region have
identified the six priority areas to deliver better care for our population.
These are:
—
Community based care
—
Planned care
—
Urgent and emergency care
—
Maternity
—
The purpose of the intervention
—
Children and young people
—
A detailed summary of the proposed intervention
—
Cancer
The programme is being shaped by six Clinical Leadership Groups (one
for each of the priorities above) which form part of the integrated whole
system model and have developed. They have each developed a number
of interventions and assessed the impacts of these interventions in terms
of delivering improved quality, better and less variable outcomes for
people across south east London and that they provide value for money
and support a sustainable whole system health and are economy.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
Each of the Clinical Leadership Groups includes clinicians, commissioners,
social care leads and other experts, Healthwatch representatives and other
patient and public voices from across south east London who have worked
together to develop these initiatives. Further information on each of the
care models is provided in each of the Clinical Leadership Group Design
Guides.
Draft in progress | 66
Proposed model(s) of care:
Delivering better care for our
south east London populations
Engagement and input into the Clinical Leadership Groups
•
Our Healthier South East London overarching programme has
encouraged and supported engagement from a wide range of
stakeholders and patients.
•
In particular, the Clinical Leadership Group membership comprises
representatives from CCGs, Local authorities, patient and public voices,
the voluntary sector, public health and clinicians. Their insight has been
woven into the care models and their design. This was via events that
created an opportunity for communities and patients to explore proposed
changes to the models and find solutions together to meet specific
challenges identified in the case for change.
•
In addition, we recognise that the experience and perspectives of patients
and others are integral to the development of a truly service user centred
model. Service users, patients and members of our local communities
have therefore been engaged through a variety of mechanisms.
•
The programme has engaged a large group of public and patient voice
(PPV) representatives with a growing focus on ensuring they represent
the needs of the whole population including those who experience
inequalities. The programme has an active Patient and Public Advisory
Group (PPAG) and each model of care has been developed with the input
of a small group of PPVs.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
In addition, patient stories have been gathered from across south east
London to help groups think through what elements of a new model of care
could be of benefit to individuals and any current barriers to receiving
effective quality care we should consider changing for the future. The aim
is also for these patient stories to facilitate wider discussions with partners,
patients and the public about their own experiences of health and social
care in order to encourage and facilitate discussion to inform service
development in the strategy. The following two pages summarise patient
views on the Community Based Care model and the overarching system
model.
•
Importantly, the model design recognises the need for a continuous quality
improvement culture during implementation and delivery whereby
providers and commissioners act as system stewards facilitating a
feedback and improvement cycle underpinned by the voice of the patient.
Engagement to date
•
Specific engagement for the Clinical Leadership Groups has been
managed through the Innovation Unit as co-design sessions held different
locations to reach the population of the six boroughs. The sessions
targeted a mixed group of participants (including community, patients,
carers, clinicians, provider representatives and representatives of care
homes). This engagement is in addition to those led by individual CCGs
and is in addition to the involvement of Patient and Public Voices in the
Clinical Leadership Group membership and through workshop attendance.
Draft in progress | 67
Proposed model(s) of care:
Delivering better care for our
south east London populations
Engagement to date
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 69
Draft in progress | 70
Community
Based Care
The vision for Community Based Care
•
Community Based Care aims to focus on the following:
—
Strong and confident communities supporting people to maintain
and regain health and social wellbeing and to continue to live at
home.
—
Delivery of primary and community based care in the broadest
sense, to geographically coherent populations and at a scale that
respond to the varied needs and characteristics of our
communities with a focus on reducing inequalities.
—
A broadly defined integrated “care team” for the population,
including community physical & mental health, social care, housing,
voluntary sector and specialists services coming together around the
holistic needs of the person.
—
Primary, community and social care that focuses on delivering
proactive prevention, equitable and timely access, effective coordination and continuity of professional accountable services
for individual’s care.
—
A systematic risk stratification and problem solving approach
to identify people who require additional co-ordinated
multidisciplinary and multi agency assessment, support and
treatment to improve their quality of life, live more independently and
have rapid access to specialist community based support when
needed, including those requiring support within an end of life
pathway.
—
Involved and informed patients and carers, with care plans
developed by and with them, to support them to stay independent
and active and encourage self-management.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
Adaptable and capable staff working together between hospital and
community services, mental health, social care and the voluntary sector to
provide joined up, flexible assessments and care packages to provide a
seamless service from a patient’s perspective.
•
Responsive services providing access from 8am – 8pm seven days a
week, so that patients are confident they will receive a prompt assessment
if they are at risk of admission to hospital, and proactively planned
discharge from hospital to ensure re-ablement care and follow up is
provided.
•
Delivery of consistently high standards of care with clear outcome
measures that can demonstrate improvements in population health, quality
of life, quality for care and effectiveness of care across south east London.
•
For those with multiple complex needs or long term conditions, a focus on
secondary prevention with the aim of improving underlying conditions
and preventing deterioration or development of further long term
conditions.
•
Recognition that the future healthcare needs to be sustainable, with a
shift in spend towards prevention and care delivered outside of hospital.
•
Connected and intelligent IT that shares health information not just data.
Use of technology in people’s home that allows the delivery of healthrelated services and information via telecommunications technologies to
support self-management and independence.
•
A relentless focus on the physical health and wellbeing of people with
enduring and significant mental health problems.
Draft in progress | 71
Community
Based Care
Characteristics of Community Based Care
•
Delivery of community based care through the platform of Local Care
Networks will be achieved in line with seven Characteristics of Care:
—
More accessible primary and community care
—
Timely and prompt assessment
—
Enhanced health promotion and disease prevention
—
Proactive and empowering care
—
Seamless co-ordinated care
—
Multidisciplinary holistic care
—
Continuity of care professional
•
Community Based Care will be delivered through Local Care Networks .
The services available will be proactive, accessible, coordinated and
provide continuity; with a flexible, holistic approach to ensure every contact
counts. This will be primary care delivered to geographically coherent
populations, at scale, whilst still encouraging self-reliance
•
24 local care networks are being developed to support whole populations
across south east London. This will be a universal service covering the
whole population ‘cradle to grave’. A local care network will involve
primary, community and social care colleagues working together and
drawing on others from across the health, social care and the voluntary
sector to provide proactive patient centred care. Services will be delivered
in ways that respond to the varied needs and characteristics of our
communities.
•
This is core to the Community Based Care Target Model which provides a
summary of the central community based care services which are part of
the Local Care Network and how they work with other services in the
system. This also summarises how these services are 'big hitters' for the
whole system. More detail on the Community Based Care Target Model is
provide on the following slide.
Local Care Networks
•
Local Care Networks are a key characteristic and centrepiece of the
strategy and sits within Community Based Care (CBC)
•
The CBC Clinical Leadership Group aims to support people to live
healthier lives and reduce those people exposed to risk factors either by
birth or behaviour. For people with a long term condition, Community
Based Care will take a rehabilitative/ re-ablement approach enabling
people to manage their own health positively and to prevent deterioration
wherever possible. For those people with complex long term conditions or
who are in the last year of life, support will be available to enable them to
continue to lead as full and active life as possible.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 72
Community
Based Care
The Community Based Care Target Model
•
The strategy sets out an agreed target model for local care networks that will deliver community based care. It is intended that each Local Care Network
across south east London delivers the target model. However, the target model will have to be tailored to the local community that it serves.
Integrated Single System Leadership and Management
‘The Core’ (as a minimum all
LCNs should encompass)
Serving geographically
coherent populations
between 50,000 – 150,000
Southwark
•
•
•
•
•
Greenwich
Bexley
Lambeth
Lewisham
•
•
•
•
•
Leadership team
All general practices working at
scale (federated with single IT
system and leadership)
All community pharmacy
Voluntary and community sector
Community nursing for adults and
children
Social care
Community Mental Health Teams
Community therapy
Community based diagnostics
Patient and carer engagement
groups
Bromley
Working with…
•
•
•
•
•
•
•
•
•
•
•
•
•
Strong and confident communities
Accessible hospital outpatient treatment
clinics and acute oncology (urgent and
emergency and cancer care)
Specialist opinion (not face to face) and
clear specialist service pathways
Pathways to Multi Disciplinary Teams
Integrated 111, London Ambulance
Service and Out of hours system
(interface with Urgent care centres colocated with emergency department
model)
Housing, education and other council
services
Community based midwifery teams
Private and voluntary sector e.g. care
homes and domiciliary care
Cancer services
Children’s integrated community team and
short stay units
Rapid response services
Carers
And there will be others..
Big hitters
•
•
•
•
•
•
•
•
•
•
•
Supporting patients to manage their own
health (Asset Mapping, Social Prescribing,
education, community champions etc…
Prevention – Obesity, Alcohol and Smoking
Improved Core general practice access plus
8-8, 365
Enhanced call and recall – improves
screening and early identification and
management of long term conditions
Reduction in gap between recorded and
expected prevalence in long term conditions
Supporting vulnerable people in the
community including those in care homes
and domiciliary care
Reduction in variation (level up) primary
care management of long term conditions
Reablement – Admissions avoidance and
effective discharge
Multi Disciplinary Teams configuration –
main long term conditions
groups (incl. mental health) and Frail elderly
End of Life Care
Integrated Pathways of care
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 73
Community
Based Care
Community Based Care delivered by Local Care Networks
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 74
Community
Based Care
Local Care Network Development & Mobilisation
•
Local Care Networks form the core of the Community Based Care model. The proposed high-level approach to implementation of Local Care Networks across
south east London is therefore central to the strategy. It has been described as:
The case for
change and
outcomes
Identify why we
need to change
and what we
want to achieve.
Design
Agree the Target
Model (‘the core’,
‘working with’
and ‘big hitters’)
Strategic impact
assessment
Demonstrate the
activity & finance
implications for
the Target Model
assessing the
value equation;
patient outcomes
over cost
Local
interpretation
Using the target
model to
articulate shared
design principles,
interpret these to
meet the needs
of local
communities
Provider models
Looking at the
localised Target
Model, outline
options and select
provider model (for
example the
provider models
described in the
Five Year Forward
View)
Contracting and
business models
With a preferable
provider model
selected,
commissioners
consider the
contracting models,
and providers the
business model, that
enables them to
deliver
GP federation
Determination of core services and shared leadership
Determination of services that link into the Local Care
Network
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Population and
health outcomes achieved
Value
realisation = true cost of achieving those
outcomes
outcomes
Draft in progress | 75
Draft in progress | 76
Planned
Care
Planned care model
Key Features of the model
Standardisation
1
Reducing variation across the planned care pathway
from referral practice to discharge through the
co-development of high level standards.
Diagnostics
2
•
•
•
•
Enhance patient management by GPs
Rapid access to diagnostics for GP’s
Evidence based standardised Clinical pathways
Shared results across the system supported by
integrated IT systems
Elective Care Centres
3
Provider collaboration to create centres of excellence
for high volume specialities that drive up quality of
service provision and improve outcomes for patients
• Orthopaedic (hips and knees)
• Ophthalmology
Pathway Review
4
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
•
•
•
Urology
Neurosurgery
Nephrology
Gynaecology
Draft in progress | 77
Planned
Care
Intervention 1: Standardisation
The case for change
•
Patients do not receive the same standard of care across south east
London. In particular, there is variation in patient experience and
procedure outcomes for Planned Care.
The proposal
To co-develop high level standards across the planned care pathway
from referral to discharge.
•
Standardisation means patients can expect to receive the same standard
of care at every point on the planned care pathway. This initiative
therefore proposes to develop high level standards across the planned
care pathway from referral through to discharge.
•
Through this we recognise that standardisation is one of the primary
methods to reduce variation in a system* and that it is the foundation
upon which improvement in quality and costs is built**
References:
*Kohn LT, Corrigan JM. Donaldson MS, editors. To err is human: building a safer health system. A report of
the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National
Academy Press; 2000)
**1IHI: 1. Standardization as a mechanism to improve safety in health care. Rozich JD1, Howard
RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK)
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 78
Planned
Care
Intervention 2: Diagnostics
The case for change
•
NHS Atlas of Variation in Diagnostic Services have highlighted variation
in the provision of healthcare.
•
In particular, there is variation in GP access to diagnostics and access to
rapid diagnostic pathways across south east London
•
Non standardised diagnostic pathways leads to costly waste and
inefficiency in the system, delays and unnecessary duplication of tests all
impacting on patient experience and patient outcomes. This initiative
therefore aims to address this problem.
•
2.
•
The proposal
•
•
Diagnostic services underpin the effective and efficient management of
patient pathways and ensure that decisions made about patient care can
be made as quickly and accurately as possible*.
Evidence based standardised clinical pathways: Explore
potential and impact of local innovation programmes such as
Transforming Outcomes and Health Economics Through Imaging
(TOHETI) – GSTT & KHP.
Serious but unspecific symptom pathway - international case
study: Danish Model (Dr P Vedsted)
This model uses a "3 legged diagnostic strategy“ based on:
1.
Alarm Symptoms - urgent suspected cancer referral indicated
2.
Non Specific, serious symptoms (the difficult ones) referral to a
Diagnostic centre - fast multidisciplinary assessment
3.
Vague Symptoms ( the common)
•
If the GP cannot allocate the patient to an alarm pathway e.g. weight loss,
fatigue, cough etc, then the GP performs a filter function - imaging and
bloods within 2 days, e.g. CT body cavity with electronic transmission of
results to practice within 2 days.
•
If no diagnosis is reached following this initial set of tests , then the next
step is referral to a diagnostic centre which involves a single responsible
clinician working with a team of co-ordinators and imaging specialists.
Two models have been proposed to provide this service.
1.
Patient outcomes are negatively affected by inefficient and late diagnosis.
The TOHETI programme aims to improve patient outcomes and health
sector cost-effectiveness by changing the way in which imaging is used as
a diagnostic and therapeutic tool. This model could be considered for wider
use across south east London
References:
*NHS Atlas of Variation in DS 2003
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 79
Planned
Care
Intervention 3: Elective Care Model - Orthopaedics: Hips &
Knees
Case for change
•
•
The Briggs Report (March 2015) states that the population is living longer
and by 2030 over 15.3 million people in the UK will be over the age of 65
years. As a consequence, we will see an ever increasing demand on our
health resources which are already stretched (such as orthopaedic
referrals from GPs to secondary care providers which are currently
increasing by 7-8% per annum).
Variation in practice is therefore unsustainable and needs addressing
urgently. A more cost effective, patient outcome driven and coordinated
Planned Care Model is needed
The proposal
•
•
New provider models of partnership
Elective Care models are cost effective and deliver a multitude of benefits
for staff, patients & the organisations they serve.
This initiative therefore focuses on elective care centres for high volume
specialities. which would:
—
Consolidate service configuration across south east London
—
Provide a standardised pathway of planned care which:
o
Reduces variation in the quality of care and clincial outcomes
for patients
o
Minimises negative risk and error thus improving patient safety
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
As an example. the benefits and outcomes evidenced by south west
London Elective Orthopaedic Centre (SWLEOC) are:
—
Improved quality of care seen in reduced waiting times from 7.3 to 5.2
months.
—
Patients achieved their estimated date for discharge
—
90% patients achieved their estimated date for discharge (the national
average is 50%)
—
Average lengths of stay reduced from 6.2 days to 4.9 days
—
Cancellation rates at 1.86% (the national average is 4.3%)
—
Reduction in procurement costs resulting in an annual saving for
London of c. £3m
—
Reduction in post operative complications, saving over £700 per
patient compared to UK averages. If replicated nationally, this could
save up to £92m across England and Wales.
—
Positive patient feedback
Draft in progress | 80
Planned
Care
Intervention 4: Clinical pathway review
Case for change
•
Across south east London there is variation in service provision and
patient outcomes.
The proposal
•
•
The Planned Care Clinical Leadership Group has requested data
pertaining to the following 5 specialities:
—
Urology
—
Neurosurgery
—
Nephrology
—
Gynaecology
—
Dermatology
This data will enable a clinical pathway review of each speciality to
highlight whether there are opportunities for standardisation,
consolidation or to test new models of patient care.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 81
Draft in progress | 82
Maternity
Maternity model
Key Features of the model
1
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Primary prevention and targeted wellness programmes
within the Local Care Network (LCN)
2
Assessment of pregnancy risk at or before 10 weeks to
assign the most appropriate midwife team from the outset:
a)
LCN community based midwife teams for low risk
b)
Specialist condition focused teams for high risk
c)
On-going communication with primary care and other
community based services
3
Midwife Led Continuity of Care and support:
a) Every women has a named midwife providing
continuity and co-ordination of care developing individual
care plans and reflecting individual needs
b) Continuous assessment of risk throughout pregnancy
c) Facilitating easy access to specialist care when
required
4
Culture of birthing units to encourage straightforward birth
and improve the experience for low risk women
5
Achieving the London Quality Standards and supporting
improvement in the quality of service, safety, outcomes
and satisfaction.
6
Better co-ordination through postnatal and neonatal
phases to improve mother and baby flows and experience
7
Smooth handover to LCN with continuing advice and
support on healthy choices.
Draft in progress | 83
Maternity
Intervention 1: Pre-conceptual care
The case for change
•
There are increasing numbers of women with more complicated health
needs due to obesity and diabetes and a range of other long term
conditions as well as lifestyle choices that impact on pregnancy and long
term health outcomes for mothers and babies. This initiative aims to
address these issues.
The proposal
•
This proposal includes access within the Local Care Network to provide
advice on lifestyle and pre-pregnancy support to optimise pregnancy.
•
It is important to improve the health of women before they conceive in
order to increase their outcomes and experience of pregnancy and birth.
This links with initiatives such as “making every contact count” which
states that every contact an individual makes with a healthcare
professional is also used where possible to maintain or improve their
health and wellbeing.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 84
Maternity
Intervention 2: Access to Midwifery Antenatal Support by
10 weeks
The case for change
The proposal
•
Due to a lack of early access a number of issues have been identified.
These include:
•
This initiative focuses on access to midwifery antenatal support by 10
weeks .
—
Late access to maternity care can have an impact on outcomes for
mothers and babies leading in some cases leading to poorer
outcomes and increased mortality rates.
•
Currently the national standard for antenatal support is 12 weeks and 6
days and so this proposal will achieve compliance with standards (e.g.
sickle cell) and enable informed choice through prenatal screening.
—
Delaying the first antenatal appointment stops a women making an
informed choice of all the available antenatal screening services,
such as screening for infectious diseases, including HIV and
hepatitis B, as well as for haemoglobin disorders such as sickle cell
disease and thalassaemia.
•
This model supports direct-access to maternity care or access via a GP
referral, following which the women should be seen within a maximum of 2
weeks.
—
Nutritional supplements such as folic acid are most effective early in
pregnancy and women could be given early advice on diet and
exercise. Earlier engagement also enables an early risk assessment.
—
Whilst the majority of women do have their first antenatal
assessment in the first few weeks of pregnancy up to 12% of
women in some parts of SEL do not come into the service early on in
their pregnancies.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 85
Maternity
Intervention 3: Continuity of Midwife-led Care
The case for change
•
This also makes appointments more effective and reduces duplication.
There are a number of benefits associated with midwifery-led continuity of
care and no adverse effects compared with models of medical-led and
shared care, including for example a reduction in epidurals and
instrumental births and increased chances of a straightforward birth. This
reflects the importance of the maternity workforce and how their
interventions at each stage can contribute to the achievement of high
quality and safe maternity care.
•
The model also includes the availability of high quality information to
support women to make informed decisions / choices – which lead in turn
to better outcomes and enables informed choice of place of birth.
•
Continuity links with early access and identification of risk factors, enabling
referral to more specialist maternity care pathways if required – this
includes early access to community based antenatal services and
empowering women through ease of access, enabling triage where
required to more specialist obstetric or multidisciplinary services. Sharing
these pathways with continuity of midwife care will help to “normalise birth”
and increase choices on care and place of birth for women on these
pathways.
Midwifery led care has a number of benefits, for example:
—
Midwifery care is important for high quality and safe care
—
Women who receive midwife continuity of care are less likely to
experience preterm birth or lose their baby before 24 weeks
gestation and overall it is associated with several benefits for
mothers and their babies.
The proposal
•
•
This initiative proposes that every woman will have a named midwife to
improve women’s experience of maternity care. For example, this will
prevent women repeating themselves at each visit to maternity services,
particularly if they have mental health, physical health or social care
issues.
•
The development of a core and standardised offering for every woman
with a named midwife will provide continuity and co-ordination of care
antenatally and postnatally in community and hospital settings including
for high risk and specialist pathways.
•
This will provide continuity and safety for women. In particular through
providing further support, women will feel more comfortable to disclose
domestic abuse or mental health problems as a result of knowing the
midwife.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
References:
Midwife-led continuity models versus other models of care. Cochrane Review . Sandall et al (2013)
The contribution of midwifery care to high quality maternity care. Royal College of Midwives. Sandall J.
Discussion of findings from a Cochrane review of midwife-led versus other models of care. Sandall et al (2009)
Can we prevent postnatal depression? A randomised control trial . Marks et al (2013)
DH (2007) Maternity Matters
Draft in progress | 86
Maternity
Intervention 4: Continuity of Care (cont.) - Obstetric and
Specialist Care
The case for change
•
Multiple pathways by condition are shared where appropriate with other
services such as primary care which will enable the centring of pregnancy
within the wider social infrastructure and developing sustainable and long
term relationships within the local care network.
•
The proposal also involves a multidisciplinary team and step up to
condition specific care includes continuity of midwife care. The named
midwife providing continuity is kept throughout the pregnancy although the
woman may see other midwives and professionals as part of her care. This
means that the named midwife will have an operational / organisational
aspect to her role in supporting the woman.
•
Continuity enables ease of “step-up” at any stage during pregnancy to
obstetric care so that the woman can be maintained on her maternity
pathway but with specialist input when required.
This initiative highlights:
—
The importance of clinical leadership and multidisciplinary working to
ensure safe, high quality and effective care for all women.
—
It is important that all within the multidisciplinary team recognise
each others responsibilities to improve safety.
—
More senior obstetrician cover on labour wards has been shown to
reduce both caesarean section rates and complications.
The proposal
•
•
This initiative involves an early identification of risk factors, streaming into
high/low risk, social/medical risk pathways – this includes the initial risk
assessment with a midwife and early risk stratification so that the woman
can be directed to the right support and specialist / multidisciplinary team
as well as triage to the right midwifery team.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
References:
DH (2007) Maternity Matters
Society for Maternal-Fetal Medicine: Safe Prevention for the Primary Caesarean Delivery (March 2014)
Evidence-based strategies for reducing caesarean section rates: a meta analysis, Chaillet et al (2007)
Draft in progress | 87
Maternity
Intervention 5: Increasing Out of Labour Ward births
The case for change
•
•
This initiative highlights that:
—
It is important to give low risk women information and advice about
all available birth settings, so they can make a fully informed
decision.
—
The care a woman receives during labour can affect her, emotionally
and physically in the short and long term, as well as the health of her
baby.
—
It is important to enable a woman to feel in control of what is
happening and to have her wishes respected as well as focusing on
contributing to a positive birth experience, good communication and
support and care from staff.
This initiative focuses on women and their families receiving the best
possible information and communication to ensure that they are able to
make an informed decision about where to have their babies – at home,
in a hospital alongside birth centre or in a hospital obstetric unit. This
involves explaining to both new mothers and women who already have
children that they may choose any birth setting and that they will be
supported in their choice of birth setting.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
—
“Advise low risk multiparous women (women who have previously had
children) that a home birth or a birth centre birth is particularly suitable
for them because the rate of interventions is lower and the outcomes
for the baby is no different.”
—
“Advise low risk nulliparous women (women who have not given birth
before) that planning to give birth in a midwifery led birth centre is
particularly suitable for them because the rate of interventions is lower
and the outcome for the baby is no different compared with an
obstetric unit. If they plan birth at home there is a small increase in the
risk of adverse outcomes for their baby.”
•
The maternity model supports increasing the rate of out of obstetric unit
births in SEL. Each maternity service have alongside birth centres, which
are beginning to prove popular with women suitable for this option. The
rate of home births in SEL is low and the maternity model supports an
increase from current rates in home birth where appropriate.
•
The findings show that women who choose and are suitable for home and
midwife-led birth centre births, have birth experience that are positive and
lead to high quality emotional and psychological outcomes for both mother
and baby with a low risk of adverse outcomes. In addition studies have
shown that there are economic (financial) advantages of providing more
care in out of obstetric unit settings for low risk women.
The proposal
•
However it is important that the best guidance from the National Institute
for Clinical Excellence (NICE) recommendations are:
References:
DH (2007) Maternity Matters
Society for Maternal-Fetal Medicine: Safe Prevention for the Primary Caesarean Delivery (March 2014)
Evidence-based strategies for reducing caesarean section rates: a meta analysis, Chaillet et al (2007)
Draft in progress | 88
Maternity
Intervention 6: Postnatal and neonatal care
The case for change
•
For neonatal care the model supports better co-ordination through both the
postnatal and neonatal phases in particular in relation to the examination of
new born babies within 72 hours of birth. This can become a “bottleneck”
within maternity services with mothers waiting for this examination before
discharge and for those out of area. It is proposed that this check if
necessary could be performed at home by a midwife, thus reducing length
of stay for some women.
•
The model supports services working collaboratively in the postnatal phase
(including maternity, health visiting, children’s centres and primary care) to
support women initiating and continuing breastfeeding. The aim is to
achieve the level 3 (the best) Unicef Baby Friendly Initiative standards to
support women in recognising the importance of breastfeeding and to
enable mothers to continue breastfeeding for as long as they wish.
This initiative highlights that:
—
Postnatal (after birth) support should be based on the individual
needs of women and families.
—
Breastfeeding initiation and continuation should be a priority..
The proposal
•
•
This initiative focuses on developing postnatal care to improve access to
support for women and babies – ensuring that there are sufficient
postnatal options in the community and hospital for women and that
continuity of midwife led care continues. In addition, it aims to develop
better communications and information sharing with primary care and
health visiting to enable a smoother transition from maternity services to
primary care and health visiting support in local care networks.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
References:
Unicef UK (2013) The Evidence and Rationale for the Unicef UK Baby Friendly Initiative Standards.
NHS Commissioning Board: (July 2012): Commissioning Maternity Services
NICE Clinical Guidelines (2006). Routine postnatal care of women and their babies
Draft in progress | 89
Maternity
Intervention 7: The London Quality Standards
The case for change
The proposal
•
•
This initiative highlights that
—
Midwives should be the main care-giver for normal labour and birth
and form partnerships with obstetricians and other clinicians for
women with complex labours.
—
Multi-disciplinary team working and excellent clinical leadership
should be developed in all services.
—
One-to-one midwifery care should be provided for all women during
established labour.
—
There should be increased involvement of consultant obstetricians
on the labour ward in the care of women with complex pregnancies
and in the supervision and training of medical staff.
—
Postnatal support should be arranged in line with NICE guidance on
postnatal support
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
The initiative focuses on the achievement of the London maternity quality
standards, which is ongoing and integral to the maternity model. One of the
key issues for the maternity strategy will require an assessment of the
impact of achieving the requirement for 24/7 consultant presence on labour
ward, this involves the setting of a trajectory and timeframe and developing
a quality framework or criteria around the agreed solution. To achieve this
requirement, additional consultant obstetricians will be required and a
stepped approach and trajectory is being developed.
References:
The London Health Programmes (2013), The London Quality Standards
NHS Commissioning Support for London (2011), A framework for developing services
Draft in progress | 90
Draft in progress | 91
Children and
Young People
Children and Young People model
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Key features of the model
1
Primary prevention and wellness
• Within the local care network, focusing on the well child.
• In the context of the family setting, looking after the child or
young person’s physical, social, emotional and mental well
being.
2
Children’s integrated community team delivering:
• A range of proactive services for children with more complex
needs
• Early intervention for acute illness and supported early
discharge
• Management of short-term conditions
• Signposting and navigation through the system
3
Extended GP hours
• For general practice from 8 to 8
• With closer links to short stay paediatric units and
emergency departments, to enable better co-ordination and
to help prevent unnecessary hospital admissions
• To be delivered via the Community Based Care model .
4
Short stay paediatric units
• Co-located with an ED
• Designed to ensure that children and young people are
returned to the community as quickly as possible and
unnecessary hospital stays are avoided
• With close links with the Children’s Integrated Community
Team
5
Planned care pathways
• With referral advice and guidance tools
• Specialist advice and support back into the community
6
Supported transition to adult services
Organised by Local Care Networks and Children’s Integrated
Community Teams
Draft in progress | 92
Children and
Young People
Intervention 1: Primary prevention and wellness
The case for change
The proposal
•
•
This initiatives highlights that:
—
Four out of six boroughs are bottom quartile for percentage of
children aged under 16 living in poverty, with an area average of
24.6% versus England figure of 19.2% and London 23.7%.[1]
—
It is estimated that less than 50% of our children and young people
are living healthy lives and that 44% of our young people experience
inequalities or are putting their health at risk
—
Childhood excess weight levels in south east London (for year 6 –
10/11 year old pupils) are consistently higher than the London
average and significantly above the England average, with levels
ranging from 29.9% to 41.2% and average of 38.8% (16% higher
than England and 4% higher than London).[2]
—
Toxic stress’ (where children in families experience stress due to
parental mental health issues, domestic violence and/or substance
abuse) has a high incidence of prevalence in south east London and
is predictive of poor health and mental health outcomes
—
—
There has been a big increase in the number of young people being
admitted to hospital because of self harm. Over the last ten years
this figure has increased by 68%.[3] 1 in 10 children and young
people aged 5-16 suffer from a diagnosable mental health disorder that is around three children in every class[4] - and between 1 in
every 12 and 1 in 15 children and young people deliberately selfharm[5].
In the context of the family setting, we need to ensure that every
child’s or young person’s physical, social and emotional well being
are looked after.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
This initiative focuses on:
—
A holistic approach which needs to be adopted by health, social care
and education services to ensure that every child’s or young person’s
physical, social and emotional well being is looked after. We need our
communities to be resilient in order to help our children and young
people – and their families and carers - remain healthy; championing
healthy living that will support their long-term health and well being –
both physical and emotional.
—
Supporting self-care, through proposing that Community Champions
should be appointed across south east London. Provided by the
voluntary sector, these individuals will help to deliver health care
promotion and prevention. For example, they could lead community
food and exercise programmes or help to develop parenting skills to
help Tackle ‘Toxic Stress’.
—
Community champions providing a better link between service
providers, helping to signpost children and young people to the
appropriate services; helping to ensure that the first contact is the
right contact.
[1] Source: PHE Public Health Outcomes Framework indicator 1.01ii, data for year 2012.
[2] Source: PHE Public Health Outcomes Framework indicator 2.06ii, data for year 2013/14
[3] Source: YoungMinds (2011) 100,000 children and young people could be hospitalised due
to self-harm by 2020 warns YoungMinds. London: YoungMinds.
[4] Source: Green, H., McGinnity, A., Meltzer, H., et al. (2005). Mental health of children and
young people in Great Britain 2004. London: Palgrave.
[5] Mental Health Foundation (2006). Truth hurts: report of the National Inquiry into self-harm
among young people. London: Mental Health Foundation.
Draft in progress | 93
Children and
Young People
Intervention 2: Children’s integrated community team
The case for change
•
Children, young people and their families/carers tell us that:
—
knowing which service to access and how to access them can be
confusing and the process is very complicated.
—
referrals take too long and appointments are hard to get
—
service provision is not joined up; they feel that the services do not
talk to each other – they have to repeat the same information over
and over again
—
•
they want access to paediatric specialists who take their concerns
more seriously and communicated better with children
GPs tell us that they would value access to specialist advice
The proposal
•
•
This initiative therefore focuses on developing Children’s Integrated
Community Teams that will:
—
deliver better integration of services for children and young people;
—
Improve care co-ordination
—
bring together a core group of paediatric services;
—
improve Mental Health Integration; and
—
improve in-reach and out-reach.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
As a result the model defines a Children’s Integrated Community Teams
as providing
—
a range of proactive services for children with long-term conditions
and care needs;
—
early intervention for acute illness;
—
supported early discharge;
—
safeguarding; and
—
management of short-term conditions for children with and without a
long-term condition
Given the number of children and young people in each borough is less
than 75,000 it is not viable to establish a Children’s Integrated Community
Team in every Local Care Network. It is envisioned that there will be one
team, working closely with each of the Local Care Networks within that
locality.
Draft in progress | 94
Children and
Young People
Intervention 3: Extended GP hours for general practice
The case for change
The proposal
•
•
Local Care Networks will provide extended hours from 8am to 8pm and out
of hours cover to help provide 24/7 cover to improve urgent care. This will
help to reduce the lack of access to timely care in the community
•
The service will be staffed by GPs and emergency nurses. They will have
rapid access to paediatric specialists for children and young people with
long term conditions, including both physical and mental health.
•
Extended hours will also enable better co-ordination of care and help
prevent unnecessary hospital admissions
This initiative identifies that:
—
Many of the families/parents we spoke to highlighted the difficulties
of accessing GP appointments.
—
Families wanted flexibility of when they could visit care professionals
- children and babies can have strict routines so appointments can
be very disruptive: : I want flexibility and ease of access to care at
times convenient for me
—
Families/parents are often risk averse: you can’t take any risks with
children; they seek reassurance quickly when their child is ill
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 95
Children and
Young People
Intervention 4: Short stay specialist paediatric assessment
units
The case for change
The proposal
•
Unnecessary admissions are to be avoided; and so as far as possible,
children and young people need to be treated in the community. Care in
the community is not only better for their physical well being but also for
their emotional well being.
•
This proposal focuses on the development of a short stay paediatric
assessment unit (the Unit) that will hold children and young people for
assessment for no longer than 24 or 48 hours. Such Units will operate
seven days a week on a 24/7 basis.
•
However, there are times when a child or young person needs urgent
care, either due to an unforeseen incident or to a change in a previously
well-managed long-term condition. In these cases, they need to be
assessed by a paediatric specialist as quickly as possible. Such crises
can happen at any time; not just in working hours.
•
The Unit will be co-located with emergency departments to ensure safety
and increase effectiveness – and easy access to diagnostics. Senior
clinical staff will be available at times of peak demand, including during
evenings and weekends. Bed numbers will be determined by local
demand but need to allow for variable demand.
•
Once assessed, there needs to be a coordinated and rapid response to
the child’s or young person’s care, especially in cases where there may
be an underlying but unrelated condition - such as mental health .
•
As required, staff will be able to access other specialities quickly; for
instance, mental health.
•
Ultimately, the expectation is that the child or young person will be
discharged at the end of 24/48 hours; staff will work closely with
community nursing teams to facilitate early discharge and on-going care in
the community.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 96
Children and
Young People
Intervention 5: Planned care pathways
The case for change
The proposal
•
•
The initiative aims to develop a coordinated approach to planned care both admittance and discharge – managed through the Children’s
Integrated Community Team and the child’s/young person’s Local Care
Network.
•
A coordinated approach will ensure that there is less duplication of effort
and that the well being of the child – and his/her family – are taken into
consideration. For instance, better planning will take account of the
impact on the young person’s schooling.
This initiative identifies that:
—
Not every child and young person in south east London receives the
same standard of care; there is variation in experience and
outcomes.
—
There are unnecessary delays in the patient journey; time from first
appointment, to test, to getting results and receiving treatment which
could be quicker and more efficient.
—
Delays in discharge to home from hospital can mean poorer
outcomes , with increased risk of poor physical and emotional well
being.
•
The approach will also allow for safe discharge planning, taking into
account the support the child or young person will need once home to
ensue full re-enablement.
—
Extended hospital stays can have an adverse effect on the wider
family; a carer’s loyalties can be divided and a sibling can be upset if
his/her routine is upset.
•
In taking this proposal forward, there will be closer working with the
Planned Care Clinical Leadership Group.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 97
Children and
Young People
Intervention 6: Supported transition to adult services
The case for change
•
Our young people are ill prepared for transition to adult services. Even the
well young person may not know how to book an appointment with a GP
or where else they might go to for medical advice. We need to start
preparing them earlier to take care of their own health and well being; as
early as Year 9.
•
The initiative aims to improve transition services across all conditions to
reduce variability imbedded in the Local Care Networks and in the
Children’s Integrated Community Teams.
•
Services will put the young person at the centre of their transition plan.
There will be greater collaboration and communication with the young
person; taking into account their views and aspirations.
•
Those young people with more complex needs require continuity of care
for longer and when they do transition to adult services there is often a
passing over rather than a dialogue between parties.
•
Transition will be coordinated by a transition coordinator who may come
from either the community or acute setting, depending on where the young
person has received most of their care.
•
Young people with mental health issues can often fall between two stools.
CAMHS will work with them until they are 16 but they are not covered by
adult services until they are 18. At an age when young people are
particularly vulnerable, there could be a lost year that could have a
damaging effect not only on their mental health but their overall health
and well being.
•
•
GPs complain that they are not always included in the care planning of
young people with more complex conditions, yet are expected to organise
their care at 18 with no previous insight or knowledge.
•
Although effective transition is recognised as vitally important,
experiences across south east London are variable. Such variability fails
to take account on individual need.
All transition coordinators will work closely with the young person; for
instance, taking them to clinics in the adult setting. They will also organise
meetings between the relevant paediatric and adult clinicians to agree the
future care plan. They will ensure that the GP now looking after the young
person is aware of their history. The coordinator will also remain in contact
with the young person for a period of time after they have moved to adult
services in order to provide the individual with support at a time when they
may feel quite vulnerable. The duration will vary from patient to patient,
according to the complexity of their case but could be for as long as a year.
Transition coordinators will need to be well informed about generic teenage
health issues such as skin problems, worries about weight, puberty and
sexuality. They will also need to understand the psychological and social
difficulties that are common among adolescents such as depression,
anger, risk taking behaviour and non adherence to treatment. They will
have close links to the Children’s community integrated health team to help
support these wider issues.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 98
Draft in progress | 99
Executive
Summary
Urgent and
Emergency
Care Model
Urgent and emergency care model
Key Features of the model
Achieving the London Quality Standards in all areas:
• Acute medicine
• Emergency general surgery
• Emergency departments
• Critical care
• Fractured neck of femur
Meeting the Facilities Specification for:
• Urgent care centres (UCC)
• Emergency centres (EC)
• Emergency centres with Specialist Services (ECSS)
• U&EC system
1
Improving access in Primary Care, in hours and out of hours, to unscheduled care.
GPs, Urgent Care Centres (UCCs) and Emergency Departments (ED) functioning in a closely
linked co-ordinated way; responsive community care, including specialist response teams, will
prevent un-necessary hospital admissions with easy access to specialist advice for GPs as an
alternative to ED referral
1. 8am – 8pm 7 days a week
2. Standalone Urgent Care Centres with the same standards
3. Community based rapid access teams including a home ward.
2
Specialist advice and referral
4. Access to specialist advice
5. Access to a specialist response clinic
3
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Improved 111 capability and LAS onward referral
6. London Ambulance Service will be able to redirect to appropriate services, such as the
rapid access team, home ward or hospital based specialist clinics and excel in navigating
patients to the right part of the system
7. 111 are able to give advice, provide internal triage and coordinate onward referral to other
parts of the system other than the ED
4
An enhanced single “front door” to the Emergency Department.
8. Bringing together UCCs and the ED in a single governance structure and providing expert
streaming across all sites
5
Emergency Department interface with Mental Health services
9. This will also allow for earlier identification of MH cases (including Dementia) reducing
length of stay and enabling quicker streaming to specialities for mental health patients by
having Psychiatric Liaison nurse (PLNs) and Triage joint assessments.
10. Quicker interface with specialist services like drug and alcohol
11. Quicker interface with under 18 mental health liaison teams
Draft in progress | 100
Urgent and
Emergency
Care Model
Intervention 1: 8am – 8pm 7 days a week
complicated system which in itself has contributed to increasing demand by
sending people around various services, confused about who to call and
where to go.’ (Transforming Urgent and Emergency care services in
England – NHSE).
The case for change
Local Care Networks with extended staffing and hours to reduce the lack of
access to timely care in the community
The proposal
The proposal
•
LCNs will:
• Provide extended hours from 8am-8pm and out of hours cover so there is
24/7 cover to provide improved urgent care
• Be staffed by GPs and nurse practitioners
• Link to rapid access services to support the frail, elderly and those patients
with long term conditions.
• This will include mental health liaison for patients in crisis such as perinatal,
drugs & alcohol, children & young people and older people & dementia
patients.
—
have longer opening hours, improved access for unregistered patients
and reduce the need to go to the Emergency Department
—
work closely with Rapid Access Services in the community and in the
hospital setting
•
In south east London we want existing standalone urgent care centres to be
seen as a service rather than a location. There could be co-location with
GP practices and potentially other services such as dermatologists for
example. We also want social care to be part of the urgent care centre
service.
The current points of access for care can be confusing for the public and
health care professionals and lack a single clinical governance structure.
Opening times can differ as well as the type of care that can be received.
‘All the public want to know is that if an urgent care problem ever arises,
they can access a service that will ensure they get the right care when they
need it. They do not want to decide whether they should go to an major
injuries unit, a walk in centre or A&E, or whether they should ring their GP,
111 or 999. We shouldn’t expect people to make informed, rational
decisions at a crisis point in their lives: the system should be intuitive, and
should help people to make the right decision. We have created a
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
be integrated over time with the Local Care Network service model and
be part of the Emergency Department clinical network to improve
safety and quality
Urgent Care Centres could encompass all existing urgent care facilities
which are not Emergency Departments such as Walk-in Centres, Minor
Injuries Units and “Darzi” Centres. There will be clear standards for all
Urgent Care Centres, for example in relation to opening hours and staffing,
and an expectation that they will work within the Urgent Care Network to
broaden their role in providing timely access to services. All Emergency
Departments should have a co-located Urgent Care Centre, wherever
possible. (Professor Jonathan Benger, National Clinical Director for Urgent
Care for NHS England, updates on the Urgent and Emergency Care
Review)
The case for change
•
—
•
Intervention 2: Standalone Urgent Care Centres with the same
standards
•
In order to provide consistent and less confusing points of care in the
community setting we propose standalone Urgent Care Centres which will:
Draft in progress | 101
Urgent and
Emergency
Care Model
Intervention 2: Community based teams including a
homeward (urgent care in the home)
The case for change
The proposal
•
•
•
Currently the only service available 24/7 is the Emergency Department.
Stable short term medical needs are met by admissions to hospital due to
a risk averse culture and lack of confidence in community skills to support
patients in a home setting.
In addition, currently one trust is not meeting the standard for Timely
access, seven days a week to, and support from, onward referral clinics
and efficient procedures for discharge from hospital and one trust at
weekend.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
We propose a rapid access team that will:
—
Be a single point of access providing navigation for GPs, clinical
advice and supporting cross boundary working and speeding up
discharge with more care packages for the elderly away from the
Emergency Department.
—
Direct patients onto the Home Ward or other specialist teams.
—
Risk stratify patients with enhanced/faster access for very vulnerable
patients.
—
Have integrated IT that is also patient held to support cross boundary
and service working
—
Be consistently capable of assessing and treating people in their own
home or nearby.
—
Give all settings the confidence they need to hold patients safely until
they are able to move to the next part of the system.
—
Enable care homes in particular to be capable of holding onto the
patient, assessing and treating those with long term conditions and
mental health conditions.
Draft in progress | 102
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Intervention 3: Access to specialists advice
The case for change
•
•
As an example a trial in Bristol has an advice line which is working using
smart technology. Previously the GPs spent half the patient appointment
time going through the hospital switchboard to be directed to an answer
phone. Or if they did speak to the emergency team it could be a less
experienced doctor answering who might err on the side of caution. GPs
were unsure whether to make an urgent referral to outpatients or ask for an
emergency cardiac admission.
•
With the new telephone advice line GPs now get through to a consultant
cardiologist in less than 15 seconds and agree a decision on how to
manage the patient while they are still in the building. The service gets
GPs straight through to a senior grade doctor during the actual patient
consultation.
•
GP Care now plans to extend the service to other specialties - with
gynaecology, paediatrics and general medicine the next likely options. The
organisation also plans to include specialists from other hospitals so that
GPs receive advice from their local consultant teams.
•
The software has been developed to allow practices to shape the list of
specialists according to their own preference as the system expands.
The initiative aims to better manage risk by enabling GPs to feel more
supported and reduce Emergency Department attendance.
The proposal
•
The initiative aims to:
—
Have easy access to specialist advice and enable referrals directly
to specialist care rather than having to access a specialist through
A&E. This could be made available through telemedicine, telephone
lines or community based consultants.
—
Provide advanced access to local urgent care for minor
illnesses/injuries for vulnerable patients and a prioritising of over
75s.
—
Contract incentives to make this happen as currently this takes place
by goodwill.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 103
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Intervention 4: Specialist response clinic (located in
hospital)
The case for change
•
Currently the Emergency Department can be the only route to assess and
treat patients directly referred from GPs and community services.
•
As a result a large number of patients are turning up at the front door of
the emergency department with a GP letter because of a lack of access
to hot clinics.
•
Patients with long term conditions who experience an urgent care need are
seen by someone who knows them. In addition, the service will allow for
GP and carer referral. The model will not require new staff but will expect
staff to be used in the clinics rather than ward rounds as short term
medical needs are met in clinic rather than being admitted.
•
The initiative will encompass a consistent approach to service across
elderly/mental health/social care pathway and will be co- located with the
emergency department as the optimum location in the hospital.
•
In addition follow up clinics will be available during the week.
The proposal
•
A specialist response clinic and team will be established that will provide:
—
A community service in a hospital that can carry out diagnostics
such as blood and urine testing, X-Rays,
—
Examination couches, but not beds as patients will not be admitted
to be assessed and treated within the clinic.
—
Rapid response times and a multi-disciplinary service
—
Supported discharge home
—
Specialist Gerontology, mental health
—
A fast track OP clinic
—
Potential links to faster than a 2WW referral for Cancer
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 104
Urgent and
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Care Model
Intervention 5: London Ambulance Service (LAS) refers to
the most appropriate pathway
The case for change
•
There is a lack of understanding about parts of the system, other than the
Emergency Department, that London Ambulance Service could refer into.
Pathways do exist, but these vary across SE London which can be
confusing and the turnaround time to respond can be inconsistent. This
can also mean crews from out of area are reluctant to use these
pathways. GPs are also not easily available during hours to support
alternative pathways for patients. Therefore this initiative aims to alleviate
these problems.
The proposal
•
—
Use the London Ambulance Service control room to put more calls
through to 111 (not just during surge periods) and give patients the
confidence that they will have good outcomes from using this service
rather than 999.
—
Have rapid access to information and specific patient plans with a
possible link to GPs during ‘In hours’ to enable alternative pathways
for patients with long term conditions and frequent callers.
—
Implement alternative care pathways through integrated working (and
attitudinal changes).
—
Use SEL wide pathways that avoid complexity and confusion and
consider using technology better to support this – smart phones so
that ambulances crews can call to easily check pathways and a way
of storing pathways so they can be accessed and updated quickly.
—
Tackle the reactive risk averse culture, seeing rates of acceptance as
a joint problem between the referrer and the receiver and consider
building in consequences for not accepting a referral. Once a service
doesn’t accept a referral it may prevent further referrals to that
service.
Under this initiative London Ambulance Service will be able to:
—
Operate an ‘internal triage’ approach to improve directing patients to
best access points and appropriate services, such as the rapid
access team, home ward (remove -or hospital based specialist
clinics - until this is clearer) and excel in navigating patients to the
right part of the system
—
Operate a ‘call ahead’ system to the emergency department triage
nurse for mental health patients to enable a parallel assessment to
take place at triage (see mental health interventions). This may
mean a Mental Health assessment en route.
—
Navigate the system easier through a simplified, accurate and up-todate Directory of Services – combined referral pathways and ‘one
book’ for all pathways. Better communication of pathways and
hospital liaison officers to challenge crews if alternative pathways
available.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 105
Urgent and
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Intervention 6: Enhanced 111 capability
The case for change
•
There is a lack of understanding about parts of the system, other than the
Emergency Department, that 111 could refer into.
The proposal
•
To improve this we propose that 111:
—
Call handlers are educated/trained in the new models for SEL
—
Are able to give advice, provide internal triage and coordinate
onward referral to other parts of the system other than the
Emergency Department
—
Operate 24/7 managing ‘appointments’ to Out-Of-Hours services or
Emergency Department to support demand management
—
Use clinicians to make decisions
—
Provide a simplified DOS
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
An Enhanced 111 service will be provided. This will be a smart call to
make, helping people get the right advice or treatment in the right place,
first time. This service will:
—
Be an integral part of the Urgent Care Network
—
Have knowledge about you and your medical problems, so the staff
advising you can help you make the best decisions;
—
Allow you to speak directly to a wider range of professionals (e.g. a
nurse, doctor, paramedic, member of the mental health team,
pharmacist or other healthcare professional);
—
If needed, directly book you an appointment at whichever urgent or
emergency care service can deal with your problem, as close to home
as possible;
—
Still provide you with an immediate emergency response if your
problem is more serious, with direct links to the 999 ambulance
service, and the enhanced ability to book appointments at Emergency
Centres.
Draft in progress | 106
Urgent and
Emergency
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Intervention 7: Urgent care centre and the emergency
department in a single governance structure and providing
expert streaming across all sites
The case for change
•
—
Decisions are made with the correct pathway and outcome in mind to
avoid unnecessary delays when the patient is ready to go home
—
Earlier identification of Mental Health cases (including Dementia) with
quicker and direct streaming to PNL for mental health patients+
—
The role is not covered by bank or agency staff
—
Access to paediatric specialists at ‘front door’ and other specialist
services such as Drug and Alcohol.
This initiative recognises that:
—
There is a need to reduce emergency department waits, allow
patients to be re-directed immediately, and be seen and treated
through rapid, expert early assessment.
—
The points of access for care need to be less confusing for the public
and health care professionals.
—
Better value comes with co location
—
There is currently no streaming at the PRUH for C&YP
The proposal
•
This initiative proposes:
—
A single clinical governance structure for urgent care centres and
emergency departments
—
A single front door for urgent care centres and emergency
departments.
—
GP led minors service
—
PALs with same 8-8 hours of operation.
—
Cross working and training of ENPs and GPs across the emergency
department and urgent care centre to improve capacity and
capability of injury and illness.
—
An appropriately qualified streaming decision maker that will stream
patients at the front ‘door’ to get the initial decision right and direct
patients to the correct department - Majors, Minors, the urgent care
centre or back to their GP
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 107
Urgent and
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Intervention 7: Urgent care centre and the emergency department
in a single governance structure and providing expert streaming
across all sites
The proposal cont/d…
—
Utilises the PALS officer appropriately.
•
Suggested competencies for front door streamer
—
Asks for guidance if unsure regarding patient redirection.
—
Uses active listening skills, to establish an accurate history from the
patient.
—
Streams patients for further assessment who are a potential for
redirection.
—
Effectively acquires and utilises the signs and symptoms presented
by the patient and acts accordingly.
—
Streams patients who could be redirected into the emergency
department – if appropriate.
—
Demonstrates an ability to prioritise the patient’s condition, in relation
to actual/potential severity of injury/illness.
—
Adheres to presentations listed when using triage bypass form.
—
Requests appropriate x-rays.
—
Provides analgesia where appropriate.
—
Allocates patient to the appropriate stream, taking into account
departmental workload.
—
Is able to list patient presentations not to be redirected according to
the policy.
—
Requests all redirected patients to complete patient redirection form.
—
Provides directions to locations away from the emergency
department.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 108
Urgent and
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Intervention 8: Parallel assessments
The case for change
The proposal
•
•
•
•
•
The current model of clinical triage with a separate Psychiatric Liaison
Nurse assessment is often the cause of a long waits and breaching of
emergency department targets. This can result in patients absconding
and re-attending.
The prevalence of mental health conditions amongst older people
inpatient in the general hospital is estimated at 60% (Parsonage et al,
2012). The use of acute hospital services by people with dementia is
rising and emergency admissions for people with dementia account for
nearly 10% of all hospital admissions. 95% of acute hospital admissions
for people with dementia occur in an emergency, with over 60% of these
coming through emergency departments, even though 25% of all
emergency presentations in people with dementia are preventable
(Parsonage et al, 2012).
In emergency departments, the main focus of liaison psychiatry work is
on self-harm, severe mental illness and alcohol-use for adults of working
age, and delirium and dementia for older adults. The high number of selfharm presentations in England each year means that this should
therefore be a key focus for hospital-based services. There has been a
50% increase in the use of Emergency Care in the last decade, and there
is evidence that the urgent and emergency care system is finding it
increasingly difficult to meet indicators such as the four hour wait time in
Emergency Departments and ambulance handover targets. The literature
suggests that there is a need to find solutions that will
To reduce these waits for mental health patients there will be:
—
Experts streaming at the front door (see Enhanced Front Door) to
allow for earlier identification of mental health cases (including
Dementia) with quicker streaming to specialities for mental health
patients. This means training the emergency department nurses on
the front door to better recognise mental health needs and refer to
mental health services faster.
—
The potential for mental health screening to be carried out during the
ambulance journey
—
Parallel working of the Psychiatric Liaison nurse within the emergency
department at an early stage ensuring rapid intervention and moving
away from the medical model of clearance.
—
Enabling of the police to better recognise mental health needs and
being able to refer to mental health services rather than bringing
patients to the emergency department.
—
A Dr and Nurse mental health professional in the emergency
department at peak times.
increase the flow of patients through the health and care system (The
King’s Fund, 2013).
•
There is therefore clear demand for a service such as liaison psychiatry
that will help support the movement of patients through the system.
(Developing models for Psychiatry liaison models).
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 109
Urgent and
Emergency
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Intervention 8: Parallel assessments
The proposal cont/d…
•
Specification and Guidance on levels of Liaison Psychiatry Services Developing Models for Liaison Psychiatry Services – Guidance 2013
recommend four levels:
•
Core Liaison Psychiatry Services - These services have the minimum
specification likely to offer the benefit suggested by the literature. Core
will serve acute health care systems with or without minor injury or
emergency department environments where there is variable demand
across the week, including periods of no demand where a 24-hour staffed
response would be uneconomical. This model mainly serves emergency
and unplanned care pathways and will provide a timely response to all
mental health presentations in the emergency department within one hour
between 9-5 M-F.
•
Core24 Liaison Psychiatry Services - These services have the minimum
specification likely to offer the benefit suggested by the literature where
there is sufficient demand across the 24 hours period to merit a full
service. Typically these acute health care systems are hospital based in
urban or suburban areas with a busy emergency department. This model
mainly serves emergency and unplanned care pathways.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
Enhanced 24 Liaison Psychiatry Services - These services have
enhancements to the minimum specification to fit in with gaps in existing
pathways and services. Often they have additional expertise in addictions
psychiatry and the psychiatry of intellectual disability. Demography and
demand may suggest additional expertise with younger people, frail elderly
people or offenders, crisis response or social care. This may extend to
support for medical outpatients. This model mainly serves emergency and
unplanned care pathways but extends to support elective and planned care
pathways where mental health problems co-exist.
•
Comprehensive Liaison Psychiatry Services - Comprehensive services are
required at large secondary care centres with regional and supra-regional
services. These services include Core24 level services but will have
additional specialist consultant liaison psychiatry, senior psychological
therapists, specialist liaison mental health nursing, occupational and
physiotherapists. They support inpatient and outpatient areas such as
neurology, gastroenterology, bariatric surgery, plastic and reconstructive
surgery, pain management and cancer services. They may support other
condition specific elements such as chronic fatigue / ME and psychosexual
medicine. Comprehensive services run over office and extended hours
supported by the core service running twenty four hours, seven days a
week. They may include specialist liaison psychiatry inpatient beds. This
model serves emergency and unplanned care pathways as well as elective
and planned care pathways where mental health problems co-exist.
Draft in progress | 110
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Intervention 8: Parallel assessments
The proposal cont/d…
•
•
•
The benefits we might expect from an effective model of liaison
psychiatry service?
There is now growing evidence for the impact of liaison psychiatry
services. Descriptive evidence shows a list of benefits including:
—
decreased length of stay,
—
reduction in psychological distress,
—
improved service user experience, improved dementia care
—
And enhanced knowledge and skill of general hospital clinicians
(Parsonage et al, 2012).
—
Reducing psychological distress following self-harm, and reducing
suicide
—
Improved compliance with NHS Litigation Authority Risk Management
Standards and the Clinical Negligence Scheme for Trusts (CNST)
(Joint Commissioning Panel for Mental Health, 2012).
Benefits apparent in the literature include:
—
Improved service user experience
—
Increased knowledge and understanding of mental health issues
amongst general hospital staff
—
Improved care outcomes
—
Reduced emergency department waiting times
—
Reduced admissions, re-admissions and lengths of stay
—
Reduced use of acute bed by patients with dementia
—
Reduced risk of adverse events
—
Improved compliance of acute trusts with legal requirements under
the Mental Health Act (2007) and Mental Capacity Act (2005)
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 111
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Intervention 9: Specialist service interface D&A
The case for change
•
•
•
Currently two out of our five hospitals (2013/14 data) are not meeting the
London Quality Standards for the following: ‘Emergency departments to
have a policy in place to access support services seven days a week
including:
—
Alcohol liaison,
—
Mental health
—
Older people’s care
—
Safeguarding
—
Social services’
There are often delays to other specialist services such as Drug and
alcohol teams due to the ‘drop off’ between the patient taking themselves
from the emergency department to the drugs and alcohol service.
In South London the impact of alcohol is significant. The recent Screening
and brief Intervention Programme for Sensible drinking study (SIPS)
found that 40% of attendances at King’s College and St Thomas’s
Hospital emergency department were alcohol related. Alcohol related
inpatient admissions to acute care have doubled in the past 8 years in
England and now account for 14% of all acute admissions in King’s
Health Partners (KHP). A study in South West London found that 50% of
adult mental health admissions were alcohol related.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
During 2011, emergency department attendances at St Thomas’ Hospital
and Kings College Hospital, coded with ‘apparently drunk’, ‘alcohol
dependent’ or ‘alcohol cited on the GP letter’ totalled 400 patients per
month.
•
In outer London, the Sutton Health Profile 2011 indicates an above national
value for rates of ‘Increasing and higher risk drinking’. Although ‘hospital
stays for alcohol related harm’ were below average at 1,523 admissions
per 100,000 population.
•
The case for action in South London is strong, six out of 12 South London
Health and Wellbeing Boards have prioritised alcohol harm reduction, and
most others have priorities that are affected by alcohol. There are early
gains that can be made to reduce the burden on the health and social care
system by addressing service access, early interventions and prevention
approaches.
The proposal
•
This initiative proposes:
—
Drug and Alcohol professionals and a rapid access to the drugs and
alcohol service from the emergency department to reduce the ‘drop
off’ between the patient taking themselves from the emergency
department to the drugs and alcohol service
—
Low cost interventions
—
Having Drug & Alcohol professionals sited in the emergency
department.
Draft in progress | 112
Urgent and
Emergency
Care Model
Intervention 10: Specialist service interface for paediatric
mental health
The case for change
•
There has been a big increase in the number of young people being
admitted to hospital because of self harm. Over the last ten years this
figure has increased by 68%.[1] 1 in 10 children and young people aged 516 suffer from a diagnosable mental health disorder - that is around three
children in every class[2] - and between 1 in every 12 and 1 in 15 children
and young people deliberately self-harm[3].
•
For paediatric mental health patients there can be significant periods of
time between both:
•
—
Arrival in the emergency department to the referral being made
—
And from referral being made to being seen
There are four key issues for paediatric mental health patients that
present in the Emergency Department that can lead to the waits
described above:
1.
In hours cover for paediatric mental health liaison is variable across
SEL. Both in and out of hours there is a wide variation of resource
particularly in those trusts where there is no in-house paediatric
mental health provision
2.
Out of hours paediatric mental health provision is poor in some
trusts, and even in those trusts with in-house provision, is less out of
hours than in hours. This means the waiting time can be more than
twice as long out of hours. Typically the majority of paediatric
deliberate self harm (DSH) cases attend out of hours.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
3.
The policies on admitting paediatric mental health patients to
paediatric beds vary across hospitals. This may lead to patients in
some hospitals suffering far more significant delays in admission than
those elsewhere. Any admission requiring a child or adolescent
psychiatric bed invariably suffers significant delay, whatever the
originating emergency department, because of the national bed crisis.
4.
Whilst the lack of paediatric mental health staff cause some delays,
(for example a child may have to wait overnight in the emergency
department until CAMHS can send a liaison nurse), the longest
emergency department breaches are typically due to the difficulty in
accessing paediatric mental health inpatient beds. Children may
occasionally be admitted to an adult mental health ward or otherwise
remain in the emergency department.
•
Data from repeat audits carried out by the KCH paediatric liaison service
for under 18s presenting to the emergency department over a three month
period confirmed the two stages of delay – arrival to referral and referral to
being seen. Out of hours the waiting time can be more than twice as long
as in hours.
•
Data for St.Thomas’ is expected to reveal that patients are seen quicker for
the initial assessment, but this is still longer out of hours. However the
significant delay is in accessing inpatient beds.
•
In the PRUH, Lewisham and QEW site emergency departments it is
expected there may be only limited family therapist sessions or potentially
no service provision as well as difficulties accessing inpatient paediatric
mental health beds
[1] Source: YoungMinds (2011) 100,000 children and young people could be hospitalised due to selfharm by 2020 warns YoungMinds. London: YoungMinds.
[2] Source: Green, H., McGinnity, A., Meltzer, H., et al. (2005). Mental health of children and young
people in Great Britain 2004. London: Palgrave.
[3] Mental Health Foundation (2006). Truth hurts: report of the National Inquiry into self-harm among
young people. London: Mental Health Foundation.
Draft in progress | 113
Urgent and
Emergency
Care Model
Intervention 10: Specialist service interface for paediatric
mental health
The case for change cont/d
•
NICE Clinical Guidance 16: 1.9.1.3: states ‘all children or young people
who have self-harmed should normally be admitted overnight to a
paediatric ward and assessed fully the following day before discharge or
further treatment and care is initiated. Alternative placements may be
required, depending upon the age of the child, circumstances of the child
and their family, the time of presentation to services, child protection
issues and the physical and mental health of the child; this might include
a child or adolescent psychiatric inpatient unit where necessary.’
•
There are several models for providing out of hours emergency department
based services for children and young people:
—
Core trainee in psychiatry with access to CAMHS on call ST and
consultant (this is the model SLaM use);
—
Core trainee with access to consultant CAP telephone supervision
and multispecialty consultant cover;
—
multi-professional out of hours CAMHS professional with
ST/Consultant CAP cover;
—
Multi-professional out of hours CAMHS professional with multispeciality ST/consultant cover.
—
There are also a range of models in terms of how much emergency
cover is provided (e.g. only till 23.00 rather than overnight).
The proposal
•
In order to meet NICE guidance this initiative proposes to:
—
Provide specialist input at an early stage to avoid long waits
especially in the 16-18 year age range.
—
Provide an increase in specialist services within the emergency
department according to level of need across SEL
—
Aim for entry to referral within 1 hour from streaming or Triage nurse
to the paediatric mental nurse (more triage nurses and medics, as
well as slicker IT (King’s College Hospital and, possibly, Guy’s and
St Thomas’ Trust use paper)
—
Build in Nice guidance being mindful that the DOH or Government
don’t state NICE is mandatory and CQC don’t penalise for being
non-compliant.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 114
Draft in progress | 115
Cancer
Cancer model
Key Features of the model
Primary prevention: Best delivered in the Local Care Network
Early detection
1
•
•
•
•
Increased screening rates to national benchmark through targeted engagement
Diagnostics: Pilot project – serious but unspecific symptoms pathway
Promotion of early diagnosis and equal access to treatment for all people, focus
on individuals who shared one or more of the nine protected characteristics e.g.
older people, individuals with mental health needs and/or a learning disability.
Professional development for all staff within Primary Care
Treatment and Transition
2
Provider collaboration to create networked centres of excellence:
• Non complex cancer treatments and support closer to home
• Access to appropriate information and support for patients and carers
• Acute Oncology Services – networked and supported by integrated IT
• Consistently meet the access time scales on our cancer services
• Routine use of the recovery package
Living with and Beyond Cancer; Cancer as a long term condition
3
•
•
•
•
•
•
•
Stratified pathways of care
Support for people living with the adverse consequences of cancer treatments
Comprehensive support for carers
Psychological support for people living with Cancer
Inclusion of Cancer as a criteria for referral to exercise/physical activity on
prescription schemes
Support to return to work, study or volunteering
Routine use of the recovery package
End of Life: Best Delivered in the Local Care Network
4
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
•
•
Ensure a dignified death irrespective of setting
Ensure consistent use of coordinate my care
Advance Care planning
Draft in progress | 116
Cancer
Intervention 1: Increase screening rates to national
benchmark through targeted engagement
The case for change
The proposal
•
•
Taking a south east London view, rates of screening for Breast, Cervical
and Bowel screening, with the exception of Bromley and Bexley Clinical
Commissioning Group for Breast Screening, do not currently meet the
national benchmark as shown in the tables below.
Cervical
Bexley
Ages
25 - 64
77%
National
Benchmark
Bowel
Ages
60-74
80.00%
Bexley
47.00% 60%
National
Benchmark
Bromley
76.60% 80.00%
Bromley
48.70% 60%
Greenwich
71.30% 80.00%
Greenwich
41.10% 60%
Lambeth
34.90% 60%
Lambeth
71%
80.00%
Lewisham
72.70% 80.00%
Lewisham
39.30% 60%
Southwark
72.30% 80.00%
Southwark
34.60% 60%
Breast
Ages
47-73
Ages
50-70
National
Benchmark
Bexley
59%
73%
70%
Bromley
63%
72%
70%
Greenwich
51%
63%
70%
Lambeth
49%
58%
70%
Lewisham
52%
62%
70%
Southwark
51%
61%
70%
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
The Cancer Clinical Leadership Group propose a suite of evidence based
interventions to improve screening rates which focus on targeted
engagement work within the local care network. These include:
−
Opportunistic face-to-face health promotion within the GP practices
−
Telephone out-reach offered by multi-lingual staff
−
Tackling DNA through
o
Reminder letters
o
Flags on IT systems to identify patients who DNA screening
o
Actively working with ‘did not attend’ to support and encourage
participation
−
Home testing kits coordinated by ‘the hub’
−
‘Catch all’ automated letter system on 60th Birthday’s
−
Communication of eligibility for breast screening to women aged 73+
years
−
Targeted prevention conversations with patients and carers
Source: London Cancer Alliance
Q4 2013-14
Metrics Pack (Produced June 2014)
Draft in progress | 117
Cancer
Intervention 2: Diagnostics (sits in the Planned care Clinical Leadership Group)
Pilot project: Patients with serious but unspecific symptoms
The case for change
•
Cancer Research UK (CRUK) has very persuasive economic analysis
showing potential savings in treatment costs if there’s a shift in the
percentage of patients detected at early stages. Delivery of this vision will
mean a 10% increase in those patients diagnosed early which is equivalent
to about 8,000 more patients living longer than five years after diagnosis.
•
It has been shown that the GP indicates potential alarm symptoms in up to
12% (Ingebrigsten et al, 2013) of all consultations and suspects a serious
disease in need of further elucidation in 6% of consultations (Hjertholm et al,
2014) (Figure 1). A study showed that 10% of these patients had a new
serious diagnosis within 2 months. This means that when the GP suspects
serious illness there are reasons to support the GP in having access to
relevant investigations (Nylenna, 1986).
The proposal
•
This initiative is a three-legged strategy in diagnosing cancer taken from
the example pathway trialled in Denmark.
•
This model includes urgent referral pathways for suspicious symptoms of a
specific cancer, urgent referral to diagnostic centres when we need quick
and profound evaluation of patients with nonspecific, serious symptoms
and finally easy and fast access to ‘No-Yes-Clinics' for cancer
investigations for those patients with common symptoms in whom the
diagnosis of cancer should not be missed.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
References:
(Br J Cancer. 2015 Mar 31; 112(Suppl 1): S65–S69.
Published online 2015 Mar 3. doi: 10.1038/bjc.2015.44PMCID: PMC4385978A differentiated approach to
referrals from general practice to support early cancer diagnosis – the Danish three-legged strategy
P Vedsted1,* and F Olesen1)
Draft in progress | 118
Cancer
Intervention 3: Promotion of early detection and equal
access to treatment for older people
The case for change
The proposal
•
•
Macmillan reports that the UK has some of the worst cancer survival rates
in Europe for older people. Every year there are around 14,000 avoidable
cancer deaths in people over 75 . One of the reasons for this is that they
are sometimes not offered the right treatment. Studies have shown that
inequalities exist in terms of access to and outcomes from treatment for
older people, for example, breast cancer patients over 70 are much less
likely to receive surgery than those under 70.
•
Older people often present with cancers at a later stage and are more likely
to have their cancers diagnosed through emergency routes. Cancer
treatment rates are thus lower in older people – both factors have an
impact on survival rates.
•
In addition cancer mortality rates for older people in the UK are improving
at a much slower rate than in the younger population.
•
For this purpose, this initiative aims to:
−
Raise awareness and promote early detection for older people
−
Encourage collaborative working in secondary care
In addition research undertaken by Macmillan and the Department of Health
recommended the following interventions to address inequalities in care and
improve the older patient outcomes and experience:
−
Engage elderly care specialists as active part of the cancer care team
& adopt a Multi Disciplinary Team approach to assessment &
management of patients
−
Have early appropriate assessment
−
Ensure patients have maximum benefit for treatment
•
As a result, this initiative aims to promote early detection and treatment in
older people.
−
Manage other health conditions
−
Link with voluntary sector agencies
•
Whilst there have been some substantial improvements across the six
boroughs premature mortality from cancer is still above London and
England average.[1] 125 deaths would be saved if three inner boroughs and
Greenwich succeeded in reducing their cancer mortality levels to the
national average.[2]
−
Support staff through training and access to resources.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
[1] Under 75 mortality from cancer for years 2011-13 (DSR per 100,000): SEL average – 148, London – 138, England – 144. Source:
PHE Public Health Outcomes Framework indicator 4.05i
[2] Based on crude calculations from Under 75 cancer mortality DSR rates for years 2011-13. Source: Source: PHE Public Health
Outcomes Framework indicator 4.05i and GLA Population Projections 2014.
Draft in progress | 119
Cancer
Intervention 4: Professional development for Primary Care
Staff
The case for change
•
•
Cancer Research UK (CRUK) has very persuasive economic analysis
showing potential savings in treatment costs if there’s a shift in the
percentage of patients detected at early stages. Delivery of this vision will
mean a 10% increase in those patients diagnosed early which is equivalent
to about 8,000 more patients living longer than five years after diagnosis.
Community-based healthcare staff and local volunteers are ideally placed
to promote cancer awareness in their local area.
2. Significant Event Audit (SEA) - which promotes good practice through
learning from significant events
3. Making every contact count; training for staff to promote and support
early detection including:
o
Pharmacists
o
Practice nurses – Macmillan practice nurse course
o
Roll out of Very Brief Advice (VBA) for all professionally trained
staff
o
Front line primary care staff in CRUK Talk Cancer package
The proposal
•
To enable recognition of early signs and symptoms, three interventions are
proposed:
1. Promote implementation of the Cancer Decision Support (CDS) Tool
to support early detection in General Practice. CDS is an electronic
tool developed by Macmillan. It is designed to be used as part of
every day GP practice and assess the risk of a patient having an
existing, undiagnosed cancer and will help GPs assess patients with
possible cancer more effectively thus supporting early detection.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 120
Cancer
Intervention 5: Provider collaboration to create networked
centres of excellence
The case for change
The proposal
•
There is a an opportunity to reduce variation in patient experience, patient
care and outcomes through better coordinated services and standardised
patient pathways across south east London.
•
•
Across south east London, we are not consistently meeting the access time
scales on our cancer services.
—
Acute Oncology Services
—
Non Complex chemotherapy treatment options closer to home
•
Outcomes in SEL lag behind national and international comparators and
there is variation in rates and quality of 2WW referral
—
Consistently met cancer standard wait times
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
For this purpose, this initiative aims to provide networked cancer services
supported by integrated IT systems, to include the following suite of
interventions:
o
A detailed review of any patient waiting over 100 days
o
South east London 62 day cancer waits group – which provide a
system wide approach to speed treatment pathways
o
Implementation of 2WW NICE Guidance
—
Access to appropriate information and support for Patients and Carers
—
Routine use of the Cancer Recovery Package.
Draft in progress | 121
Cancer
Intervention 6: Non complex chemotherapy treatment
options closer to home
The case for change
•
Many of the drugs used to treat cancer can be safely delivered away from
major cancer centres. Community chemotherapy are where patients
receive their chemotherapy treatment outside of the accredited cancer
centres and cancer units in facilities nearer to home such as a GP surgery
or in their own homes.
•
The key drivers for delivering chemotherapy services in the community are
improved patient choice and experience and managing the on-going
increasing demand for chemotherapy. Additionally, in some circumstances
there is the potential for it to deliver efficiencies, particularly where physical
expansion is required.
The proposal
•
This next step for this intervention will be to agree a south east London
model for delivering non-complex treatment options closer to home.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 122
Cancer
Intervention 7: Access to appropriate information &
support for patients and carers
The case for change
The proposal
•
•
•
The NHS Five Year forward view outlines that patients don’t always have
the information they need and, crucially, the support to understand the
issues. 87% of people affected by cancer want to know more about their
disease, 50% of cancer patients forget most of the information given to
them within minutes of their consultation (Macmillan).
Various studies have shown that 16% who would like to receive information
about their condition do not receive any at all and 43% would like more
information than they are given.
•
Macmillan funded research has shown that 37% of people with cancer
found the whole cancer support system confusing and would benefit from
structured support and guidance on managing their condition.
•
43% of people use the internet to access cancer information. For people
living with something as life changing as cancer, speaking to others in the
same position can be a vital way to deal with emotions (Macmillan).
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
This initiative includes:
—
A Care/Case navigator role which will be able to provide information
on where/how to access appropriate information for patients and
carers such as psychological support,
—
An acute oncology services 24/7 advice line
—
Support to facilitate patients and carers to access existing on-line
support services
—
Support to signpost patients and carers to Cancer advice and support
centres
Draft in progress | 123
Cancer
Intervention 8: Acute Oncology Services (AOS)
The case for change
•
•
There are a high percentage of patients first presenting in A&E with a
previously unidentified cancer diagnosis, cancer patients also present with
chemotherapy and radiotherapy complications as well as progressive
disease symptoms.
This leads to inappropriate admissions via A&E to non specialist treatment
and care with extended length of stay in general medicine beds as patients
wait for specialist care. This impacts on patient experience and potentially
can have adverse clinical outcomes. The five year Cancer commissioning
(p29) states that whilst AOS has been introduced and currently exists
within south east London, there is variation in provision and failures to
comply with AOS metrics.
The proposal
•
This initiative proposes coordinated and consistent Acute Oncology
Services networked and supported by integrated IT systems.
•
National expectation – NCAG report and Cancer Reform Strategy
recommended the establishment of an acute oncology service in all
hospitals by 2011, at the latest, for quality and safety reasons:
—
—
To enable close integration with the Clinical Haematology team, as
well as Palliative Care, acute Medicine, acute Surgery, Radiology,
Pathology etc. and to lead chemotherapy and oncology services at
hospital level
—
To provide chemotherapy in appropriate local settings
•
Coordinated Acute Oncology Services provide consistent standards of care
and improved access to oncology specialists supported by integrated IT
systems for sharing patient records.
•
Early review provides a member of the Acute Oncology Team:
—
24/7 access to telephone advice from an Oncologist
—
Fast track clinic access from A&E/MAU
—
Access to information on individual patients across the Trust/Trusts
—
Protocols for the management of oncological emergencies and
referral pathways from A&E and MAU
—
Specific pathways for the investigation and treatment of malignant
spinal cord compression (MSCC).
To provide early recognition, better treatment, fast referral to
appropriate team, earlier discharge
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 124
Cancer
Intervention 9: Routine use of the Cancer Recovery
Package
The case for change
•
•
The Recovery Package has been developed and tested by the National
Cancer Survivorship Initiative (NCSI) (NHS Improvement 2012) to assist
people living with a diagnosis of cancer to prepare for the future, identify
their individual needs and support rehabilitation to enable people to return to
work and or a near normal lifestyle.
•
The Recovery Package has been designed to complement the stratified care
pathway (NHS Improvement 2012) which enables individualised follow-up
care as a supported self management programme, shared care or complex
care.
There is a need for better coordination across primary, secondary care and
the third sector to achieve seamless service provision and support patients
to transition home.
The proposal
•
Routine use of the Cancer Recovery Package will ensure care is
coordinated, transition home is supported and patients are empowered to
take good life style choices.
•
The ‘Recovery Package’ is a combination of different interventions, which
when delivered together, will greatly improve the outcomes and
coordination of care for people living with and beyond cancer. These are:
—
A Holistic Needs Assessments and care planning at key points of the
care pathway,
—
A Treatment Summary completed at the end of each acute treatment
phase, sent to patient and GP and in secondary care
—
A Cancer Care Review completed by GP or practice nurse to
discuss the person’s needs, and
—
A patient education and support event, such as a Health and
Wellbeing Clinic, to prepare the person for the transition to
supported self management, which will include advice on healthy
lifestyle and physical activity.
Reference:
National Cancer Survivorship initiative – Macmillan, Department of Health, NHS England
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 125
Cancer
Intervention 10: Implement stratified pathways of care
The case for change
•
There were 186,000 people living with and beyond cancer in London in
2010, it is estimated that there will be 364,000 in London by 2030
(Macmillan).
•
Currently there is not enough personalised care for patients and patients’
needs change over time (Macmillan) Tailored care is required to support
individual needs, to support healthy life style choices and transition back
into their lives.
The proposal
•
Stratified means that the clinical team and the person living with cancer
make a decision about the best form of aftercare based on their knowledge
of the disease, the treatment and the person and how much support that
they feel they need (National Cancer Survivor initiative).
•
There are three forms of aftercare:
—
Supported Self Management – where patients are given the
information about self management support programmes or other
types of available support, the signs and symptoms to look out for
and who to contact if they notice any, what scheduled tests they may
need such as annual mammograms, and how they get in touch with
professionals if they have any concerns.
—
Shared Care – where patients continue to have face to face, phone
or email contact with professionals as part of continuing follow up.
—
Complex Case Management – where patients are given intensive
support to manage their cancer and/or other conditions.
Reference:
National Cancer Survivorship initiative – Macmillan, Department of Health, NHS England
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 126
Cancer
Intervention 11: Better management and support for people
living with the adverse consequences of Cancer treatments
The case for change
The proposal
•
•
•
Given the growing number of people who are living with cancer, there has
been a shift from seeing it as a fatal illness to a chronic one, where people
may be in one of a number of possible stages, ranging from diagnosis,
active treatment, remission and relapse to end of life. This shift has led to a
growing focus on survivorship, and on the long-term needs of those living
with and after cancer.
Evidence shows that many of these cancer survivors have unmet needs
particularly at the end of treatment, whilst others are struggling with
consequences of treatment that could be either avoided or managed
(Macmillan).
—
70-100% of patients receiving anti-cancer treatments are affected by
fatigue that may persist for years (National Cancer Action).
—
30% of cancer patients have unmet needs after treatment for cancer,
which could be addressed by rehabilitation (National Cancer Action)
—
Late effects of radiotherapy and chemotherapy leads to a raised risk
of heart disease and diabetes (TCST)
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
The initiative includes:
—
Greater access to physical health support for people who experience
the unwanted consequences of treatment pathways
—
Enabling access to Social Care – aids/services to facilitate
independent living, social support - Citizens Advice
—
Practice nurse training – up-skilling the generalist workforce to
support patients
—
Developing a strategy for lymphedema based on best practice
examples
—
Rehabilitation pathways (National Cancer Action Team guidance)
—
Linking patients with right services for support:
o
Access to specialist services for lymphedema and pelvic
radiation disease
o
Access to generalist services for

Sexual dysfunction (men and women)

Psychological support

Chronic Fatigue

Pain management

Sleep management
Draft in progress | 127
Cancer
Intervention 12: Comprehensive Support for Carers
The case for change
•
The model encourages:
•
Across the UK, at least 1.1 million people are currently caring for a friend or
family member with cancer.
—
Adopting Macmillan’s guidance outlined in Identifying cancer carers
and signposting them to support
•
As the number of people living with and beyond cancer continues to rise,
from two million to four million by 20302, the number of carers is also
rising. Sadly, many people caring for someone with cancer remain hidden.
They care in isolation, unaware of support services that may be available to
them. Carers in the UK make a major contribution to society. Their care is
invaluable to the person who needs it, and the economic value for health
and social care is an estimated £119 billion each year. Cancer carers
provide care worth at least £14.5 billion each year.
—
Enabling and supporting carers in their care giving roles with access
to range of support options – group, on-line etc.
—
The provision of training in which carers can train alongside
professionals to support them in their care giving roles
—
Offering carers needs assessment as routine
The proposal
•
The initiative includes early identification of carers to support them in their
own needs as well as signpost them to information, support and advice.
•
Carers should also be included in advanced care and discharge planning
which can ensure that the person with cancer will be supported at home.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Reference:
Macmillan – ‘do you care’ making identification and support for carers a priority
Draft in progress | 128
Cancer
Intervention 13: Psychological Interventions
The case for change
•
In the first year after cancer diagnosis about 25 per cent of people
experience psychological distress, with symptoms of anxiety and
depression severe enough to affect their quality-of-life.
•
There is however, variation in the provision of emotional and psychological
support services across London.
•
The government’s mental health outcomes strategy ‘No Health Without
Mental Health places considerable emphasis on the connections between
mental and physical health.
•
In addition, the London Mental Health Strategic Clinical Network in
partnership with the Transforming Cancer Services Team for London has
produced guidance to support commissioners and service providers in
improving psychological support across the cancer pathway. The south east
London programme proposes to follow these recommendations upon
publication.
The proposal
•
The initiative includes:
—
Early identification of carers to support individuals.
—
Considering a persons mental wellbeing at all stages of their journey
—
Facilitating greater access to Psychological interventions to promote
mental health & well-being
o
Access to psychological support: during treatment phase Level 2 CNS, Level 3/4 psychiatric liaison services
o
Access to psychological support post treatment (patient and
carer) – IAPT (self/GP referral).
o
Reviewing outcomes and learning from the London Cancer
Alliance eHNA pilot model – “pathway for Mental Health and
Psychological support services for adults”
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Reference:
National Institute for Clinical Excellence (2004) Guidance on Improving Support and Palliative Care
for Adults with Cancer.
Draft in progress | 129
Cancer
Intervention 14: Inclusion of Cancer as a criteria for referral
to exercise/physical activity on prescription schemes
The case for change
•
Evidence shows that physical activity can reduce the risk of developing
breast, bowel or womb cancer preventing an estimated 3,400 cases of
cancer every year in the UK. Aerobic exercise like running, cycling or
swimming can help alleviate fatigue during or following cancer treatment
(Macmillan).
The proposal
•
The initiative includes:
—
Physical activity to be ‘prescribed to patients’ by their GP’s following
cancer treatment where appropriate
—
A named professional to encourage and facilitate access to
opportunities to undertake physical activity – both Cancer and noncancer specific options/schemes.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 130
Cancer
Intervention 15: Support to return to work, study or
volunteering
The case for change
•
Macmillan states that over a third of the two million people living with
cancer in the UK are of working age (18–64 years). Work is an integral part
of helping people get back to normality and for many, it can also be a
financial necessity.
•
However, the reality is that those who want to return to work don’t always
receive the support they need, thus preventing them from benefiting both
employers and making a significant contribution to the UK economy.
—
Level 2 – Active support for self-management:
o
—
Health professionals and other support staff with some specialist
knowledge of work-related cancer issues should provide
resources to help people self manage so they can return to work.
Level 3 – Specialist vocational rehabilitation:
o
People who have complex needs should be referred to a
vocational rehabilitation service for specialist case management
support.
The proposal
•
This models proposes adopting a new model for vocational rehabilitation
services.
•
Macmillan, as part of the National Cancer Survivorship Initiative (NCSI),
piloted a new model of vocational rehabilitation services for people with
cancer. The evaluation identified three different levels of work support to be
offered as routine:
—
Level 1 – Open access to information and support:
o
All service providers and health professionals should ask
people living with cancer who are in work or have the potential
to work about their employment situation.
(Making the shift - Providing specialist work support to people with cancer)
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 131
Cancer
Intervention 16: Implementation of the Cancer Recovery
Package
The case for change
•
There is a need for better coordination across primary, secondary care and
the third sector to achieve seamless service provision and support patients
to transition home.
•
The Cancer Care review and patient well being event can take place in the
local care network.
•
The Recovery Package has been developed and tested by the National
Cancer Survivorship Initiative (NCSI) (NHS Improvement 2012) to assist
people living with a diagnosis of cancer to prepare for the future, identify
their individual needs and support rehabilitation to enable people to return to
work and or a near normal lifestyle.
•
The Recovery Package has been designed to complement the stratified care
pathway (NHS Improvement 2012) which enables individualised follow-up
care as a supported self management programme, shared care or complex
care.
The proposal
•
•
Routine use of the Cancer Recovery Package will ensure care is
coordinated, transition home is supported and patients are empowered to
take good life style choices.
The ‘Recovery Package’ is a combination of different interventions, which
when delivered together, will greatly improve the outcomes and
coordination of care for people living with and beyond cancer. These are:
—
A Holistic Needs Assessments and care planning at key points of the
care pathway,
—
A Treatment Summary completed at the end of each acute treatment
phase, sent to patient and GP and in secondary care
—
A Cancer Care Review completed by GP or practice nurse to
discuss the person’s needs, and
—
A patient education and support event, such as a Health and
Wellbeing Clinic, to prepare the person for the transition to
supported self management, which will include advice on healthy
lifestyle and physical activity.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Reference:
National Cancer Survivorship initiative – Macmillan, Department of Health, NHS England
Draft in progress | 132
Cancer
Intervention 17: Ensuring a dignified death irrespective of
setting
The case for change
The proposal
•
There is potential to improve the experience of care in the last year and
months of life. The Parliamentary and Health Service Ombudsman report
‘Dying without dignity’ (p4) states that:
•
•
“the experience of people who are dying and their loved ones of the care
provided by the NHS is a recurring theme in complaints”
Implementing the 5 priorities outlined by the Leadership Alliance for
the Care of Dying People “One Chance To Get it Right” (June 2014).
These include:
•
Key themes and issues were identified as:
o
The possibility that a person may die within the next few days or
hours is recognised and communicated clearly, decisions are
made and actions taken in accordance with the person’s needs
and wishes
o
Sensitive communication takes place between health care
professionals and the dying person, and those identified as
important to them
o
The dying person, and those identified as important to them, are
involved in decisions about treatment and care
o
The needs of families and others identified as important to the
dying person are actively explored, respected and met as far as
possible
o
An individual plan of care, which includes symptom control and
psychological, social and spiritual support, is agreed, coordinated and delivered with compassion.
—
Not recognising that people are dying and not responding to their
needs
—
Poor symptom control
—
Poor communication
—
Inadequate out-of-hours service
—
Poor care planning
—
Delays in diagnosis & referral for treatment b
The initiative therefore support improved patient experience at end of life
through
—
—
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Promoting autonomy at end of life to facilitate dying in a place of
choice.
Reference:
NHS England (Nov2014) Actions for End of Life Care 2014-16.
Draft in progress | 133
Cancer
Intervention 18: Ensuring a dignified death irrespective of
setting
The case for change
•
Coordinate My Care (CMC) is a service dedicated to preserving dignity and
autonomy at the end of life. Its care pathways enable health professionals
from primary and secondary care to put the patient at the centre of health
care delivery. This service is underpinned by an electronic solution. The
CMC record can be accessed 24/7 by all health and social care
professionals who have a legitimate relationship with the patient.
•
The record can display diagnosis, prognosis, advanced care plan,
resuscitation status and patients wishes for end of life. A patient can
access and contribute to their own record.”
The proposal
•
The initiative proposes:
—
Implementation of ‘Coordinate My Care’
—
Support for professionals to access and use CMC
—
Ensuring consistent use of ‘Coordinate My Care’ across south east
London – monitor and audit.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
References:
BMJ - Coordinate My Care: a clinical service that coordinates care, giving patients choice and
improving quality of life
Clare Smith,1 Libby Hough,1 Chi-Chi Cheung,2 Catherine Millington-Sanders,3 Eileen Sutton,4 Joy
R Ross,1,5 Michael Thick,5 Julia Riley1,5 December 6, 2012 - Published by group.bmj.com
Draft in progress | 134
Cancer
Intervention 19: Advance Care Planning
The case for change
•
A diagnosis of cancer may prompt planning for future care. Planning future
care is important in case a person becomes ill unexpectedly and becomes
unable to make choices and decisions about treatment, healthcare or make
financial plans for their loved ones (Macmillan).
The proposal
•
The initiative recognises the need to:
—
Start conversations early to facilitate greater choice and control over
care options
—
Advance care planning to promote early assessment of end of life
needs, advance care planning, including the following suite of
interventions:
o
Living wills, advance decisions and advance statements
o
Advance decision to refuse treatment
o
Your wishes for future care
o
Lasting Power of Attorney.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 135
Draft in progress | 136
Benefits/outcomes
of achieving our
vision
Purpose of the Outcomes Framework
Approach to selecting indicators to measure the
performance of the strategy
•
The primary aim of delivering the “Our Healthier South East London”
strategy and vision is to develop ways to improve the health and care
outcomes for south east London communities and people.
•
To measure if the strategy is delivering the outcomes a number of indicators
were selected that will demonstrate the strategies performance against the
outcomes.
•
A framework which sets out measures to monitor the impact of the strategy
on outcomes has been developed through engaging with our partners
across health and care providers, Public Health, clinicians and public and
patients. This framework sets out the measures that demonstrate the
effectiveness of the strategy in achieving the outcomes allowing us to
quantify the strategies impact.
•
Hundreds of indicators exist across health and social care, however a small
number is required in order to remain focused. These will be complex and
more focused on care models than at a CCG or Local Care Network level.
The aim for this process was to strike a balance between an appropriate
number of measures by applying the following principles to selecting the
indicators and through feedback from stakeholder groups including public
health:
•
Principles applied for selecting indicators:
Focusing on the achievement of outcomes
•
•
By implementing the strategy and its care models the aim is to reduce the
variability in outcomes we see today as outlined in the case for change and
to improve the overall health and care outcomes for people across south
east London.
Our outcomes aim to improve health, reduce health inequalities and make
sure that services are consistently of a high standard both in terms of
clinical outcomes and patient experience. Inputs/ process measures may
be used as proxies to identify these.
•
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
—
outcome focused where possible
—
addresses the challenges set out in the Case for Change
—
reflect the new clinical models of care
—
reflect the whole pathway of health and care, including mental health
—
indicators that predominately come from existing sources drawing on
national frameworks, emerging frameworks from other parts of the
country and local data sources. It should be noted that a number of
placeholders have been included where indicators are being
developed nationally.
By following these principles it will be possible to measure the impact of the
strategy and be able to measure and compare south east London with other
health and care economies.
Draft in progress | 137
Benefits/outcomes
of achieving our
vision
Structure of the framework
•
The framework is made up of the following core elements:
•
•
•
•
It should be noted that, while indicators are aligned with certain domains, many of
them could be included in a number of different areas.
Domains: The high-level grouping or classification of outcomes that
are measuring similar things. There are a number of existing
• Some measure, such as mortality, may not be completely associated with
outcome frameworks which were reviewed and based on those
healthcare services. It is important to recognise associated factors that influence
frameworks, four ‘domains’ that are common across them were
these measures.
selected. Outcomes within these domains will represent performance
Measuring outcomes at different levels
across the system and for different population groups.
• Outcome measures for Our Healthier South East London can be used in a number
Outcomes: The overall impact of the strategy on the health and wellof different ways and at different levels.
being of our populations and individuals in south east London
• While the outcome framework below focuses on the achievement of the overall
Indicators: The measures selected to demonstrate the achievement
strategy at a south east London level, they can be applied at different levels in the
of the outcome. These are as outcome focused as possible but in
system as set out below:
some cases a process/structure measure has been used as a proxy.
—
South East London Whole System Outcomes: A small, focused, number
of outcome indicators at a system level to demonstrate the overall impact of
the strategy as outlined on the following pages.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
—
CCG outcomes: CCGs already have a large number of outcomes and
measures, both local and national; these will remain There will be alignment
with the whole system model outcomes for those outcomes and measures
where the 6 CCGs can achieve greater impact together
—
Local Care Network outcomes: Over time, Local Care Networks will be
measured on their performance in a number of ways;
1.
At a strategic level a common set of measures across the Local Care
Networks that demonstrate the performance of the Local Care Network
linked to the whole system outcomes
2.
Local level measures for areas of concern /improvement that may vary
between boroughs and Local Care Network areas, for example because
of demographic differences (set by individual CCGs) and
3.
Contractual performance measures that will link to both strategic and
local outcomes
Draft in progress | 138
Benefits/outcomes
of achieving our
vision
•
is possible to measure many of the indicators in the framework at all levels.
However, in some instances local measures and methodologies will need
to be defined in order to routinely capture and monitor performance.
Measuring performance at a local level will also be supported by the
development of patient-linked data sets where possible. These have been
highlighted as TBC in the framework.
System transformation measures
•
•
•
In addition to the whole system outcomes, a number of system
transformation measures can be applied to demonstrate how organisations
across south east London are implementing the strategy. Many of these
measures will be linked to outcomes and will be able to act as proxy
indicators until outcomes are realised.
—
Financial: It is anticipated that, by delivering care in a more integrated
way and with greater emphasis on prevention, there will follow a
range efficiency and financial benefits across the system. These are
articulated as part of the financial impact assessment.
Developing a baseline
•
A baseline is currently being developed to understand current performance
and agree the scale of improvement the strategy is expected to deliver.
Whole System Outcome Framework
•
The following pages set out the whole system Outcome Framework. This
includes supporting information:
These measures will be developed as we move towards implementation
and will be led by the clinical and operational teams developing these
models.
—
The definition and rationale for each indicator
—
Method of collection,
For example;
—
Frequency of collection
—
Readiness of the data to be collected and measured
—
The level at which it can or potentially can be measured
—
Outputs and processes: Care models will begin to define how certain
interventions will be delivered. Through this process a range of
outputs and process measures will be defined. For example, the
number of patients who have a care plan.
—
Quality: A core component of the strategy is improving the quality of
care and, in particular, supporting providers to achieve the London
Quality Standards. Many of these measure are, not directly
measuring outcomes but rather look at the standards that should be
in place in order to improve outcomes. Through the development
and implementation of the care models, it will be important to
monitor performance against national and regional quality standards
such as the London Quality Standards.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 139
Benefits/outcomes
of achieving our
vision
Whole System Outcome Framework
Outcome framework to monitor the impact of the strategy
Population Health
Outcome
Preventing
people from
dying
prematurely
and can live
longer and
healthier
lives
Indicator
Indicator
Source
Definition
Rationale
Type
Frequency
Readiness
S
E
L
L
A
L
C
N
Potential Years of Life Lost
(PYLL) from causes
considered amenable to
healthcare
NHSOF 1a,
CCGOF 1.1
Potential years of life lost (PYLL)
rate from causes considered
amenable to healthcare.
To ensure that the NHS is held to account for
doing all that it can to prevent amenable deaths.
Deaths from causes considered ‘amenable’ to
healthcare are premature deaths that should not
occur in the presence of timely and effective
healthcare. Each CCG has were required to set
out a level of ambition to improve this in their 3 and
5 year plans.
Data
Annual
X
X
Disease Burden: Incidence
and/or prevalence of major
chronic conditions
- Diabetes
- Obesity (adult and 16-18)
- Chronic Obstructive
Pulmonary Disorder
- Cardiovascular Disease
QOF
Analysis based on QOF data
which can be used to determine
impact on prevalence at a local
level. Notes (1) QOF measures
Obesity from 16 (2) some of
these may increase if there is an
increase in reporting and/or early
detection - this should be
recognised as positive.
A number of health issues in the case for change
have been identified as a ‘high burden’ of ill health
across south east London where the trend or
outlook is worsening
Data
TBC
X
X
X
Premature mortality (under
75) from the major causes of
death in SEL:
- Cardiovascular diseases,
- Cancers
- Respiratory diseases
(COPD)
- Alcohol specific mortality
HSCIC /
CCG OF
A measure of the likelihood of
dying of CVD, Cancer or COPD
under the age of 75, which
allows for comparisons between
populations with different age
profiles and over time.
Premature mortality and differences in life
expectancy are both significant issues. There is a
difference in life expectancy between the most and
least deprived wards of 8.7 years for women and
9.3 years for men. About 11,000 people died
prematurely across south east London over the
period 2009 to 2011, with four boroughs being
classified in the “worst” category for premature
mortality outcomes in England.
Data
Quarterly
X
X
T
B
C
The biggest causes of premature mortality are
cardiovascular diseases,
cancers and respiratory diseases. Mortality rates
for these diseases have decreased significantly
over recent years, but rates continue to be
considerably above London average (SEL Case
for Change)
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
KEY
South east London (SEL)
Local Authority (LA)
Local Care Network (LCN)
Draft in progress | 140
Benefits/outcomes
of achieving our
vision
Whole System Outcome Framework
Outcome framework to monitor the impact of the strategy
Outcome
Indicator
Population Health
Reduction in gap in life
expectancy between the most
and least deprived
Indicator
Source
ONS, PHOF,
GLA data
store
Definition
Rationale
Type
Frequency
Life expectancy at birth: the average
number of years a person would expect to
live based on contemporary mortality rates.
Figures calculated by Office for National
Statistics using ONS mortality data and midyear population estimates
The average number of years a
person would expect to live
based on contemporary mortality
rates. For a particular area and
time period, it is an estimate of
the average number of years a
new-born baby would survive if
he or she experienced the agespecific mortality rates for that
area and time period throughout
his or her life.
Data
Annually
Data
Quarterly
(TBC)
Reducing
differences in
life
expectancy
and healthy
life
expectancy
between
communities
Readiness
S
E
L
L
A
X
X
X
X
L
C
N
There is a difference in life
expectancy between the most
and least deprived wards of 8.7
years for women and 9.3 years
for men. About 11,000 people
died prematurely across south
east London over the period
2009 to 2011, with four boroughs
being classified in the “worst”
category for premature mortality
outcomes in England.
Major causes of death between
communities linked to level of
deprivation. Mortality rates for:
- Circulatory, cancer, and
respiratory conditions (need to
confirm for each borough)
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
HSCIC
(Primary Care
Mortality
Database)
There are a number of contributing factors
to the life-expectancy gap. One of the major
factors is the major causes of death. For
example, in Lambeth, the major contributing
factors are Circulatory, cancer and
respiratory conditions
(http://www.lambeth.gov.uk/sites/default/file
s/ssh-Lambeth-Life-Expectancy-2014.pdf).
Capturing this information at a local level
could act as a proxy for health inequalities
See above.
Local
analysis
required
X
KEY
South east London (SEL)
Local Authority (LA)
Local Care Network (LCN)
Draft in progress | 141
Benefits/outcomes
of achieving our
vision
Whole System Outcome Framework
Outcome framework to monitor the impact of the strategy
Quality of Life
Outcome
People are
independent,
in control of
their health,
and able to
access
personalised
care to suit
their needs
Indicator
Source
Indicator
Definition
Rationale
Type
Frequency
Readiness
S
E
L
L
A
Permanent admissions to
residential and care
homes, per 100,000
population (both over 65
and 18-65) (All
admissions)
ASCOF 2A,
BCF (just
over 65)
This is a two part-measure reflecting the
number of admissions of younger adults (part
1) and older people (part 2) to residential and
nursing care homes relative to the population
size of each group. The measure compares
council records with ONS population
estimates. The working group also agreed that
it would be necessary to capture admissions
from different parts of the system.
Avoiding permanent placements in
residential and nursing care homes
is a good indication of delaying
dependency, and local health and
social care services will work
together to reduce avoidable
admissions. Research suggests
where possible people prefer to stay
in their own home rather than move
into residential care.
Data
6 monthly
X
X
Unplanned hospitalisation
for chronic ambulatory
care sensitive conditions
HES, CCG
2.6, NHSOF
2.3i
Directly age and sex standardised rate of
unplanned hospitalisation admissions for
chronic ambulatory care sensitive conditions
for persons of all ages. These conditions
include, for example, diabetes, epilepsy and
high blood pressure.
This outcome is concerned with how
successfully the NHS manages the
conditions through looking at
unnecessary hospital admissions.
Data
Quarterly
(rolling)
X
X
Complications associated
with diabetes
CCG OF 2.8
Indirectly age and sex standardised rate for
complications associated with diabetes, per
100 people with diabetes.
This is an outcome measure that
captures exacerbations in existing
conditions. This should promote
preventative activities to reduce the
occurrence of complications.
Data
Annual
X
X
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
L
C
N
T
B
C
KEY
South east London (SEL)
Local Authority (LA)
Local Care Network (LCN)
Draft in progress | 142
Benefits/outcomes
of achieving our
vision
Whole System Outcome Framework
Outcome framework to monitor the impact of the strategy
Quality of Life
Outcome
Health and
care services
enable
people to live
a good
quality of life
with their
long term
condition
Indicator
Indicator
Source
Definition
Health-related quality of life for people with a
long-term mental health condition
CCG OF 2.16
Average adjusted health status
(EQ-5D™) score for individuals
reporting that they have a longterm mental health condition,
based on responses to a
question from the GP Patient
Survey.
Proportion of adult carers who have as much
social contact as they would like
ASCOF /
PHOF 1.18ii
This measure shows the
proportion of carers who
reported that they have as much
social contact as they would like.
The measures are calculated
from data collected in the Adult
Social Care Survey and the
Carers Survey. The question
from the Carers Survey is
Question 11; “Thinking about
social contact you’ve had with
people you like, which statement
best describes your present
social situation?
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Rationale
There is a clear link between
loneliness and poor mental and
physical health. A key element
of the Government’s vision for
social care is to tackle
loneliness and social isolation,
supporting people to remain
connected to their communities
and to develop and maintain
connections to their friends and
family. This measure will draw
on self-reported levels of social
contact as an indicator of
social isolation for both users
of social care and carers.
S
E
L
L
A
Annual
X
X
TBC
X
X
Type
Frequency
Survey
Survey
Readiness
L
C
N
KEY
South east London (SEL)
Local Authority (LA)
Local Care Network (LCN)
Draft in progress | 143
Benefits/outcomes
of achieving our
vision
Whole System Outcome Framework
Outcome framework to monitor the impact of the strategy
Outcome
Effectiveness of Care
Treatment is
effective and
delivers the
best results
for patients
and service
users
Indicator
Source
Indicator
Definition
Rationale
Type
Frequency
Readiness
S
E
L
L
A
X
Emergency readmissions
within 30 days of discharge
from hospital all
admissions
CCGOF 3.2
Total number of emergency admissions
episodes for people of all ages where an
acute condition that should not usually
require hospital admission was the primary
diagnosis. The indicator shows information
on the number of emergency admissions
per 100,000 population. This indicator has
been indirectly age and sex standardised.
To measure the progress in helping people
to recover as effectively as possible. This is
a short-term outcome measure.
Data
Annual
X
Patient Reported Outcome
Measures for elective care
services
PROM data
The EQ-5D index case mix adjusted
average and total health gain from patients’
reported improvement in health status
following elective procedures.
To ensure elective care is covered by the
NHS Outcomes Framework. Over time the
number of PROMS may be increased.
Survey
Annual
X
Proportion of older people
(65 and over) who where
still at home 91 days after
discharge from hospital
into
reablement/rehabilitation
services
NHSOF 3.6i,
ASCOF 2B
Proportion of older people (65 and over)
who where still at home 91 days after
discharge from hospital into
reablement/rehabilitation services
This measures the benefit to individuals
from reablement, intermediate care and
rehabilitation following a hospital episode,
by determining whether an individual
remains living at home 91 days following
discharge – the key outcome for many
people using reablement services. It
captures the joint work of social services
and health staff and services commissioned
by joint teams, as well as adult social care
reablement.
Data
Annual (can
be
produced
monthly
locally)
X
Survival rates for cancer in
the effectiveness of care
outcome (1 and 5 years)
NHSOF 1.4
/ CCG OF /
ONS
One-year and five-year net survival for
adults suffering from cancer.
A measure of the number of adults
diagnosed with any type of cancer in a year
who are still alive five years after diagnosis.
ONS still publish survival percentages for
individual types of cancers. These can be
found at:
http://www.ons.gov.uk/ons/rel/cancerunit/cancer-survival/cancer-survival-inengland--patients-diagnosed-2007-2011and-followed-up-to-2012/index.html
Data
Annual
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
X
L
C
N
T
B
C
KEY
South east London (SEL)
Local Authority (LA)
Local Care Network (LCN)
Draft in progress | 144
Benefits/outcomes
of achieving our
vision
Whole System Outcome Framework
Outcome framework to monitor the impact of the strategy
Effectiveness of Care
Outcome
Indicator
Source
Indicator
Definition
Rationale
Type
Frequency
Readiness
S
E
L
L
A
L
C
N
A reduction in the
average length of stay
(acute bed days)
SUS data
A reduction in the average length of stay
from an agreed baseline position
The length of time patients spend in
hospital for specific conditions has a large
impact on overall health system costs. It
also impacts on the quality of patient care
exposing them to potentially negative risks
such as increased frailty. A reduction in
the length of stay will demonstrate a
system that is working well and that
supports patients along the pathway of
care.
Data
Quarterly
(potential for
more frequent
measurement)
X
X
T
B
C
Delayed transfers of care
from hospital per 100,000
population (18+)
ASCOF and
Existing Data
A delayed transfer of care occurs when a
patient is ready for transfer from a
hospital bed, but is still occupying such a
bed. This is also a core BCF measure
This measures the impact of hospital
services (acute, mental health and nonacute) and community-based care in
facilitating timely and appropriate transfer
from all hospitals for all adults. This
indicates the ability of the whole system to
ensure appropriate transfer from hospital
for the entire adult population, and is an
indicator of the effectiveness of the
interface within the NHS, and between
health and social care services. Minimising
delayed transfers of care and enabling
people to live independently at home is
one of the desired outcomes of social
care.
Data
Quarterly
(potential for
more frequent
measurement)
X
X
T
B
C
Emergency admissions
for acute conditions that
should not usually require
hospital admission
CCGOF 3.1,
NHSOF 3.3a
Total number of emergency admissions
episodes for people of all ages where an
acute condition that should not usually
require hospital admission was the
primary diagnosis. The indicator shows
information on the number of emergency
admissions per 100,000 population. This
indicator has been indirectly age and sex
standardised.
To measure the progress in helping
people to recover as effectively as
possible. This is a short-term outcome
measure.
Data
Quarterly
X
X
Delivering the
right care, at
right place, at
the right time
along the
whole cycle
of care
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
KEY
South east London (SEL)
Local Authority (LA)
Local Care Network (LCN)
Draft in progress | 145
Benefits/outcomes
of achieving our
vision
Whole System Outcome Framework
Outcome framework to monitor the impact of the strategy
Quality of Care
Outcome
Commitment
to people
having a
positive
experience of
care
Caring for
people in a
safe
environment
and
protecting
them from
avoidable
harm
Indicator
Indicator
Source
Definition
Rationale
Type
Frequency
Readiness
S
E
L
L
A
Patient experience of hospital
care (composite measure of
inpatient, outpatient and A&E)
NHSOF 4b
Patient experience measured by
scoring the results of a selection of
questions from the national inpatient
survey looking at a range of elements
of hospital care.
To capture the experience of
patients who have recently received
medical treatment in hospital. Over
time it may be possible to move to a
single measure of satisfaction for all
health and care services.
Survey
Annual
X
Patient experience of GP
services
NHSOF 4a
Patient experience of GP services,
measured by scoring the results of one
question from the GP Patient Survey
All south east London CCGs have
lower than average GP access
(Case for Change)
Survey
Annual
X
X
Patients experience of
Integrated Care (Placeholder
– currently under
development)
NHSOF and
ASCOF
TBC
TBC
TBC
TBC
-
-
Proportion of people who use
[social care] services who feel
safe
ASCOF 4A
This measure shows the proportion of
people who use services who feel safe,
and is calculated from data collected in
the Adult Social Care Survey. The
relevant question drawn from the Adult
Social Care Survey is Question 7a:
“Which of the following statements best
describes how safe you feel?”
Survey
TBC
X
X
Percentage of professionals
who report they are ‘satisfied’
or ‘very satisfied’ with their job
Provider staff
surveys
Exact definition and method TBC
Survey
TBC
X
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Based on recent research the
satisfaction levels among a
hospital's staff are closely linked to
the quality of healthcare it provides.
As such, staff satisfaction can be
included as a proxy for the quality of
care.
(http://qualitysafety.bmj.com/content
/early/2013/02/20/bmjqs-2012001540.full)
L
C
N
-
KEY
South east London (SEL)
Local Authority (LA)
Local Care Network (LCN)
Draft in progress | 146
Benefits/outcomes
of achieving our
vision
Whole System Outcome Framework
Outcome framework to monitor the impact of the strategy
Quality of Care
Outcome
Caring for
people in a
safe
environment
and
protecting
them from
avoidable
harm
Indicator
Indicator
Source
Definition
Rationale
Type
Frequency
Readiness
S
E
L
L
A
L
C
N
NHS safety thermometer
(for all settings within
scope):
- pressure ulcers
- falls
- urinary tract infections
(UTIs) in patients with a
catheter
- new venous
thromboembolisms (VTEs)
HSCIC
The NHS Safety Thermometer is the
measurement tool for a programme of work to
support patient safety improvement. It is used to
record patient harms at the frontline, and to
provide immediate information and analyses for
frontline teams to monitor their performance in
delivering harm free care. Measurement is
across care settings including; Acute Hospital
Ward, Community, Community Hospital Ward,
Hospice, Mental Health Community, Nursing
Home, Other, Own Home, Residential Care
Home. Providers should be measured against all
settings within scope of the contract.
Together these measures will ensure
that providers are delivering safe care
and protecting patients and service
users from harm.
-
-
X
X
-
Reduction in the variation of
care across SEL(1): To
demonstrate the variations
in care a number of
measures can be used that
are consistent across all 24
Local Care Networks.
Measures could include:
- Emergency department
attendances
- Emergency admissions
- Emergency readmissions
- Referrals
SUS data
A number of indicators, linked to the case for
change, that will demonstrate key variations in
care across SEL. The exact detail for these will
be determined through community based care
implementation group and agreed across SEL.
For many of these indicators it will be possible to
build these from existing data sets on a quarterly
basis. This would require the combination of
SUS, ONS deprivation and Exeter Registrations
There is variation in the quality of care
across SEL. As LCNs are developed
they should be able to impact on some
of the core measures that indicate
quality of care.
-
-
X
X
X
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Activity measures are used as a proxy
in this instance to highlight potential
variations based on need. For
example, the kings fund have
identified that the rate of emergency
admissions in the most deprived areas
is more than twice the rate in the least
deprived areas in England. Conversely
referrals for some procedures are
lower in areas of greater deprivation.
KEY
South east London (SEL)
Local Authority (LA)
Local Care Network (LCN)
Draft in progress | 147
Benefits/outcomes
of achieving our
vision
Whole System Outcome Framework
Outcome framework to monitor the impact of the strategy
Quality of Care
Outcome
Caring for
people in a
safe
environment
and
protecting
them from
avoidable
harm
Indicator
Reduction in the variation of
care across SEL(2): To
demonstrate the variations
capture the % of GP
practices 'achieving' or
'higher achieving' against
the GP outcomes
framework
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Indicator
Source
GP
Outcome
Standards
Definition
Rationale
Type
Frequency
The Quality and Outcomes Framework (QOF) is
the annual reward and incentive programme
detailing GP practice achievement results. QOF
awards surgeries achievement points for:
managing some of the most common chronic
diseases, e.g. asthma, diabetes; implementing
preventative measures, e.g. regular blood
pressure checks; the extra services offered such
as child health care and maternity services; the
quality and productivity of the service, including
the avoidance of emergency admissions to
hospital; compliance with the minimum time a
GP should spend with each patient at each
appointment
There is significant variation in
achievement of GP outcomes, both
within and between boroughs. Best
performance against GP outcomes
across south east London was
Bromley where 54% of practices are
‘achieving’ or ‘higher achieving’
practices; the worst performance was
in Lambeth where this figure is only
12%. The equivalent England average
is 62%. (SEL Case for Change)
Data
TBC
Readiness
S
E
L
L
A
L
C
N
X
X
X
KEY
South east London (SEL)
Local Authority (LA)
Local Care Network (LCN)
Draft in progress | 148
Draft in progress |
149
Financial impact
and affordability
Introduction
•
•
•
•
In estimating the affordability challenge facing south east London and the
impact of proposals in this consolidated strategy, we have undertaken a
number of pieces of analysis. Given the timescales we were working to and
the developmental status of the proposals developed by the Clinical
Leadership Groups, it would not have been practical or cost efficient to
construct a sophisticated bottom up model of the health and social care
economy before and after the proposed changes.
Rather, our approach was to provide an indication of the expected impact
of our interventions on the financial challenges facing the health and social
care economy making use of the best available data from a range of
publicly available sources and information provided to us by the
participating parties.
•
While our findings will need to be revisited and tested in detail at the design
phase, we believe that the results provide a clear and robust indication of
the benefits and costs associated with the proposals in the strategy.
Throughout our analysis, our estimates of impacts take a system-wide
view. That is to say that they consider the impact of solutions in terms of
cost of provision given the limited funding coming into the system (i.e.
through CCG allocations). As such, at this stage, our impacts are not
considered on an individual organisation basis (i.e. how much more or less
commissioners would have to pay for the new services under the existing
tariff payment structure).
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
—
Clinical models should provide value for money for the entire system
rather than individual organisations.
—
It may be necessary to share benefits between organisations in order
to encourage change.
—
Existing payment structures may no longer be the best method to
enable change.
Data sources
Approach
•
This reflects that:
The primary data sources used in our analysis are as follows:
—
Reference costs (2013/14) with significant adjustments (agreed with
local providers) to allow for the dissolution of South London
Healthcare NHS Trust.
—
CCG five year financial plans.
—
Provider long term financial models or annual plan templates.
—
Hospital Episode Statistics (HES) data using the Healthcare
Evaluation Data (HED) tool (https://www.hed.nhs.uk/info).
Engagement
•
We have developed strong local engagement from Finance Leads across
the south east London health economy as evidenced by very good
attendance/participation at monthly meetings, an agreed memorandum of
understanding for information, setting out data sharing principles and rapid
responses to any data requests.
Draft in progress | 150
Financial impact
and affordability
Overall impact
•
•
•
The overall savings presented below are system-wide cost savings, i.e.
they relate to reductions in the cost of provision following the changes in
activity. Thus they can be counted against the £1.1bn affordability
challenge.
The table below shows the potential impact of the proposed changes under
three investment scenarios:
1. Scenario 1: 30% of gross benefits reinvested.
2. Scenario 2: 40% of gross benefits reinvested.
Further to these savings, individual organisations will still be required to
achieve their own efficiency savings. This is true both of providers (in terms
of traditional CIP efficiencies) and commissioners (i.e. prescribing QIPPs,
which will continue regardless). Therefore it is important not to count the
saving presented below as the only effort to close the affordability gap. In
making this saving we must take account of the impact it has on other
organisations to achieve their own efficiency targets. For example acute
providers may struggle to achieve the same levels of CIP savings as
forecast if they are attempting to do so on a smaller overall cost base.
3. Scenario 3: 50% of gross benefits reinvested.
•
In the table below, a positive number is a net benefit to the system, while a
negative number is a net investment. However, given the strong links
between Community Based Care and the other Clinical Leadership Groups,
the segmentation below is somewhat arbitrary, reflecting that an investment
in Local Care Networks may be required in order to derive a saving
elsewhere.
•
Further detail on impacts for each Clinical Leadership Group can be found in
Appendix E.
Clinical Leadership Group
Scenario 1
Net benefit (2019/20) (£m)
Scenario 2
Net benefit (2019/20) (£m)
Scenario 3
Net benefit (2019/20) (£m)
Urgent & Emergency Care
92
80
67
44
38
32
9
7
6
14
12
10
Community Based Care*
(12)
(12)
(12)
Total
161
138
115
Children & Young People
Planned Care
Maternity
Cancer
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 151
Financial impact
and affordability
Closing the affordability challenge
System wide income/expenditure (£ millions)
•
The graphs on this page demonstrates how the benefits from the
programme can be combined with savings within individual organisations
to close a substantial amount of the £1.1 billion affordability challenge.
The benefits shown are as follows:
1.
Programme gross benefit.
2.
Provider efficiencies at 2.5%: The provider finance leads feel that
a 2.5% CIP may be reasonable in addition to efficiencies generated
through the programme.
5,900
5,903
5,672
5,400
5,078
4,900
4,812
•
It is important to note that both of these savings are presented
gross of investment requirements (which total £90 million in the
programme central case). It is expected that these investment
requirements will, at least in part, be satisfied through additional funding
requested through the Five Year Forward View and committed by the
Government. Taking south east London’s proportionate share of the £8
billion committed would imply that £248 million is available for this
purpose.
•
The central case assumes the £231 million gross benefit with 40%
investment (the high case and low case are 30% investment and 50%
investment respectively).
•
The resultant position is a £266 million affordability challenge for
the South East London health care economy.
Expenditure (Do Nothing)
4,400
Expenditure (Strategy)
Expenditure (Residual)
3,900
2013/14
Revenue
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
NB: Profiling of benefits shown above may significantly change as implementation
plans are developed.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 152
Financial impact
and affordability
Initial estimate of acute bed requirement
• Using historical NHS bed occupancy data for the acute providers
and our projections of bed demand considering demographic/nondemographic growth assumptions we have estimated the bed
gaps/increases show in the table below.
• We have modelled the impact of the strategy on overnight bed days
to be a net reduction of 138,000 and a net increase in day case bed
days of 25,000. This translates directly to a number of beds using
various occupancy rates as shown in the table below.
• This only relates to acute beds and we would expect a proportion
of this activity to be provided within community beds. Also note that
the ‘do nothing’ position does not reflect any potential reductions
associated with QIPP delivery post 2014/15 plans or Better Care
Fund related non-elective admission reductions.
Baseline bed days/beds
2013/14
Growth (2019/20)***
Gross change
(2019/20)
Net change
(2019/20)
1,178,000
198,000
(339,000)
(140,000)
Overnight beds (current occupancy rates*)
3,571
601
(1,015)
(414)
Overnight beds (85% occupancy rates)
3,571
861
(1,092)
(231)
181,000
30,000
(5,000)
25,000
Day case beds (current occupancy rates*)
595
99
(15)
84
Day case beds (68% occupancy rates)
595
254
(19)
235
Overnight bed days
Overnight
Day case bed days
Day case
Total bed days
Total
Strategic impacts bed days/beds
1,359,000
228,000
(343,000)
(115,000)
Total beds (current occupancy rates*)
4,166
700
(1,030)
(330)
Total beds (revised occupancy rates****)
4,166
1,115
(1,111)
4
* Bed occupancy source: Bed occupancy for the year estimated using the average of KH03 quarterly returns from NHS England for Q4 2013/14 – Q3 2014/15.
(GSTT: 81%, KCHT: 94%, LGT: 94%, DGT: 95%, weighted average: 90.5%).
** These figures have been fixed at current occupancy levels and 2013/14 activity.
*** These figures relate to a level of increased demand as shown above and an additional number of beds due to requiring lower occupancy levels.
**** The total revised occupancy rates are blended across the inpatient overnight bed and day case bed rates shown earlier in the table.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 153
Draft in progress | 154
Draft in progress | 155
Infrastructure &
Estates Supporting
Strategy
Summary
•
•
The Estates Supporting Strategy is an essential element of Our Healthier
South East London strategy programme if we are to be able to support the
delivery of our new models of care in a way which ensures they deliver the
outcomes we aim to achieve. We must understand the capacity of our
capital assets, estates and facilities across south east London to utilise,
reduce or develop these in the most appropriate way to meet the needs of
our population.
There is a clear synergy between the south east London need to
reconsider estates and the national and London wide direction of travel.
‘The five year forward view sets out an integrated agenda and new care
models over the next five years. In addition, Better Health for London
outlines the evidence base for re-evaluating the utilisation and value of
NHS estate in London.’ (The Healthy London Partnership Estates
Programme). Therefore, our Estates Supporting Strategy has made clear
links with the work being delivered at a London wide level by the ‘Our
Healthy London Partnership - Estates Programme’ being led by London
CCGs and NHS England.
Scope
•
The Estates Supporting Strategy will:
—
Support development and utilise the London wide outputs of the Our
Healthy London Partnership Estates Programme;
—
Reference the TSA Transaction Agreement including the review of
Orpington hospital required to be completed by October 2016;
—
Establish an estates and assets database and the current level of
investment and capital developments already in process;
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
—
Consider all new models of care to determine the characteristics of
any estate needed and how best to utilise current estate in order to
deliver optimal utilisation and functionality;
—
Encourage Clinical Leadership Groups to examine non-NHS estate
solutions for delivery of new models of care in the community, when
NHS estate is not fit for purpose or available. These could be
community assets (libraries, leisure centres, church halls), social care
or voluntary sector facilities or commercial arrangements. This may
support the integration of NHS services with other wellness services,
encourage engagement from those who may not traditionally attend
NHS services and re-frame NHS services as part of the local
community and not as an institution of illness;
—
Work cohesively with all supporting strategies to fully understand the
need for physical buildings and assets in line with other options
proposed to support delivery of services, specifically IT and
workforce;
—
Establish a joint working group with providers (including primary care
general practice), commissioners, Community Health Partnership
(CHP), NHS Property Services (NHSPS) and NHS England in order
to identify potential reconfiguration options. Implementation may
require public consultation on the options.
Requirement
•
The Estates Supporting Strategy aims to address specific requirements for
Our Healthier South East London that provide additional support to facilitate
delivery of the strategy, building upon London wide programme delivery
where the time scales allow. The estates strategy will be built into the
delivery programmes for all models of care as appropriate and financial
impacts further detailed within the Financial modelling.
Draft in progress | 156
Infrastructure &
Estates Supporting
Strategy
Approach
The below diagram details the approach for the estates supporting strategy.
High level approach to developing estate plans to support the implementation of the strategy.
Central programme- working with CCGs and providers
Delivered by CCGs/Providers
Assess (baseline & new models) Gaps
The baseline
Key Enablers
Identify the
configuration of the
current estate
(including major
assets / capital
equipment), how it
is used and for
what purpose it is
best suited.
Research
New models of care
Gap Analysis
Determine the type, scale and
characteristics of estate and major
assets that south east London will
need to deliver the new models of
care identified within Our Healthier
South East London.
Identify
difference
between the
requirement
and the
baseline
Options
Proposals
Identify actions
needed to be
taken to reach
the desired
future state
Detailed Design
Challenges and Opportunities
Design and
Deliver
Identify the challenges that any
reconfiguration of estate may have
alongside opportunities
Address specific
requirements
of the strategy
Working in collaboration with NHS England, NHS Property Services and Community Health Partnership
National and London policies and initiatives
Plans from the workforce and IM&T supporting strategies
Stakeholder Engagement
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 157
Infrastructure &
Estates Supporting
Strategy
Next steps
Establish the baseline
•
Identify the configuration of the current estate (including major assets /
capital equipment), how it is used and for what purpose it is best suited.
Are there opportunities for co-locating delivery of health services in nonhealth estate?
—
Work with Our Healthy London asset database
—
Source any additional available information on relevant estate and
assets (Update of TDA) including other community buildings
—
Gain information on the purpose current estate can be used for
—
Identify ownership of estate
—
Identify capital developments already in progress
—
Identify policy changes that could impact estate changes
—
Establish baseline of current investment: financial and resource
Understand the requirement
•
Determine the type, scale and characteristics of estate and major assets
that south east London will need to deliver the new models of care
identified within Our Healthier South East London.
—
Clinical Leadership Groups to establish the needs of their
interventions from estates and major assets
—
Working in collaboration with the Clinical Leadership Groups
determine the type, scale and design of estate required for the new
models
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
—
Assess the functionality and utilisation of estate needed (hot desks /
Scanning equip / theatres / diagnostics / Local Care Network hubs?)
—
Consider requirements in light of workforce and IM&T supporting
strategies
—
Establish estate standards to improve equality of health and care
provision and outcomes in south east London
Addressing the gap
•
Focusing on the difference between the requirement and the baseline, what
actions need to be taken to reach the desired future state? Identify the
challenges that any reconfiguration of estate may have
—
Conduct gap analysis between the outcomes of stage 1 and 2
—
Identify potential challenges to be addressed as work progresses:
financial; equipment; environmental; resource; skills; engagement.
—
Identify options for estates reconfiguration
—
Understand the organisation specific impact of estate change as
linked to commissioning
—
Understand elements of estate change that will impact on
implementation and those that may need wider consultation
—
Test and refine options with key stakeholders to gain a consensus on
the estates requirements and how this can be delivered
Draft in progress | 158
Draft in progress | 159
Workforce
Supporting
Strategy
Summary
•
•
Better Health for London, the Five Year Forward View and Our Healthier
South East London have all identified the need to focus on developing a
modern workforce in order to support the delivery of innovative new models
of care.
Requirements
•
Delivery will also require significant cultural and behavioural changes; for
instance, we need the entire workforce to make every contact count and to
appreciate that patients want more say in the care they receive. The
workforce will also need to work differently with each other; there needs to
be greater integration and more dialogue between parties - rather than a
simple passing on of information and/or a patient. Not only do
commissioners and providers need to work more closely together but there
also needs to be greater cooperation and integration across pathways.
•
Whilst it is acknowledged that it is for the providers to determine their actual
workforce requirements, as a programme we need to model the whole
system’s future requirements across south east London in sufficient detail to
inform a possible pre-consultation business case. For instance, we need to
understand the likely shifts in activity from acute to primary care – and the
consequent impact on where our workforce will need to be located.
•
The workforce supporting strategy also needs to take account of the London
Transformation Group’s work and we are part of the pan-London network.
•
In summary, the workforce supporting strategy will support providers and
commissioners as required and hold a system-wide view of the future
workforce for south east London. The strategy will feed into the overall Our
Healthier South East London strategy, as well as any potential PreConsultation Business Case.
The workforce in south east London will be a key enabler of the Our
Healthier South East London strategy
Scope
•
•
•
Our workforce supporting strategy is identifying the key actions that should
take place in order to move the workforce in south east London from where
it is today to where it needs to be in the future. For instance, we know that
the future care delivery will involve empowering patients and promoting
independence, making every contact count and fostering an environment
where colleagues engage with each other rather than refer and hand-over.
With these significant changes on the horizon, understanding what patients
will require in the future and challenging existing ways of working, will allow
us to plan for a workforce that is fit for purpose and sustainable.
The workforce supporting strategy will need to clearly articulate how the
workforce is going to deliver what south east London needs; this will
include new ways of working (i.e. flexibility, rotations, different staff groups
doing different tasks to today, team work & collaboration) and different
working locations (i.e. more staff working in the community as opposed to
acute settings).
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 160
Workforce
Supporting
Strategy
Findings to date and next steps
Findings to date
•
Workforce numbers in Primary Care and Community Pharmacy
•
•
are estimated to grow by 22%. This reflects an anticipated demographic
changes; primarily in response to an aging population and an increase in the
numbers of those with long-term conditions.
•
Given the mismatch between the increasing demand and low growth in
supply, we need to consider how things could be done differently. For
instance, are there roles that could be filled Third Sector resources or
community volunteers? We also need to look closely at retention and the
secondary care providers are already meeting to consider this.
With funding from Health Education South London, we have:
A baseline of the current workforce in south east London established
•
This demonstrates that c.62K FTEs are employed across a range of
settings of care in south east London. Approximately 40% of these work
in the acute sector.
•
Nurses are the largest cohort in acute, community and mental health
settings; c. 13K FTEs. The social care workforce numbers c 19K FTES, of
whom c. 11K are unpaid carers.
•
The recruitment and retention of quality nursing staff is a key challenge.
Nursing vacancy rates range between 14% and 16% across providers.
This compares to vacancy rates for medical staff of 6% - 12%. Vacancy
rates in social care are reportedly low; 2% - 6% across all staff groups.
•
These vacancy rates mean that there is a significant cost in using agency
staff and locums.
•
Overall, the workforce in south east London, the workforce is projected to
grow by 1.3% year on year to 2019/20. The largest area of projected
growth will be in nursing within the acute sector which is projected to grow
by 19% as providers seek to fill vacancies and reduce their dependency on
agency staff.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
A methodology to define the characteristics of the new workforce
developed
•
This is being used by our Clinical Leadership Groups, which include PPV
representation, to identify the characteristics of the workforce required to
develop their new schemes and interventions.
•
The methodology is allowing each Clinical Leadership Groups to map skills
and experience to the new interventions and identify where capability gaps
lie. Each Clinical Leadership Group will also consider an indicative number
of staff in each group required to deliver the models of care.
•
In turn this will inform wider workforce planning and identify where training
and development will be required.
Draft in progress | 161
Workforce
Supporting
Strategy
Approach
The below diagram details the approach for the workforce supporting strategy.
High level approach to developing workforce supporting strategy to support the implementation of the strategy.
Central programme- working with CCGs and providers
Assess
A baseline of
the current
workforce in
south east
London
established
Gaps
Key Enablers
Options
Identify current different in supply and
demand
Vacancy rates
Delivered by CCGs/Providers
Growth in
workforce
A methodology
to define the
characteristics
of the new
workforce
developed
Detailed Design
Map skills to
interventions
Articulate the workforce
supporting strategy
Clinical Leadership
Group driven
workforce
challenges and plan
Reach out to the
workforce
Assessment
against
London quality
standards
Working in collaboration with Heath Education South London
Stakeholder Engagement
National and London policies and initiatives
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 162
Workforce
Supporting
Strategy
Next steps
Articulate the workforce supporting strategy
Reach out to the workforce
•
The work being carried out by each Clinical Leadership Group will inform
the content for the workforce supporting strategy across south east
London; both at Clinical Leadership Group and at system-wide level.
•
•
The outputs from each Clinical Leadership Group will be consolidated into
a document that describes the system-wide workforce challenges and
required actions, as well as those that are specific and unique to individual
Clinical Leadership Group s. This will also require input from both
commissioners and providers.
If the workforce owns the new models of care, implementation will be more
successful and staff satisfaction higher. Workforce representatives will be
helping to define the characteristics of the workforce that will be required to
deliver the new models of care but we need to involve more frontline staff as
the work progresses. There are compelling examples of where the
involvement of workforce in a co-design relationship has delivered significant
benefit; for example, the experience in Greenwich regarding integration.
•
We also need to ensure that the workforce understand what is being
undertaken and why. Therefore, the strategy team is working closely with
the Programme’s communication team to develop key messages that will
help to secure commitment to the new models of care and reassure them
that the changes will be positive not only for the communities and patients
we serve but for them as well.
•
A key aim of the Programme is to increase staff satisfaction; we are
considering how best to gauge staff satisfaction both today and as a
consequence of implementation of the strategy.
•
The workforce supporting strategy will need to include the planned
approach for realising the change needed. Given this, the input from each
Clinical Leadership Group on the level of change required will help to
describe the short/medium/long-term actions that are needed to deliver the
workforce of the future in south east London.
•
From a whole system point of view, the strategy also needs to consider
where south east London is failing to meet the London Quality Standards
and whether workforce is a key contributor. If it is, the strategy needs to
consider how this might be addressed.
•
Stakeholder management will also be a component of the workforce
supporting strategy in terms of how the enablers will be delivered (e.g.
Royal Colleges, Deaneries, Health Education South London).
•
In describing the enablers, the workforce supporting strategy will need to
identify at a system-wide level where investment will be required; for
instance, in new roles, training or development.
•
This will require input from commissioners, providers and Health Education
South London and will be fed into the financial model.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 163
Draft in progress | 164
Information Management
and Technology
Supporting Strategy
Summary
•
Our Healthier South East London’ aims to improve health, reduce
inequalities and ensure that local services consistently meet safety and
quality standards and are clinically and financially sustainable.
•
The strategy proposes a whole system model with Community Based Care
delivered by Local Care Networks, as the foundation for the whole system
model providing person centred service to geographically coherent
populations and five high priority pathways providing services to cohorts of
people.
•
Information and IT will be a key enabler for the strategy. Specifically it can
support staff in new ways of working and empower patients to be active
participants in their care.
•
Key considerations for understanding the IM&T requirements to support the
strategy and any gaps are
—
•
National and London initiatives and policies: There are a number of
National and local initiatives and policies that may support the
implementation of the strategy. These are:
o
Five year forward view
o
London Health Commission
o
Personalised Health and Care 2020
•
Identifying uniformities at a south east London level so there are consistent
ways of working. For example, adopting the same data quality standards,
and staff identification processes for who should be viewing/editing data
and design principles…
•
Gaps and any investment costs: Understanding where these are not
currently accounted for in CCG and or provider plans, and are needed to
implement the strategy.
Scope
•
To enable the “Our Healthier South East London“ whole system model and
pathways, the work has considered;
—
Information exchange and interoperability across south east London
health and care organisations and patients, and the systems and tools
that support this.
—
Benefits that may arise from collective agreement at a south east
London level, for example:
—
Identifying design principles and ways of working
—
Identifying areas where a collective IT/digital investment could have
greater impact. For example in enabling self-care and prevention,
pregnancy support, developing digital Local Care Networks…
CCG IM&T strategies: Each CCG has its own IM&T strategy and
implementation plans, which have been reviewed and initial assessments
made to determine support for the strategy.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 165
Information Management
and Technology
Supporting Strategy
High level overview of the method used for the IM&T supporting strategy
High level approach to developing IM&T plans to support the implementation of the strategy.
Central programme- working with CCGs and providers
Assess
Key Enablers
Current plans
•
CCG Plans
•
London wide
and national
strategies &
policies
•
Clinical
Leadership
Groups
requirements
•
Research
Gaps
Options
Agreed
Prioritised
Requirements
Clinical Leadership Groups and whole
system model
Initiatives
that
Support the
requirements
Delivered by CCGs/Providers
Gap
Analysis
Solution
options and
examples
from
elsewhere
Detailed Design
High level
Roadmap
and
Implementatio
n Costs
Detailed
Requirements
Transition
Plan
Target
Operating
Model
Transition
Costs
Information Governance
Stakeholder Engagement
National and London policies and initiatives
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 166
Information Management
and Technology
Supporting Strategy
Understanding the IM&T Requirements of the Care Models
and Whole System Model
•
The requirements that could support the strategy on the following slides
have been gathered in a number of ways:
•
The IT/digital guidance direction setting from National and London initiatives,
specifically
Through the 6 Clinical Leadership Group workshops and planning
meetings
—
NHS Five Year Forward View
NHS England
1. Cancer
—
Personalised Health and Care 2020
National Information Board
—
Better Health For London
London Health Commission
2. Planned Care
3. Urgent and Emergency Care
4. Maternity
5. Children's and Young People
6. Community Based Care
Considering case studies and evidence of what has worked elsewhere,
for example
•
Looking at system level initiatives that have supported similar strategies
(integrating primary, secondary, community and social care information to
enable new ways of working and in particular enabling Local Care
Networks and multidisciplinary teams
•
Pathway specific initiatives to enable key interventions
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 167
Information Management
and Technology
Supporting Strategy
Summary of IM&T findings to date and next steps
•
The primary key requirements of interoperability between GP systems and primary and secondary care are planned and/or being implemented at various
speeds with all CCGs moving to GP systems that will enable sharing of records across GP practises supporting Local Care Networks and will be interoperable
via the Medical Interoperability Gateway with Acute led portal solutions, KHP online and Connect Care at Lewisham. To various extents CCGs have plans in
place to align with some of the key IT/Digital guidance in the 5YFP IT/Digital, London Transformation Programme, 2020 Personalised Health and Care and
Implementing these guidelines would meet many of the strategy requirements. However additional transformation initiatives that may require agreement and
funding at a south east London level have not been explored or agreed at this stage.
Gaps for the strategy identified to date
Considerations for next stage of work
Interoperability with Local Authorities will be needed to fully
enable the strategy and plans for this are not well understood
at the time of writing but form part of the next steps of work
•
KHP online and Connect Care timelines for going live could be after some
federations/Local Care Networks are up and running
•
Further work to asses if there are confirmed plans for KHP online and
Connect Care solutions to integrate with Local Authorities and if there are
any associated costs for CCGs
•
Interoperability between KHP online and Orion Connect Care connect
could resolve boundary issues across south east London. An assessment
is needed to understand impact of this, for example number of patients that
cross over and the costs vs benefits case ( is it worth doing?).
•
Additional transformation initiatives that may require agreement and
funding at a south east London level have not been discussed. For
example, could moving to a more mature Digital solution to enable Local
Care Networks and Community Based Care provide greater benefit?
2 separate interoperability solutions:
•
KHP online (Lambeth, Southwark, Bromley)
•
Connect Care (Bexley, Lewisham, Greenwich)
•
Ability of CCGs to meet the guidelines set out in National
and London initiatives (funding)
•
•
•
•
Possible funding/investment case needed to speed up
support for key parts of the strategy, for example for Multi
Disciplinary Teams working in Local Care Networks and
LA integration
South east London Whole System Outcomes. There is a
requirement to set up a monitoring and reporting service.
This service will need to be agreed and procured on behalf
of the 6 CCGs. is it part of the transformation cost or
business as usual costs?
There is no central capital funding pot to fund any SPG
IM&T initiatives. Capital funding pot from NHSE but
application would be for 16/17
Staff Training will be required as new systems and ways of
working are introduced. Further work to understand what
training is included in CCG and provider plans and costs of
training to CCGs
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Southwark
•
Investment may be needed to implement key parts of the strategy and or
to ensure consistency in implementation timelines across the six CCGs, for
example, to enable the Community Based Care and Local Care Networks
•
Capital funding: if any investment is required, a business funding case will
need to be developed for 2016/17
•
Revenue costs such as licencing, staff training and project management,
yearly service management for KHP online and Connect care. Part of the
next steps is to understand if these costs are picked up in CCG planning
•
Understanding the IT investment set out in CCG and provider financial
plans. Once we have done this, determine costs associated with:
•
Any planned IT changes that are not included in the plans.
•
Any further changes that we are proposing through the programme to
improve consistency of IT provision across the system.
Greenwich
Bexley
Lambeth
Lewisham
Bromley
Draft in progress | 168
Draft in progress | 169
Risks and
Challenges
Risks to implementation of the Strategy
•
There are risks to delivering the Strategy which are closely monitored and assessed for impact The following are high level risks which have been identified to
the implementation of the strategy. This list will be reviewed regularly through the Clinical Executive Group, Implementation Executive Group and Clinical
Commissioning Board.
Title
Risk
Impact
Mitigations
1. Information
Systems
•
Lack of integrated or interoperable
information systems undermines
ability to integrate services across
the health system in south east
London
•
Possible duplication of system, process
or information, resulting in poorer patient
experience, poor quality of services
across integrated pathways and
additional cost
•
•
IM&T supporting strategy workstream established.
Utilising existing integration initiatives across SEL to
support strategy
2. Workforce
Capability
•
Existing workforce skills or capability
to deliver new models of care
•
New models of care may not be
implemented
Services may not be delivered safely
Patient satisfaction
Staff satisfaction issues
Quality and effectiveness of care
•
Workforce supporting strategy workstream
established
Work in hand to identify gaps between capabilities
required to deliver new models of care and those
available in current workforce
Key characteristics and skills being identified for
training purposes
•
•
•
•
•
•
3. Delivery
Timeframe
•
It may be challenging to complete
•
required activities and assurances in
time to go to consultation, if required,
in December, particularly as a result
of needing to engage patients and
service users in the process
Delay to programme implementation for
those elements which might require
formal consultation or loss of support
from partners and stakeholders for some
or all of the strategy
•
On-going dialogue with NHSE to agree assurance
process and detailed communications and
engagement plan to test critical path
4. Delivery
Timeframe
•
Insufficient time for good processes
in terms of governance, decision
making and ownership
•
The strategy and associated documents
are not owned by all stakeholders across
SEL
•
We will maintain four key activities: intensive
engagement with partners and stakeholders;
ensuring NHS England is engaged; careful mapping
of governance and decision making; and meeting
with NHSE by mid-June to review the approach
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 170
Risks and
Challenges
Title
Risk
Impact
Mitigations
5. Clinical
Leadership
Group Impact
Analysis
•
Modelling: Finance and Activity
•
The impact analysis does not fully close
the identified affordability gap but does
make significant progress towards doing
so. It is not yet clear if this is sufficient
•
6. Financial
•
sustainability of
health system
New service models do not deliver
reduced demand for hospital care or
hospital capacity does not reduce in
line with demand
•
Potential increased system costs through •
duplication of services
System may not be sustainable
7. Patient / Public •
Resistance to
Change
If partners and stakeholders are not
sufficiently engaged throughout the
development of the five year strategy
– or if the case for change is not
sufficiently convincing - any proposed
service change could be subject to
significant local opposition
•
•
•
•
•
Further engagement required
Possible legal challenge
Delays to implementation of changes
leading to increased cost and delay
Need to amend strategy in response to
concerns
•
•
•
•
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Explore and incorporate additional QIPP and CIP
opportunities and continue to explore options with
NHSE
Making sure there are clinical input into the
design of care models and that they have
sufficient impact on activity
Engagement activities will be undertaken with a
broad range of partners and stakeholders
throughout the development and implementation
of the strategy
Dedicated communications and engagement
enabling workstream to coordinate these
activities
Patient and Public voices in all key groups to help
shape strategy
Strategy reflects input from partners and
stakeholders
Draft in progress | 171
Draft in progress |
172
Delivering the
strategy
Care model design process
•
The interventions within the Our Healthier South East London Strategy have been designed by Clinical Leadership Groups and the detail of these are set out in
the ‘Proposed models of care’ section.
•
The overarching process undertaken by the Clinical Leadership Groups to design and deliver their respective care models is shown below. Along this process
is continual decision making and iteration using a range of qualitative and quantitative evidence, including local clinical judgement.
•
Importantly, we need to decide what is implemented at south east London and what is implemented locally; in addition to the process for appraising care model
design and delivery options.



Case for Change
Finance and
activity baseline
Future demand
and funding
envelope
Current health
outcomes
Model the interventions
Agreed scale
of affordability
challenge
Agreed whole
system
outcomes
Proposed care
models and
interventions
Activity shifts identified
through a triangulation
process using
benchmarking, academic
evidence and clinical
judgement
CLG consideration
of options for
delivery leading to
agreed care models
and interventions
Detailed options
appraisal
Implementation
planning
Split interventions
by implementation
or detailed options
appraisal
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
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Delivering the
strategy
Localising the interventions
•
Implementation of the models may happen at both CCG and south east London level. In order to provide the right support to CCGs and provider organisations,
Clinical Leadership Group working groups will need to consider the level at which each intervention should be implemented. There are two broad routes for
taking interventions forward which reflect the different characteristics of the care models. Depending on the route the programme team may offer a different level
of support. This is set out below:
Route
Characteristics of intervention
Type of support offered by the programme team
•
Local implementation: CCGs lead the
detailed design and development of the
care models
•
•
•
Will benefit from local implementation
Less need for standardisation
Primarily out of hospital
•
•
Implementation toolkit development
Implementation advice and guidance
•
SPG implementation: Detailed design
and development of model takes place at
an SPG level with involvement of
impacted CCGs
•
Directly impacts one or more providers delivering
services across CCGs
Requires a high-level of standardisation
Involves/impacts a number of CCGs
•
‘Hands on’ project management support
•
•
•
Regardless of the route, a central reporting process will be established to track the implementation of schemes. This will support the monitoring of benefits and
anticipated impact.
•
Implementation plans are currently being developed which will set out the required support to deliver these interventions. This process will confirm the
implementation route, required level of support and supporting governance.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 174
Delivering the
strategy
Introduction to the option appraisal structure
Our Healthier South East London has defined and agreed a number of interventions to improve health outcomes for south east London. For most interventions,
implementation planning can commence immediately. However, there are areas where the impact of the strategy needs further consideration because there is
more than one option for delivery, and it could result in significant service change. These interventions will have to undergo a robust options appraisal process.
This option appraisal process aims to identify the best way, or way(s), of delivering the overarching strategy and realising its full benefits. It filters the many
potential options for how the interventions can be implemented, and is designed to identify options that are recommended for further work, and, if appropriate,
for formal consultation
Overview of the process
• Initially, inputs and impacts from the overarching strategy will be used to identify those areas where there are options for delivery and where significant
service change may be required. This will define the scope of the options for consideration. A key input into this process is the completion of a baseline and
gap analysis of the London Quality Standards.
• The scope will identify service areas which may require significant service change and/or several options for delivery. Workshops will be held that will focus
on each of these service areas and develop service specific options which will then undergo service specific appraisal. Those options which pass this
process will then be combined to produce a number of whole system options which will proceed through the whole system appraisal process.
• This will result in a short list of options which could go to consultation, if required.
This process is summarised in the following slide
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 175
Delivering the
strategy
Process for appraising options
•
In order to identify the best way or way(s) of delivering the overarching
strategy, an options appraisal process is required to realise its full benefits.
This focuses on those options which may lead to significant service
change. This approach filters the many potential options for how the
system can be implemented and is designed to identify options that are
recommended for further work
•
It is proposed that the filtering of options will occur through two gateways of
assessment against criteria; hurdle criteria and evaluation criteria (the
diagram on the following page provides an overview of the methodology).
•
The criteria against which the options will be assessed should be agreed
before commencing the appraisal. Moreover, the likelihood of optimal
implementation of options is increased by gathering wide ranging
stakeholder contribution to the formation and specificity of criteria.
•
Although some interventions do not in their own right require a detailed
options appraisal, the result of implementing those interventions could
impact on the appraisal of other interventions because they will lead to
shifts in settings of care and volumes of activity. As a result, it is important
to consider the scope of a detailed options appraisal and how to account for
whole system changes within the appraisal of individual interventions.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 176
Delivering the
strategy
Options for appraisal methodology
13 July – 28 Aug
28 Aug – 12 Sept
Develop scope and supporting
information
Identify areas where there are options
for service delivery and reconfiguration
may be required. A number of inputs
will be used (strategy impacts, LQS
Provider baseline and planning
assumptions including cost of
implementation) In a partnership
approach develop principles for
agreeing service level options
12 Oct – 19 Oct
Develop service level
options
Working groups will be
formed to develop service
areas/CLGs options using
the agreed principles
.
Consolidate options at a
whole system level
Consideration of the options in
the context of the whole
system. This will consider the
consequences and
interdependencies of the
service level options from a
whole system perspective,
eliminating options against
agreed criteria.
19 Oct – 3 Nov
3 Nov – 7 Dec
Non-Financial Appraisal
The whole system options
identified proceed to the
appraisal process.
Financial appraisal and
Consolidation
The initial short list of options
proceed to a financial appraisal.
A short-list of options will be
developed by conducting a
non-financial option appraisal.
This will determine the final short
list of options that may require
consultation
Evaluation criteria for the
next stage will be developed
and agreed.
Develop scope
•
•
Clinical models
LQS baseline
Supporting information
•
•
•
•
•
•
Finance and Activity
Estate and service
baseline
Design principles
Strategy outcomes
Provider baselines
Initial specialty level
breakdown
Develop
options
on
agreed
service
area
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Appraisal
of service
specific
options
Consolidate service
level options into
whole system options
Appraisal of whole
system options (Nonfinancial)
Appraisal of whole
system options
(Financial)
Short list
of options
Draft in progress | 177
Delivering the
strategy
High level programme plan
The high level plan on the next page shows at high level the next stages of the plan for implementation, option appraisal and consultation if required. It is
ambitious and dependent on partners and key stakeholders continuing to engage with and support the work as it develops. This timeline has been tested
with provider organisations and other stakeholders.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 178
Draft in progress | 179
Draft in progress | 180
Appendices
Introduction
Principles
•
•
•
•
•
The Our Healthier South East London governance is designed to ensure a
partnership approach to design and delivery, while remaining
commissioner-led and clinically-driven and ensuring that the needs of local
people are at the heart of the strategy.
The governance approach is based on a number of overarching principles
and assumptions:
—
It must ensure the Commissioning Strategy is based on local needs
and aspirations, listening to local voices and building on work at
borough level, whilst taking into account national and London policies
—
It must be open and transparent throughout the process, from
identification of need, to implementation of the strategy, with
opportunity for challenge by patients and the public
The structure will enable effective decision-making and oversight and clear
ownership of deliverables and benefits at all stages of the programme. It
will operate in an open and transparent manner, and takes account the
voices of stakeholders across the south east London community.
—
Patient safety and quality must be at the heart of decision making
—
Decisions should take into account patient, carer and community
voice
The purpose of this section of the document is to outline the following
aspects of the governance of the programme:
—
The roles, responsibilities and accountabilities of the CCGs, NHS
England and all partner organisations must be explicitly defined
The governance structure has been designed to be consistent with the
NHS England Strategic Planning guidelines to support joint commissioning
and strategic planning, building on well established collaborative
relationships within the six boroughs and NHS England.
—
Principles
—
There should be clear points of accountability for all deliverables
—
Structure and high-level memberships
—
—
Key roles and functions
Programme governance should provide assurance that the
anticipated benefits of the programme will be delivered
—
Arrangements that will be put in place for collaboration and advice
—
The core programme will be responsible for ensuring that contributing
projects and programmes deliver the planned benefits of the
programme in line with the critical path and overall timetable
—
Duplication of effort should be minimised across the health system
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 181
Appendices
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 182
Appendices
Key roles and elements
•
The roles and elements of the Our Healthier South East London specific
governance bodies are outlined below. The overall structure reflects
initial planning guidance (NHSE, LGA, TDA and Monitor - 04 November
2013) including approach to joint working and units of planning. Structure
and membership have been designed to best support the development of
the Commissioning Strategy and it is likely that this will need to be
revisited at key points in the programme lifecycle – in particular when the
programme moves on to a delivery footing.
•
In south east London the function of the Strategic Planning Group is being
delivered primarily through the Clinical Commissioning Board, supported
by South East London Partnership Group and the Implementation
Executive Group.
•
The programme is led by the Clinical Commissioning Board (CCB),
which acts as the overall programme board. The CCB is commissionerled and clinically-driven and steers and makes decisions on the
development and delivery of the strategy. Members of the CCB have the
authority to make decisions on the scope of the programme on behalf of
their respective organisations. All workstream SROs within the
programme are accountable to the CCB for delivering their agreed share
of the benefits of the programme.
•
The South East London Partnership Group is the strategic and
partnership forum for the programme. The group is clinically-led and will
frame and shape the commissioning strategy on behalf of the CCB,
providing collective system leadership and oversight to the programme.
Key programme decisions require the support of the Partnership Group.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
The Clinical Executive Group (CEG) brings together clinical leaders
(including social care professional leaders), patient and public voices and
Healthwatch representation from across south east London to frame and
provide oversight of clinical design work by providing guidance and
assurance to the individual clinical leadership groups and managing
interdependencies across the group. It also acts as a conduit for the
management and escalation of clinical risks.
•
The Implementation Executive Group (IEG) is the executive group
supporting the CCB, providing oversight of planning, implementation,
benefits realisation and assurance. The IEG also steers the mobilisation
workstream, and has a continuing responsibility to make recommendations
to the CCB on the optimal structure and scope of the programme.
•
The Public and Patient Advisory Group (PPAG) is the collective forum
for the strategy’s patient and public voices to contribute to shaping the
strategy’s content and the programme’s processes, to share learning,
provide peer support, facilitate wider engagement and disseminate
messages and provide feedback on key programme materials.
•
Programme design and delivery is undertaken by combination of
contributing clinical groups, projects and programmes at varying points in
their lifecycle, each requiring the appropriate treatment from a governance
and operating perspective.
Draft in progress | 183
Appendices
Collaboration and advice
•
The programme links to a number of existing advisory and collaborative
bodies. Relationships have been established with these groups as
appropriate as part of mobilisation and ongoing delivery.
•
Health and Wellbeing Boards (HWBs) provide oversight, advice and
input into the programme at borough level, focused on improvement of
the health and wellbeing of their local populations, reducing health
inequalities, and encouraging joined up working across commissioners.
As well as being engaged and involved in the co-development of the
Commissioning Strategy, ensuring alignment with local Health and
Wellbeing Strategies, Health and Wellbeing Boards have agreed Better
Care Fund plans
•
Health Overview and Scrutiny Committees (HOSCs) will provide local
scrutiny and review in line with statutory requirements under the Local
Government Act 2000 and Health and Social Care Act 2012
•
The programme links to the South East London CCG Stakeholder
Reference Group for advice and oversight in relation to engagement on
the development of the Commissioning Strategy, in order to ensure that
the views of patients, service users, the public and their representatives
are heard and acted upon
•
The programme links to local Healthwatch teams in each borough to
ensure that proposals developed as part of the Commissioning Strategy
take account of the voices of consumers and those who use local health
and social care services.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
An external Clinical Advisory Group will be established, if and as required
at later stages in the programme, to ensure that any proposed clinical
changes are designed in a manner which ensures wide ranging clinical
engagement in service design and alignment with national and London-wide
quality standards; and that clinical services will be safe and sustainable both
during transition and post implementation.
Draft in progress | 184
Draft in progress | 185
Appendices
Terms of Reference – Clinical Commissioning Board
Terms of
reference
The Clinical Commissioning Board (CCB) acts as the overall programme board. The CCB is commissioner-led and clinically-driven. It steers and
makes decisions on the development and delivery of the strategy. Members of the CCB have the authority to make decisions on the scope of the
programme on behalf of their respective organisation. All workstream SROs within the programme are accountable to the CCB for delivering their
agreed share of the benefits of the programme.
The role of the Clinical Commissioning Board is to:
• Agree the 5-year commissioning strategy for south east London for final approval by CCG Governing Bodies and NHSE
• Act as the decision-making authority regarding the objectives, scope and benefits of the programme
• Commission and be assured of clinical and partnership-focused input from the South East London Partnership Group
• Be the forum where the CCGs and NHSE can hold themselves and each other collectively to account
• Ensure that the programme delivers on its objectives of safety, quality and clinical and financial sustainability
• Seek assurance of and approve the progress of the programme against its objectives and plans
• Agree actions and make decisions to resolve escalated risks, issues and dependencies from the programme
• Remove obstacles preventing or hampering development and successful implementation
• Approve the funding and structure of support for the programme, and monitor and make decisions on spend
• Set the parameters for other groups within the governance structure based on recommendations from the Implementation Executive Group
Chairing and
facilitation
Co-chairs: 1 Clinical Chair or other senior clinician from within south east London CCGs and NHSE Medical Director for South London
Membership
CCG Chief Officers (x6)
CCG Clinical Chairs (x6)
NHSE Direct Commissioning Leads
NHSE Director of Delivery, South London
Non-voting: Representation from local authorities (up to 3 chief executives)
Healthwatch (1 Member on behalf of the 6 south east London Healthwatch organisations)
Patient and Public Voice (x2)
Quorum
A CCG Chief Officer/Clinical Chair or nominated deputy from each CCG
NHS England Representation
Frequency &
duration
Usually bi-monthly meetings, but additional meetings may be convened as required for the effective management of the programme
Secretariat
Our Healthier South East London programme team
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 186
Appendices
Terms of Reference – South East London Partnership Group
Terms of
reference
The South East London Partnership Group is the strategic and partnership forum for the programme. It is clinically-led and frames and shapes the commissioning
strategy on behalf of the Clinical Commissioning Board, providing collective system leadership and oversight to the programme. Key programme decisions will
require the support of the Partnership Group.
The role of the South East London Partnership Group is to
• Ensure that the programme recognises the public health challenges across south east London and is developed to reflect the needs of the local population in south east
London
• Provide clinical and local leadership and oversight to the programme on behalf of the south east London health system, ensuring that innovative whole system solutions are
developed in line with programme objectives
• Shape and agree the Vision, Case for Change Clinical Models and Outcomes for the Commissioning Strategy and shape options for implementation
• Provide oversight to the Clinical Executive Group and Clinical Leadership Groups in ensuring that all elements of the strategy:
• reflect national and London clinical quality standards
• are sustainable clinically and financially
• Resolve strategic issues between the Commissioning Strategy Programme and other projects, programmes and strategies within partner organisations
• Provide commitment and endorsement in support of the programme objectives across the local health system and provide visible leadership for implementing agreed
initiatives
• Ensure effective communication and engagement takes place regarding the programme within stakeholder organisations and with other partners
Chairing
Chair:1 CCG Clinical Chair
Membership
CCG Chief Officers (x6)
CCG Clinical Chairs (x6)
Provider CEOs (x7)
Provider Medical Directors (x7)
Local Authority CEOs (x6)
Representation from NHS Trust Development Authority
Representation from NHS England
Quorum
CCG Clinical Chairs – over 50% (3/6 organisations)
Provider Trust Representation – over 50% (4/7 organisations) – including nominated deputies. To include minimum 1 provider of acute services, 1 provider of mental health
services and 1 provider of community services
Local Authority Representation – over 50% (3/6 organisations)
NHS England Representation
Frequency &
duration
Usually meetings every two months, but more frequently if required
Secretariat
Our Healthier South East London programme team
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Representation from London Ambulance Service
Representation from Health Education South London (HESL)
Representation from South London Health Innovation Network/Academic Health
Science Networks
Representation from Public Health
In attendance: Our Healthier South East London and programme team members as
required
Draft in progress | 187
Appendices
Terms of Reference – Clinical Executive Group
Terms of
reference
The Clinical Executive Group supports the Partnership Group by providing oversight of clinical design work, providing assurance and managing interdependencies
across the individual clinical leadership groups. It acts as a conduit for the management and escalation of clinical risks across the programme.
The role of the Clinical Executive Group is to:
• Provide collective clinical leadership for the strategy’s development and delivery
• Provide clinical assurance and oversight of all clinical design work within the programme
• Ensure that clinical interdependencies have been fully recognised and risks mitigated/managed appropriately
• Define the tasks and membership for Clinical Leadership Groups based on the direction set by the Partnership Group
• Oversee the development of models of care and key interventions by Clinical Leadership Groups
• Ensure that the models of care developed, and associated hospital and community based interventions:
• reflect national and London clinical quality standards
• meet the ambitions of the CCGs and NHS England for the strategy for south east London
• are sustainable clinically and financially
• Consider the workforce implications and provide recommendations to the workforce enabling workstream
• Contribute to shaping options for implementation
• Ensure that clinical redesign projects have plans in place to deliver safe services during any transition and change
• Act as the conduit for the management and where appropriate escalation of any clinical risks identified across the programme
Chairing and
facilitation
Co-chairs:1 CCG Clinical Chair plus 1 secondary care clinical leader
Membership
CCG Clinical Chairs (x6)
Provider Medical Directors (x7)
NHS England (South London) Medical Director
Local Authority Representation: Senior children’s and adults’ social care professional leaders (x2)
Representation from other clinical and social care professions as needed
Our Healthier South East London Programme Director and other programme team members as required
Quorum
CCG Clinical Chairs – over 50% (3/6 organisations)
Provider representation – over 50% (4/7 organisations) – including nominated deputies. To include minimum 1 provider of acute services, 1 provider of mental health services
and 1 provider of community services
NHS England representation
Local Authority representation
Frequency &
duration
Usually every 6 weeks, but may meet more frequently in line with the needs of the programme
Secretariat
Our Healthier South East London programme team
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 188
Appendices
Terms of Reference – Implementation Executive Group
Terms of
reference
The Implementation Executive Group (IEG) is the executive group supporting the CCB, providing oversight of planning, implementation, benefits realisation and
assurance. The IEG also steers the mobilisation workstream, and has an ongoing responsibility to make recommendations to the CCB on the optimal structure and
scope of the programme.
This forum is accountable directly to the Clinical Commissioning Board. Its role is:
• To hold programme workstreams to account for delivering against their agreed scope and benefits
• To act as an acceptance gateway for projects, programmes and other schemes of work moving from the design stage into implementation, and from implementation into
business as usual
• To act as the conduit for programme functions such as tracking of progress, monitoring benefits realisation, managing dependencies and interdependencies, identifying
mitigating actions for issues and risks, identifying issues and risks that need to be escalated and identifying workstream resource requirements/constraints
• To support the Clinical Commissioning Board with executive input and oversight across the workstreams of the programme as needed
• To guide the programme through OGC Gateway reviews pre-consultation engagement and formal consultation, as appropriate
The remit of the IEG includes all workstreams within the Our Healthier South East London Programme
Chairing
Co-chairs: NHS England Director of Delivery for South London and 1 CCG Chief Officer
Membership
CCG Chief Officers
NHS England Medical Director for South London
NHS England Representation (Specialised and Primary Care)
Chair of Chief Financial Officers Group
Chair of Directors of Commissioning Group
Workstream SROs (where not COs)
Our Healthier South East London Programme Director
Where a member is unable to attend, they will usually nominate a deputy
Quorum
CCG COs – over 50% (3/6 organisations)
Local Authority Representation
NHS England Representation
Frequency &
duration
Usually fortnightly meetings of 1.5 hours, but may meet more frequently in line with the needs of the programme
Secretariat
Our Healthier South East London programme team
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 189
Draft in progress | 190
Appendices
Case Study: St Christopher's Bromley Care Coordination
Service (BCC)
Patient-centred end of life care in Bromley
•
Bromley Care Coordination has now been operating for a year. It was short
listed for a Health Service Journal award and recently won a Hospice UK
Innovation award. Users of the service have given it high praise:
•
"My GP discussed this new service with me and I was very happy for my
mother to be referred. The first visit was lovely. It put a new emphasis on the
care for my mother and showed me that it was no longer just about the
practical matters but she allowed me to see this time as a truly special time
with my mother. It was amazing really. I know I wouldn't have been able to
do that on my own. This service has given me huge confidence that I can
cope and I can care for my mother at home knowing that I have back up 24
hours a day." - Cecilia Willatt, carer for her mother Dorothy, aged 94 who
has Parkinson's disease
Overview
•
The final days of life are very important. For people with advanced illness
or frailty the type of care they receive and where they receive it has an
enormous impact on their experience. It creates long lasting memories for
their loved ones too – positive and negative. St Christopher's Bromley
Care Coordination Service (BCC) is rising to the challenge of making sure
people can spend their final days in the place of their choice which is
usually at home.
•
The team cares for people in their own homes and supports family
members and carers so they can make decisions that reflect patients'
preferences. It's just one of the ways NHS Bromley Clinical
Commissioning Group is investing in services that make a real impact on
older people and their carers and families.
•
•
Dr Mandy Selby, GP and Clinical Lead at NHS Bromley CCG, said, "Most
of the patients who are referred to the service are elderly and need to be
registered with a Bromley GP and thought to be living in their final year.
The service has been specifically designed to pick up individuals who
normally would not be referred for specialist palliative care."
The service is staffed by nurses who have a wide range of experience
spanning heart failure, dementia, respiratory disease, and palliative care.
The service operates from the St Christopher's Bromley site in Orpington
and receives management support from St Christopher's.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Service Model
•
The model looks to enable people with progressive and advanced illness or
frailty to:
−
receive timely, well-coordinated care in the final year if life
−
die with dignity in a place of their choice
−
It also looks to:
−
provide support to their families: and
−
reduce unnecessary hospital admissions
Draft in progress | 191
Appendices
Case Study: St Christopher's Bromley Care Coordination
Service (BCC)
Unique Features
Challenges
•
Case-finding patients in the final year of life
•
•
Nurse specialist assessment
Hospital referrals lower than planned (staff now seconded into secondary
care)
•
Advanced care planning and Coordinate My Care record
•
Many patients not known to other services so the BCC nurse
•
Referral and engagement of other services to support integrated care
(including four hour direct access to community equipment)
•
Delivery of care with 24 hours access to advice and support
•
Assigned key workers
•
Monitoring and review with rapid response for those whose conditions
change
•
Personal care service up to 6 weeks post-hospital discharge
(Potential ) Impact
•
High proportion (83%) of patients dying at home.
•
Avoiding unplanned admissions in the final year of life - two of on
average 3 admissions costing £6.5k.
•
Estimated cost of new service supporting a caseload of up to 800 - £300K
•
Increased CMC utilisation - patients have an agreed & accessible plan
for the end of their lives – from 25 to 51% of expected prevalence and
from 64 to 644 recorded deaths in 12 months.
•
30% of caseload live alone
•
55% of caseload not known to community or social care at time of referral
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 192
Appendices
Case Study: NHS Greenwich Clinical Commissioning
Group
Integration - that’s what you need
•
NHS Greenwich Clinical Commissioning Group has found innovative
ways to integrate healthcare services. It was once the case that older
patients in the Royal Borough of Greenwich faced long stays in hospital.
Health services were not integrated with social care teams and, as a
result, the over-65s spent too long awaiting community support.
•
Today, the story is very different. Gone is this ‘silo’ approach —where
different departments operate independently—and, in its place, NHS
Greenwich Clinical Commissioning Group (CCG) has created an efficient,
streamlined service. “We used to have a lot of fragmentation, which led to
delays in people getting care packages so they stayed in hospital longer,”
says Dr Rebecca Rosen, GP Clinical Commissioner at the CCG. “Now
the approach is joined up and quick. Integration has led to significant
reductions in hospital admissions and delayed hospital discharges, and a
range of rehabilitation services being provided at home or in intermediate
care facilities.”
Caring outside of hospital
•
There will always be health emergencies at care homes, GP surgeries
and A&E units. What Greenwich CCG has done is ensure that teams of
nurses, social workers, occupational therapists and physiotherapists work
together to respond within 24 hours. The Joint Emergency Team (JET)
liaises with GPs and identifies people who need help but don’t necessarily
need admission to a hospital or a care home. Instead, patients are
assessed and treated at home or through short-term residential care in
the community. The Hospital Integrated Discharge Team enables people
to leave hospital safely more quickly by organising the support they need
and Community Assessment and Rehabilitation Teams (CAR) provide
rehab and support to aid their recovery.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
•
Care navigators have meaningful conversations with people to understand
the whole picture and what it would take to improve a person’s health and
wellbeing. From this a personalised plan is co-produced. Some people, for
example, might prefer their partner to get them ready instead of being
assisted by a stranger. “This is all about supporting people to stay at home
for as long as they can,” says Jane Wells, Oxleas’ Director of Adult
Community Services. “People can regain their independence where
possible without assumptions being made about their needs.”
•
Transforming health and social care through partnership has won the
teams national praise. In 2013, Greenwich was selected by the
government as a ‘pioneer’ in the world of integration.
•
Chosen from 100 applicants, Greenwich Coordinated Care (GCC) was
recognised for saving nearly £1 million from the social care budget and
allowing people to be cared for in the community rather than in hospital.
Making services more responsive to local people won the GCC the top
award for innovation in social care at the Municipal Journal Achievement
Awards 2014. The transformation has been achieved through a partnership
between the CCG, the Royal Borough of Greenwich, Oxleas NHS
Foundation Trust, local GPs and the local voluntary sector.
Draft in progress | 193
Appendices
Case Study: Lewisham Community Connections - Asset
mapping supporting social prescribing
Service Model
Impact
Community Connections
•
Open to all Lewisham residents 18+ deemed vulnerable
•
Funded by LA: £600k for 18 months (9 staff)
•
Delivered by a consortium of charity organisations
•
Facilitators see clients in the community (e.g. home, coffee shop, library)
and deliver a person centred approach to understanding personal needs
and wants
•
Signpost and support clients to attend local groups and organisations
•
Development workers mapped all groups in Lewisham incl. those only
found by getting on foot and looking
•
Engage with groups and organisations to develop their delivery of support
for local people’s needs
Impacts expected:
•
Reduced A&E attendances, admissions and GP appointments (system is
being put in place to monitor this)
•
Improves quality of life and prevents deterioration of health
•
600+ clients have been supported by the team (in 18 months)
•
160+ local organisations accepting referrals (in 18 months)
•
40+ local groups have been supported to develop plans to increase what
they can deliver (in 18 months)
•
Clients previously supported are now volunteering, supporting new clients
to attend groups (in 18 months)
•
Anecdotal evidence of a reduction in GP appointments. for those
supported(in 18 months)
Unique Features
Challenges
•
Buy in
•
GP and hospital departments buy in variable
•
Very variable referral rates from different practices
•
•
•
•
•
•
Referrals from GPs, hospitals, word of mouth, community groups/orgs.,
hairdressers, shopkeepers etc.
The community is involved in looking after itself
Information sharing on everything available
Facilitators and volunteers support clients to attend groups
Established befrienders for housebound clients
Arranges transport to get to groups for those less able
Has set up forums between local organisations to engage them in tackling
issues together – Breakfast group in South Lewisham (GPs, Counsellor
and local organisations)
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Meeting certain needs in Lewisham:
•
Dementia support in the community
•
Support specifically for men
•
Support specifically catering for those aged 30-55
•
Groups and activities for young adults with learning or physical disability
that meet their needs as young people
•
Evening & weekend groups
•
Groups/services with transport provided
•
Wheelchair/stokes/mobility require an escort
Overcoming these:
•
Working with the community to establish new groups
•
Highlighting the needs of the diverse community.
Draft in progress | 194
Appendices
Case Study: Bromley - Prevention – Obesity, Alcohol and Smoking
Service Model
Challenges
•
Targeting the pre-diabetic population with an intensive lifestyle support
programme to prevent the onset of Type 2 Diabetes (one of two pilots in
Europe) following NICE PH Guidance 38.
•
Lack of referral capacity in comparison to need - most at risk to be referred.
Others at high risk can be referred to the Walking Away from Diabetes 3hr
intervention.
•
Unique Features
•
•
Primary Care to identify pre-diabetic patients (targeting priority
communities) through the Health Checks and Diabetes Audit and refer for
intervention:
Potential high drop out rates - Primary Care to receive motivational skills
training.
•
practical, tailored advice, support & encouragement to help people be more
physically active, achieve and maintain a healthy weight and eat a healthier
diet for 12 months.
•
Quarterly monitoring by Primary Care and Weight Watchers as well as 24
month follow up.
(Potential ) Impact
•
•
Impacts expected:
—
Treating 100 adults who are high risk of Type 2 diabetes, with an
intensive lifestyle intervention can….
—
Prevent 15 new cases of type 2 diabetes1
—
Prevent 162 missed work days2
—
Avoid the need for BP/Cholesterol pills in 11 people3
—
Add the equivalent of 20 good years of health4
—
Avoid £57,000 in healthcare costs5
There are approx. 11.5k people in Bromley who are deemed high risk and
could benefit
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
1.
2.
3.
4.
5.
Knolwer et al (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or
metformin. N Engl J Med; 7: 346(6):393-403
DPP Research Group (2003) Within-trial cost-effectiveness of lifestyle intervention or metformin for the
primary prevention of type 2 diabetes. Diabetes Care;26(9):2518-23
Ratner et al (2005) Impact of Intensive Lifestyle and Metformin Therapy on Cardiovascular Disease
Risk Factors in the Diabetes Prevention Program. Diabetes Care 28 (4): 888-894
Herman et al (2005) The cost-effectiveness of lifestyle modification or metformin in preventing type 2
diabetes in adults with impaired glucose tolerance. Ann Intern Med. 2005;142:323-32
Ackermann et al (2008) Translating the DPP into the community. Am J Prev Med 35 (4), pp. 357-363;
estimates scaled to 2008
Draft in progress | 195
Appendices
Case Study: Bromley - Prevention – Obesity, Alcohol and Smoking
• Identify pre-diabetic patients through the NHS Health Checks and Diabetes Audit
• Refer patients using the eligibility criteria
• Referral includes starting blood measurements, repeated blood test at 6, 12 and 24 months (including
a weight measurement at 24 months)
• Referral includes starting blood pressure measurement, repeated at 3, 6, 9, 12 and 24 months.
• Undertake Motivational Interviewing training, utilising techniques to support and motivate patients
throughout the process.
• Provide feedback through the qualitative monitoring interview process
Primary
Care
Weight
Watchers
•
•
•
•
•
•
•
Implement the Weight Watchers Diabetes Prevention Pilot Programme
Manage the referral hub
Deliver objective data to PH team for quantitative data collection
Deliver self reported data to PH for evaluation
Qualitative evaluation of outcomes
Gaining consent to share data and secure data transfer
Deliver the information session and continued support for all partners
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 196
Appendices
Case Study: Southwark - Improved Core general practice
access plus 8-8, 365
Service Model
Challenges
•
Two clinics accessible via general practice or GP out of hours service. All
patients will be telephone managed by a senior clinician.
•
Keeping everyone engaged whilst working at pace
•
Working with new provider organisations
•
The service in the south (replacing a walk in centre) will offer same
day/next day appointments
•
Delegated APMS contract
•
The service in the north will provide a mixture of routine and urgent
appointments.
•
Provider ability to work with ambiguity within a negotiated framework
•
Ability to collect data to evaluate integrated pathway due to overlap with
core contract
•
Ensuring consistent application of pathway at practice level.
•
This vision is to put GPs at the heart of providing local health services
Unique Features
•
Shared patients record system
•
Service model co-designed with practices and patients
•
Delivering services through a practice-led federated model
•
Telephone management by a senior clinician
(Potential ) Impact
•
Reducing variability in quality, access and patient outcomes
•
Supporting patients to find the right service at the right time
•
Improve and increase primary care capacity
•
Promote consistency of care across general practice.
•
Reducing reliance on unscheduled care services.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 197
Appendices
Enhanced call and recall – improves screening and early
identification and management of long term conditions
Service Model
•
Intervention to improve awareness and uptake of bowel cancer screening
in ethnically-diverse areas
Unique Features
•
Face-to-face health promotion on bowel cancer screening to invitees’ in 9
GP Practices;
•
Health promotion delivered by telephone only to patients of 9 other GP
practices
•
24 practices of similar size as comparators
(Potential ) Impact
•
Median gFOBt kit uptake in the target population (aged 59–70) was
46.7% in the telephone practices, 43.8% in the face-to-face practices and
39.1% in the comparison practices
•
Personally delivered health promotion improved uptake of bowel cancer
screening in areas of low socio-economic status and high ethnic diversity
– with telephone intervention most effective
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 198
Appendices
Lewisham Neighbourhood Primary Care Improvement Scheme Reduction in gap between recorded / actual prevalence of long
term conditions
Service Model
•
•
The scheme enables primary care to target its efforts/resources to achieve
specific indicators over a range of priority clinical areas including diabetes,
cancer, COPD, hypertension, PPI, flu, pneumococcal and childhood
immunisations
Since September 2014:
—
574 cases of newly recorded / diagnosed Type 2 diabetes
—
220 newly diagnosed COPD patients
—
758 newly diagnosed hypertensive patients
Unique Features
Challenges
•
GP practices are encouraged to advance care through a variety of
means, including working collaboratively in ‘Neighbourhoods’.
•
•
Neighbourhoods have begun to establish their own mechanisms to
deliver the scheme, for example through sharing dedicated admin
resource or appointing leads for clinical areas across all practices
Data quality (coding) issues – consistency and accuracy
(Potential) Impact
•
Increased self-management for people with long term conditions
•
A positive impact on access to primary care
•
To build on the collaborative working within Neighbourhoods
•
Reduced variation
•
Improved health outcomes for people with long term conditions
•
To provide a platform for the delivery of population based care
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 199
Appendices
Lambeth (& Southwark) Diabetes Modernisation Initiative Reduction in variation (level up) primary care management of long
term conditions
Service Model
Challenges
•
Intermediate multi-disciplinary team clinics
•
Increasing complexity being managed out of hospital including:
•
Structured education & self-management support for patients
•
increasing follow-ups
•
Improving primary care management of diabetes
•
need to review specialist clinical capacity
•
Increasing demands on primary care
Unique Features
•
Telephone/email support by DSN
•
Joint in-practice patient clinics run in practices by DSN & practice staff
•
“Virtual clinics” by DSN-led review of patients on diabetes registers
•
Intensive support of DSN and GPWSI for practices with lowest HbA1c
control, blood pressure control & detection rates
(Potential) Impact
•
Improved management and control leading to better outcomes and
reduction in hospital activity
•
The overall spend on planned diabetes care per person on the diabetes
register has reduced
•
Improvements in biological outcomes for targeted practices
•
High levels of patient satisfaction
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 200
Appendices
Greenwich - Re-ablement – Admissions avoidance and
effective discharge
Service Model
(Potential) Impact
•
The Community Assessment and Rehabilitation teams work in partnership
with Greenwich Council to provide community-based assessment,
rehabilitation and prevention services for people over 18 years of age.
•
Reductions in DTOC’s. Improvement in A&E attendances and admissions
avoided.
•
•
Referrals are taken directly from patients who need the service and from
health and social care professionals.
64% assisted require no ongoing support from LA (London average is
50%).
•
7 % reduction in clients needing long-term care.
•
Increased use of assistive technology (up by 21 %), and a reduction in the
number of service users requiring home care
•
Savings of £900,000 to the local authority's care budget, and of 5.5 % to
NHS community health budgets
Unique Features
•
Neuro-rehabilitation, for injuries and conditions including head injuries,
Stroke, Parkinsons, Cerebral Palsy and MS and MND
•
Dietetics, for people require dietary/ nutritional advice/support
•
Mobility assessments and intervention
Challenges
•
Assessment and rehabilitation of activity of daily living (ADL), with a
reablement focus
•
Demand through A&E/ACUTE Discharges
•
Workforce
•
Falls intervention
•
Increase in frailty
•
Help to manage a long-term condition.
•
Financial balance across health and social care system
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 201
Appendices
Bexley Case Management Multi Disciplinary Team configuration –
main long term condition groups (incl. mental health) and Frail elderly
Service Model
(Potential) Impact
•
•
GP-led model of an integrated multi-disciplinary team approach using
innovative models of communication, to planning care for patients with
complex needs, and monitoring outcomes
Unique Features
•
Holding multi-disciplinary team meetings to plan patients care in an
integrated and holistic way whereby effectiveness is maximised through:
•
The benefits of this approach include:
—
better coordinated care for patients
—
avoidance of admissions to care homes and hospital
—
improved medicine management
As part of the overall Integrated Care Older People programme:
—
Greater use of risk stratification to identify patients to be discussed
—
1,867 admissions can be prevented (approximately 5 per day)
—
Involving the social workers
—
13,130 acute bed days saved (reduction of approximately 37 beds)
—
Enabling all professionals to identify patients that they are concerned
about
—
Disinvesting £4.02m from the acute sector.
—
Circulating/sharing the patient list prior to the meeting so that
professionals have the opportunity to review their own care records
—
Using conference call facilities to enable professionals to dial in
when they are unable to attend meetings
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 202
Appendices
Bexley Case Management Multi Disciplinary Team configuration – main long term condition groups (incl. mental health) and
Frail elderly
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 203
Draft in progress | 204
Appendices
London Quality Standards
•
•
•
In February 2013 the London Quality Standards were published. These
built on the London quality standards for acute medicine and emergency
general surgery which were published in September 2011 and
commissioned from 2012.
The London quality standards outline the minimum quality of care that
patients attending an emergency department or who are admitted as an
emergency should expect to receive in every acute hospital in London.
Similarly, the maternity services quality standards represent the minimum
quality of care women who give birth should expect to receive in every
unit in London, where applicable.
•
− The workforce supporting strategy;
− Maternity Clinical Leadership Group ;
− Children and Young People Clinical Leadership Group ; and
− Urgent and Emergency Care Clinical Leadership Group
•
The aim is that these standards will help to significantly improve flow
within the hospital and improve the care and experience for patients. The
London quality standards are therefore an important consideration for the
proposed clinical models.
Acute providers in south east London undertook a self assessment in
2013 against these standards, the results of which can be found on the
NHS England website and in the following link:
http://www.england.nhs.uk/london/our-work/quality-standards/.
•
These results demonstrate that across the main south east London
providers a number of standards had not been met. Therefore it our
intention that the Our Healthier South East London Programme will
develop strategies that will meet these standards.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Within each of these areas we aim to understand the current situation
against each standard. We plan on holding conversations with individual
providers regarding the London quality standards. In particular we will focus
on:
− Current progress and status against the standard;
− Existing plans to meet the standards; and
− Additional amounts of funding required to meet the standards.
2013 self assessment
•
The standards will specifically be focussed on in the following areas:
•
This will then form a baseline to enable us to understand specific areas of
focus the care models and workforce supporting strategy need to address in
order for all London quality standards to be met.
Draft in progress | 205
NB: The financial data contained within slides 21-23 and 151-153, along with the
information within this appendix, may be subject to change following discussions
with providers and CCGs with respect to the modelling. This includes the figures
for the initial estimate of acute bed requirement (slide 23 and replicated in 153),
which are subject to change following feedback from providers regarding
specifics around their data, benchmarking methodology and bed occupancy
assumptions.
Draft in progress |
206
Appendices
Clinical Leadership Group financial impacts
•
The following pages show more detailed financial impacts (in terms of
gross benefits) for each of the Clinical Leadership Groups, along with the
activity metrics considered when estimating these impacts.
•
Workshop attendees were asked to consider how the changes were likely to
move current performance in comparison with these peers (i.e. moving to
upper quartile performance or beyond).
•
These metrics were discussed at the Clinical Leadership workshops,
alongside a series of benchmarks demonstrating current performance
against a series of peers.
•
The exception to this process was the Community Based Care group, which
instead considered a number of ‘big hitters’ (schemes that were felt to have
the potential to have the greatest impact). These schemes were modelled
using a bottom-up approach, often considering work that had already taken
place on a CCG basis, when setting up pilot schemes.
Clinical Leadership Group
Urgent & Emergency Care
Potential gross saving (£m)
Over 18s
81
Under 18s
15
Children & Young People
15
Planned Care
46
Maternity
9
Cancer
15
Community Based Care*
48
Total
230
* Savings attributed to certain Clinical Leadership Group s may be as a result of CBC initiatives. For example, enhanced primary care within CBC will result in reduced A&E attendances for which
the benefit has been attributed to U&EC. Further understanding of the CBC initiatives is required to remove all elements of overlap with benefits from other Clinical Leadership Groups.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 207
Appendices
Clinical Leadership Group financial impacts
The following pages show more detailed financial impacts (in terms of gross
benefits) for each of the Clinical Leadership Groups, along with the activity
metrics considered when estimating these impacts.
Workshop attendees were asked to consider how the changes were likely to
move current performance in comparison with these peers (i.e. moving to upper
quartile performance or beyond).
These metrics were discussed at the Clinical Leadership workshops,
alongside a series of benchmarks demonstrating current performance against
a series of peers.
The exception to this process was the Community Based Care group, which
instead considered a number of ‘big hitters’ (schemes that were felt to have the
potential to have the greatest impact). These schemes were modelled using a
bottom-up approach, often considering work that had already taken place on a
CCG basis, when setting up pilot schemes.
Clinical Leadership Group
Urgent & Emergency Care
Potential gross saving (£m)
Over 18s
81
Under 18s
15
Children & Young People
15
Planned Care
46
Maternity
9
Cancer
15
Community Based Care*
48
Total
230
* Savings attributed to certain Clinical Leadership Group s may be as a result of CBC initiatives. For example, enhanced primary care within CBC will result in reduced A&E attendances for which
the benefit has been attributed to U&EC. Further understanding of the CBC initiatives is required to remove all elements of overlap with benefits from other Clinical Leadership Groups.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 208
Appendices
Urgent and emergency care: Summary of benefits
CLG
Metric
A&E attendances
U&EC
(over
18s)
Non-elective admissions
Non-elective length of stay
Re-admissions
% change in activity
Potential saving (£m)
Performance benchmark
-23%
20
2nd best in class*
-8%
31
Best in class
-19%
30
Best in class
-4%
1
Best in class
Urgent and emergency care (over 18s) sub-total
U&EC
(under
18s)
A&E attendances
Non-elective admissions
81
-23%
6
2nd best in class*
-8%
9
Best in class
Urgent and emergency care (under 18s) sub-total
15
Urgent and emergency care total
97
* Best in class for this peer group was Brent CCG. As we were comparing attendances to major A&E, we chose to treat Brent as an outlier since they had recently
closed an A&E department which was skewing their figures.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
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Appendices
Urgent and emergency care: Summary of activity shifts
Baseline activity
CLG
U&EC
(over 18s)
Metric
Strategic impacts: activity
2013/14
Growth
(2019/20)
Gross change
(2019/20)
Net change
(2019/20)
Gross change
(2019/20)
Net change
(2019/20)
A&E attendances (attendances)
497,000
87,000
(135,000)
(49,000)
n/a
n/a
Non-elective admissions (FCEs*)
180,000
32,000
(17,000)
15,000
(86,000)
Non-elective length of stay (bed days)
899,000
158,000
n/a
n/a
(160,000)
14,000
3,000
(650)
1,350
(3,000)
Re-admissions (FCEs*)
Urgent and emergency care (over 18s) sub-total
U&EC
(under 18s)
Strategic impacts: bed days
(91,000)
(249,000)
(91,000)
A&E attendances (attendances)
163,000
29,000
(45,000)
(16,000)
n/a
n/a
Non-elective admissions (FCEs*)
55,000
10,000
(5,000)
5,000
(8,000)
8,000
(8,000)
8,000
(257,000)
(83,000)
Urgent and emergency care (under 18s) sub-total
Urgent and emergency care total
* An FCE is a finished consultant episode, used as a measure of inpatient activity. It is distinct from an admission in that a patient can have multiple episodes of care in one spell in hospital (normally
due to receiving treatment for multiple conditions or multiple treatments for a single condition).
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
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Appendices
Children and young people’s care: Summary of benefits
CLG
Metric
% change in activity
Potential saving (£m)
Performance benchmark
A&E attendances (under 18s)
-3%
1
Upper quartile
Non-elective admissions
(under 18s)
-7%
7
Upper quartile
Non-elective length of stay
(under 18s)
-38%
7
Upper quartile
Re-admissions (under 18s)
-7%
<1
Upper quartile
CYP
Children and young people’s care total
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
15
Draft in progress | 211
Appendices
Children and young people’s care: Summary of activity shifts
CLG
Metric
2013/14
Growth
(2019/20)
Gross change
(2019/20)
Net change
(2019/20)
Gross change
(2019/20)
Net change
(2019/20)
A&E attendances (attendances)
163,000
29,000
(6,000)
23,000
n/a
n/a
Non-elective admissions (FCEs*)
55,000
10,000
(4,000)
6,000
(6,000)
Non-elective length of stay (bed days)
93,000
16,000
n/a
n/a
(31,000)
7,500
1,300
(350)
950
(370)
CYP
Re-admissions (FCEs*)
Children and young people’s care total
(37,370)
(21,370)
(21,370)
* An FCE is a finished consultant episode, used as a measure of inpatient activity. It is distinct from an admission in that a patient can have multiple episodes of care in one spell in hospital (normally
due to receiving treatment for multiple conditions or multiple treatments for a single condition).
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
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Appendices
Planned care: Summary of benefits
CLG
PC
Metric
% change in activity
Potential saving (£m)
Performance benchmark
Economies of scale (MSK)
N/A
5
n/a**
Economies of scale
(Ophthalmology)
N/A
2
n/a**
Elective length of stay (MSK)
-10%
1
Upper quartile
First to follow-up ratio (MSK)
-16%
2
Upper quartile
First to follow-up ratio
(Ophthalmology)
-16%
2
Best in class
N/A
35
Average of peers
Further opportunities in other
specialties*
Planned care total
46
* For planned care, we have built upon the Orthopaedics and Ophthalmology savings presented to the Clinical Leadership Group planning group, estimating potential savings in other specialties
associated with providing care at a unit cost similar to peers.
** Economies of scale have estimated using of the Department of Health’s ‘Provider Economics Commissioning Impact Assessment Model’ (available at:
https://www.gov.uk/government/publications/provider-economics-impact-assessment-model).
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 213
Appendices
Planned care: Summary of activity shifts
CLG
Planned
care
2013/14
Growth
(2019/20)
Gross change
(2019/20)
Net change
(2019/20)
Gross change
(2019/20)
Net change
(2019/20)
Elective length of stay (MSK) (bed days)
26,000
4,000
n/a
n/a
(3,000)
1,000
First to follow-up ratio (MSK)
(appointments)
87,000
15,000
(11,000)
4,000
n/a
n/a
127,000
22,000
(16,000)
6,000
n/a
n/a
(3,000)
1,000
Metric
First to follow-up ratio (Ophthalmology)
(appointments)
Planned care total
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
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Appendices
Maternity: Summary of benefits
CLG
Metric
% change in activity
Potential saving (£m)
Performance benchmark
-54%
6
Best in England
Movement from Obstetrics to
Midwife-led units
-8%
2
n/a
Length of stay (Obstetrics: all
remaining births)
-16%
2
Upper quartile
Reduction of emergency Csections*
M
Maternity total
9
* This saving relates to reducing the overall C-section rate at each trust down to 20% which represents a ‘Best in England’ scenario. This reduction in C-sections has been assumed to be applied to only
emergency C-sections within Obstetrics and therefore the 54% is the reduction in emergency C-sections. When compared to all C-sections, this reduction equates to a 31% reduction.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 215
Appendices
Maternity: Summary of activity shifts
CLG
2013/14
Growth
(2019/20)
Gross change
(2019/20)
Net change
(2019/20)
8,420
570
(2,650)
(2,080)
Reduction of normal births in Obstetrics
(FCEs*)
16,430
1,110
(1,310)
(200)
Corresponding increases in midwife-led
births (FCEs*)
4,000
270
3,960
4,230
72,200
4,880
n/a
n/a
Metric
Reduction of emergency C-sections
(FCEs*)
Gross change
(2019/20)
Net change
(2019/20)
(11,900)
Maternity
(14,700)
Length of stay [Obstetrics: all births] (bed
days)
Maternity total
Obstetrics/midwife-led overall summary
(8,100)
(20,000)
Baseline activity
Strategic impacts: activity
(14,700)
Strategic impacts: bed days
Obstetrics births (FCEs*)
24,600
1,660
(3,960)
(2,280)
(24,000)
(19,120)
Midwife-led births (FCEs*)
4,000
270
3,960
4,230
4,000
4,420
Maternity
* An FCE is a finished consultant episode, used as a measure of inpatient activity. It is distinct from an admission in that a patient can have multiple episodes of care in one spell in hospital (normally
due to receiving treatment for multiple conditions or multiple treatments for a single condition).
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
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Appendices
Cancer care: Summary of benefits
CLG
Metric
% change in activity
Potential saving (£m)
Performance benchmark
Reduction in treatment costs
through earlier detection*
N/A
7
Best in England
Emergency admissions
(Cancer)**
-9%
2
Upper quartile
Average length of stay
(Cancer)**
-21%
5
Upper quartile
First to follow-up ratio
(Cancer)**
-11%
1
Best in class
C
Cancer total
15
* These savings associated with reductions in treatment cost due to early detection have been estimated for all cancers, but is a high case scenario and not linked to any particular initiatives. The saving
is estimated by comparing SEL levels of Stage 1/2/3/4 diagnosis compared with the ‘best in England’ diagnosis levels.
** Cancer patients have been identified using the recorded primary diagnosis. It is important to note that this will not identify all cancer patients as some may have relevant secondary diagnoses. This will
lead to an over-estimation of impacts for the urgent and emergency care group and an under-estimation of impacts for the cancer one.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 217
Appendices
Cancer care: Summary of activity shifts
CLG
Metric
Emergency admissions (Cancer) (FCEs*)
Cancer
Average length of stay (Cancer) (bed
days)
First to follow-up ratio (Cancer)
(appointments)
Cancer total
2013/14
Growth
(2019/20)
Gross change
(2019/20)
Net change
(2019/20)
Gross change
(2019/20)
Net change
(2019/20)
4,000
600
(400)
200
(5,300)
104,000
13,000
n/a
n/a
(24,000)
72,000
13,000
(10,000)
2,000
n/a
n/a
(29,300)
(16,300)
(16,300)
* An FCE is a finished consultant episode, used as a measure of inpatient activity. It is distinct from an admission in that a patient can have multiple episodes of care in one spell in hospital (normally
due to receiving treatment for multiple conditions or multiple treatments for a single condition).
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
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Appendices
Community based care: Summary of benefits
Intervention
Gross saving
Investment cost
Net benefit
£18.7m
(£7.5m)
£11.2m
Asset mapping
£0.8m
(£1.5m)
(£0.7m)
Prevention – diabetes
£1.4m
(£0.6m)
£0.7m
£3.2m+ *
(£15.5m)
(£12.3m)
£0.2m
£0.0m
£0.2m
**
(£4.5m)
(£4.5m)
£6.3m
(£4m)
(£2.3m)
***
(£15.7m)
(£15.7m)
*
(£1.5m)
(£1.5m)
End of life care
£9.6m
(£5.4m)
£4.2m
Medicines Management
£5.6m
(£2.6m)
£3.0m
Supporting Vulnerable in the Care Home
£2.1m
(£0.8m)
£1.3m
£47.9m
(£59.6m)
(£11.7m)
Improved Long Term Conditions management**
Improved core GP
Improved call/recall – bowel cancer
Reduction in variation between recorded/expected prevalence
Diabetes Modernisation
Reablement
Multi Disciplinary Team Configuration – Case Management
Total
* Additional benefits not shown here have been included in the urgent and emergency care group.
** Saving based on benchmarked spend on long term conditions in our CCG peer groups.
*** The majority of benefits associated with this intervention are associated with social care.
Note: Savings attributed to certain other clinical leadership groups may be as a result of community based care initiatives. For example, enhanced primary care within community based care will result in
reduced A&E attendances for which the benefit has been attributed to urgent and emergency care. Further understanding of the community based care initiatives is required to remove all elements of
overlap with benefits from other Clinical Leadership Groups.
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 219
Appendices
Clinical Leadership Group investment requirements
•
Work to develop the supporting strategies for Workforce, Estates and
IM&T, which will be key inputs to the investment cost estimates, is ongoing.
•
Therefore scenarios are presented below which demonstrate assumed
investment costs based on proportions of the total benefits (with the
exception of community based care, where the costs and benefits of the big
hitters have been estimated using a bottom-up approach of each particular
intervention and so only one scenario is presented).
•
The scenarios presented are as follows:
— Scenario 1: Reinvestment costs of 30% of benefits
— Scenario 2: Reinvestment costs of 40% of benefits
— Scenario 3: Reinvestment costs of 50% of benefits
Clinical Leadership Group
Scenario 1
Investment costs (£m)
Scenario 2
Investment costs (£m)
Scenario 3
Investment costs (£m)
Urgent & Emergency Care
(5)
(17)
(30)
Children & Young People
(1)
(3)
(5)
Planned Care
(2)
(8)
(14)
Maternity
(1)
(2)
(3)
Cancer
(1)
(3)
(5)
Community Based Care
(60)
(60)
(60)
Total
(69)
(92)
(115)
A partnership of Bexley, Bromley, Greenwich,
Lambeth, Lewisham and Southwark Clinical
Commissioning Groups and NHS England
Draft in progress | 220