Clinical Strategy
2015 to 2018
Version Control Sheet
Version
1
Date
Author
070815
Dr J Medhurst
2
210915
Dr J Medhurst
3
29.09.15
Dr J Medhurst
Status
For submission
to TDA
For submission
to the Board
Approved by
Board
Comments
Includes stakeholder
comments
Central London Community Healthcare NHS Trust
© 2015 Central London Community Healthcare NHS Trust
Contents
Section
Page
1.
Introduction
4
2.
Vision and Priorities
5
3.
The CLCH Population
7
4.
Partnership and Joint Ventures
8
5.
Activity and Income
9
6.
Current Clinical Services
10
7.
The Current Clinical Model
12
8.
Quality
15
9.
The Case for Transformation
21
10.
Clinical Commissioner Changes and Plans
27
11.
New Model of Care
32
12.
Developments in Clinical Nursing
42
13.
Clinical Service Planning
43
.
Service Development Plans
13.1 Plan 1
44
13.2 Plan 2
48
13.3 Plan 3
51
13.4 Plan 4
56
14.
Risks
58
15.
Conclusion
59
16.
References
60
Appendix
1
Examples of changes made as a result of complaints and
patient stories,
2
CLCH Performance Scorecard
CLCH Clinical Strategy
Date of Issue:September 2015
Page
61
64
Central London Community Healthcare NHS Trust
CLCH Clinical Strategic Plan
CLCH Clinical Strategy
Date of Issue:September 2015
Central London Community Healthcare NHS Trust
Current Clinical
Model
Factors in Strategy
Development
Clinical Strategy 2015-2018
CLCH Clinical Priorities and Trust
Priorities
New Clinical model
Contracted activity
Existing clinical model plus:
Factors affecting change:
Current Clinical Model:
 Active support for selfmanagement
 Primary &Secondary
Prevention
 Improving End of Life
Care
 Effective Meds
Management
 Ambulatory Care
 Care Co-ordination –
integrated health &
Social care








New Characteristics:
Policy Changes
Patient Choice/Experience
Economic pressures
QIPP
Technology
System changes
Harm Free Culture
Contract activity changes
through procurement
The Patient Perspective
Commissioning Priorities and
Plans
 Local CCGs
 At Risk Services
 Commissioning Intention
themes
 Other changes to the
Commissioning Landscape
 Health Economy Initiatives
Public Health Data
CLCH Clinical Strategy
Date of Issue:September 2015




Multi-disciplinary team
working
New kind of partnership
working
Supports new
specialist/generalist
relationships
Seeing the patient through
a holistic lens
Examples seen in four
transformation service
developments:
1.
Managing long term
conditions in the
community
2.
Early discharge and
transition services
3.
Integrated Children’s Care
4.
Delivering Improved care
through technology
1.
Introduction
“…. The changing needs of our patients – often frail, some with dementia, many with
multiple other health problems – coupled with the opportunities of new technology
may mean we can better support people at home and locally.”1
Simon Stevens, Chief Executive Officer, NHS England, 4 June 2014
This clinical strategy, 2015-2018, has been written for, and about, the patients to
whom we deliver care. The clinical strategy sits at the heart of the work of the
organisation and links to CLCH’s other strategies outlined in the Integrated Business
Plan. This strategy outlines the direction of travel for the clinical services in the light of
known commissioning intentions, and the Trust acknowledges that a number of other
enabling strategies and plans will, in turn, drive the detailed plans for the individual
specialties and Divisional clinical services.
Community services have as their defining characteristic the delivery of care to
patients in and close to their own personal environments. However it is a pathway of
care that culminates in that home based consultation and those pathways are
changing. This means that CLCH will evolve and change reflecting the emergence of
different clinical relationships and working practices.
CLCH is the largest standalone community trust in London and offers a population of
around 1 million people services that help them remain healthy, recover from an
episode of ill health or that intervene to keep them out of hospital.
CLCH, in common with all NHS providers faces a profound set of challenges to
deliver high quality care to a population that is living longer with limited resource
allocation alongside significant recruitment challenges. Our challenge, however,
remains unchanged. That is to improve the health and care to our population. To
succeed at this challenge CLCH intends to increase the quality of the care we deliver
when we find unnecessary variation, maintain the quality of care we know to be good
and improve the efficiency of how we do this through integration and streamlining of
care.
1
http://www.england.nhs.uk/2014/06/04/simon-stevens-nhs-confed
5
2. Vision and Priorities
Our Vision: Great care closer to home
Our Mission: Working together to give children a better start and adults greater
independence
The Trust’s mission reflects the fact that in delivering great care we believe we are at
our best when we work together in partnership with other organisations. We thus
embed the mantra of “working together” in our mission to deliver great care, which is,
of course, the Trust’s primary concern, and is therefore embedded in the vision itself.
Whilst working in partnership is beneficial, CLCH also believes that community
services benefit greatly from being delivered by a stand-alone provider dedicated
exclusively to community healthcare. This we see as our core and unique strength: no
other community health care organisation in London can match our breadth of diversity
in terms of service, local patient population knowledge and geography with a focus on
a preventative agenda of keeping people healthy and supporting them when they are
unwell.
Table 1 sets out the Trust Strategic Priorities and demonstrates how they align with the
10 Clinical Principles the trust has adopted.
Table 1
Clinical Principles
1
Optimise clinical outcomes and patient safety
2
Develop and strengthen care pathways
3
4
5
6
7
8
9
Embed an organisational approach to
improvement
Have system wide perspective
Develop partnerships that promote integration
of care
Improve patient experience (no care about me,
without me)
Develop clinical and organisational leaders
Have a unified culture of high standards that
promotes compassion, openness and candour
Be innovative and bold in the use of
technological innovations
10 Deliver improved services
Alignment to the Trust’s
Strategic Priorities
Quality
Transformation/Integration
Leadership/Governance
Leadership/Governance
Transformation/Integration
Quality
Leadership/Governance
Quality
Leadership/Governance
Transformation/Integration
Value for Money
Quality
Value for Money
6
Definition of the Trust Strategic Priorities
Quality
We believe that good quality healthcare is a fundamental priority for all care delivered in
NHS services.
We were pleased to be awarded a “Good” rating by the CQC in the inspection undertaken in
Spring 2015, but we can improve.
We define quality through three lenses – patient experience, safety and clinical
effectiveness.
Transformation/Integration:
By transforming the operations of our clinical and corporate functions we will more
effectively provide services which respond better to patients’ needs and commissioners’
requirements.
Our Trust is making a committed and sustained contribution to the system-wide integration
of services which will see the transformation of existing services into new, improved models
of care with enhanced integration between health and social care providers.
We have an ambitious and large-scale corporate transformation programme with Capita that
will see CLCH is changing the way its services are organised.
Leadership/Governance
We aspire to a leadership culture that enables engagement, positivity, caring, compassion
and respect both for staff, and patients.
Engagement with patients, the public and staff through a variety of mechanisms is used to
gain insights that assist us in improving patient experience and the quality of care. Change
is then enabled through supportive line management and meaningful engagement in
decision-making are factors linked to improved employee health, productivity and retention
rates.
Value for money
This priority links closely to that of transformation and integration as we improve services
and ensure that we are sustainable for the future by solidifying our financial position.
The majority of this priority will be linked to the efficiency savings we will be required to
make over the coming years.
However we will continue to focus on improving the outcomes and safety as we explore how
to reduce the cost of achieving those outcomes.
Growth
Our primary objectives for growth are to deliver stability, quality and value for patients,
partners and commissioners. We have a realistic growth plan which does not increase risks
for the organisation or our existing commissioners, patients and taxpayers.
7
3.
The CLCH Population
3.1
Central London Community Healthcare Trust (CLCH) serves a population which
includes approximately one in ten Londoners, predominantly the 1 million people living
and working in Barnet, Hammersmith & Fulham, Kensington & Chelsea and
Westminster (Figure 1).
3.2
Increasingly, services are being delivered in neighbouring boroughs and in
Hertfordshire, Hounslow, Harrow and Brent, where CLCH has been awarded new
business in the form of COPD, respiratory, sexual health services, Diabetes, and
School Nursing.
3.3
In addition the considerable influx of daily workers and tourists into the central
boroughs more than trebles the resident population during the working week.
3.4
CLCH provides care in London, a world city with around 270 nationalities speaking
more than 300 languages. Ethnic diversity is matched by religious diversity, with
London providing home to sizeable Muslim, Hindu, Sikh and Jewish communities.
London also has extremes of wealth and deprivation, with its richest and poorest
residents often living in close proximity. Recently we have been successful in being
chosen to provide services in new boroughs such as Hertfordshire
Figure 1
8
4.
Partnerships and joint ventures
CLCH has a number of partnerships and joint ventures that enable the Trust to offer
comprehensive and innovative patient care, working with:

Imperial College Healthcare NHS Trust
o
Community Diabetes Service
o
Running an urgent care centre in Charing Cross and at Hammersmith Hospital
o
Imperial Health Partners Academic Health Partnership on the Collaborative
Translational Research and Development project

Community Independence Service (CIS) with Imperial College Healthcare NHS Trust,
GP networks and mental health trusts

CLCH is a member of Imperial College Health Partners, which drives innovation
through collaboration with other health providers and universities in North West London

Chelsea and Westminster Hospital NHS Foundation Trust and Imperial College
Healthcare NHS Trust to identify the incidence of, and clinically effective responses
to, the treatment of leg ulcers

Chelsea and Westminster Hospital FT in delivering Hertfordshire Sexual Health
Services

NWL commissioners as key members on the Whole Systems integrated care
programme, aiming to integrate health and social care across patient pathways

CNWL (with them as a secondary contractor), on delivering prison healthcare in
Wormwood Scrubs, and working to improve access to psychological services
(IAPT) with us as a secondary contractor),

Barnet and Chase Farm Hospitals NHS Trust and the Royal Free London NHS
FT on the Triage Rapid Elderly Assessment Team (TREAT) and Post-Acute
Enablement (PACE) service projects, which move patients into the community
setting more quickly, freeing up costly and sought-after acute beds

West Hertfordshire Hospitals NHS Trust on COPD and community respiratory
services


CLCH works In conjunction with Middlesex University CLCH is involved in direct
training of nurses
Charing Cross and Hammersmith - Urgent Care Centres
9
5.
Activity and Income
In 2014/15 the Trust’s total income was £198.4m and it employed just over 2,400 whole
time equivalent (WTE) staff. Services are now provided from over 600 sites.
In 2014/15 CLCH Trust had a total caseload of 243,838 patients with an outturn of
2.40m patient contacts. Of all the patient contacts, 45% are provided in the home. Over
three quarters of our income for this activity was received from block contracts with
only a small proportion from cost and volume contracts.
The four main CCG commissioners, which contribute almost two thirds of CLCH’s
clinical income, are shown in Figure 2.
Figure 2
10
6.
Current Clinical Services
Central London Community Healthcare, (CLCH), is one of a new generation of health
providers who provide care for patients requiring help and support at home or within
community settings.
Currently CLCH has 69 services including children’s community healthcare, supported
hospital discharge and integrated care, continuing care, community nursing,
rehabilitation and palliative care beds, four Walk in Centers, three Urgent Care Centers
and offender healthcare at HMP Wormwood Scrubs.
The CLCH health care professionals provide high quality healthcare either in people’s
homes or at convenient local clinics, helping people to stay well and manage their own
health with the right support.





Care is provided from more than 69 different services on more than 629 sites,
ranging from district nursing, health visiting and home-based rehabilitation to
specialist diabetes services and dietetics sessions.
Care is provided for people with long-term conditions like respiratory illnesses and
heart disease as well as to new mothers with their babies.
Services are provided for children and young people and the homeless, as well as
those who are coming to the end of their life.
Our NHS walk-in centres across London can be attended by anyone without an
appointment as an alternative to A & E for less serious injuries and illnesses.
The full breakdown of our services is shown in Table 2:
Table 2: CLCH service divisions
Division
Barnet
Community
and Specialist
Nursing
Services
Description
Clinic-based services, bedded services,
specialist nursing services, cardiovascular
disease (CVD) services and locality
services across Barnet, Kensington &
Chelsea, Westminster, Hammersmith &
Fulham and West Hertfordshire. Specialist
Nursing and Therapies represents 34% of
the Trust’s income
Services
MSK, podiatry, podiatric surgery,
nursing homes, palliative care
(community service and bedded
unit), continence, tissue viability,
urology, respiratory, anticoagulation, stoma, heart nursing,
Parkinson’s, dietetics, diabetes,
specialist weight management,
phlebotomy, 24hr nursing, adult
speech therapy, community
matrons, care navigation, falls,
intermediate care, two bedded
units (Jade and Marjorie Warren),
rapid response, post-acute care
enablement service (PACE).
11
Networked
Community
Nursing &
Rehabilitation
Children’s
Health and
Development
Services
Allied Primary
Care Services
Multidisciplinary nursing and rehabilitation
services are provided in patients’ homes,
in community clinics or in rehabilitation
units across Kensington & Chelsea,
Hammersmith & Fulham, Westminster and
Barnet. Services cover adults’ community
nursing, adults’ community rehabilitation
services, adults’ rehabilitation bedded
services and therapies bedded services in
partnership with Care UK. Networked
Community Nursing & Rehabilitation
accounts for 23% of the Trust’s income.
The division comprises all the Trust’s
children’s services and delivers care
across Hammersmith & Fulham,
Kensington & Chelsea, Westminster and
Barnet, as well as Brent from 1st April
2015. Main services include health
visiting, school nursing, paediatric
therapies and complex children’s
nursing. The division also provides
services for Looked After Children and has
close links with the corporate safeguarding
team that support all services across the
Trust. Children’s Health and Development
accounts for 21% of the Trust’s income.
17 different primary care service lines are
provided across Hammersmith & Fulham,
Kensington & Chelsea, Westminster and
Barnet. Several are delivered in
partnership with both social services and
non-NHS organisations. Allied Primary
Care Services account for 22% of the
Trust’s total income.
Community nursing, rapid
response, night nursing,
community matrons, case
management, community
rehabilitation, community
independence service,
intermediate care, falls
prevention, neurology
rehabilitation, wheelchair
services, early supported stroke
discharge, wheelchair service,
bedded rehabilitation at Athlone
House and Alexandra House.
Health visiting, school nursing,
speech and language therapy
(SLT) services for children and
adults, acute / out-patients SLT
services, children and young
people occupational therapy
services, children’s community
nursing teams, paediatric
dietetics, safeguarding children
and adults’ services.
Offender health, sexual health,
health improvement, TB, HIV,
primary care mental health, GPs
with special interests (GPwSI),
learning disabilities (Barnet),
dental, interpreting, smoking
cessation, homeless, walk-in
centres and urgent care centres.
12
7.
The Current Clinical Model
This section sets out a description of the types of care that make up the present clinical
caseload of CLCH. As the previous section highlights, provision of care to adults and children
in their homes and their communities is the fundamental bedrock of care delivery within a
community trust. The type of care, however, varies depending on the identified patient/client
group. The model below sets out components of that care.
Active support for
self –management
Primary
Prevention/Health
Promotion
Care co-ordination
Core
Community
services
Managing
Ambulatory
Conditions
Effective
medicines
management
7.1
Secondary
Prevention
Improving
management of
end-of-life care
Active support for self-management
Self-management support can be viewed in two ways:
1. A portfolio of techniques and tools to help patients choose healthy behaviours.
2. A fundamental transformation of the patient–caregiver relationship into a
collaborative partnership.
Both are important in the holistic management of patients that receive care from
CLCH and will be supported through a cultural shift that always puts the
patient/client, at the center of the clinical decision making process.
7.2
Primary prevention
Effective primary prevention helps patients to avoid health problems before they occur.
Giving children the best start in life provides the greatest benefits, for example CLCH
supports and encourages mothers to breastfeed and provides immunization
programmes. However primary prevention is valuable at any point in life. Working with
other primary care providers especially general practitioners, CLCH is committed to
take action to reduce the incidence of disease and health problems within the
13
population either through universal measures that reduce lifestyle risks or by targeting
high-risk groups.
7.3
Secondary prevention
Secondary prevention, systematically detecting the early stages of disease and
intervening before full symptoms develop, is based on a range of interventions that are
often highly effective in reducing the widening gaps in life expectancy and health
outcomes (Marmot Review 2010). CLCH currently provides has services for Chronic
Obstructive Pulmonary Disease, (COPD), Heart Disease and Diabetes.
7.4
Improving the management of End of Life Care
Research suggests that when people are asked about their preferred place of care, the
majority of people will state a preference to be cared for at home or in a Hospice
(Gomes B et al, 2013).
The CLCH End of Life Care Strategy (2015-18) sets out our plans to




improve end of life care and the experience for people and carers using our
services at the end of their lives,
improve access to end of life care services,
improve choice and the coordination of services to reduce inequalities of
service provision and
increase the proportion of patients who are cared for and die in their preferred
place of care.
The End of Life Care Strategy includes the provision of end of life care for children and
adults with any advanced, progressive or chronic illness regardless of diagnosis. It
focuses on generalist and specialist palliative care, including care given in all settings
of CLCH (including at home, all community based services, in-patient, specialist inpatient palliative care services, day Hospice, specialist community palliative care
services, prison health and nursing and residential care).
7.5
Effective medicines management
Medicines management optimises the use of medicines both by patients and the NHS,
protecting against the risks associated with the unsafe use and handling of medicines.
It supports safe, appropriate and cost-effective prescribing, as well as helping patients
to have their medicines at the times they need them, in a safe way and have
information about their medicines made available to them. Good medicines
management can help to reduce the likelihood of medication incidents and hence
patient harm.
CLCH improves the management of medicines by delivering:
14



7.6
Medication reviews in patients’ homes, residential and nursing care settings to
ensure prescribing standards are met and help with co-ordination of domiciliary
support to avoid hospital readmissions due to suboptimal medicines use.
Medicines reconciliation on admission and written notification on discharge for
patients in our rehabilitation, continuing, intermediate and palliative care wards to
support safe transfer of information about patient medication on admission and
discharge.
Analysis of prescribing data and provide non-medical prescribers with information
to benchmark prescribing performance.
Managing ambulatory care sensitive conditions
Ambulatory care sensitive conditions, (ACS), are chronic conditions for which it is
possible to prevent acute disease deterioration and reduce the need for admission to
hospital. This can be achieved through:






active management such as vaccinations and vaccination programmes
better self-management
disease management or case-management
lifestyle interventions
primary/community and outpatient service provision
social and integrated health and social care provision
ACS conditions are categorised as being acute, chronic and other/vaccine preventable.
Examples are shown in table 3.
ACS emergency admissions are avoidable and emergency admission rates for ACS
conditions are viewed as an indicator for the quality of primary and community
healthcare provision.
Table 3
Acute conditions
Chronic conditions
Cellulitis
Dehydration
Dental conditions
Angina
Asthma
Chronic obstructive
pulmonary disease
Congestive heart failure
Convulsions and epilepsy
Diabetes complications
Ear, nose and throat
Gangrene
Gastroenteritis
Other Vaccine
Preventable (OVP)
conditions
Influenza
Pneumonia
Tuberculosis
Children’s services are investigating what illnesses generate emergency admissions
for local children and plan to define that suite of conditions enabling focused work on
supporting management of these conditions in the community.
15
8.
Quality
The definition of quality in health care, enshrined in law, includes three key aspects:
patient safety, clinical effectiveness and patient experience. A high quality health
service exhibits all three. However, achieving all three ultimately happens when a
caring culture, professional commitment and strong leadership are combined to serve
patients, which is why the Care Quality Commission is inspecting against these
elements of quality too.’
Five Year Forward View, DH 2014
The CLCH Trust Quality Strategy April 2013 – March 2016 established three
‘Campaigns for Action’.
Campaign One – A Positive Patient Experience
Campaign Two – Preventing Harm
Campaign Three – Smart, Effective Care
Each of the three campaigns has a strategic Trust wide group to drive the campaign,
provide organisational assurance and to report to the Quality Committee. These are the
Patient Experience Group (Campaign One),the Patient Safety and Risk Group
(Campaign Two) and the Clinical Effectiveness Group (Campaign Three).
8.1
Campaign One – A Positive Patient Experience
The Trust is improving patient experiences and has developed both formal groups to
engage with our patients and broader communication techniques such as surveys. It is
through these wide ranging activities that people contribute to the strategy and the
development changes to the Trust’s clinical activities. These are described below.
8.1.1
Key meetings with patient representation
The Trust Patient Experience Group (PEG) and Quality Stakeholder Reference Group
(QSRG) both include patient and public representation, and provide regular forums for
staff and patients to share perspectives, consult on new developments and raise
quality-related issues across the Trust. The role of the PEG is to monitor and support
patient experience in Central London Community Healthcare NHS Trust (CLCH). The
QSRG is structured in particular around the annual Quality Accounts process, but also
looks more broadly at the quality, patient and public perspectives in relation to wider
Trust decision making.
8.1.2 Patient Reported Experience Measures (PREMS) and Friends and Family Test (FFT)
The Patient Experience Team works successfully with clinical divisions to increase the
volume of surveying across services through telephone, tablet and kiosk surveys along
with an increasing use of comment cards. The team has deployed mobile tablet
devices in each of the divisions which are being used. Every service is asked to set its
own target for completing surveys, ensuring that all services get feedback, and this is
then discussed and finalised at the Patient Experience Group meeting. Work is also
16
being undertaken within Offender Health to establish the best method of gaining
feedback from service users and how we can incentivise them to take the time to
provide feedback.
CLCH receives the highest number of responses to the FFT question of any community
trust in London, with the next closest only having half our number.
8.1.3
PLACE (Patient-Led Assessments)
Patient assessors are fundamental to the success of PLACE (Patient Led Assessment
of the Care Environment) and must form at least 50% of the PLACE team. The PLACE
assessment considers premises with inpatient services from a non-clinical perspective
and assesses five areas:
• Cleanliness;
• Condition, appearance and maintenance;
• Food and hydration;
• Privacy, dignity and wellbeing; and
• Dementia Friendly Environment.
8.1.4
Sign up to Safety and other Trust wide initiatives
CLCH is one of two Community Trusts which has taken part in a report to identify how
Trusts are bringing patient experience data together. The report includes a case study
of our recent patient engagement events as part of our Sign up to Safety campaign.
The report can be found at: http://www.membra.co.uk/case-studies/making-sense-andmaking-use-patient-experience-data
8.1.5
Patient Stories
The Trust has collected and analysed a range of patient stories (250 in 2014/15) and
over the last quarter has undertaken themed analysis of these using the CQC Domains
for each Division. Stories are presented at each Trust Board meeting and at the Quality
Stakeholder Reference Group meetings. Changes as a result of patient stories have
taken place in many services such as Intermediate Care Team, School Nursing
Service, Athlone House Rehabilitation Unit, Falls Services, Wheelchair Services,
Podiatry, and the Neuro-Rehabilitation Team.
Examples of how changes have been made as a result of complaints and patient
stories, are illustrated in Appendix 1.
8.1.6
‘You Said, we Did’ – acting on the patient voice
CLCH has a range of ‘You Said we Did’ improvements which demonstrate the changes
we are implementing as a result of patients’ feedback. The feedback from patients will
continue to be monitored both locally and across the trust to evaluate the impact of
changes.
17
8.1.7
Example of actions taken as a result of the 15 Steps Challenges2
Actions are taken forward by the service and are reported to the Quality Stakeholder
Reference Group. Actions have included:



Update and review podiatry brochure. Encourage distribution within main
reception and with first time referrals.
Recruitment of volunteers to support reception, to assist with activities and
patient story collection and support for family and friends day.
Stressing the importance of the welcome and the queuing system to make sure
people are seen appropriately.
Key overarching themes/issues from the Patient Experience data relate to waiting
times, access to services, and communications. Each service receives the patient
feedback monthly and many local initiatives are developed from the feedback received.
In addition there are some trust wide programmes to improve patient experience.
These include the implementation of our End of Life Care Strategy with related workstreams, Achieving Excellence Together programme for District Nurses, and the
Compassion in Care programme which incorporates a myriad of improvement projects
to improve the experience of patients. As part of the Compassion in Care programme
the trust has introduced staff development called ‘Knowing you Matter’ to emphasise
the need for compassionate care and developing resilience.
8.1.8 Listening Events
The Trust carried out Listening events during May 2015 across our four principle
boroughs, with the focus on understanding patient experience for the development of
Trust ‘Always Events’. Each was led by a non-executive director who introduced
sessions and participated in and listened to the discussions. An online survey and
telephone interviews were also conducted to gather views. Key themes were identified
and are illustrated in Figure 3 below.
The Trust will develop an ‘Always Event’ plan which will provide a framework for what
should happen for every person, every time they encounter healthcare from CLCH.
2
http://www.institute.nhs.uk/productives/15stepschallenge/15stepschallenge.html
18
Figure 3
I want people
looking after me to
be ‘experienced’,
‘professional’ and
‘competent’
Continuity of care
– I like to see one
person throughout
my care
Small things
matter such as
being on time and
appearance
Healthcare
professionals
should be
well-prepared
Good communication
skills are very
important to me
Compassion. I want you
to listen to me and it is
very important to me
that you treat me as an
individual not a condition
8.1.9
Being seen quickly
and also having the
option of late
appointments.
Friendly manner - a
welcoming smile
goes a long way,
especially when I am
feeling anxious.
Involving Patients in Research
Increasing work is being done to engage with patients to deliver the best care to the
communities we serve through the use of research. There are a number of ways in
which we seek to involve and engage patients in this and other aspects of research
including:






Involving members in research projects
Liaise with researchers and advertise studies in GP surgeries and health centres to
increase and facilitate recruitment to studies
Utilise CLCH’s external webpage – currently research features there and members
of the public are directed to the Head of Research & Development
Encourage researchers to involve patients at the outset in their research projects
including in the design
Draw on the national research campaign by the NIHR: ‘Research saved my life’
Raise awareness at annual CLCH research conference
8.1.10 Development of a membership and Council of Governors
As CLCH progresses towards Foundation status, the Trust is developing a membership
and Council of Governors. The membership will be made up from the people we care
for, our partners, staff, and local communities; they will be able to elect governors who
19
represent their views. Through the Council of Governors, members will be able to
influence the way we develop and improve the healthcare we deliver, making us more
accountable and more responsive to local healthcare needs.
8.2
Campaign Two – Preventing Harm
The safety of our patients and staff is an absolute priority and good progress has been
made towards building a culture of openness and learning from experience. An example
of this is the work being undertaken on pressure ulcers. CLCH is committed to providing
the highest quality services possible for the patients/users/clients we serve. Good quality
healthcare depends on getting the basis right; safe, effective harm free care provided
wherever possible at home or as near to home as possible in a clean and pleasant
environment.
CLCH actively encourages the reporting of all incidents and this has been a key element
of Campaign Two of the Trust Quality Strategy: Preventing Harm. Staff are reminded of
their responsibilities to report incidents during a new staff induction e-module and
through regular contact between the Patient Safety Managers and the divisional staff.
The current Quality Strategy (April 2013 – March 2016) will be refreshed within the year
with further measures of success identified.
In 2015 we launched the Trusts safety improvement plan as part of the national Sign up
to Safety campaign, developed with support from the Kings Fund. The Trust will host
four Sign up to Safety workshops each year and is actively engaging with frontline
clinicians to support them in identifying and resolving a safety issue relevant to their
area. In addition to this the Trust held listening events with patients and members where
they were asked what more is possible around safety if patients and clinicians worked
more closely together. Themes were identified from this and were shared with clinical
staff who are leading on the development of service improvement plans.
8.3
Campaign Three – Smart, Effective Care
Safe and effective care delivery requires a focus on maintaining good practice through
the adoption and adherence of accepted standards, and identifying areas for
improvement through inquiry and review. CLCH has separated the different clinical
strands into separate working groups that are clinically led. These include the following:
8.3.1
Adoption and adherence to accepted standards








NICE Core Working Group
Medicines Management Group
Falls Steering Group
Catheter Associated Urinary Tract Infection (CA-UTI) Steering Group
Venous Thromboembolism (VTE) Working Group
Pressure Ulcer Working Group
Record Keeping Steering Group
Policy Ratification Group
20

8.3.2
End of Life Care Steering Group
Improving Outcomes through Inquiry and Review




Clinical Outcomes
Much work has been undertaken developing outcomes, and this is illustrated further
in the document.
Research
Audit
Service evaluation
8.4
An example of how the trust has performed in the area of providing for the three
campaigns for action (a positive patient experience, preventing harm and smart
effective care) is provided in the Performance Indicators in Appendix 2
8.5
The Clinical Quality Governance Structure is illustrated in figure 4.
Figure 4.
21
9.
The Case for Transformation
The NHS is facing one of the most challenging financial and organisational environment
seen in decades. A sustainable system of healthcare needs to be delivered locally
which resonates with the national assessment.
9.1
External Case for Transformation
Commissioners and providers are expected to be able to cope with the challenges of an
aging population and increased prevalence of chronic diseases, as well as shift
the current focus from acute care towards prevention and the facilitation of self-care and
integrated care. This care needs to be well co-ordinated, and resources need to be
directed to the patients with greatest need so that (King’s Fund 2015).
9.1.1
Background
A number of documents have been published recently which support the case for
transformation.
The Kings Fund has published discussion pieces regarding the future configuration of
community Trusts. These show an emerging consensus about the impact that
community services can have and what is needed to improve their effectiveness.
The main steps identified to transform care include providing services which:
 Reduce the complexity of services
 Build multidisciplinary teams for people with complex needs, including social care,
mental health and other services
 Support these teams with specialist medical input and redesigned approaches to
consultant services–particularly for older people and those with chronic conditions
 Offer an alternative to hospital stay
And
Organising services in order to:
 Wrap services around primary care
 Build an infrastructure to support the model based on these components including
much better ways to measure and pay for services
 Develop the capability to harness the power of the wider community
9.1.2 The conclusion supported the need for service changes that incorporated QIPP
challenges and resulted in improved quality of care and service, the use of innovation
leading to a productive efficient service and that focused on prevention as well as
treatment.
9.1.3
The Five year Forward View, published by the DH in 2014, highlighted that the
traditional divide between primary care, community services, and hospitals has
22
increasingly become a barrier to the personalised and coordinated health services
patients need.
The report identified that over the next five years and beyond, the NHS will increasingly
need to dissolve these traditional boundaries. Long term conditions are now a central
undertaking of the NHS; caring for these needs requires a partnership with patients
over the long term rather than providing single, unconnected ‘episodes’ of care. As a
result there is now quite wide consensus on the direction the NHS will be taking.
Changes needed:
•
Increasingly we need to manage systems – networks of care – not just
organisations.
•
Out-of-hospital care needs to become a much larger part of what the NHS does.
•
Services need to be integrated around the patient. For example a patient with
cancer needs their mental health and social care coordinated around them.
Patients with mental illness need their physical health addressed at the same time.
The Five Year Forward View articulates the need and expectation that providers will be
able to continue to find between 2-3% efficiency savings up until 2020. This will not be
done unless we genuinely transform our clinical and support operations.
9.1.4
The Dalton Review, carried out by Sir David Dalton, Chief Executive of Salford Royal
Hospital NHS Foundation Trust, was commissioned by the Secretary of State for
Health to undertake a review of how different organisational forms could accelerate
service transformation - to meet the challenge of improving both the quality and
sustainability of clinical services. The outcome of the review, published in December
2014, describes a spectrum of potential relationships ranging from the relatively
informal, such as strategic clinical networks, through to more formal contractual
relationships between organisations; and finally consolidated organisational forms such
as multi-site hospital chains. The review proposes that the greater the degree of
consolidation the greater the efficiency gains to be made.
9.1.5
The NHS Confederation published a discussion paper in July 2015 focusing on the
role of community health services in reshaping care. The early thinking in this paper
focuses how community services and primary care could work even more closely. It
suggests;
i.
ii.
iii.
iv.
v.
Community-based models co-ordinated around people’s needs
Community services’ focus on whole-person in order to help lead and develop
care models
Partnership between community health and primary care, where community
health services could provide practical support to enable primary care to work
at a much larger scale more quickly
Through community services enable better ways for specialists and generalists
to work together, support self –management, and develop the crucial
partnerships for prevention and wellbeing.
Care models need to use innovations found across health services
23
vi.
vii.
Population needs and input from staff and patients to drive the new care
models
A strategic approach to maximizing the value of community health services.
9.2
Internal Case for Transformation - Key drivers for change for CLCH
9.2.1
The key drivers influencing the clinical strategy stem from patients’ changing needs,
commissioners’ strategies and developments in technology, economic pressures and
government policy.
9.2.2
With the population growth taking place across London directly correlated with
healthcare needs, healthcare activity is expected to increase and to change (Figures 5
and 6)
Figure 5, Population projections by geography, 2014-2019, in thousands.
Source: Office of National Statistics
9.2.3 Each borough and county that CLCH serves has an individual profile but all are
expecting growth in the over 65 population (figure 5).
24
9.2.4 Although London currently has lower levels of people with long term conditions than the
England average, demographic trends mean that in the future we will have a much older
population with more complex health needs. Combined with a growing population, there
is increasing health needs in London.
Figure 6: Population % with LTC, by common LTC types.
Source: Quality and Outcomes Framework, Disease Register, 2012
9.2.5 Increasing numbers of patients with multiple long term conditions adds to the
complexity of their healthcare needs and the impact of multi-morbidity is profound.
People with several long term conditions have markedly poorer quality of life, poorer
clinical outcomes and longer hospital stays.
9.2.6 Providers of community healthcare, such as CLCH, have the expertise to manage
multiple conditions and can seamlessly integrate with partners, such as primary care,
which means that most patients with long term conditions can be effectively managed
outside of acute hospitals, reducing the cost to the NHS whilst improving patient
experience. Using information from public health data such as the JSNAs and Atlas of
Variation, will enable CLCH to work in partnership with the wider primary care
community to deliver tailored efficient clinical services.
9.2.7
Other notable factors include:


9.2.8
The total number of children under 18 is rising, the main growth taking place in the
over 5s, which shows there is a rising demand for school nursing.
An increasingly diverse population with contrasting deprivation profiles.
Community health care services need to be tailored to the needs of an ethnically
diverse population, for example by providing non-English language support,
supporting access to healthcare and self-management.
The projected increase in children and younger people is illustrated by age group in
Figure 7.
25
Figure 7 - Population (‘000s) under 19 by geography 2014 - 2019
A summary of the key factors affecting change are listed in Table 4.
Table 4
Policy Changes
Two themes in national policy that are currently
influencing our healthcare environment are the drive for
greater health and social care integration and the desire to
shift care out of hospital settings, closer to home.
New models of commissioning focus on the patients’
journey through the healthcare system. Streamlining this
journey makes it easier for patients to follow and
encourage joint working relationships between providers.
The Five Year Forward View has clearly stated the
importance of supporting health prevention, promotion and
well-being in the populations. Two new service models will
make a difference to patients - the primary and acute care
system (PACS) model, and the multispecialty community
provider (MCP) model. The Trust will be working with
closely with commissioners and other healthcare
organisations to explore the potential impact these could
have on patient care and us as a standalone community
trust
Patient Choice and
Experience
Increasing patient expectations for choice and
personalised budgets. Patient choice is a particularly
important driver where there is competition between
providers.
Economic Pressures
All NHS services are under funding pressure, driving a
26
need for greater efficiency whilst maintaining or improving
quality of services.
Technology
A Culture of Harm Free
Care
Commissioning
Intentions
System Changes
Diagnostic equipment is reducing in size and cost
enabling many diagnostic procedures to be undertaken in
a community setting, providing opportunities to improve
quality and experience whilst making efficiencies for
providers and reducing costs.
The Francis report, (February 2013), The Berwick report,
(August 2013) and Keogh report, (July 2013) restate the
duty of healthcare providers to make paramount the
quality of patient care, especially patient safety.
The most important of these, reflected both in national and
local intentions, are co-ordination of care in managing
conditions out of acute hospitals to reduce unnecessary
attendances. Secondly, to enhance preventative
measures in children and adults to reduce the prevalence
and impact of disease and its consequent costs for
society.
In October 2013 the Secretary of State accepted the
proposed changes to NHS services in North West London
which will reduce the current hospital provision to five
major acute hospitals as the implementation of the
strategy named ‘Shaping a healthier future’ begins. This
requires enhancing primary and community healthcare to
achieve more care in and closer to home.
Co-commissioning by Barnet CCG and London Borough
of Barnet is leading to integrated locality based teams.
Workforce
New challenges are introduced through delivering the
clinical and organisational priorities of high quality safe
care, which is clinically led. The following principles
establish a cultural framework:






The QIPP Challenge
Clinical leadership capacity
Professional development and partnership
opportunities
Competent and empowered workforce
Clinical engagement with the commissioning process
Clinical service redesign ensuring that care pathways
reflect the service user needs at the centre
A well- motivated, cared for workforce to deliver
exceptional services
The QIPP challenging, focusing on delivering better
quality care using innovation at the same time as driving
up performance and preventative measures, is a feature
of the longer term strategy.
27
10. Clinical Commissioner Changes and Plans
Analysis of current commissioner priorities highlights the continued focus on relocating
care from acute to community settings, and the integration of care around patient
needs.
10.1
Public health commissioning priorities include health promotion and prevention. We are
working in partnership with a number of Boroughs to prioritise health promotion and
prevention strategies that focus on obesity, oral health, sexual health and healthy
lifestyle choices for families
We have jointly appointed an integrated partnership project lead with the three inner
London boroughs. The project will design and implement integrated pathways between
health and social care providers making it easier for families to support their children to
have the 'best start in life'
10.2
Local Clinical Commissioning Groups
CLCH is increasing its focus on strengthening relationships with all our commissioners
as we believe strong relationships enable effective strategic and operational care. The
CCGs provide 68% of CLCH’s income
P
10.3
Commissioner Intention themes
In order to succeed in the market, providers need to respond to commissioner
priorities. Table 5 summarises the CLCH view of CCG strategic priorities, their relative
importance, and which market segments will be impacted.
The most important of these, reflected both in national and local intentions, are co–
ordination of care and managing conditions out of acute setting to reduce unnecessary
attendances, admissions and re-admissions
Table 5 – CCG commissioning intentions
Commissioner
intentions –
priorities
Encourage first
point of contact
outside the acute
to reduce
unnecessary
attendance and
admission
Implications for providers
Key segments
impacted
Need network of access points that reach different
patients in the community, e.g. schools, social clubs,
care homes, etc. Ensure that locations are
convenient.
Patients and carers need to be educated about their
care options and appropriate access points, as do
those who patients and their carers rely on, e.g. GPs,
Ambulance Service, 111.
Urgent care,
LTC, end of life
Introduce care pathways that prescribe / encourage
appropriate care outside the hospital.
28
Coordinate care
to strengthen
patient handling
and quality of
care
Integrate health
and social care to
prioritise
prevention and
reduce
duplication
Introduce case management and care coordinators,
supported by cross–organisation/agency multi–
disciplinary teams.
Requires significantly increased trust between
organisations to enable more joint / joined-up
working.
Requires clear roles and responsibilities, and agreed
escalation protocols.
Requires increased data, data quality, access and
sharing, and a single view of the patient.
Requires 24/7 ‘live’ coverage.
Requires improved coordination of care to ensure
planned hand-overs are smooth. Includes need to
align on prevention, education and treatment.
Much closer working with social care required at a
minimum to achieve better outcomes.
LTC, end of life,
disabilities, early
discharge and
transition
LTC, end of life,
disabilities, early
discharge and
transition
Potential organisational and budgetary mergers
required to make this integration real.
Requires agreed set of outcome metrics, allowing
comparability. An opportunity to self-define outcome
measures and promote performance.
Development of new contractual frameworks – e.g.
lead provider.
Put greater focus
on outcomes to
consistently drive
up quality of care
Anticipate growing demand for performance
transparency – from commissioners, from patients
directly. Anticipate in time greater use of PbR and on
a compulsory basis.
All segments
Requires better systems and data to track and report
performance; stronger service line performance
management.
An increased focus on harm-free care after the Mid
Staffordshire report will require both rigorous
monitoring and reporting of safety.
29
Expect increase of personal health budgets from
current pilots and integration of health and social
care budgets.
Opportunity to more fully leverage technology –
mobile health, telehealth and advances in med–tech
devices enabling increased care at home.
Requires more coordination with primary care and
social care to link education and prevention with
treatment.
Innovate and
tailor packages of
care around
patient needs to
empower the
patient and
ensure patient
centricity
Will drive demand for easily accessible, timely and
transparent performance quality
Greater choice for individual patients as to where and
how they are treated.
LTC, universal
children,
disabilities
Healthcare providers will need to appeal directly to
the patient and better understand their individual
needs. Branding and marketing will become
necessary organisational competencies.
‘Back–office’ systems and processes will need to be
streamlined to support value for money delivery of
bespoke packages of care.
Requires staff that truly prioritise the patient – values
and behaviours must be aligned.
Provide 24/7
patient access to
reduce overall
cost of the
system and
improve patient
experience
Requires material changes to current operating
models, with
(i)
(ii)
(iii)
(iv)
10.4
LTC, end of life
CLCH will respond to these intentions and work with commissioners to ensure the
success of their strategies through ensuring our strategy is aligned with theirs. By way
of example, Hammersmith & Fulham’s Strategic plan 2012-2017 states its strategic
aims as to increase the role of the patient, improve integration, improve governance,
reduce unscheduled care and the building of empowered teams with the right
intelligence 3 . CLCH has heard this intention and responded through, for example, its
focus on quality, its approach to adaptive governance that will always ensure we use
the best model possible for each situation, and our roll-out of QlikView, which gives
P18F
3
structured demand/capacity planning beyond
current norms
reliable support systems such as 111 with
compliance to prescribed sign-posting,
much more coordination across organisations
changes to job descriptions and flexible
working arrangements (v) increased capacity.
P
Hammersmith & Fulham CCG: Strategic Plan 2012 – 2017
30
teams at the front line the data they require to run their business units supporting work
in integrated shared records.
10.5
Other changes to the commissioning landscape
With a significant shift in the Trust’s income from NHS England to local authorities,
CLCH faces a major change in its commissioning landscape over the coming years.
The intentions of CLCH’s non–CCG commissioners are shown in Table 6.
Table 6 – Non–CCG commissioning intentions
Commissioner
Services
affected
Commissioning arrangements/intentions

Older people
services and
social care
Local
Authorities
Children’s
public health
(5–19) (e.g.
school
nursing)
Public health







Offender
health

NHS England
Children’s
public health
(0–5) (to
transfer to LA
by October
2015)




Through the introduction of Health and Wellbeing Boards,
councils have a greater role in joining up services for older
people across housing, health and social care
Councils are increasingly coming together to commission
services in partnership with healthcare e.g. West London
Alliance, Tri- borough arrangements and the Better Care Fund
Local authorities receiving ring-fenced public health grant to
deliver against Public Health Outcomes Framework
On–going work to disaggregate public health budgets and
contracts
Contract efficiencies being sought (e.g. Barnet – 5% savings in
drug and alcohol services; increased productivity in school
nursing)
Some investment in new services (e.g. Barnet – weight
management, childhood obesity)
National team sets budgets; services commissioned by 10
regional area teams
Single national service specification under development, aiming
to reduce inequalities of access. This will make it harder for
providers to differentiate their service provision in tender
responses
Key commissioning principle is to ensure the same standard
and quality of care is provided in prisons as can be expected in
the community
Commitment made to increase the number of health visitors by
4,200 against May 2010 baseline of 8,092 and to transform
health visiting services by April 2015 (1,151 to 1,842 in London)
April 2013 – New service specification for children's public
health services (0–5) issued
Single child health record
Immunisation programme development opportunities
31

GPs
Dental care
10.6



More consistent approach to improve standards of primary care
and tackle unwarranted variations
Ensuring common, core offer for patients
Payment for quality through QOF
Co-commissioning of primary care


Addressing longstanding access problems
Drive for quality and consistency
Whole Systems Integrated Care (WSIC)
Whole Systems Integrated Care is a pan-system approach that aims to integrate the
various agencies from differing sector backgrounds into a stronger and more
streamlined multi-disciplinary team (MDT) driven care delivery model, centred on
primary care registered populations. WSIC will challenge and inform developments in
the predictive management of high-risk patients focused on care co-ordination, case
management and early intervention. It will also reduce the pressure from unplanned
episodes on acute providers whilst increasing the acuity and complexity of care
delivered within the home.
The WSIC services are available described separately for each location in the IBP.
10.7
Case Manager
The new Case Manager (CM) and Health and Social Care Assistant (HSCA) roles will
provide a single point of contact for patients and their carers to deal with both health
and social care aspects of their lives. These roles will work to coordinate care across
health, social care, and the voluntary sector to make it simpler for patients and their
carers to access information and understand the various services involved in care of
the individual.
10.8
Community nursing Tri Borough Transformation programme
Community nursing is a core service for CLCH and a key element of all community
care for patients in the Tri Borough. Over the last few years, a number of challenges
have arisen for the service, including the impact of QIPP programmes, unreliable data
collection and performance information, changes in systems and technology, the
advent of the WS programmes within the three CCGs, recruitment and workforce
challenges and an increasing focus on community nursing by commissioners.
In response to these challenges, improvements have been put in place within the
service, including implementing system 1, developing new case manager roles,
reconfiguring services around CCG and GP structures, and a divisional workforce plan
alongside the CLCH Achieving Excellence Together programme for community
nursing.
The nursing transformation programme is described further in section 12.
32
11.
CLCH New Model of Care
Consideration of the Case for Transformation (external and internal) in section 9, along
with the Clinical Commissioner Plans in section 10, have influenced the way CLCH has
developed its new Model of Care, a key feature of this strategy.
11.1
The care provided by CLCH has focussed on the delivery of quality care for patients
receiving core services. This was supported by the CQC in awarding the Trust the
status of “Good” following its visit in April 2015. The focus of this is to help to transform
services to meet national and local priorities in a patient focussed and effective way.
Provision and delivery of the enablers required to implement the clinical priorities
through the new model of care are essential.
11.2
CLCH, like all national healthcare organisations, is facing the combined challenges of
increasing demand for healthcare service during a time of funding constraints.
This theme is a golden thread within national guidance, commissioning intentions and
our organisational plans.
11.3
The core activities, described in the current model remain constant, and these are the
provision of care to adults and children in the following domains:







Primary prevention
Secondary prevention
End of life care
Medicines optimisation
Management of ambulatory conditions
Care coordination
Supporting self-management
11.4
However the drivers described above have led CLCH to increase our focus on
maximising value for our patients and clients that is achieving the best outcomes at the
lowest cost, (Porter, Lee, 2013) as the pattern of care delivery changes. CLCH is
committed to improving quality and improving efficiency across our organisational
teams and within the local health system. Some of these efficiencies will be delivered
by improved managerial activity such as smarter procurement and the control of the
cost of agency staff. CLCH is building on the work of the Carter review (June 2015), to
identify these efficiencies.
11.5
The new model will have the following characteristics:

Multidisciplinary team working

New kind of Partnership working

Supports new specialist/generalist relationships

A holistic lens and proactively enabling patient engagement
Figure 8 depicts this new model of care.
33
Figure 8 – New model of care
11.6
This model has a number of enablers which include:
1.
2.
3.
4.
5.
6.
Engagement with Patients
The adoption of enabling IT
Establishment of CBUs
Leadership and Engagement
Skills Behaviours and Training
Quality Improvement Methodology
11.6.1 Engagement with patients
Activities taking place with the formal engagement of patients is well documented in
Section 8 and Appendix 1. We will endeavour to develop more actives over the next 3
years throughout the patients’ care delivery process, putting them at the centre of the
pathway.
34
11.6.2 Enabling IT
There are a number of IM&T enablers that will support delivery of the clinical strategy,
these include:







The development of a clinical system as the core patient record ensuring the
clinical picture is available in electronic form
Interoperability to allow the seamless sharing of information between Trust and
partner systems in the delivery of integrated care
Mobile working using a Virtual Desktop Infrastructure that is device and operating
system agnostic meaning that all clinical and corporate applications can be
accessed and recorded in the community supporting a timely electronic patient
record, working with partners and maximizing the time spent delivering care to
patients
Assistive technologies to empower patients to take greater control of their care,
increase access and to deliver this in the most effective manner
Business Intelligence available to operational staff to improve service delivery
Having IM&T as a service that allows it to be easily scaled in mobilizing new
services
In order to achieve data sharing across organisational boundaries CLCH has
procured and implemented TPP SystmOne to replace RiO as its core clinical
system. This change receives the support of the tri-borough commissioners and
enables GPs and community health practitioners to share patient records, giving
easy access to changes in medicines, test results and appointments. The next
step is to have a single patient record with direct access to clinical diagnostics.
11.6.3 Establishment of Clinical Business Units
CLCH has been preparing for these challenges, and one change which has already
taken place in the trust has been the introduction of the distributed leadership model.
This model allows for those with clinical as well as managerial experience to lead the
development of care from the patient-facing service level upwards.
In 2014/15 the Trust re-organised its frontline services into clinical business units
(CBUs.) The CBU structure encourages clinically-trained staff to take on managerial
responsibility and assume greater control and decision-making authority and clusters
together similar service lines. This structure also allows for the maximisation of the
experience effect and the development and rapid sharing of innovation across the
Trust. A key purpose of CBUs is to allow clinical leadership to flourish and develop, and
give room for ambitious and talented professionals to grow. Figure 9 below illustrates
the CBU structure.
35
Figure 9
The appointment of Assistant Directors of Quality (ADQs) to each of the four divisions
has supported the Trust, and in particular its staff, to embed quality of care into each of
the services throughout the divisions.
11.6.4 Leadership and Engagement
Three quarters of the 3000 staff employed by CLCH are clinical and they are often the
first point of contact for patients. Effective leadership for improvement requires
engaging clinicians to participate in change efforts and to build support for these
activities among their colleagues. Leadership development therefore needs to extend
“from the board to the ward”.
Working together, managers and clinicians jointly solve these problems and drive
improvement, culminating in better patient outcomes and experience.
CLCH is committed to the development of clinical leadership in three ways:
1. The development of a forum where organisational clinical leaders meet to review
strategic information and inform strategic decisions through a clinical leadership
group.
2. Enhanced medical/doctor leadership throughout the organisation through the
appointment of clinical directors.
3. Divisional level clinical leadership of our Clinical Business Units (CBUs).
A fuller description of the CBUs is held in the IBP.
11.6.5 Skills, behaviours and training
The education and development of CLCH staff, described in the education strategy, is
essential in ensuring that the workforce has the right skills, behaviours and training,
and that they are available in the right numbers to support excellent healthcare and
healthcare improvement. It is also essential that the clinical workforce meets their
statutory requirements for training and is responsive to the changing needs of our
services.
36
These enablers ensure the strategy links education to improvements in patient
outcomes through focusing on 5 domains of:
 Excellent education
 A competent and capable workforce,
 A flexible workforce that is receptive to research and innovation,
 Professional practice which is underpinned by our organisational values and
behaviours
 Enabling and supporting participation.
11.6.6 Quality Improvement methodology
Quality improvement methods are an essential enabler for any organisation looking to
increase the value of service delivery. Improvement methods such as Lean and Six
Sigma have been widely adopted by high performing organisations in the engineering
and manufacturing industries as a way of increasing quality whilst simultaneously
reducing costs. The NHS has been slower to embrace the quality improvement
movement due to the challenge of translating these established approaches within a
more complex, service based environment. As a result, there is a degree of uncertainty
about which approach is best for NHS organisations to adopt. Over the past 15 years,
research into the development and application of improvement methods in healthcare
organisations has concluded that there is no single ‘best’ approach. Researchers have
concluded that, in healthcare, it is less important to focus on methodology than on how
this is implemented.
CLCH has therefore adopted a flexible improvement methodology which contains the
core elements of the traditional improvement approaches, but which is best aligned to
existing models and language. The approach to implementing this method will be
detailed within the CLCH Continuous Improvement and Innovation strategy.
The methodology itself covers the four basic elements which should be considered
when attempting to make improvements:
1.
Involve the right people
Curiosity is the precursor to improvement. Unless we think there is a better way of
doing things, we won’t try to improve. Diverse perspectives inspire curiosity. The
involvement of patients, carers, staff, public and partners enables us to identify:




What is important/what matters
How it feels now
What changes could make things better
Whether anything improved after we make changes
37
2.
Take a systems/process perspective
The NHS is one of the most complex systems in the world. An appreciation of how
complex systems work and how care processes operate within complex systems is
fundamental to identifying effective ways to make efficient, sustainable
improvements.
3.
Plan for the human impact of change
Most change efforts fail to achieve their intended aims. Typically this is due to a
failure to appreciate and plan for the impact of change on the people involved.
Understanding and anticipating people’s needs when implementing change, can
avoid generating unnecessary anxiety, frustration and resistance.
4.
Use a robust implementation model
All improvement requires change, but not all change leads to improvement. A
robust method for testing and evidencing the effectiveness of ideas before
implementation ensures a safe, efficient and effective approach to introducing
changes.
11.6.7
Measurement of outcomes
The act of systematically measuring outcomes aligned with costs invariably leads
to improvements in patient outcomes and value for money However, in previous
years, significant effort has been applied to measuring processes and process
outputs that capture compliance with contractual requirements. This is focusing on
what we do, rather than the impact that it makes on our patient population.
Donabedian suggests that to ensure high quality service delivery, we must monitor
all aspects of the care process.
38
Donabedian model for quality of care
The current challenge therefore, is to define outcomes that matter to the patients they
apply to and that cover the full cycle of care for a condition or an episode.
Significant work has been done in 14/15 to begin defining and measuring outcomes
that matter in services across CLCH. Further work is required to engage with our
patients to ensure they are meaningful to them and to develop a reliable IT platform
that clinicians can use in their day to day practice that matter to services across CLCH.
This work is beginning to highlight areas of variation in care that will drive the Trust’s
improvement activities.
Analytical skills’ training is also required so that appropriate interpretation of this data
occurs driving the identification of opportunities for improvement.
CLCH continues to explore opportunities to work with other system stakeholders and
their commissioners to develop a wider framework of outcomes across the
organisation’s care pathways.
11.6.8 Measurement of cost
Traditionally community trusts have been paid using a block contract mechanism that
does not account for increases in demand or suitably align payment to either clinical
outcomes or clinical delivery. This means that there is very little scrutiny of the cost of
care to an individual.
The development of a Business Intelligence (BI) team is allowing data presentation to
operational staff which includes both cost and outcome, so that that action can be
taken to identify and deliver service improvements and improve those clinical
outcomes. {Very recently national bodies have launched a two year programme to
develop “currencies” capturing relevant outcome and costing measures for community
healthcare services equivalent to those developed for mental health care services.}
39
11.7 The New Clinical Model in the Strategic Context
The new model of care has been designed to create the conditions for CLCH to
engage successfully with transformational change. The change required will of course
be diverse and emergent but will be underpinned by the clinical principles described
earlier.
The new Clinical Model is illustrated in Figure 10 below. This model, is building on the
current clinical model and it links to the Trusts Clinical principles, demonstrating that
the Trust is adhering to the Clinical Principles, described in Table 1 on page 5 of this
document.
Figure 10
11.8
Improving quality and efficiency in the longer term
11.8.1 The focus for improving quality and efficiency will alter over time. Recent thinking from
the Health Foundation (2015), describes this shift in Figure 11 as follows:
40
Figure 11
This model has 5 key themes which are:





Scientific discovery, technology and skills
Focus on population health
New ways of delivering care
Process improvement for quality and productivity
Active cost management
11.8.2 The model shows how the current focus is to drive efficiency using actual cost
management. There is no doubt that this focus will continue but needs to be
augmented with an increase focus on clinical redesign that delivers improved
quality and efficiency. The plan to achieve this will be set out in CLCH’s quality
improvement strategy.
11.8.3 The Forward view and our commissioner’s intentions clearly set out a requirement to
deliver increased caseload within primary and community care settings. Currently
CLCH is involved in the development of localised changes, such as the
implementation of care navigators and the PACE scheme, but will strengthen its
involvement in wider integration initiatives as wider networks and collaboratives
develop, fulfilling its role as a key stakeholder within the wider system.
11.8.4 As a key service provider within this emerging health system CLCH is required to
strengthen its focus on transforming population health so that the people we deliver
care to can be supported to live longer healthier lives. The development of a prevention
strategy will set out how the Trust will respond localised public health data, will
41
contribute to the wider prevention agenda and align service capacity to demographic
need.
11.8.5 Finally the Trust will continue to encourage and support the use of innovation and
technology in the delivery of safe and effective services including supporting research
and experimenting with innovative care technology
11.8.6 The five themes, set out above, have been used to develop a matrix that sets out how
CLCH will respond these components across the 3 years’ time span of this strategy.
Component
Part
Active cost
management
Year 1



Process
Improvement


New ways to
deliver care
Focus on
population
health
 Produce a CLCH
prevention
charter

Innovation
QIPP
Non-clinical
support service
transformation
Development of
desktop clinical
outcomes
dashboard
Training in
management of
variation
Work with
stakeholders on
experiments in
integration
Produce
Innovation
strategy
Year 2



Ongoing
System wide training
in quality
improvement
methodology
Data driven
improvement
Year 3

Ongoing

QI is Business
as usual

Established
new models of
care

Participate in
collaborative system
redesign

Systematically
analyse need to align
with outcomes
 Deliver flexible
outcome
focused health
system

Embed processes to
identify and
experiment with
innovation
 Track record
of innovation
11.8.7 Beneath this overarching strategy the annual business planning process will capture
the strategic plans of the divisions within CLCH, for the next 5 years and will
demonstrate alignment with the clinical principles. This will create a layered strategy
with a series of interlinked plans that reflect the clinical specialty of the division and
their direct influencing factors.
42
12.
Developments in Clinical Nursing
A Community nursing Tri Borough – Transformation programme is underway to
address challenges that have arisen for the service.
Community nursing is a core service for CLCH and a key element of all community
care for patients in the Tri Borough. Challenges and concerns have identified the need
to:



address concerns relating to the need for further enhancement of the service, in
particular to ensure the highest standards of clinical and operational performance
(and its measurement and visibility),
explore new models of care and collaborations, and
to build strong relationships between the service and clinical commissioners,
demonstrating its crucial role in future community care delivery
There may be an opportunity to build on the work started by the Whole Systems
programmes of the three inner London CCGs.
Aims of the transformation programme
The programme proposes to:


bring together a number of existing initiatives within the service to provide structure,
support and sustainability to these as a more coordinated programme of
improvement (Year 1)
build on this foundation a transformational new service model, benchmarked to the
highest standards, delivering true whole systems care (design Year 1, implement
Year 2)
43
13. Clinical Service Planning
In terms of taking the strategy forward, a number of service developments have been
initiated by Clinical Divisions, they are:




Managing long-term conditions in the community
Early discharge and transition services
Integrated children’s care
Delivering improved care through technology
These service developments are illustrated in Figure 12 below. The service
developments are described more fully below and in the IBP.
Figure 12 - CLCH Service Developments
44
13.1
Service Development Plan 1 – The management of defined long-term conditions
in the community
Overview
CLCH has, and will continue to, reconfigure models of care to improve patient
pathways and management of LTCs, developing clinical models in collaboration with
patients and service users, capitalising on community care expertise to promote selfmanagement of LTCs
The Trust will increase the skills of its staff to be able to manage the more complex
long term conditions (diabetes, chronic obstructive airways disease, heart failure,
epilepsy etc) and develop joint expertise with colleagues in the care of long term
conditions (including GPs, care home staff and carers). We will actively work with
primary care to develop long-term skills in the community to support GPs to manage
long-term conditions and maintain well-being and health for patients.
CLCH will actively review and explore with our patients and partners the education
packages we provide, ensuring that they meet the needs of an empowered and
educated patient population.
The Trust believes it can manage an increase in the complexity of the community
patients, which previously would have required a hospital admission, and which will
require the support of highly skilled specialists, ‘real time’ patient records across
community, primary and acute providers and using technology alongside a case
management approach to achieve this ‘shift’ of care into the community.
Through active participation in whole systems work we will continue to support the
MDT model of identifying patients with one or more long term condition and
supporting them with integrated community and primary care services.
Current situation
Some existing core services, such as district nursing, already have a significant focus
on the management of LTCs. However, to support the step change and to secure
further business growth we are developing new, innovative and evidence-based clinical
delivery models for the treatment and management of LTCs. Respiratory-related
illnesses and diabetes are the two main ones that CLCH will seek to treat in the
community.
Responding to these changes CLCH plans to:




grow CLCH’s specialist community skills and become a clinical leader in the LTC
field
develop robust core generic skills so that patients receive holistic care
risk stratify patients, based on the complexity of their long term condition, into one
of four tiers
include end-of-life care as an important aspect of the full service offering
45
Activity description
COPD/Respiratory
The initial focus will be on growing and developing the already successful COPD
service model, then to use it as the blueprint for developing clinical service models and
pathways for other respiratory related conditions, for example asthma and
bronchiectasis.
Diabetes
Where there has been a historic focus on community MDTs, development will focus on
supporting primary care to deliver long-term diabetes management with the support of
specialist services.
Working for Barnet
In Barnet CLCH will deliver integrated LTC pathways with the Royal Free in London
and the emerging GP networks.
Working with the CCG pathways for diabetes, CLCH envisages a co-designed work
programme over 3 years that focuses on increasing community support and education.
The CCG plans to decrease out-patient activity by 50%, and as such it is expected that
community diabetes service are planned to expand by £300k annually.
Capacity implications
There are a number of implications for delivering the forecast increase in business in
this plan whilst ensuring the continuity of high quality care:

There will need to be a single patient record with direct access to clinical
diagnostics. This work is underway through the implementation of SystmOne 4
Mobile working devices are required (IM&T strategy). These will maximise direct
face to face time with patients by improving productivity and reducing travel time
Work will be undertaken with developers to innovate cutting edge health
technologies that can improve quality of life and/or productivity
P86F


4F4P
Workforce implications
CLCH’s CBU structure encourages “clinician managers” to lead services. This will be
supported by capability-based development and support to key managers . CLCH has
plans to appoint an end-of-life care research lead, and will pursue research grant
opportunities with which to fund this. There will also be a development programme
implemented for staff to ensure a high level of competency of care for priority LTCs.
P
In developing a workforce CLCH will focus on education and training of the following
4
IBP Chapter 5, Service Developments: 5.3 Service Development Plan 5, Delivering improved care through
technology
46
staff groups:
 Medical Staff
 Specialist Community Nurses
 Community (District nurses)
 Allied Health Professionals (especially pharmacists, podiatrists, dieticians and
physiotherapists)
 Support Staff (Social care and health care assistants)
With respect to resourcing, CLCH has plans to reduce vacancies through international
recruitment, developing and retaining staff and creating organisational structures that
develops both the skilled and generic workforce.
Outline development timeline
Table 7: Outline LTC service development timetable, 2014-2020
Board Level Lead: Deputy Chief Executive
Year
Actions and Milestones
Review and refine current COPD and develop new LTC models
Develop evidence base to demonstrate benefits in clinical
effectiveness and patient experience
Model detailed workforce and capital requirements for expansion
2014/15
(Completed)
Model IM&T requirements including care technology investment
Expansion of services to existing commissioner (West Herts)
Detailed market analysis to identify and target further CCGs that
would benefit from the services
Commencement of Hounslow Diabetes Service by CLCH
Integrated LTC community services hub opens to co-located LTC
services in Barnet
2015/16
Detailed workforce analysis of educational and staffing needs
Service reviews completed in line with CCG pathway redesign to
shape OOH pathways for respiratory, diabetes and heart failure
Improvement in productivity driven by the introduction of innovation
in mobile working and skill mix balancing
47
Commencement of new Respiratory and Heart Failure pathways in
Barnet
Competency review of staff in management of LTC following delivery
of education packages
2016/17
Peer education and support delivered as part of all LTC service lines;
with patients part of service evaluation and design
Primary care engaged within all LTC service lines; with analysis of
primary care risk stratification, public health and admission data to
inform service development and performance
Completed review of service offerings for LTC in neurological LTCs
2018-2020
Further expansion within the M25 and its closest environs beyond
current boundaries (aligned with wider growth goals)
New pathways delivered with the focus on neurological LTC
Risks and mitigations
Table 8: Risk and mitigations for management of LTC service development
Risks
Difficulty in recruiting and
training suitable staff
Mitigations



Difficulty in retaining our
specialist clinical staff



Commissioner funding
pressure restricts new
investment


Carefully manage expansion plans to allow time
to recruit and train
Grow your own
Provide a centre of excellence ( Education and
Research)
Alignment with universities
Develop a clear clinical model
Engagement with commissioners, involvement in
developing robust business cases
Technology
Development of clinical services models for other
LTCs
Commissioner intentions
This service development responds to the following commissioner intentions:
 Encourage first point of contact outside the acute to reduce unnecessary attendance
and admission
 Coordinate care to strengthen patient handling and quality of care
 Integrate health and social care
 Provide 24/7 patient access to reduce overall cost of the system and improve patient
experience
 Innovate and tailor packages of care around patient needs to empower the patient
48
13.2 Service Development Plan 2 – Promoting early discharge and encouraging
hospital avoidance
Overview
This service development identifies patients in acute hospitals who are suitable for
early discharge and care support provided by specialist nursing, district nursing and
other care providers such as social care. The purpose is to reduce the length of stay
in hospital and to provide the care that the patient needs in the community setting,
either at home or in local clinics, thus creating a seamless care pathway.
It builds upon the success of our Post-Acute Enablement (PACE) service in
partnership with Royal Free London NHS FT (RFL), which CLCH started at the
Royal Free (Hampstead) and has now expanded to Barnet and Chase Farm
Hospitals Trust. The intention is for CLCH to market it to other acute providers and
commissioners beyond its core areas, and offer a responsive solution that follows
patients wherever they live, across multiple geographies and partner providers. The
current PACE model will also be expanded to include children, and will cover
ambulatory care as well as supported discharge.
Activity description
PACE reduces the length of stay in hospital by proactively identifying patients in acute
hospitals who are well enough to be discharged, so that the last three to five days of
their acute care can be completed at home, where they will remain under the clinical
care of their hospital consultant. The service has a team in place that assesses
patients who, if suitable for discharge and if agreed by their consultant, will receive the
necessary support to return home and be given the care they need as part of their
recovery. This includes intravenous device management, taking bloods and complex
dressing changes. CLCH is working with its acute partner to review other clinical
offerings that could be offered to increase the flexibility of the packages and, as a
consequence, increase bed availability.
In 2013/14 alone PACE successfully discharged 3,200 patients, a saving of more than
6,000 bed days. In 2014, another acute hospital with which we have long-standing links
was identified to expand this service further.
As part of expanding PACE, involvement with the patient needs to start at an earlier
stage in their acute admission. Identifying patients in A&E or a Medical Assessment
Unit (MAU) proactively would feed more referrals into the service.
Through PACE, there are three principal areas to which value can be added:

Discharge management:
By discharging patients who need onward support post-hospital and coordinating
their care across the locality and different services

In-patient re-ablement:
49
By maximising rehabilitation and re-ablement potential the risk of re-admission can
be minimised, and social and clinical care requirements can be reduced

Post-discharge care:
The specialist care required for early discharge after a stay in an acute hospital is
co-ordinated, with a seamless pathway and an improved experience for the patient.
The patient can be linked to any on-going community care that may be required to
prevent re-admission for similar or new conditions.
Workforce implications
To deliver this service development the existing PACE model will be refined to
ensure that it is fully transferable across geographies, including understanding
workforce implications. Additional well-trained staff will be required. As well as a
core complement of substantive staff, a flexible bank of additional staff will be
required to meet the daily peaks and troughs in activity.
Other implications
We will ensure that the IM&T platforms and data sharing arrangements are in place
to allow us to share clinical records across our acute trust partners and also with
primary care.
Outline development timeline
Table 9: Outline timeline for PACE service development
Board Level Lead: Deputy Chief Executive
Year
2015/16 onwards
Actions and Milestones
By When
Develop the clinical model to extend to children as
well as adults, given changes to children’s pathways
15/16
Expand the services to two new acute trusts within the
current boroughs
15/16
Gradual expansion from 2016 to other customers in
NCL and then across London
16/17
Further expansion beyond current boundaries, aligned
with wider growth goals
17/18
50
Risks and mitigations
Table 10: Risks and mitigations
Risks
Mitigations

Potential difficulties of working at remote
locations, e.g. ensuring appropriate handover to
local and primary care providers

Developing detailed partnership and
governance requirements with each
new provider

Not able to access and share clinical data, i.e.
different providers’ IT systems

Clear contractual arrangements

Expanding into CCGs where we have no
presence

Investment in IM&T, including the
move to SystmOne
Commissioner intentions
This service development responds to the following commissioner intentions:




Localising routine medical services for better access closer to home
Changing service delivery in acute hospitals
Initiatives to avoid or reduce the need for emergency and hospital-based care
Improving the quality and expertise of community care
51
13.3
Service Development Plan 3 – A new model of care for children
Overview
The number of children under nineteen years is rising across London, with the main
growth in the over fives. To help CLCH achieve its mission of “Working together to
give children a better start”, we have developed a model of care for children from
birth to aged nineteen years that will help improve their health and life chances.
The Children’s Health and Development Services division has been involved in
significant transformation to improve the care of every child in our care. This
included the management of referrals, children’s records, looking at the pathways of
care, assessing needs and risks, identifying where the children who are referred to
our services live and how we can work towards a single children’s health record.
A number of recommendations came out of this work, including:





where CLCH teams should be located
the boundaries of their work (i.e. zoning)
how care can be improved through better management of travel time and the
use of mobile and web based technology
what we do for children in terms of our pathways and care bundles
the skills mix of teams
Through a single point of access, the children’s model of care aims to create multidisciplinary teams designed to deliver services via defined care pathways to children
and young people based on their level of need. Clinically-led teams will be designed
around patient pathways to meet the needs of the patient.
Activity description
Through a single point of access, the children’s model of care creates multi-disciplinary
teams designed to deliver services through defined care pathways to children and
young people based on their level of need. Clinically-led teams are designed around
patient pathways to meet the needs of the patient. The children’s transformation
programme has a series of projects which support this, 5 of which are described below:
1)
Integration of children’s complex care
CLCH has started to design and implement an integrated service delivery for children
with complex needs across our four main commissioners’ children’s nursing and
therapy services. It is aligned with the CLCH 0-19 services model of care and child
development centre provision, and NICE guidance and with connecting care for
children.
The single point of access for children with complex care creates one referral pathway
for dietetics, children and young people’s occupational therapy, speech and language
52
and children’s community nursing services, therefore ensuring the provision of
coordinated delivery. The service also improves information sharing between CLCH
and stakeholders and also internally within CLCH services.
2)
Children’s health information hub interoperability
The Trust is developing interoperability of the children’s health information hub with
other health information systems, so that information can be shared within and across
organisational boundaries.
3)
Health matters
The Trust has developed Health Matters as an innovative approach to school nursing.
Health Matters is an interactive school website designed to promote and support young
people towards independent management of their own health care needs. It draws
from young people’s relationship with interactive media in their everyday lives.
One of the most challenging roles for the school nurse is supporting young people to
become independent managers of their own health care.
CLCH’s aim is for all school children to know where to find appropriate health
information, and when and how to access health care by the time they leave school.
The website is managed by the school nurse and is accessible by staff, pupils and their
families. There are film clips, links to specialist sites and a problem page for children to
leave their own anonymous messages. It raises the profile of the school nurse, gives
information about the school health service and re-enforces health messages that are
promoted each term on notice boards and screens around each school. Students and
their parents can send an appointment request direct to the school nurse via the
website, and school staff can send referrals.
4)
Best start in life - Integrated pathway for 0-2 year old services
A wide range of research shows that the early years, and particularly conception to age
2, is a crucial phase of human development and is the time when focused interventions
can give positive outcomes for individual children and their families. Therefore, CLCH
is developing a model which aims to bring together a universal, targeted and enhanced
service into a single pathway, with an emphasis on identifying need much earlier and
more systematically across all early years’ services. This will be done through three
main themes:
 More rigorous targeting of children and families with additional needs
 Achieving this through greater integration of our collective services across
healthcare agencies reducing duplication and inefficiencies
 Improved joint commissioning
5)
Allergy pathway
The allergy patient pathway is a good example of integration in action. Previously,
integration was lacking and, in some instances, there was not a full understanding from
53
those involved of the complex nature of allergies and their symptoms. As no specialist
clinics were in place, patients in the allergy pathway often found themselves being
referred to acute hospitals by GPs who were not trained in identifying allergies. This
resulted in patients not receiving the correct care, further impacting on their condition. It
also led to costly unplanned hospital admissions. In order to tackle this, we have set up
multidisciplinary workshops that offer introductory sessions followed by advanced,
condition-specific training sessions for those involved in the patient pathway.
This training promotes better management of allergic conditions through primary and
community health, whilst creating strong links to secondary care, supported by peers
and other professionals in the community. The pathway is supported by the creation of
specialist allergy clinics in the community where patients can be referred by their GP
when further investigation or advice is needed.
As well as assisting with diagnosis, these clinics act as an education centre for newlydiagnosed patients and their parents, whilst also being a one-stop shop for worried
parents of children with on-going conditions. Coordinated through these clinics, nurse
specialists can also visit children at school, further improving the patient journey and
reducing hospital admissions.
Workforce implications
The division has a management structure based on five clinical business units (CBU)
designed through service specialty and/or geographical location. The CBU structure
enables the development of further pathway working across teams. The management
of the division is supported by a divisional director of operations, a clinical lead, and an
assistant director of quality. It is anticipated that the service redesign will mean a
reduction of 18.08 WTE, and this reduction has been quality impact assessed as part
of the CIP process.
54
Outline service development timeline
Table 11: Outline service development timeline
Board Level Lead: Deputy Chief Executive
Year
Actions and Milestones
By When
Transforming children’s care programme, which supports Model of Care delivery



2015/16







2016-20







Development of a single health record and automation of several data
notifications for children through the interoperability project
Achievement of integration with social care teams across all four
boroughs, including 2 year check for children
Implementation of Children and Family Bill, resulting in care
packages for children and new income opportunities
Further development of web-based technology to improve access for
patients and children
Health matters to be developed for antenatal and pre-school
Integration of care services for children with complex needs to enable
a single point of access for children and families
Development of immunisation business in line with new programmes
for children
Implement mobile solutions to achieve improved patient experience
and staff engagement
Development of ambulatory care pathways with acute providers to
reduce A&E usage and outpatient referrals linked to Connected Care
for Children
Redesign of children’s community nursing and speech and language
therapy workforce to improve delivery of new income work streams
Further development of immunisation business in line with new
programmes for children
Develop marketing plan to access to £371m children’s service
market in London and M25
As services transfer to local authorities, develop an action plan to
seek out and monitor opportunities with the commercial team
Integration of care services for children with complex needs to enable
a single point of access for children and families – link with education
boards and local authorities to enable whole systems integrated
approach
Support in Child Health Information Systems beyond the 4 boroughs
Further develop mobile solutions to achieve improved patient
experience and staff engagement
Widen scope of web-based care to preschool and anti-natal children
with complex needs
March
2016
March
2016
March
2019
55
Risks and mitigations
Table 12: Risks and mitigations
Risks



Lack of staff engagement in the
delivery of the required changes
jeopardises the success of the new
model
Reduced commissioner funding for
existing services puts QIPPs to be
generated by the model at risk
Failure to deliver the necessary
supporting IT and estate infrastructure
Mitigations
 Ensure clear dialogue with staff
throughout the process and embed
communication and engagement within
CBU and team structures in the division
 Continue close working with
commissioners; develop contingency
QIPP plans for the lesser ‘at risk’
services
 Work with IM&T to ensure plans are
aligned and include clinical input to
ensure they meet service needs
This service development responds to the following commissioner intentions:










Safe, effective clinical practice
Value for money with reduced overheads
Responsive services that listen to patients, children and families
Updated service specifications with a focus on outcomes
Safe transfer of services into new commissioning arrangements
Services working in partnership along pathways
Evidence of patient involvement with service redesign
Greater assurance of service delivery, more than just metrics
More innovations to support these requirements
Safeguarding practice at exemplar level
56
13.4
Service Development Plan 4 – Delivering improved care through technology
In today’s health economy, it is essential that data can be shared across organisational
barriers.
Overview

Information sharing - CLCH has procured TPP SystmOne to replace RiO as its
core clinical system. SystmOne will enable GPs and community health
practitioners to share patient records, giving easy access to changes in
medicines, test results, etc.
Recognising that we provide services in partnership with GPs who do not use
SystmOne, the Trust will continue its development of Interoperability to enable
sharing capabilities between systems.

Mobile devices - Over the next two years, the Trust will focus on the
implementation of mobile working and deployment of mobile devices to
clinicians.

Business intelligence - More integrated data flows are required across HR,
Finance and SystmOne into the data warehouse.

Building infrastructure and resource capability - Improving IM&T
infrastructure is a priority, and an ambitious programme has been underway
since July 2014 to strengthen and improve the entire network.
Benefits
For the patient:
 Less time taken up with administrative tasks means more clinician contact time
 Convenience, easy access, no travel, e.g. telehealth and telecare
 Encourages independent living by allowing self-monitoring, self-management, and
self-care outside of a hospital
For commissioners:
 Enables more care to be provided out of hospital, which helps reduce costs
 Sharing information and patient records across systems and organisations leads to
greater integration of services
For CLCH:
 Providing a near real-time flow of information to clinical staff while they are working
in the community allows them to update clinical records in the patient’s home
 Innovation through technology can differentiate CLCH from its competitors
 Supporting CLCH’s growth agenda, e.g. taking on new staff and patient records
quickly as part of the merger/acquisition of another community trust
 Drawing insight from clinical activity and business data helps CLCH remain
competitive and demonstrates quality of service
57
Estate implications
Successful implementation of the IM& T strategy will facilitate a reduction in the estates
footprint and reduce the associated overhead. For example, mobile working and mobile
devices enable clinical staff to access records on the day’s caseload without going into
the office to pick up notes.
Virtual meeting rooms/video conferencing allow a handover between teams without
being physically present in the same location. If information is entered at the point of
care, there is no need for staff to return to base to update the clinical system.
Equipping staff with their own dockable mobile device means that they can touch base
at a local site without the need for a permanent desktop PC.
Workforce implications
The balance of skills within IM&T will move towards commercial and service
management, with fewer technical delivery skills required as the delivery model
changes towards the procurement of commodity technology ‘as a service’, rather than
in-house.
Outline service development plan
Table 13: Outline service development plan,
Board level lead: Director of Finance, Corporate Performance and Resources
Year
Actions and Milestones
2015/16 Implementation of replacement clinical system
Further implementation of mobile working
Information sharing with partners extended across GPs and key
stakeholders
Transition to strategic partner for delivery of IM &T services
Extension of Business Intelligence and implementation of self-service
reporting
Hardware refresh
2016/17 Utilisation of cloud delivery models for IT services
to
Digitisation of all service delivery
2019/20
Implementation of Voice over Internet Protocol telephony (VOIP)
Automation of manual processes and forms
58
13.
Risks
The environment in which CLCH operates is changing in all areas of the clinical
strategy efforts have been made to minimise and mitigate risks where possible.
Nine strategic risks have been identified and are currently monitored on the Board
Assurance Framework (BAF). These risks which affect the clinical strategy directly,
incorporating quality of care, are outlined below.
Clinical Risk
1
2
3
BAF Risk: Risk that implementation of the Performance Management
Framework is undermined by the following risks:

That the Trust new BI system (Qlikview) does not provide the
necessary reports and detail of information to allow clinicians and
managers to run their services and improve clinical quality.

Risk that the new Business Intelligence system (Qlikview) will not be
accurate due to poor quality operational data input and keeping
leading to clinicians and managers refusing to utilise the system to
manage services.

The risk that clinicians and managers at all levels do not embrace the
new business intelligence system (Qlikview) to improve the
management and decision making relating to clinical services.
BAF Risk: Risks to operational functions and quality related to
implementation of electronic health records.
BAF Risk: Failure to maintain, deliver and promote high quality services,
triggers breach of regulatory requirements and reduces quality of care
delivery and experience to patients and service users.
59
14.
Conclusion
The Clinical Strategy, 2015-2018, describes how CLCH intends to maximise the
value we offer to health service, building on our strengths of multidisciplinary working
within our commissioned communities of adults and children.
It acknowledges that change in disease profiles and economic restraint will drive
changes but sets out how positive experiences of care is maintained and how health
outcomes continue to be improved as CLCH works within and across our
commissioned health systems.
60
References
CLCH Integrated Business Plan, 2015
The Dalton Review: Examining new options and opportunities for providers of NHS
care, December 2014. [Online]. Available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/384126
/Dalton_Review.pdf (accessed 05 August 2015)
The Five year Forward View October 2014. [Online]. Available at:
https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (accessed 05
August 2015)
The Francis Report: Report of the Mid Staffordshire NHS Foundation Trust Public
Inquiry February 2013. [Online]. Available at:
http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspubli
cinquiry.com/report (accessed 05 August 2015)
The Keogh report, Review into the quality of care and treatment provided by 14
hospital trusts in England: overview report, July 2013. [Online]. Available at:
http://www.nhs.uk/nhsengland/bruce-keogh-review/documents/outcomes/keoghreview-final-report.pdf (accessed 05 August 2015)
The National End of Life Care Strategy (2008) [Online]. Available at:
https://www.gov.uk/government/publications/end-of-life-care-strategy-promoting-highquality-care-for-adults-at-the-end-of-their-life (accessed 05 August 2015)
The NHS Confederation (July 2015) The art of the possible: What role for community
health services in reshaping care? Discussion Paper
Porter and Lee (2013) The Strategy That Will Fix Health Care, Harvard Business
Review.
[Online]. Available at: https://hbr.org/2013/10/the-strategy-that-will-fix-health-care/
(accessed 05 August 2015)
The Kings Fund Transforming our health care system, (2013 – updated June 2015)
[Online] Available at: http://www.kingsfund.org.uk/publications/articles/transformingour-health-care-system-ten-priorities-commissioners (accessed 21 September 2015)
61
Appendix 1
Patient Engagement, examples of actions taken
Table 1: Example of changes made as a result of complaints
Specialism
What we did…
Phlebotomy
 An online booking system is going live
 An email booking system has been introduced
 More staff have been employed to manage the phone
service and reception
 Volunteers have been taken on to assist with
signposting patients
Continuing Care- Garside
 New mobile phones for the nurse in charge to carry
Nursing Home
have been introduced. Family members are given the
telephone numbers in case they are unable to contact
reception, particularly outside of normal service hours.
District Nursing Service The service is currently reviewing operating hours of
Hammersmith & Fulham
all community nursing services to ensure more
seamless cover.
 Further training in catheter care is underway for the
District Nursing Service.
GPs with Special Interests
 Service identified that there was a lack of disabled
Lilyville Surgery
access within this particular surgery therefore has
moved the service to a more accessible location.
Table 2: Example of changes made as a result of patient stories feedback
Team
You said
We did
Intermediate Care Team,
Kensington and Chelsea
“The amount of time I had
to wait between the initial
assessment and the
therapist’s assessment was
long and not clearly
communicated to me.”
Team Lead has worked to
create a standardised
timeframe for assessments and
follow up. This is now to be
communicated to the clients
through circulation of the
team’s operational procedure.
School Nursing Service
“I’m not sure how to access
the service or where to find
the nurses.”
Advertising campaign of school
nursing service planned to
include more school assembly
notices and a poster campaign.
Linked in with ‘Health Matters’
website.
Athlone House
Rehabilitation Unit
“Patients were feeling
unsure as to when their
therapy had been planned
New timetables initiated for
patients which include a floor
plan to indicate where sessions
62
Falls Services
in for and what their day
structure was to be.”
are being held and patient
centred goals
1) Patient stories
highlighted concerns with
the print quality of the Falls
home exercises leaflet specifically the images of
the exercises.
1) We now only print the
programme for home exercises
rather than photocopying the
document.
2) Concerns were raised by
clients who required
support to access the
transport vehicles for the
community strength and
balance group.
2) The Falls CLCH transport
contract was re-negotiated with
an alternative provider to
ensure there was sufficient
support to assists clients to get
on and off the transport vehicle
safely.
Jade Ward
"I don't have a toothbrush
or mouthwash with
me and there's nowhere to
buy these things from
here.”
Volunteer-led amenities trolley
for patients to buy essentials
trialled on Jade Ward. The
Volunteer Services Manager
has received funding to roll this
out fully.
Wheelchair Services
“I waited much too long to
get my wheelchair.”
Increased number of
Rehabilitation Assistants who
can prescribe basic
wheelchairs with guidance,
reducing wait times for service
users.
Podiatry
“You said you would like
more information about the
service before your first
appointments.”
We are reviewing a Podiatry
Pamphlet and have asked SPA
to add this to all new inner
borough Podiatry appointment
letters.
Neuro-Rehabilitation
Team
“My GP surgery is not
wheelchair accessible and I
have difficulty with
transport, particularly out of
borough.”
We contacted 10x GP
practices within the South
Westminster area and
identified that none of them
offer sufficient disabled access.
We contacted the PALS
service to request advice on
how to address this issue.
They recommended that we
pass on this information to
NHS England to be addressed.
NHS England is now involved
directly with the GP practices
63
to rectify the situation.
Neuro-Rehabilitation
Team
“It is difficult to understand
all the different professional
roles and the service
provider responsibilities.”
We created a Services
Navigation Chart to provide all
new MND patients, explaining
‘who does what’ with specific
contact numbers.
Neuro-Rehabilitation
Team
“The adaptations to my
bathroom were very slow
and we couldn’t find out
any information.”
We contacted Able -2 and they
have given us a named contact
in the home improvement
agency (Westminster Council)
who will chase urgent jobs.
Neuro-Rehabilitation
Team
‘The Neuro rehab team is
easy to contact and come
quickly when needed. Their
review timings have been
just right. There are people
in this service who really
care about their patients.’
We will provide in-service
training to the wider MDT
neuro team across CLCH to
discuss themes from our
patient stories and disseminate
best practice.
64
Appendix 3 – Key Performance Indicators - the 3 ‘Campaigns for Action’
Quality Campaign
Key Performance Indicator
Trajectory
Target
Target
Jun-15
YTD
95.0 %
95.0 %
92.5 %
93.8 %
85.0
79.4
83.7
82.2
Proportion of patients whose care was explained in an understandable way
90.0 %
90.0 %
91.3 %
91.6 %
Proportion of patients who were involved in planning their care
80.0 %
80.0 %
79.0 %
81.2 %
Proportion of patients rating their overall experience as good or excellent
80.0 %
80.0 %
90.4 %
90.7 %
Number of PREMS responses
1,600
1,600
1,672
1,724
20% reduction in complaints related to poor communication and attitude (baseline 2012/13 data)
35
3
5
16
20% reduction in complaints related to poor communication and attitude (baseline 2012/13 data)
35
3
5
16
Number of compliments received this month
n/a
n/a
27
33
90.0 %
90.0 %
96.0 %
83.8 %
n/a
n/a
13
15
Proportion of complaints responded to within 25 days
90.0 %
90.0 %
100.0 %
100.0 %
Proportion of complaints responded to within agreed deadline
100.0 %
100.0 %
100.0 %
100.0 %
Proportion of complaints acknowledged within 3 working days
100.0 %
100.0 %
100.0 %
100.0 %
Proportion of patient-related incidents that were harm free
54.0 %
54.0 %
71.2 %
72.3 %
30% increase in harm free incidents from 2012/13 baseline
1,970
164
306
830
73
6
3
9
Proportion of patients who were treated with respect and dignity
Friends and family test - net promoter score
A Positive Patient
Experience
Patients' Experience
Caring & Responsive
Services
A Positive Patient
Experience
Patients' Complaints,
Concerns & Compliments
Caring & Responsive
Services
Preventing Harm
Incidents & Risk
Safe Services
Performance
End of Year
Proportion of patients' concerns (PALS) responded to within 5 working days
Number of complaints received this month
50% reduction in medication incidents that caused harm from 2012/13 baseline
65
50% reduction in falls incidents that caused harm from the 2012/13 baseline
97
8
7
32
50% reduction CLCH acquired category 2-4 pressure ulcers from the 2012/13 baseline
212
18
50
137
Zero tolerance of new (CLCH acquired) category 3 & 4 pressure ulcers in bedded units
0
0
0
3
100.0 %
100.0 %
100.0 %
87.5 %
100 %
100 %
108 %
111 %
Statutory and mandatory training compliance
90.00 %
90.00 %
89.95 %
89.94 %
Proportion of patients with harm free care
98.0 %
98.0 %
94.1 %
92.0 %
Proportion of patients who did not have any NEW harms
98.0 %
98.0 %
98.3 %
97.0 %
Proportion of patients who did not have a pressure ulcer
98.0 %
98.0 %
95.1 %
93.7 %
Proportion of patients with Category 2 pressure ulcers (old)
2.0 %
2.0 %
1.9 %
2.1 %
Proportion of patients with Category 3 pressure ulcers (old)
2.0 %
2.0 %
0.7 %
0.8 %
Proportion of patients with Category 4 pressure ulcers (old)
2.0 %
2.0 %
1.6 %
2.2 %
Preventing Harm
Prevalence (NHS Safety
Thermometer)
Proportion of patients with Category 2 pressure ulcers (new)
2.0 %
2.0 %
0.3 %
0.7 %
Proportion of patients with Category 3 pressure ulcers (new)
2.0 %
2.0 %
0.3 %
0.4 %
Safe Services
Proportion of patients with Category 4 pressure ulcers (new)
2.0 %
2.0 %
0.1 %
0.3 %
Proportion of patients who did not have a fall
98.0 %
98.0 %
98.6 %
98.3 %
Proportion of patients with no harm - falls
2.0 %
2.0 %
0.7 %
0.8 %
Proportion of patients with low harm - falls
2.0 %
2.0 %
0.5 %
0.6 %
Proportion of patients with moderate harm - falls
2.0 %
2.0 %
0.2 %
0.3 %
Proportion of patients with severe harm - falls
2.0 %
2.0 %
0.0 %
0.1 %
Proportion of patients who died - falls
2.0 %
2.0 %
0.0 %
0.0 %
Proportion of external SIs with reports completed within deadline
Percentage of time bedded units achieving minimum staffing each month
66
Smart, Effective Care
Effective Services
Proportion of patients who did not have a catheter associated UTI
98.0 %
98.0 %
99.5 %
99.0 %
Proportion of patients with a catheter associated UTI (old)
2.0 %
2.0 %
0.2 %
0.5 %
Proportion of patients with a catheter associated UTI (new)
2.0 %
2.0 %
0.3 %
0.5 %
Proportion of patients who did not have a venous thromboembolism
98.0 %
98.0 %
100.0 %
99.8 %
Standardised mortality ratio in bedded units
3.8 %
3.8 %
0.0 %
0.4 %
Proportion of services capturing patients' clinical outcomes
100.0 %
75.0 %
80.0 %
78.1 %
Proportion of patients who were satisfied with the wait for treatment
80.0 %
80.0 %
75.2 %
77.3 %
Proportion of patients reporting a positive Goal Attainment Score
90.0 %
90.0 %
83.7 %
86.5 %
Proportion of safety alerts due, and responded to, within deadline
100.0 %
100.0 %
100.0 %
91.1 %
67