LONDON BOROUGH OF SUTTON
HEALTH AND WELLBEING BOARD
MONDAY, 30TH JUNE, 2014
5.
SOUTH WEST LONDON COLLABORATIVE COMMISSIONING 5 YEAR
STRATEGY (Pages 1 - 292)
Appendix 2 Joint Health and Social Care Strategy in Sutton including:
• Executive Summary, Joint Health and Social Care Strategy in
Sutton
• Joint Health and Social Care Strategy in Sutton, Plan
Enquiries to: Alexa Coates, Committee and Management Services Support Manager,
020 8770 5094
[email protected]
Copies of reports are available in large print on request
This page is intentionally left blank
Page 1
Agenda Item 5
Report to the Sutton
Clinical Commissioning Group Governing Body
Date of Meeting: 4th June 2014
Agenda No: 6.1
ATTACHMENT: 17
Title of Document:
Draft South west London 5 year strategic plan
Purpose of Report:
For Review
Report Author:
Lead Director:
Charlotte Joll, Programme Director, SWL
Dr Chris Elliott, Sutton CCG Chief Officer
Collaborative Commissioning
Executive Summary:
The document sets out the 5 year strategic plan for the South West London Strategic
Planning Group. It covers 8 clinical areas, setting out initiatives in each which will collectively
form the response of the SPG to the case for change for south west London.
Key sections for particular note (paragraph/page), areas of concern etc:
Chapter 3: Case for Change
Chapter 4: Clinical workstreams
Chapter 5: Sustainability
Recommendation:
The Governing Body is asked to review the strategic plan. All CCGs in SW London will
consider feedback on 12th June at the SWL Strategic Commissioning Board and Sutton CCG
will be asked to approve any amendments at our 18th June Governing Body meeting.
Committees which have previously discussed/agreed the report:
The plan was approved to go to CCG GBs by the SWL Strategic Commissioning Board on
the 19th May 2014
Financial Implications:
The proposals in this plan have yet to be fully costed but need to be considered in the context
of an overall shortfall of £210 million in CCG budgets. A fully costed implementation plan will
be brought back to the Governing Body for approval at a later stage.
Equality Impact Assessment:
Not undertaken at this stage. Once proposals included in the plan are fully worked up prior to
implementation they will be subject to a Quality Impact Assessment.
Communication Plan:
A communication plan has been developed for sharing the plan with local stakeholders,
including Health and Wellbeing Boards. Involvement to date has been significant, with
stakeholders engaged primarily through the clinical design process, the SWL Forum and
numerous events, including a broad stakeholder meeting on the 8th May.
Information Privacy Issues:
N/A
Page 1 of 1
Agenda Item 5
Page 2
South West London Draft 5 Year Strategic Plan
South West London Collaborative Commissioning
South West London Draft 5 Year Strategic Plan
23rd May 2014 Draft Submission
Version 2.00
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
Page 3
Agenda Item 5
South West London Draft 5 Year Strategic Plan
South West London Collaborative Commissioning
Table of Contents
Chapter 1:
Introduction.................................................................................................................. 1
Chapter 2:
Vision ............................................................................................................................ 7
Chapter 3:
Case for Change ............................................................................................................ 9
Chapter 4:
Clinical workstreams .................................................................................................... 41
Section 1: Children’s services.......................................................................................................... 43
Section 2: Integrated care............................................................................................................... 69
Section 3: Maternity care ............................................................................................................... 103
Section 4: Mental health................................................................................................................. 123
Section 5: Planned care .................................................................................................................. 145
Section 6: Transforming primary care ............................................................................................ 161
Section 7: Urgent and emergency care........................................................................................... 199
Section 8: Cancer care..................................................................................................................... 225
Chapter 5:
Sustainability ................................................................................................................ 231
Chapter 6:
How we will work together ......................................................................................... 259
Chapter 7:
Governance .................................................................................................................. 267
Appendices:
Appendices ................................................................................................................... 275
Appendix 1:
Children’s Care ................................................................................................. 277
Appendix 2:
Integrated Care ................................................................................................ 281
Appendix 3:
Performance against NHS Outcomes Framework Domains ............................ 285
RAFT FOR CCG GOVERNING BODY DISCUSSIONS
Page 4
Agenda Item 5
Chapter 1: Introduction
South West London Collaborative Commissioning
Chapter 1: Introduction
5 Year Strategic Plan
23rd May 2014 Draft Submission
Version 2.00
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
1
Page 5
Agenda Item 5
Chapter 1: Introduction
South West London Collaborative Commissioning
Contents
Introduction from south west London CCG Chairs ................................................................................. 3
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
2
Agenda Item 5
Page 6
Chapter 1: Introduction
South West London Collaborative Commissioning
Introduction from south west London CCG Chairs
Working together to improve the quality of care in south west London
As GP leaders of new commissioning organisations getting to grips with the challenges facing local
health services, it has become increasingly clear over the last year that we are facing a potential
crisis. Whilst our budgets have not been reduced in real terms, rising demand from an ageing
population and the costs of new technologies and drugs mean we have to address a gap of around
£210m a year by the end of 2018/19. Sustaining existing levels of access and quality in this context
is increasingly difficult both for us as commissioners and for local providers such as hospitals, GPs
and mental health Trusts. However, we are adamant that quality needs to improve – as referenced
in the case for change chapter, services are not meeting minimum quality standards and when
benchmarked against national and international evidence, are falling well short of where we think
they should be.
This presents us with a dilemma; either we can oversee a continuous decline in our local health
system followed by organisational failure and a need for external intervention, or we work with
clinical colleagues and local people to agree a planned set of changes that deliver the care that our
residents deserve within the funding available to us in south west London. As the custodians of the
health system, and as local GPs, we believe the latter is the only acceptable way forward. We will
work with other clinicians in the local health system, our local authority partners and local people
over the coming months to look at what some of these changes might be.
Our services are inter-dependent and the challenges we face cross borough boundaries. We need
closer working between our hospitals and also between the hospitals, GPs, community and mental
health services if we are to improve quality for everyone in south west London and make the local
NHS sustainable. We do not believe it would be possible to achieve the scale of change that is
needed by working independently at borough level. We will work with our Local Authorities, Health
and Wellbeing Boards, mental health trusts, primary and community care providers, local hospitals,
patients and neighbouring Clinical Commissioning Groups (CCGs) to achieve substantial and lasting
improvements in our health services.
We unanimously support the south west London case for change, reinforced nationally by NHS
England’s Call to Action 1. If we do not address these challenges, we know that local services will
decline in quality and that we will not be able to meet the required quality and safety standards.
Our CCG governing bodies and NHS England (direct commissioning), who commission primary care
and specialist services in south west London, have agreed to work jointly to develop new strategies
for local health services. This includes this 5 year strategic plan for south west London.
We remain committed to improving our hospitals
We agree that all future hospital services should be commissioned against the London Quality
Standards – which are minimum safety standards developed by senior clinicians, based on the
1
Everyone Counts: Planning for patients 2014/15 to 2018/19, NHS England, 2013, London
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
3
Page 7
Agenda Item 5
Chapter 1: Introduction
South West London Collaborative Commissioning
guidance of Royal Colleges and other equivalent bodies – and that all hospitals must provide sevenday services which are not only consultant-led, but largely consultant delivered. We know this will
not be easy – as there are not enough senior and experienced doctors to fulfil these roles, and so the
hospitals will have to work together to achieve this. We also expect our hospitals to comply fully
with the recommendations set out in the national review of urgent and emergency care by Sir Bruce
Keogh 2 and to be financially sustainable.
As commissioners of primary care and specialist services in south west London, NHS England (direct
commissioning) will work with us as part of a south west London ‘strategic planning group’ to
develop long term, sustainable improvements for patients. This collective work, and the work
undertaken by a range of groups described in the governance chapter (7), will be overseen by the
‘Strategic Commissioning Board’.
Our 5 year strategic plan includes bold ambitions for improving community, GP, mental
health and specialist services
We have listened to feedback from local people and we agree that we should look at local health
services in a holistic way.
Our draft strategic plan is structured as follows:
•
•
•
•
•
•
Chapter 2: Vision – sets out the vision for the strategy
Chapter 3: Case for Change – sets out the context and arguments for the proposed changes
in the document
Chapter 4: The clinical strategy for south west London – setting out, by pathway, the
interventions which CCGs will put in place over the five years of the strategy. The pathways
discussed are as follows:
o Children’s services
o Integrated care
o Maternity care
o Mental health
o Urgent and unscheduled care
o Primary care transformation
o Planned care
o Cancer care
Chapter 5: Sustainability – which describes how we will work to ensure services in 2018/19
are clinically and financially viable
Chapter 6: How we will work together – detailing how we work with our partners and
engage with a broad range of stakeholders, both in developing and implementing the
strategic plan
Chapter 7: Governance – setting out the structures we have put in place which oversee the
development and delivery of the strategy
2
High quality care for all, now and for future generations: Transforming urgent and emergency care services in
England – Urgent and emergency care review End of Phase 1 report, NHS England, 2013, London
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
4
Agenda Item 5
Page 8
Chapter 1: Introduction
South West London Collaborative Commissioning
The 5 year strategic plan is closely mapped to the 2-year and Better Care Fund plans
The 5 year strategic plan sets the direction of travel for health services across south west London.
We have deliberately separated out the objectives for years 1-2 of the plan from those to be
delivered in years 3-5, in order to demonstrate the close tie between each CCG’s 2 year operational
plan and the themes identified in this document. The strategic plan does not include any detail of
the range of interventions taking place in each borough, for this information please consult each
CCG’s individual plans, however the themes align closely across all six boroughs. In addition the
Better Care Fund plans, developed jointly by CCGs and local authorities, give the full detail of the
interventions planned in 2014/15 and 2015/16 to transform integrated services in the community.
The major themes from this work are captured in the Integrated Care section of this strategy.
We are committed to working with local providers, patients and the public
We are committed to working with local providers, service users and the public to develop solutions
that will deliver safe, high quality care for everyone. Much public engagement was carried out prior
to the establishment of South West London Collaborative Commissioning and we have continued to
listen to a wide range of stakeholders when developing the 5 year strategic plan. There have been
many separate engagement events, culminating in a large meeting on the 8th May to gather views
from a wide range of local organisations and patient representatives.
Should the outcome of our discussions mean major service change at any of our hospitals – which
we think is likely, given the difficulty of meeting the London Quality Standards across four hospitals –
then proposals would, of course, be subject to public consultation.
As commissioners of health and care services in south west London we are committed to working
together to improve the quality of care for our residents.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
5
Page 9
Agenda Item 5
Chapter 1: Introduction
South West London Collaborative Commissioning
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
6
Agenda Item 5
Page 10
Chapter 2: Vision
South West London Collaborative Commissioning
Chapter 2: Vision
5 Year Strategic Plan
23rd May 2014 Draft Submission
Version 2.00
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
7
Page 11
Agenda Item 5
Chapter 2: Vision
South West London Collaborative Commissioning
Vision
The overarching vision for the south west London 5 year strategic plan
“People in south west London can access the right health services when and where they need
them. Care is delivered by a suitably trained and experienced workforce, in the most
appropriate setting with a positive experience for patients. Services are patient centred and
integrated with social care, focus on health promotion and encourage people to take
ownership of their health. Services are high quality but also affordable.”
Each of the clinical workstreams in Chapter 4 presents its own vision for what care will be like and
how it will be delivered in 2018/19 for the affected section of the population in south west London.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
8
Agenda Item 5
Page 12
Chapter 3: Case for Change
5 Year Strategic Plan
23rd May 2014 Draft Submission
Version 2.00
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
9
Page 13
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
Contents
1. Health services in south west London must be responsive to issues facing the whole NHS ............. 12
2. Key drivers for change ........................................................................................................................ 13
Key driver 1: We need to improve the quality of care across south west London ............................. 13
Key Driver 2: We need to tackle the workforce gap ........................................................................... 17
Key driver 3: We need to ensure local NHS services are financially sustainable.............................. ..18
Key driver 4: We need to confront the rising demand for healthcare ............................................. 21
3. Population health and inequalities ................................................................................................... 22
4. Local performance against the seven measurable outcomes .......................................................... 23
Outcome 1: Securing additional years of life for the people of England with treatable mental and
physical health conditions ................................................................................................................ 24
1.1 Population and life expectancy data for south west London ................................................. 24
1.2 Leading causes of death .......................................................................................................... 25
1.3 Lifestyle issues......................................................................................................................... 25
1.4 Summary and strategic objectives .......................................................................................... 27
Outcome 2: Improving the health related quality of life of the 15million+ people with one or more
long-term conditions, including mental health conditions............................................................... 27
2.1 Prominent Long-Term Conditions ........................................................................................... 28
2.2 Quality of Life Indicators ......................................................................................................... 29
2.3 Summary and strategic objectives .......................................................................................... 30
Outcome 3: Reducing the amount of time people spend avoidably in hospital through better and
more integrated care in the community, outside of hospital........................................................... 30
3.1 People are being treated in a hospital setting where they could be more appropriately
treated in alternative settings....................................................................................................... 31
3.2 Community services and primary care ................................................................................... 32
3.3 Summary and strategic objectives .......................................................................................... 33
Outcome 4: Increasing the proportion of older people living independently at home following
discharge from hospital .................................................................................................................... 34
4.1 The elderly population ............................................................................................................ 34
4.2 Admissions to Residential/Nursing Care ................................................................................. 34
4.3 Summary and strategic objectives .......................................................................................... 35
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
10
Agenda Item 5
Page 14
Chapter 3: Case for Change
South West London Collaborative Commissioning
Outcome 5: Increasing the number of people with mental and physical health conditions having a
positive experience of hospital care ................................................................................................. 36
Summary and strategic objectives ................................................................................................ 37
Outcome 6: Increasing the number of people with mental and physical health conditions having a
positive experience of care outside hospital, in general practice and in the community ................ 37
Summary and strategic objectives ................................................................................................ 37
Outcome 7: Making significant progress towards eliminating avoidable deaths in our hospitals
caused by problems in care .............................................................................................................. 38
Summary and strategic objectives ................................................................................................ 39
5. Conclusion ......................................................................................................................................... 39
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
11
Page 15
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
1. Health services in south west London must be responsive to issues
facing the whole NHS
There is a broad consensus among doctors and nurses both nationally and locally that the NHS needs
to change. NHS England’s A Call to Action highlights the clinical, financial and logistical challenges
faced across the country and requires local commissioners to put forward plans to tackle these. The
NHS must respond to new challenges, such as increasingly more complex needs and higher
expectations of quality, alongside more long-standing challenges such as rising demand, financial
balance and the availability of sufficient, suitably skilled staff.
We need to celebrate what is already working well whilst being honest about the issues the NHS is
facing. Despite progress across all settings, current services are inconsistent, do not meet the
recommended safety and quality standards and are not financially sustainable.
Clinicians from south west London, alongside patients, have led the way in designing clinical
standards, yet these standards are not currently being achieved in full across our hospitals. Whilst
these standards are ambitious they represent the minimum, not the maximum, level of clinical
quality we, and our patients, expect.
We need to ensure patients receive this standard of care at a time when NHS funding is not
increasing as quickly as its costs. Each year, NHS organisations will have to find efficiency savings
just to deliver the same level of service. For south west London clinical commissioning groups
(CCGs) there is a forecast “do nothing” savings challenge of approximately £210m by 2018/19 to
achieve a 1% surplus.
All change brings a degree of uncertainty, and change in the NHS is particularly unsettling for many
stakeholders. As clinically led organisations, we are clear that:
•
we are not currently receiving the quality of care we want from our hospitals
•
we cannot deliver care to the quality that we want without changing the way in which
services are provided in south west London
•
we face a significant financial challenge today and, without change, this will become far
worse in the future.
An important consideration for our 5 year strategic plan is ensuring local commissioners treat
mental health and physical health services with a ‘parity of esteem’, under which all organisations
need to assign the same priority to the development of mental health services as physical health
services.
As ever it is important to understand the local context when considering any change and this chapter
sets out specific challenges faced in south west London. Whilst the CCGs have decided to work
together with NHS England as a strategic planning unit, much of the individual work taking place in
each borough will continue to be led by local organisations. This case for change will focus on the
broader trends which the five-year strategic plan needs to address, rather than on some of the
individual problems CCGs are tackling, which will be addressed in CCG specific plans.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
12
Agenda Item 5
Page 16
Chapter 3: Case for Change
South West London Collaborative Commissioning
In light of the challenges we face, south west London has been selected as one of eleven challenged
health economies that will receive support with strategic planning in order to secure sustainable
quality services. We are now working with PwC, who are providing intensive support to our strategic
planning.
The case for change outlines where performance needs to be improved across the health system,
setting out our four key drivers of change. We then discuss our progress against the seven
measurable outcomes identified by NHS England. These outcomes give us a framework around
which to identify and develop the interventions which will be explained later in the five-year
strategic plan.
2. Key drivers for change
There are four key drivers for change in south west London that must be addressed, namely:
•
the quality of care
•
the workforce gap
•
financial sustainable
•
rising demand for healthcare.
Key driver 1: We need to improve the quality of care across south west
London
There is clear clinical consensus around the quality of care that all acute hospitals need
to achieve, represented by the Seven Day Working Clinical Standards and London Quality
Standards
The Royal Colleges develop clinical guidelines across their respective specialisms in order to help
hospitals achieve the highest quality care for patients and make best use of the workforce. Existing
guidelines reinforce the need to deliver high quality care throughout the day and week, and in
London clinicians have worked together to develop a set of standards which builds on Royal College
guidance 1 and details the minimum safety standards patients should expect when they are treated
in hospital.
These standards are called the London Quality Standards (LQS). They were developed following the
review of adult emergency services undertaken by the London Health Programmes (LHP) in 2011 on
behalf of London’s commissioners, highlighting the variability in quality of hospital-based acute
medicine and emergency surgery in London. The LQS are based on clinical evidence, national
recommendations and best practice, and their development involved a group of over 90 clinicians
that formed multi-disciplinary expert panels, service user and public groups. They have also been
endorsed by the London Clinical Senate and the London-wide Clinical Commissioning Council.
1
Academy of Royal Colleges (2013) Changing Care Improving Quality Reframing the debate on reconfiguration
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
13
Page 17
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
Clinical commissioning groups (CCGs) in south west London have made a firm commitment to
achieving LQS across emergency, maternity and children’s services. London is not alone in requiring
higher standards of quality for patients and the aims of local clinicians have been underpinned by
national guidance that has arisen following Professor Sir Bruce Keogh’s (NHS Medical Director)
review into urgent care services across the country. The NHS Services’ Seven Days a Week Forum,
which was established as part of this review, reported in December 2013 that it had established 10
Clinical Standards for seven day working 2. These standards are broader in scope than the London
Quality Standards, applying to all NHS services rather than just acute services, but set out a
minimum level of service which patients can expect to receive wherever and whenever they fall ill.
The standards require:
•
Prompt access to consultant review and multi-disciplinary assessment
•
Availability of diagnostics to support decision-making
•
A focus on mental health diagnosis and treatment
•
Planned, safe and appropriate timing of discharges
•
The availability of support services in primary and community care to ensure that a patient
receives joined up care across all services
In December 2013, the Forum confirmed that it would require its seven-day working standards to be
implemented by 2015/16. These form a significant part of the case for change in south west London
and the achievement of seven day working will be an important step on the way to CCGs’ ultimate
objective of having LQS in place across all hospital sites. Currently some community services are not
available seven days a week, and the appropriate processes and support systems are not in place to
ensure patients can be safely discharged over the weekend.
Evidence shows that patients are currently more likely to have negative health outcomes
if they fall ill at the weekend
Providing a consistent standard of service throughout the week is a national priority for the NHS.
Some specialised services have already moved to providing high quality, consultant-delivered care
seven days a week, with demonstrable benefits to patient outcomes and service efficiency, however
the majority of care is provided over a five-day working week.
Whilst health services scale down for the weekend, the urgent and emergency needs of patients do
not. The detrimental effect of not having senior staff to make timely, accurate decisions, as well as
the other vital health professionals and support services that all play a part in caring for patients, is
clear. For example evidence shows people admitted to hospital as an emergency at the weekend
are 10% more likely to die compared to patients admitted on a weekday 3. This equates to
approximately 420 lives in London that could be saved each year if the mortality rate for patients
2
NHS England (Dec 2013) NHS Services, Seven Days a Week Forum: Summary of Initial Findings
Ayling et al (2010) ‘Weekend mortality for emergency admissions’ A large multicentre study
Quality and Safety in Health Care, 19: 213-217
3
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
14
Page 18
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
admitted as an emergency at the weekend was reduced to the level seen for those admitted on
weekdays 4.
The importance of seven-day working for good patient outcomes is highlighted through other
reviews. For example, according to research by University of Cambridge 5 on neonatal deaths in
Scotland, there is a higher risk of death when a baby is delivered outside of normal working hours.
We need to ensure that patients have access to the same level of specialist treatment whenever
they require care.
Progress to date in achieving London Quality Standards
London hospitals were audited against the adult emergency medicine and emergency surgery
standards in 2012/13, and analysis of the audit results shows that the four hospitals altogether met
only half of the 49 emergency medicine and surgery standards 6. Notably, none of the hospitals was
meeting the following standards:
•
•
•
All emergency surgical admissions to be seen and assessed by a relevant consultant within
12 hours of the decision to admit or within 14 hours of the time of arrival at the hospital
All patients on acute medical and surgical units to be seen and reviewed by a consultant
during twice daily ward rounds, including all acutely ill patients directly transferred, or
others who deteriorate
Prompt screening of all complex-needs inpatients to take place by a multi-professional team
which has access to pharmacy and therapy services, including physiotherapy and
occupational therapy, seven days a week with an overnight rota for respiratory
physiotherapy.
The tables below summarise the findings from the LQS audit of emergency standards:
Croydon
Epsom
Adult Emergency Services
Audit Standard
Medicine Surgery Medicine Surgery
Met
11
16
17
N/A
Not Met
10
10
4
N/A
St Helier
Medicine
Surgery
15
17
6
9
Kingston
St George's
Medicine Surgery Medicine Surgery
18
18
12
17
3
8
9
9
Table 1: Results from the self-assessment of trusts against the adult emergency standards 2013
Paediatric Services
Audit Standard
Met
Not Met
Croydon
Epsom
Medicine Surgery Medicine Surgery
12
16
14
N/A
8
8
6
N/A
St Helier
Medicine
Surgery
15
23
5
1
Kingston
St George's
Medicine Surgery Medicine Surgery
14
16
18
21
6
8
2
3
Table 2: Results from the self-assessment of trusts against the paediatric emergency standards 2013
4
Urgent and Emergency Care Review Team (2013) Transforming Urgent Care and Services in England Urgent
and Emergency Care Review
5
Pasupathy et al(2010)’Time of birth and risk of neonatal death at term’: retrospective cohort study
6
London Health Programme, Quality and Safety Programme: Audit of Acute Hospitals for St George’s,
Kingston, Croydon and St Helier (May 2012-January 2013)
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
15
Page 19
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
Maternity
Audit Standards
Met
Not Met
Croydon
Epsom
23
4
24
3
St Helier Kingston St George's
24
3
22
5
22
5
Table 3: Results from the self-assessment of trusts against the maternity standards 2013
These results show that we are currently meeting an average of 67% of the adult emergency
standards, 77% of paediatric standards and 85% of maternity standards 7. However, there are a few
examples of standards that are not being met by any of the trusts in south west London. These
include 168-hour consultant obstetric presence on labour wards, twice daily ward rounds in both
adult medicine and surgery and the prompt screening of all complex needs patients by a multiprofessional team with a clear multi-disciplinary plan in place within 14 hours.
We know that we cannot meet full LQS across our hospitals without making changes to the way
current services are delivered. The main reason for this is that there not enough consultants to
deliver the level of cover required. Key standards determined by local clinicians include:
•
•
•
•
•
•
•
All A&Es should establish sufficient emergency medicine consultant numbers to provide 16
hours a day, seven days a week consultant presence as a minimum 8,9
The clinical team on the AMU should be consultant led. This will typically require on average
one consultant per 25 admissions per day or less. There should be a twice-daily consultantled ward round/review of all patients in the AMU, seven days a week
There should be sufficient emergency surgeons to be present 12 hours a day, seven days a
week
There should be 24/7 cover of consultant anaesthetists, who should be available to be on
site within 30 minutes, seven days a week
All obstetric units should be staffed to provide 168 hours (24 hours a day, seven days a
week) obstetric consultant cover, regardless of the number of births
All children’s wards should have paediatric consultant cover for 14 hours a day, seven days a
week
Paediatric consultant-led 24/7 Children’s Short Stay Units (CSSUs) should be developed on all
sites that provide A&E care for children, with at least 14-hour paediatric consultant
presence.
Against reported consultant numbers in January 2013 it was calculated that in order to meet the
agreed standards across all four hospital sites in south west London over 180 more consultants
would be required by 2017/18 (see table below for breakdown). It should be noted that this
calculation covered six specialties only, and did not take into account support services such as
radiology or clinical pathology.
7
It should be noted that for those standards that were reported as being met during the week but not at the
weekend, we have recorded this as not being met.
8
London Health Programmes.Quality and Safety programme emergency departments.Case for Change
(February 2013)
9
The College of Emergency Medicine (2011) The Emergency Medicine Operational Handbook (The Way Ahead)
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
16
Page 20
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
A&E
Consultant
shortfall to
meet 112
hour cover
in 2017/18
Obstetrician
shortfall to
meet 168
cover in
2017/18
Paediatricia
n shortfall
to achieve
98 hours a
week cover
in 2017/18
Emergency
medicine
consultant
shortfall to
meet
standards in
2017/18
Emergency
surgery
shortfall to
achieve 12/7
cover in
2017/18
Anaesthetist
consultant
shortfall to
meet LQS in
2017/18
Total
predicted
consultant
shortfall in
2017/18
Croydon
4.1
9.0
11.9
3.4
6
21.8
56.2
Kingston
2.7
7.8
7.9
4.6
2
18.7
43.7
St George’s
4.1
7.5
17.8
4.1
0
0
33.5
St Helier
5.1
9
6.7
3.6
8
21.5
53.9
Total
16
33.2
44.3
15.7
16
61.9
187.3
Key Driver 2: We need to tackle the workforce gap
It is not possible to address the shortfalls described above simply by hiring more consultants, even if
the funding were available. There is a limited supply of suitable staff nationally, and even if the
hospitals could recruit sufficient staff to provide appropriate levels of clinical cover, the volume of
activity at each hospital will not be high enough to allow doctors and other healthcare professionals
to train and retain their skills. This means that merely hiring more staff is neither a workable nor
sustainable solution to raising clinical standards.
Because of difficulties in recruitment, progress towards seven-day working has been piecemeal and
out-of-hours cover remains particularly fragile 10. Owing to a reduction in training numbers, the
European Working Time Directive (EWTD) and increasing sub-specialisation, hospitals are finding it
increasingly difficult to appropriately staff on-call rotas 11. In some hospitals there are unacceptably
high levels of locum use, which gives rise to concerns about safety and value for money.
For maternity services particularly, achieving a 168 hour consultant presence will be challenging, as
the current consultant workforce would need to be significantly expanded. The Royal College of
Obstetricians and Gynaecologists (RCOG) estimated that the current UK consultant obstetric
workforce will need to increase from the present level of 1,500 to approximately 2,500 to deliver
168-hour cover in each of the 43 units in 2010 12. In south west London the Maternity and Newborn
Clinical Working Group noted that there will be several key challenges to meeting the standard:
•
•
•
•
Attracting and retaining the size of workforce required to deliver this level of cover
The additional problems caused by the need to develop EWTD-compliant rotas
The loss of junior medical training places, with around 30% of training posts estimated to
disappear over the next five years
A loss of junior medical training places, leading to a need for more consultant-delivered care
10
London Health Programmes Adult Emergency Services: Acute Medicine and Emergency General Surgery.
NHS London. September 2011.
11
Urgent and Emergency Care Clinical Working Group Final Clinical Report, London: NHS South West London,
March 2012 p. 25.
12
Maternity and Newborn Clinical Working Group Final Clinical Report, London: NHS South West London,
March 2012, p. 40.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
17
Page 21
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
•
The financial affordability of significantly increasing consultant numbers 13
For children’s services, the Royal College of Paediatrics and Child Health (RCPCH) has emphasised
that nationally there is an overall shortfall in consultant paediatricians, and warned that as a
consequence some paediatric units may have to close. 14 Given that there is not an inexhaustible
number of trained paediatric doctors and nurses, there is now a limit to how many units can be
staffed safely.
There may also be shortages in trained health professionals in some other areas of practice. The
number of doctors in training is expected to fall after growth in recent years and there are already
shortages in some areas of nursing (e.g. an additional 37 WTE midwives are required to provide oneto-one care for women in labour). 15 Additionally Croydon, Epsom and St Helier and Kingston each
have a shortfall of five interventional radiologists needed to meet LQS. 16 Unless we address these
workforce problems in a comprehensive way, we will never be able to deliver the minimum safety
standards required by our clinicians.
Key driver 3: We need to ensure local NHS services are financially
sustainable
Over the next five years clinical commissioning groups, which hold the budgets that pay for the
majority of community and hospital services, will face increasing financial pressure, in turn raising
the chances of providers suffering a deterioration in clinical quality and safety. The NHS budget is
expected to rise only in line with inflation during this time, and potentially for considerably longer.
Spending, however, is expected to rise significantly over and above inflation, assuming CCGs
continue to fund the same kind of services as they do today.
There are many reasons why spending is expected to increase rapidly:
•
The profile of the population is changing, with a larger number of older people, many of
whom will suffer from long term conditions (LTCs). LTCs require long-term treatment, and
not just in hospital but in primary and community settings also, and this treatment costs
money
•
A variety of public health trends are adding new pressures on the health system, with
patients developing conditions such as diabetes and heart disease owing to obesity and
other lifestyle factors
•
There is a trend of rising hospital activity across a range of services from A&E attendances to
out-patient appointments. Hospitals are expensive places to provide care compared with
other care settings
13
Maternity and Newborn Clinical Working Group Final Clinical Report, London: NHS South West London,
March 2012, p. 40.
14
Royal College of Paediatrics and Child Health (2013) Facing the Future: Standards for Paediatric Services.
15
The case for change for health services in South West London, NHS South West London, October 2011, p. 22.
16
London Health Programme (2012) Audit of Acute Hospitals
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
18
Agenda Item 5
Page 22
Chapter 3: Case for Change
South West London Collaborative Commissioning
•
New drugs and technologies are constantly becoming available to the NHS, and these are
often expensive to introduce and require upfront investment
•
Ageing estate has to be modernised to ensure it is fit for purpose in the 21st century.
Taken together these challenges are expected to lead to an annual savings requirement for CCGs in
2018/19 of 10.2% 17 of expenditure. This means that every year we need to find new ways of
delivering care whilst still meeting the high expectations of patients, and the minimum safety
standards set by local clinicians.
Taken together these pressures mean CCGs have to find £209m of savings over the next
five years.
The chart below shows that, without any improvements in productivity, commissioners would be
faced with a gap of £209m 18 in 2018/19 to meet the 1% surplus requirement.
South west London CCGs income and expenditure in 2018/19
The total savings target for the six CCGs, known as the QIPP (Quality, Innovation, Productivity and
Prevention) challenge, can be addressed in a number of ways. Savings can be made through more
appropriate prescribing of medicines for example, or through incentivising improvements in the
productivity of existing contracts. CCGs are committed to achieving significant savings through
17
The gap is the calculated “do nothing” in-year challenge to meet the 1% surplus requirement in 2018/19 if
CCGs delivered none of the planned QIPP schemes between 2014/15 and 2018/19. The calculation excludes
return of previous year surplus / (deficits). Source: South west London CCG Commissioning Model v0.04 (based
on CCGs’ finance template submissions NHS England on 5 March 2014.
18
South west London CCG Commissioning Model v0.04 (based on CCGs’ finance template submissions NHS
England on 5 March 2014.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
19
Page 23
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
transforming care out of hospital, thereby changing the balance of where care is delivered, creating
a better experience for patients and improving integration of services. Savings in acute services
account for £126.6 million of the planned QIPP savings over the five years, representing 67% of total
net savings.
This local drive is assisted by the national mandate to create a Better Care Fund (BCF), a joint health
and social care fund which comes into effect in 2014/15 and then is fully implemented in 2015/16.
As outlined in the letter from Sir David Nicholson to commissioners in October 2013, the BCF is a
‘game changer’ for both commissioners and providers. The ring-fenced budget for investment in
out-of-hospital care requires at a national level £2 billion of savings from existing spending in acute
services. 19 In South West London, patient flows to acute providers cut across a number of CCGs, and
commissioners recognise the need to work collaboratively to understand the activity and financial
implications for acute service providers over the five year planning timeframe.
The BCF is intended to be a significant enabler in the integration of care across providers. South west
London CCGs will transfer a minimum of £85 million to the BCF in 2015/16 20.
It is important to understand that any change to the money CCGs spend on hospital services has a
direct effect on the income of the hospital, and adds further pressure to the hospitals’ own savings
targets.
The impact of CCG transformation programmes will mean some providers will face
increasing financial pressure
The impact of QIPP, including the transformative change enabled by the BCF, is a catalyst for far
reaching change across the NHS in south west London. Acute, mental health and community
providers need to find savings over the next five years, however owing to the delivery of more care
in primary and community settings and less care in hospital settings, these challenges will be
particularly significant for acute trusts.
Providers are operating in the same challenging financial environment as commissioners, which
requires providers to deliver a high level of efficiency improvements (largely cost savings) while at
the same time making significant improvements in the quality of care. The acute sector faces the
greatest degree of challenge as a result of:
•
•
•
Ongoing efficiency requirements built into the national tariff of 4.0%-4.5% p.a.
The need to meet the LQS which impose minimum service levels necessitating the hiring of
additional consultants and other clinical staff
Potential loss of income as a result of activity shifts to other settings of care notably as a
result of the BCF.
Over the five years of the plan there is a collective need for cost savings of £360m across acute
providers, equivalent to 24% of the cost base, or average savings of 4.8% p.a.. Based on a
19
Sir David Nicholson letter to CCG leaders, ‘Planning for a sustainable NHS: responding to the ‘call to action’
(10 October 2013)
20
NHS England, ‘Total Allocations’ (December 2013).
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
20
Agenda Item 5
Page 24
Chapter 3: Case for Change
South West London Collaborative Commissioning
substantial body of opinion led by organisations such as Monitor, it is clear that the relatively high
level of cost efficiency improvements delivered in recent years by providers cannot be replicated in
future years. Monitor’s recent guidance has suggested that it considers a modest 2% p.a. savings
target is realistic, far below what is required of trusts in south west London.
In light of this evidence it must be regarded as highly unlikely that providers will be able individually
and collectively to achieve the level of savings and hence financial performance being projected.
Accordingly, given the potentially negative impact on local services, commissioners are leading a
process of more active planning to deliver a financially sustainable health economy. The dual
challenges of achieving the high levels of quality required by clinicians and patients whilst at the
same time developing services that are financially sustainable in the long term cannot be tackled
individually, it requires a collaborative approach between commissioners and providers.
Key driver 4: We need to confront the rising demand for healthcare
The demand for healthcare is rising as the population grows and ages. The population in south west
London is expected to increase by 7.2% from 1.46 million in 2013 to 1.56 million 21 in 2018. The
number of people in south west London over 65 years is projected to increase from 178,000 in 2013
to 194,000 in 2018, representing a growth of 8.9% over 5 years. 22
It is expected that more people will be living with multiple long-term conditions (LTCs). The King’s
Fund reports that for those over 65 years most people have one LTC and for those over 75 most
people have two or more. 23 For those living with chronic obstructive pulmonary disease (COPD),
data from the World Health Organisation show that death rates are almost double the EU average, 24
and 40% of people with COPD also have heart disease, 25 increasing the complexity of management.
Furthermore significant numbers have co-existing depression or an anxiety disorder 26. Studies show
that people with LTCs are twice to three times more likely to experience depression and estimates
suggest that 20% of people with LTCs have depression. 27
With an increasing number of older people, the number of people living with dementia is also rising.
Nationally, there are estimated to be 670,000 living with dementia 28 (although prevalence is lower in
south west London than the national average). If someone with dementia is admitted to hospital in
south west London they are likely to have a length of stay longer than the national average, and they
are more likely to be readmitted to hospital after discharge. People with dementia in south west
21
Population Projections Unit, ONS (2012)
Population Projections Unit, ONS (2012)
23
Making our health and care system fit for an ageing population, Oliver, D. et al., 2014, London: King’s Fund
24
An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England,
Department of Health, London: Department of Health, 2011
25
Ibid.
26
Ibid.
27
British Heart Foundation, Twice as likely: putting long term conditions and depression on the agenda, April
2012
28
Dementia: A state of the nation report on dementia care and support in England Department of Health,
London: Department of Health, 2013
22
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
21
Page 25
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
London are also more likely to die in hospital than the national average 29. Figure 6 presents the local
highlights from each of the south west London boroughs from the State of the Nation Report13
which outlines developments nationally since the Prime Minister’s Challenge was launched.
Between 2009/10 and 2012/13, A&E attendances in south west London’s four acute providers
increased by 12%. 30 During the same period, the number of A&E attendances for patients aged over
80 years increased by 16% 31 and the number of patients admitted to hospital from emergency
departments increased by 12%. 32
The pressure on emergency departments is expected to continue to rise as people live longer with
increasingly complex and multiple long term conditions. A&E attendances are projected to grow by
18.8% over the five years of the strategy. 33
3. Population health and inequalities
‘Health inequalities’ is the term that describes the unjust differences in health, illness and life
expectancy experienced by people from different sections of society. The contributing factors to
health inequalities are complex and include differences in living conditions, education, employment,
diet, levels of smoking, alcohol, exercise, and family/social support networks. However what is clear
is that health inequalities are not currently being addressed well enough. The London Health
Observatory has shown that Bangladeshi, Black African and Black Caribbean ethnic groups have
significantly lower life expectancy than the overall population of the capital. 34 The difference in
average life expectancy across south west London is 11 years. People living in parts of Wandsworth
and Croydon have a life expectancy of 76 years while in areas of Richmond it increases to 87 years.35
The NHS cannot alone address all the contributing factors driving inequalities. The single greatest
determinant of health status is income and there are significant socio-economic variations in south
west London. For example the average income of tax-payers in Richmond, at £56,100, is double the
average income of people in Croydon. 36 The most significant impacts the NHS can make on health
inequalities are unlikely to be related to big hospitals providing acute and specialised care for very ill
people, but from local improvements to community and home-based services being commissioned
by CCGs across south west London. There have been improvements across many different areas
over the past years and any changes to acute services will be underpinned by continued
development and expansion of out of hospital care.
29
Putting dementia on the map (2013), online resource available from:
http://dementiachallenge.dh.gov.uk/map/
30
A&E attendances statistics by provider 2009/10 and 2012/13, Health and Social Care Information Centre.
Note: This includes Epsom hospital. 2012/13 figures include the Croydon Urgent Care centre
31
A&E attendances statistics by provider 2008/09 and 2012/13, Health and Social Care Information Centre.
Note: This includes Epsom hospital
32
SUS data
33
Unify activity projections
34
Walters et al (2009) ‘Ethnicity and mortality in London’. London Health Observatory
35
Office for National Statistics(2013) Life expectancy by ward (2006-10)
36
HMRC Survey of personal income: average income of tax payers (March 2010)
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
22
Page 26
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
Disparity in life expectancy across the south west London boroughs is predominantly accounted for
by circulatory and respiratory conditions and cancer. Cancer alone is responsible for up to 32% of
the life expectancy gap. 37 As one of the top three leading causes of death, cancer has a national
incidence of 398.1/100,000 population. 38 Across south west London, the incidence is lower than this
national average with a higher average one-year survival rate of 69.2% (national one-year survival
rate 67.7%). 39
4. Local performance against the seven measurable outcomes
The local NHS has delivered many significant achievements over the past ten years, however there
are many areas in which care can be improved. NHS England’s seven outcome measures provide a
way of assessing our current performance and highlighting the areas which need to be addressed by
the five-year strategic plan:
The seven measurable outcomes
1
Securing additional years of life for the people of England with treatable
mental and physical health conditions
2
Improving the health related quality of life of the 15million+ people with
one or more long-term condition, including mental health conditions
3
Reducing the amount of time people spend avoidably in hospital through
better and more integrated care in the community, outside of hospital
4
Increasing the proportion of older people living independently at home
following discharge from hospital
5
Increasing the number of people with mental and physical health
conditions having a positive experience of hospital care
6
Increasing the number of people with mental and physical health
conditions having a positive experience of care outside hospital, in
general practice and in the community
7
Making significant progress towards eliminating avoidable deaths in our
hospitals caused by problems in care
We know that quality of care varies depending on where and when patients access services. There
are unacceptable variations, highlighted through performance against the LQS, in the amount of
consultant cover available at different hospitals across south west London. Too many people are
staying in hospital for longer than they need to because of the lack of appropriate services in the
community, and when they are discharged not enough people can live independently in their own
homes.
We need to improve the quality of life and not just the quality of care for our population. This
means working with local authorities and NHS England to ensure equity of access to public health
programmes for screening and immunisations, and ensuring that those with long-term conditions
37
Segmenting life expectancy gaps by cause of death, Public Health England
Cancer Research UK http://www.cancerresearchuk.org/cancer-info/cancerstats/local-cancerstatistics/?location-name-1=NHS Croydon CCG&location-1=07V
39
Cancer Research UK
38
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
23
Page 27
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
are able to better manage their own diseases and continue to live a full life for longer than they
could in the past. Patients with mental health conditions often have physical health problems as
well but have traditionally received less good care and this is not acceptable.
The following sections address each of NHS England’s outcomes in turn, and highlight current trends
in south west London and the priorities which the five-year strategic plan needs to address.
Outcome 1: Securing additional years of life for the people of England with
treatable mental and physical health conditions
People are living longer than ever and with longer life comes an increased likelihood of developing
long-term medical conditions, be they mental or physical. This has a knock-on effect of putting
further pressure on an already stretched healthcare service. Securing additional years of good
quality life for those with such conditions is a priority for modern healthcare and will need to be
tackled in a number of ways. Whilst life expectancy overall is increasing, there is a disparity between
the most and least deprived areas within individual CCGs in south west London and this will need to
be addressed in order to improve overall mortality rates. Tackling lifestyle issues such as smoking
and obesity, particularly in the more deprived areas will help, as will improving long term
management of health conditions particularly in the community, hence avoiding hospital
admissions.
Improving access to screening will enable earlier detection and treatment leading to better
outcomes for patients. Screening improves outcomes for breast, cervical and bowel cancer and for
people with diabetes, screening significantly reduces risk of sight-threatening retinopathy. The
screening programme for abdominal aortic aneurysm reduces premature mortality for men and the
antenatal and newborn programme improve health and life chances for children and families. We
will collaborate with NHS England to ensure we get best value for the population, co-commissioning
where this will deliver best value for money.
1.1 Population and life expectancy data for south west London
There are now around 1.45 million people living in south west London and our population is growing
at one of the fastest rates of any region in England. Birth rates are increasing - on average there
have been an additional 541 births each year since 2002 40 and by 2018 the population is projected to
increase by 7% and reach 1.56 million 41. The number of children expected to be living in south west
London is expected to have risen by 13,500 between 2011 and 2021 42.
Both the absolute numbers and the proportion of older people are expected to grow markedly. In
south west London the over 65s are projected to increase by 13% by 2020. This age group is the
40
Office for National Statistics(2013) Live births by local authority of usual residence by mother, general
fertility rates and total fertility rates
41
Office for National Statistics(2012) Interim 2011-based subnational population projections for England
42
Children’s Clinical Working Group, Final Clinical Report, March 2013, pg. 12
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
24
Agenda Item 5
Page 28
Chapter 3: Case for Change
South West London Collaborative Commissioning
most intensive user of health and social care. 43 Nearly two-thirds of people admitted to hospital are
over 65 years old - accounting for nearly 70% of hospital emergency bed days 44.
People living longer in south west London is good news; however, we need to ensure we have the
services in place to meet their needs.
1.2 Leading causes of death
The top three causes of death nationally in 2010 were circulatory disease (including coronary heart
disease and stroke), cancer and respiratory conditions for both men and women. Comparison with
data from 2000 has shown that the number of deaths from circulatory disease has fallen, although it
still remains the number one cause. Conversely, the number of deaths from cancer appears to have
risen slightly despite significant advances in its treatment. 45 The profile for south west London
follows the national profile of causes of death with coronary heart disease accounting for the
majority of deaths in both sexes and across the majority of age groups. These conditions will remain
a priority for CCGs when developing integrated services within the community to support people
with these common conditions.
Although not necessarily a leading cause of death, mental ill health is the single largest cause of
disability in the UK. 46 We also know that people with mental health problems have worse physical
outcomes in addition to a reduced life expectancy. In the UK men and women without mental
health problems have life expectancies of 79 and 83 respectively. For patients with mental health
problems this life expectancy for men and women is reduced to 68 and 73 respectively. 47
1.3 Lifestyle issues
A major impact in securing additional years of health for the population of south west London will be
tackling the lifestyle issues that are prevalent throughout the area and the country, i.e. smoking,
obesity and alcohol consumption. All are known to be linked to long-term health conditions such as
COPD, diabetes mellitus and chronic liver disease, all of which will shorten life and provide a huge
burden for the local health service.
Estimated smoking rates across south west London in 2011 suggest that rates are lower than for
London as a whole (20.0%) and across England (21.2%). Nevertheless, the local CCGs do report a
wide variation in smoking rates across their geographical areas, closely linked to the level of
deprivation. 19.7% of Croydon’s population in 2011 were smokers, with a similar number (19.5%) in
Kingston. Variations across the region suggest that smoking rates are as low as 9% in more affluent
areas and as high as 33% in more deprived parts of the boroughs. 48,49,50,51 It is well known that
43
Office for National Statistics(2012) Interim 2011-based subnational population projections for England
Kings Fund (2013) Older people and emergency bed use: exploring variation’
45
Deaths Registered in England & Wales in 2010 by Cause, Office for National Statistics
46
How mental illness loses out in the NHS. 2012. London School of Economics
47
A call to action: achieving parity of esteem; transformative ideas for commissioners. 2014. NHS England
48
Croydon Joint Strategic Needs Assessment, Croydon Key Dataset 2012/13
49
Royal Kingston Borough Profile 2012
50
The Health and Wellbeing of the People of Merton: Joint Strategic Needs Assessment 2013
51
Wandsworth Joint Strategic Needs Assessment 2010
44
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
25
Page 29
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
obesity is on the rise throughout England with an estimated current prevalence of 24.2%. The
London average is less than the national figure at 20.7%. The Health Survey of England in 2010
revealed that 64% of the London population were classed as overweight (40%) or obese (24%), with
1% classed as morbidly obese, giving a mean BMI for the area of 27.3. 52 There is also growing
concern about obesity in childhood, with around one in five children in early adolescence being at
risk of becoming obese with all the associated health problems. 53 Once again a wide variation was
noted across the CCGs with higher rates of obesity in areas of greater deprivation.
Alcohol is a significant contributor to long term health conditions and associated mortality and
significant numbers of the population consume excess amounts on a regular basis. The 2011 Health
Survey of England revealed that 23% men and 18% women were drinking more than the
recommended weekly levels (i.e. 21 units/week for a man and 14 units/week for a woman). 6% of
men and 4% of women were classified as ‘high risk’ drinkers with consumption exceeding 50
units/week for a man and 35 units/week for a woman. 54 The table below compares the number of
admissions per area either wholly attributable to or partly attributable to alcohol, with all except
Croydon and Wandsworth having lower admission numbers than the national average.
South west London alcohol related admissions in 2011/12
Total
Wholly-attributable
Partly attributable
PCT
Admission
Per 100,000
population
Admission
Per 100,000
population
Admission
Per 100,000
population
Croydon
7,500
2,425
1,500
437
6,000
1,988
Kingston
2,800
2,055
600
379
2,300
1,675
Sutton &
Merton
Richmond &
Twickenham
Wandsworth
7,400
2,165
1,800
474
5,600
1,691
3,100
1,846
700
414
2,400
1,432
4,800
2,322
1,400
586
3,300
1,736
England
1,220,300
2,298
304,200
573
916,100
1,725
Alcohol-related1 NHS2 hospital admissions3 based on primary and secondary diagnoses, by Strategic Health Authority
(SHA) and Primary Care Trust (PCT), 2011/12 www.hscic.gov.uk, ‘Statistics on Alcohol: England 2013’
The aim to secure additional years of life for the local population will need to address the number of
people dying before age of 65. The below table shows a breakdown of the number of premature
(defined as age<65 years) deaths per 100,000 population by CCG. Cause of death data suggest that
the predominant causes of death in this age group are circulatory disease and external causes such
as accidents and suicide, with a higher number of deaths in males. Those from manual working
backgrounds are more likely to die in this age group than those in non-manual or professional
groups.
52
The Health Survey of England, 2010
NHS England, London A Call to Action, 2013
54
The Health Survey of England 2011
53
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
26
Page 30
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
Borough
Deaths before 65 per 100,000
population 2009-2011
Wandsworth
Croydon
Merton
Sutton
Kingston
Richmond
174
153
139
139
130
121
Office for National Statistics
The lack of prevention services for mental health conditions is another major factor requiring a new
approach to care in south west London. It is commonly recognised that community and acute
mental health services are often fragmented, and the majority of resources are focused on
secondary care at the expense of appropriate services in place in the community and primary care to
prevent patients from developing conditions which require more complex treatment.
1.4 Summary and strategic objectives
The health profile of south west London is better than that of the nation as a whole, with higher life
expectancy and lower rates of smoking, obesity and excess alcohol consumption. Nevertheless, local
health services face an increasing burden with the population expanding and living longer. In order
to secure additional years of life for the population, we need to tackle health inequalities within and
between boroughs.
Securing additional years of life will be addressed in a number of ways throughout this strategic plan.
There will be a focus on prevention, including promoting access to screening programmes, and selfmanagement in the community, with utilisation of technology and access to support networks to
help patients to manage their conditions more effectively. Supporting women to achieve healthy
lifestyles is an aim of the maternity group, and tackling childhood obesity is a major focus of the
Children’s group. For those with mental health conditions people will be diagnosed earlier than ever
before, and the life expectancy gap between patients with and without mental health problems will
be reduced.
Outcome 2: Improving the health related quality of life of the 15million+
people with one or more long-term conditions, including mental health
conditions
People who have one or more long-term medical conditions account for 70% of health care
spending, 50% of all GP appointments and 70% of all hospital bed-days in England 55 and the cost per
patient rises significantly with the number of concurrent LTCs they have 56.
55
King’s Fund, ‘Delivering better services for people with long-term conditions’
‘The Importance of Multimorbidity in Explaining Utilisation and Costs Across Health and Social Care Settings:
Evidence from South Somerset’s Symphony Project’ CHE Research Paper 96, P. Kasteridis et al, University of
York Centre for Health Economics, Feb 2014
56
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
27
Page 31
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
(ETG = Episode Treatment Group classifications employed by the United Health RISC tool)
‘The Importance of Multimorbidity in Explaining Utilisation and Costs Across Health and Social Care Settings:
Evidence from South Somerset’s Symphony Project’ CHE Research Paper 96, P. Kasteridis et al, University of
York Centre for Health Economics, Feb 2014
The prevalence of LTCs rises with age. As the population continues to grow and age, the numbers
living with LTCs will rise with a higher prevalence in some specific conditions, such as cancer,
diabetes and dementia. It is estimated that the number of people living with multiple long-term
conditions will increase from 1.9 million in 2008 to 2.9 million in 2018. Between 2008/09 and
2012/13, A&E attendances in south west London increased by 13% 57 and emergency admissions
increased by 11%. The pressure on emergency departments is expected to continue to rise as
people live longer with increasingly complex and multiple, LTCs.
Advances in neonatal services and treatments for complex medical conditions mean that many more
children are surviving but often with long-term health problems 58.
2.1 Prominent Long-Term Conditions
2.1.1 Dementia
Nationally, there are estimated to be 670,000 people living with dementia 59 (although prevalence is
lower in south west London than the national average). If someone with dementia is admitted to
hospital in south west London they are likely to have a length of stay longer than the national
http://www.york.ac.uk/media/che/documents/papers/researchpapers/CHERP96_multimorbidity_utilisation_c
osts_health_social%20care.pdf
57
Department of Health – A&E attendances statistics by provider for 2008/09 and 2012/13
58
Children’ Clinical Working Group, Final Clinical Report, March 2013, pg. 27
59
Dementia: A state of the nation report on dementia care and support in England (2013) Department of
Health, London: Department of Health
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
28
Agenda Item 5
Page 32
Chapter 3: Case for Change
South West London Collaborative Commissioning
average patient stay, and in every hospital other than Kingston they are more likely to be readmitted
after discharge than the national average. 60 People with dementia in south west London are also
more likely to die in hospital than the national average. 61
2.1.2 Chronic Obstructive Pulmonary Disease (COPD)
Approximately 3 million people in the UK are thought to have COPD and 60%-85% are thought to be
undiagnosed. 62 There are very strong links between smoking and COPD, but it is estimated that
about 15% of cases are related to other causes, such as exposure to work-related fumes, chemicals
and dust. 63 This is a serious, life-limiting condition requiring considerable health services input both
in hospital and in the community.
2.1.3 Diabetes Mellitus
Diabetes presents a similar problem with approximately 3.2 million people living with the diagnosis
and a further estimated 630,000 who are undiagnosed. Large numbers of undiagnosed conditions
caused by diabetes will result in more complications and poorer health with a resulting increased
burden on the local health services. The implications for poorly controlled or undiagnosed diabetes
are very serious. Long-standing poor diabetic control can result in renal failure, lower limb
amputations and blindness, all of which have a devastating impact on quality of life and make big
demands on local health and social services. Uptake of screening for diabetic retinopathy is variable
and we will be working with NHSE London to ensure equity of access across the population.
2.2 Quality of Life Indicators
Current quality of life data in south west London give a mixed picture. GP survey data for 2013
suggest that, of those that completed the survey, approximately 47% suffered with at least oneLTC;
approximately 60% felt that they had ‘definitely’ or ‘to some degree’ had enough support from their
local services over the previous six months to help them manage with their LTC and that over 90% of
those with a long term condition felt either very confident or fairly confident in being able to
manage their own health. 64 In comparison with England as a whole, patient confidence in managing
their own condition and in the support they have received from local services seems to be on a par
with the rest of the country. However, patient satisfaction scores for seeing a GP of choice and
satisfactory opening hours are below the England average 65 and expectations of services are rising
including how patients wish to access services outside of working hours and ‘on-the go’.
60
Putting dementia on the map (2013), online resource available from:
http://dementiachallenge.dh.gov.uk/map/
61
Putting dementia on the map (2013), online resource available from:
http://dementiachallenge.dh.gov.uk/map/
62
Decramer M, Janssens W, Miravitlles M; Chronic obstructive pulmonary disease. Lancet. 2012 Apr
7;379(9823):1341-51. doi: 10.1016/S0140-6736(11)60968-9. Epub 2012 Feb 6
63
Health and Safety Executive Statistics
64
GP survey data 2013, NHS England
65
NHS England (2013): ‘Transforming Primary Care in London: General Practice A Call to action’, p 42
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
29
Page 33
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
In the past 6 months, had
enough support from local
services to help manage LTC
Confidence in managing own
health
CCG
1+ Long term
condition
Yes, definitely
Yes, to some
extent
Very
confident
Fairly
confident
Croydon
Kingston
Merton
Richmond
Sutton
Wandsworth
England
51%
46%
49%
46%
51%
42%
54%
34%
35%
33%
37%
38%
34%
39%
23%
24%
25%
24%
24%
26%
25%
41%
42%
41%
44%
42%
43%
43%
50%
51%
51%
50%
51%
49%
49%
GP survey responses 2013
2.3 Summary and strategic objectives
Over 15 million people currently live with one or more lLTC and with the ageing population and
current estimates of under-diagnosis, this number will increase. Improving the health related quality
of life for these people will have a positive impact on the health burden generated by these patients.
Improving patients’ confidence and ability to manage their own condition should reduce the burden
on local health services and reduce emergency admissions.
Primary care services are on the front line of preventing ill health, promoting access to screening
programmes, encouraging patients to self-manage and support the overall wellbeing of the
population. For patients with LTCs there will be development of relationships between primary care,
community, social care and specialist services to provide coordinated care, and there will be the
innovative use of personalised health budgets for those with mental health conditions, shown to
improve quality of life. For children there will be more collaborative working between health, social
and education professionals to work to identify and ensure appropriate referrals to CAMHS and
improved access to psychology therapies. In the community, the five-year strategic plan focuses on
prevention and management of long term conditions with utilisation of technology and access to
support networks to help patients to manage more effectively and thus secure an improved quality
of life.
Outcome 3: Reducing the amount of time people spend avoidably in
hospital through better and more integrated care in the community,
outside of hospital
Reducing the amount of time that people avoidably spend in hospital requires a number of different
approaches. We need to ensure services are available in the community to help people live
independently and, if admission is unavoidable, to ensure post-discharge services are available to
help reduce length of stay where appropriate and reduce re-admissions.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
30
Page 34
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
3.1 People are being treated in a hospital setting where they could be more appropriately
treated in alternative settings
A&E attendances are increasing. In 2012-13 there were 18.3 million A&E attendances nationally
(including major and single specialty A&E departments, walk-in centres and minor injury units). This
was an increase of 4% since 2011-12 and only 20.8% of those attendances resulted in an
admission 66. The Keogh review in 2013 identified that 40% of those patients attending A&E could
have been treated in alternative settings, suggesting that we are not doing enough to improve
integrated care outside of hospital.
The table below shows the number of emergency admissions per 100,000 population for conditions
which could normally be treated outside of hospital.
Borough
Croydon
Wandsworth
Merton
Sutton
Kingston
Richmond
Emergency admissions that should
not normally need hospital admission
per 100,000 population
1,011
975
924
815
810
757
Outcome benchmarking support pack by area: Emergency admissions for acute conditions that should not normally require
hospital admission (indirectly age/sex standardised rate per 100,000 population 2011-12)
Since 2001 the number of emergency admissions for conditions that could have been successfully
managed in primary care in England increased by an estimated 40%. 67 There is opportunity to
addressing this, for example in Children’s care. We know that 34% of non-elective inpatient
admissions of children are only one-day or less. 68 These short admissions can cause great disruption
to children and their families. In many cases they could be avoided by treating children in short stay
units, such as Paediatric Assessment Units, or at home with community support.
For the frail elderly, falls are a significant cause of admission to hospital 69 and are the leading cause
of ambulance call-outs to the homes of people over 65 70; falls prevention is also a regional priority
for the World Health Organization. 71 Around 1 in 3 people over 65 and 1 in 2 over 80 fall each
year, 72 and we know that in south west London the number of over 65s is projected to grow by 13%
by 2020, representing a significant population at risk of a hospital admission.
66
Accident and Emergency attendances in England 2012-13, www.hscic.gov.uk
Urgent and Emergency Care Review Team (2013) Transforming Urgent Care and Services in England Urgent
and Emergency Care Review
68
Children Clinical Working Group final clinical report, March 2013, page 15
69
Making our health and care system fit for an ageing population (2014), Oliver, D. et al., London: King’s Fund
70
Prevention package for older people resources (2009) Department of Health, London: Department of Health
71
Strategy and action plan for healthy ageing in Europe, 2012-2020 (2012), World Health Organization,
Copenhagen: World Health Organization Regional Office for Europe
72
Making our health and care system fit for an ageing population (2014), Oliver, D. et al., London: King’s Fund
67
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
31
Page 35
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
Delayed discharges refer to patients who are well enough to be discharged from hospital but are
unable to be owing to various reasons. These can include a lack of suitable discharge destination or
care package. A large number of delayed discharges would suggest that we are not providing
adequate integrated care in the community.
Although delayed transfers of care are lower across south west London than the national average
(9.4 per 100,000 population), 73 we know that we could still be doing better, given that there is
considerable variation in the length of delay between the best and worst performing localities with
Merton (2.5 per 100,000), Wandsworth (2.8 per 100,000), Croydon (3.4 per 100,000), Sutton (6.4 per
100,000), Kingston (6.7 per 100,000) and Richmond (7.3 per 100,000). Tackling these variations is a
major challenge and priority for CCGs across south west London.
In mental health the picture is no better. All CCGs’ mental health re-admission rates within 3 months
and 6 months were in the 3rd quartile nationally, suggesting that the management of patients in the
community needs to be improved. In addition spending on learning disabilities services is well below
the national average (£11.40 per weighted population v. £21.50 national average) 74.
3.2 Community services and primary care
Primary and community services should be the initial point of call for the majority of patients who do
not have life-threatening conditions. However, with reported difficulties in obtaining GP
appointments at convenient times and a reported lack of understanding amongst the population
about how to access out-of-hours care, large numbers are using A&E as their first port of call.
Primary care services are performing below the national average in a number of areas. Access to GP
services is lower than the national median, and there are 419.8 A&E attendances per 1000 weighted
population in south west London against a national average of 340.6 and with areas in the first
quartile having only 264.1 per 1000. 75
Clear progress has already been made in south west London in relation to urgent and emergency
care. The 111 service has been launched across the area, working as a ‘gateway’ to urgent and
emergency services. By January 2014, on average 95.5% of calls were answered in 60 seconds. Of
all 111 dispositions, on average 10% led to ambulance dispatches, 7% were recommended to attend
A&E, 54% were recommended to attend primary and community care and 28% were not
recommended to attend other services. 76
Greater integration of care in the community will be necessary in order to achieve the aim of
reducing the amount of time people avoidably spend in hospital. There are already a number of outof-hours services available within south west London in order to help prevent
inappropriate/unnecessary A&E attendances and hospital admissions and continuing plans in place
73
Delayed transfer of care per 100,000 population (All delays) 2012/13, (2013) NHS England, updated
25/10/13, available from: http://www.england.nhs.uk/statistics/statistical-work-areas/delayed-transfers-ofcare/
74
NHS England South west London SPG data pack, 2014
75
NHS England South west London SPG data pack, 2014
76
NHS Minimum data set – data to January 2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
32
Agenda Item 5
Page 36
Chapter 3: Case for Change
South West London Collaborative Commissioning
to improve these. GP-led out of hours services are available outside of normal working hours during
the week and 24 hours over the weekend and at bank holidays, in line with the rest of the country.
Alongside this there are a number of urgent care centres and minor injuries units available for nonlife threatening conditions and minor injuries. A range of community based services are also
provided within each area in order to support patients at home, either following discharge or in
order to prevent admission. These services include physiotherapy, occupational therapy, speech
and language, district nursing, community matrons, health visitors and nurse specialists.
The BCF, which will take full effect in 2015/16, provides a major incentive to CCGs to transform how
care is provided in the community. The fund will be shared between CCGs and local authorities, and
the use of the funds needs to comply with a number of national conditions, one of which is to
provide seven-day services to support discharge. Plans already developed include initiatives to
improve self-care amongst the older population, develop joint teams of health and social care
professionals to address a broader range of patient needs, and improving the availability of care
packages for people at risk of hospital admission, particularly over the weekend.
In advance of the BCF taking effect there are reasons to think current services are not offering the
highest quality integrated care to patients. Reviews conducted by the joint out of hospital
programme across south west London have noted significant differences in the approach and
coverage of community services across different boroughs, and have noted specific concerns such as
a lack of appropriate outcomes data collection. A children’s community nursing review in early 2013
suggested that very little outcomes data were being collected across south west London and that
commissioning specifications lacked detail to ensure that a uniform approach to developing
children’s nursing services was being taken across the area.
3.3 Summary and strategic objectives
Improving integrated care in the community is a major step towards reducing the burden on
secondary health services and ensuring that patients are seen in the most appropriate setting.
Greater integration and use of primary and community services will be a large part of this, and this
direction of travel has been recognised nationally through the development of the BCF. In south
west London improving the integration of care in the community is a major priority and this will
inform the development of better methods for collecting and analysing the performance of
community services, embedding outcomes data into contracts and ensuring patients have a positive
experience of care.
Reducing the amount of avoidable time spent in hospital will be addressed by urgent care by
implementation of new and enhanced health and social care schemes. There will be a focus on
prevention and self-care management of long term conditions with utilisation of technology and
access to support networks to help patients to self-manage more effectively and thus secure an
improved quality of life with the aim of reducing avoidable hospital admissions. This five-year
strategic plan sets out how integrated care services will successfully keep people out of hospital and
reduce any time that they do spend in hospital by providing high quality reablement and post
discharge support.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
33
Page 37
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
Examples of this shift away from traditional hospital-based care is evident in maternity CDG’s plans
to develop midwifery-led units and support more women to have births at home. Where a birth has
taken place in hospital the mother and baby will be supported to go home as soon as is safely
possible after birth. Similarly for those with mental health conditions there is a focus in reducing
reliance on inpatient mental health care in order to shift the balance of where care is provided to
out of hospital settings.
Outcome 4: Increasing the proportion of older people living independently
at home following discharge from hospital
People over the age of 6five-years account for approximately 70% of all unplanned hospital
admissions. 77 It can be hard to discharge older people from hospital even when they are medically
fit, and this problem becomes more exaggerated the older the patient population.
4.1 The elderly population
The 2011 National Census identified approximately 58,000 people aged 65 and over who live alone
in south west London78 and it is a major priority for CCGs to keep this population as independent as
possible in the future especially following any hospital admissions. This will rely on good social and
community support together with prompt discharge from hospital.
2011 National Census data for people aged 65+ living alone
No people >65yr old living in a
Borough
one-person household
Croydon
Wandsworth
Richmond
Sutton
Merton
Kingston
14,107
10,385
9,434
9,203
7,695
6,762
4.2 Admissions to Residential/Nursing Care
There is currently significant variation in rates of permanent admissions to residential and nursing
homes across south west London. The table below shows that in 2012/13 Richmond had 529
permanent admissions per 100,000 population, compared with only 160 in Sutton 79.
77
King’s Fund (2013) Older people and emergency bed use: exploring variation
National Census (2011) People aged 65+ living alone
79
NHS England (2014) Outcome benchmarking support packs
78
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
34
Agenda Item 5
Page 38
Chapter 3: Case for Change
South West London Collaborative Commissioning
Permanent admissions to residential and nursing care homes (rate/100,000 population, 2012-13)
Borough
Age 65+
Wandsworth
569
Richmond
529
Merton
431
Kingston
361
Croydon
240
Sutton
160
Data from the Outcome benchmarking support packs by NHS England for each Local Authority
An alternative measure of the independence of patients living at home is the number of older
people still at home 91 days after discharge to reablement or rehabilitation services. There is a
variation across south west ; however, in some areas, such as Croydon only 65.3% were still at home
following discharge in 2012/13 compared with 81.4% for London and 81.2% for England. Over the
last three years there has been a reduction in the national percentage 80 from 82.0% in 2010-11 to
81.4%. Conversely there has been an increase in the national number of permanent admissions into
residential or nursing homes per 100,000 population. These trends need to be addressed in south
west London my ensuring that care, particularly for older people is joined up and enables patients,
particularly those suffering from LTCs, to manage their own health and live independently. Schemes
developed through the BCF will be targeted at this population and are examined in further detail in
chapter 4.
4.3 Summary and strategic objectives
As the population ages, people become more dependent on carers and on health and social care
services in order to continue leading a good quality of life outside of hospital. Putting in place
services to keep people independent in their own homes will involve improving joined up support
available to older people, particularly focussing on holistic treatment of patients and the provision of
joint health and social care teams. There is a variation in the extent to which health and social care
services are currently joined up across south west London, with some areas, such as Richmond and
Croydon putting in place joint health and social care commissioning arrangements, whilst others
such as Kingston already have services in place such as Kingston at Home, which provide joined up
health and social care service provision to its population. A focus of CCG plans over the five-year
strategic plan will be to embrace the changes brought about by the BCF and to develop a
consistently high level of support in patients’ homes to allow people to continue living
independently for as long as possible.
Chapter 4 sets out a number of different initiatives to increase the proportion of older people living
independently at home after discharge. The integrated care CDG has developed plans to ensure the
right level of support is provided at home or in the community to prevent readmission and promote
independence, including improving discharge planning, post discharge support, reablement and
rehabilitation and falls prevention for older people. Overall the shift towards the community and
80
Measures from the Adult Social Care Outcomes Framework - England, 2012-13
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
35
Page 39
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
prevention services will increase the level of support available to patients to proactively manage
their conditions and increase independence.
Outcome 5: Increasing the number of people with mental and physical
health conditions having a positive experience of hospital care
There are several ways in which feedback from patients and carers is recorded and benchmarked.
We know that the customer perspective is crucial to designing high quality services, but that patients
do not feel that they are treated as customers. Some of the available information comes from the
newly introduced Friends and Family test, asking patients whether they would recommend the
service they received to others, and also through national in-patient surveys.
The friends and family results for in-patient care in December 2013 are below, and are generally
positive for all four trusts in south west London.
NHS Friends and Family results from December 2013 for inpatient care, A&E and maternity
services 81
Inpatient Care December 2013
Trust
Extremely
likely to
recommend
Likely
Neither
likely nor
unlikely
Unlikely
Extremely
unlikely
Don’t
know
Croydon Health
Services
Kingston Hospital
St George’s
Healthcare
Epsom & St
Helier University
Hospitals
65%
28%
3%
2%
1%
1%
65%
69%
29%
25%
3%
3%
2%
1%
0%
1%
1%
1%
68%
23%
3%
0%
1%
5%
Some other available information suggests that there are challenges, however, with Croydon Health
Services reporting that the trust was in the bottom quartile for overall patient experience in the
2012 National Inpatient Survey, as a result of consistently low scores for areas focussing on
communication between healthcare professionals and patients, patient involvement in decisions
especially around discharge, patients feeling they had enough privacy and cleanliness on the wards
and in bathrooms.
The focus of efforts in hospital needs to be to drive up the quality of care available to patients, and
we need to make sure that hospitals provide a positive experience for patients. Examples of this
could be providing a less acute setting for patients, for example through the development of
midwife-led units to care for women in labour who are not considered to be at high risk of
complications, or through providing planned treatment at a separate site away from the often
81
NHS Friends and Family Test December 2013
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
36
Agenda Item 5
Page 40
Chapter 3: Case for Change
South West London Collaborative Commissioning
stressful environment of an acute ward, thereby reducing the numbers of cancelled operations and
providing a better experience for patients.
Summary and strategic objectives
Patients consistently say they want the highest quality services whilst providing the best experience
of care as possible. Improving patient experience can be achieved in a number of ways, through
changing the way care is delivered to involving patients much more in the care they receive. This
will be a theme throughout each section of the five-year strategic plan.
Improving patient experience in hospital is being addressed in a number of ways with plans to
improve sign-posting of services and the provision of an uninterrupted patient ‘journey’. In
maternity, we believe that experience will be improved through better continuity of care, through
consistent provision of one-to-one care in labour and through fewer interventions.
The use of efficient surgical care pathways which are predictable and encourage greater continuity
of care will improve patient experience as they will have services such as therapy, pain management,
oncology, reablement and mental health services built in, ensuring all care is centred around the
patient. The mental health group is looking at innovative CQUINs that reward positive patient
experience with implementation of patient choice from April 2014.
Outcome 6: Increasing the number of people with mental and physical
health conditions having a positive experience of care outside hospital, in
general practice and in the community
Patient experience data are captured for services provided outside of hospital. However this
information is captured less routinely and in less detail, an obstacle which CCGS will be looking to
address as they develop services outside of hospital. A longstanding method for understanding
patient experience is the GP patient survey. Data from 2012/13 demonstrate that there is a broadly
consistent percentage (83-88%) of people who rate their experience of their GP surgery as “very
good” or “fairly good” across each borough 82.
Information is also available on community mental health services. In 2013 the Care Quality
Commission (CQC) carried out a survey of people’s experiences of community mental health services
involving 58 trusts throughout England. A total of 13,000 questionnaires were sent out with a
response rate of 29% amongst service users who were 18 years and older and received specialist
care or treatment for a mental health condition between July and September 2012. For South West
London and St George’s Mental Health NHS Trust, 850 questionnaires were sent with 225 responses
(response rate of 26.5%). 83 The results revealed that the trust was ‘about the same’ as other trusts
when responses to questions around the following areas were compared:
•
•
•
82
83
Health and social care workers
Medications
Talking therapies
NHS England (2013) GP Patient Survey
Care Quality Commission (2013) Community Mental Health Survey
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
37
Page 41
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
•
•
•
•
•
•
Care coordinator
Care plan
Care review
Crisis care
Day to day living
Overall
The only area in which the trust compared badly to other trusts was in the availability of a
documented crisis plan within their care plan (if they had one). The broader trend around mental
health services is that patients have a poorer experience of care at the transition between CAMHS
and adult mental health services, and then between adult and older people’s mental health services.
A further area where information is available is on the NHS 111 service, which was introduced to
make it easier for the public to access urgent healthcare services. Recent data give an indication of
the experience of using the system that patients have had.
Response
Croydon
Wandsworth
Sutton &
Merton
Kingston &
Richmond
% dissatisfied with 111
experience
% very/fairly satisfied
with 111 experience
% callers who fully
complied with advice
% callers where
problem resolved or
improved
9%
15%
9%
5%
86%
80%
87%
91%
90%
89%
84%
90%
82%
82%
83%
88%
Summary and strategic objectives
The data captured above suggest that there is not significant variation in patient experience across
south west London primary and community services, however one of the main focuses for CCGs is to
increase and improve the quality of data collected. Many services do not report regularly on patient
experience and ensuring a consistent approach to understanding how well services are performing
in meeting the expectations of patients is a vital step to understanding how to improve patient
experience across the health system.
Some of the measures being proposed in the five-year strategic plan to improve experience of care
outside of hospital include improved sign-posting of services so that patients are aware of which
service to access. Integrated care services will create a more joined up experience for patients, and
the increase in technology enabled services delivered from primary care and in the community will
provide patients with more information helping them to feel confident in managing their conditions.
RAFT FOR CCG GOVERNING BODY DISCUSSIONS
38
Agenda Item 5
Page 42
Chapter 3: Case for Change
South West London Collaborative Commissioning
Outcome 7: Making significant progress towards eliminating avoidable
deaths in our hospitals caused by problems in care
The need to achieve seven day working and the LQS remains the primary driver for improving quality
across the local NHS, and this challenge has accordingly been addressed earlier in this chapter.
Mortality rates of hospital inpatients have seen a 30% fall over the last ten years. Over 90% of
deaths in hospital occur in patients with unplanned admissions 84 and, as mentioned, those patients
admitted at the weekend are 10% more likely to die compared with those admitted on a weekday.
Finding a sustainable solution for achieving the quality standards set by local clinicians across south
west London will be a theme running through this document. Collaborative work between the six
CCGs will be vital to ensuring this challenge is tackled in a joined up way and that no part of south
west London is left behind in the drive to improve quality.
There are areas where the UK as a whole is being outperformed by other countries and these too
need to be tackled through the strategic plan. Stillbirth rates in England and Wales were 4.9 in 2012
and even higher in London. This makes England and Wales one of the worst performers out of all
developed countries. Much more can be done to ensure that we improve our performance against
international standards as well as local benchmarks.
In mental health care there is also significant work to be done to improve quality. Incidence of
serious harm in mental health care per 1,000 bed days is in the bottom quartile across five out of six
CCGs in south west London, with an area average of 398 incidents against a national median of 160.
Summary and strategic objectives
Elimination of avoidable deaths in hospital will be addressed primarily through the development and
achievement of a minimum set of clinical standards to which all CCGs will commission. These
advances will go hand in hand with increased support for people near the end of life in the
community, so that the majority of people can die in their preferred place of death.
There will be a range of service developments which will help to reduce avoidable harm in hospital
settings, centred around the provision of the highest quality care where it is most needed. Examples
include plans to provide better obstetric care for acutely unwell women in the peripartum period
through improved monitoring, close monitoring of healthcare acquired infections, and ensuring the
right level of consultant presence across multiple specialties.
5. Conclusion
Every CCG in south west London stands behind the case for change. The joint problems of addressing
the quality, workforce and financial challenges cannot be achieved through working at a local level, a
whole health economy solution is required. The following chapter sets out a set of initiatives which
will help to achieve the standards local clinicians have set out, however it is a joint problem and can
only be tackled by all organisations together. We cannot stand by whilst the forces outlined in the
84
Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report’ Sir
Bruce Keogh
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
39
Page 43
Agenda Item 5
Chapter 3: Case for Change
South West London Collaborative Commissioning
case for change place increasing pressure on local organisations. We need to address the workforce
and financial challenges head on and be prepared to make significant change in south west London
to deliver the level of quality and safety patients deserve.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
40
Page 44
Agenda Item 5
Chapter 4: Clinical Workstreams
South West London Collaborative Commissioning
Chapter 4: Clinical Workstreams
5 Year Strategic Plan
23rd May 2014 Draft Submission
Version 2.00
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
41
Page 45
Agenda Item 5
Chapter 4: Clinical Workstreams
South West London Collaborative Commissioning
Contents
Section 1: Children’s Services ................................................................................................................. 43
Section 2: Integrated Care ...................................................................................................................... 69
Section 3: Maternity Care ....................................................................................................................... 103
Section 4: Mental Health ........................................................................................................................ 123
Section 5: Planned Care .......................................................................................................................... 145
Section 6: Transforming Primary Care .................................................................................................... 161
Section 7: Urgent and Emergency Care .................................................................................................. 199
Section 8: Cancer Care ............................................................................................................................ 225
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
42
Agenda Item 5
Page 46
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
Children’s Services
Introduction: why children’s services are important
Protecting and promoting the health of our children and young people in south west London is an
important goal in itself. As children's early experiences are central to shaping their long-term health
and well-being, we recognise it is also critical to improving the health of the whole of our population
and reducing inequalities in health over the longer term. We believe that giving our children the
best start in life means not just focusing on good physical and mental health outcomes but also on
educational achievement, transitioning to adult services, providing a secure and safe environment
for them to grow up in and supporting them to avoid risky behaviours. We believe this can only be
achieved by working in an integrated way.
We are aware of the scale of the challenge in changing children’s services in south west London,
particularly in view of our diverse population. We believe that the best way to improve health
services is to work jointly across the Clinical Commissioning Groups (CCGs), pooling resources where
appropriate but equally recognising our diverse populations.
What does this section of the 5 year strategic plan cover?
The children’s section of the 5 year strategic plan is aimed at improving access to, and the quality of,
services and outcomes for children up to the age of 18 years in south west London. It covers acute
and urgent care, community services, child and adolescent mental health services (CAMHS), health
promotion and ill health prevention. Acute care includes neonatal intensive care and paediatric
intensive care. We recognise that CAMHS services are available to children and young people of
differing ages dependent on what area they live in, although usually for children aged up to 18 years
in full time education. The Special Education Needs Code of Practice is applicable to children and
young people aged up to 25 years of age. In these cases where children overlap between age bands
in differing services, our strategy will focus on their transition to adult services for children aged 18
and under.
NHS England (direct commissioning) is creating a 5 year strategic plan for commissioning specialist
services and primary care, as well as public health interventions for screening and immunisation in
south west London. We will ensure that our plans are aligned with these through the Strategic
Planning Unit which comprises all of the six CCGs in south west London and NHS England.
Local clinicians have previously participated in a strategic planning process for children’s services in
south west London through the Children’s Services Clinical Working Group. Their recommendations
on the design of acute children’s services have helped to form the basis of the new 5 year strategic
plan.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
43
Page 47
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
What is the vision for children’s services in south west London for
2018/19?
In south west London we have developed a vision for children’s services which combines the
ambitions for commissioning of children’s services for all of our six CCGs. We will have a service that
works efficiently and effectively across both community and hospital settings despite the challenge
of increasing demographic and system pressures facing children’s services. We want to ensure our
children receive high quality care, regardless of where they live in south west London. We want to
provide our children with the best start in life to ensure they remain healthy and achieve their social
and educational potential. This means strengthening the whole system, including focusing on
prevention and early years interventions.
We want children and young people to receive as much of their care as possible out of hospital, with
highly skilled staff able to look after children in their own homes wherever achievable. Our hospitals
will adhere to the London Quality Standards (LQS) and will deliver the same standard of acute care,
seven days a week, with senior input ‘around the clock’. Where children need to attend hospital as
urgent or emergency cases, frontline care will be delivered by consultant paediatricians and trained
children’s nurses. Some of these children will not need to stay in hospital overnight and a short-stay
model of care will be promoted where appropriate and safe. We will ensure that there are
alternatives in place for hospital care wherever possible. Children with mental health or behavioural
issues being cared for by CAMHS will have a smoother transition into adult mental health services
when they turn 18. Overall we will have earlier identification of children in need of mental health
services through robust screening and improved access to all levels of mental health support and
services. We will work more closely with schools and focus on early prevention of mental illness.
There will be a focus on prevention of ill health in children as well as promotion of health education
and healthier lifestyles, taking on a family focus where possible and appropriate. To enable this
vision for children’s care, we will need a highly skilled workforce across community and hospital
settings, where generalist and health promotion skills are abundant, and specialist paediatric care
accessible in and out of hospital.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
44
Agenda Item 5
Page 48
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
We believe that children, young people and their families in south west London should
experience care which:
•
Promotes and educates them about good health and the prevention of ill health which in
turn will encourage healthier life in adulthood
•
Minimises disruption to children and their families and carers by providing enhanced
community services
•
Will ensure that we link our plans into schools and education services across south west
London to gain as much momentum as possible to change outcomes
•
Helps avoid unnecessary hospital admissions for children by providing better services in
primary and community care
•
Is of the highest quality and delivered by suitably qualified and experienced clinicians and
nurses
•
Promotes and supports a smooth transition for young people between CAMHS and adult
mental health services
•
Improves the identification of children with mental health problems and access to CAMHS ,
as well as ensuring more children and young people recover from episodes of mental illness
•
Provides an anticipation of the same life expectancy and the same quality of life, regardless
of where in south west London they come from
Figure 1: Our vision for Children’s Services in south west London
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
45
Page 49
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
What is the national context for children’s services?
•
•
•
•
•
•
•
•
•
•
•
Childhood mortality rates are higher in the United Kingdom than the rest of Western Europe 1
Around two-thirds of those deaths happen in the first year of life 2.
The National Child Measurement Programme has observed a steady increase in overweight
and obese children in year 6 (aged 10-11) in line with the national trend, but London has
higher proportions that the national average.
The Healthy Child Programme recognises that a ‘one size fits all’ model of care is not suitable
in a diverse country such as England and that gathering robust data is important to allow
progressive universalism alongside more upstream interventions for children. 3
The Healthy Child Programme recognises that to give children the ‘best start in life’ a
universal approach to screening and health promotion needs to be blended with targeted
and intensive family based interventions for those children recognised with more complex
needs (universal plus and targeted approaches).
A&E attendances of children under five are growing faster than any other age group and over
40% of children attending A&E have problems that could have been managed better in the
community 4.
One in six children in the UK are currently living in poverty. 5
Ten percent of children between five and sixteen years of age have a mental health problem
and undiagnosed depression is a significant problem. 6
Statutory guidance for local authority in England and its partner commissioning bodies
around arrangements about education and health provision for children and young people
with disabilities and special needs is due to be introduced through the Children and Families
Act in 2014.
Commissioning for health visiting in early years will move from NHS England to local
authorities in 2015.
There is an increased pressure on safeguarding services with almost one in five children
under the age of 18 today has experienced serious physical abuse, sexual abuse or severe
physical or emotional neglect at some point in their lifetime. 7
Figure 2: National context for children’s services
1
Meeting the Challenge of the Child National Pledge, NHS England, July 2013
Why children die: death in infants, children and young people in UK, Royal College of Paediatrics and Child
Health, National Children’s Bureau, British Association for child and adolescent public health, 2014
3
Pregnancy and the First Five Years, Healthy Child Programme, Department of Health, 2009
4
Focus on Accident and Emergency, Health and Social Care Information Centre, 2013
5
Department for Work and Pensions, 2013
6
Children and Young People’s Health and Wellbeing in Changing Times, Shaping the Future and Outcomes,
2013
7
Child abuse and neglect in the UK today, Radford et al, 2011
2
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
46
Page 50
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
What is the local context for children’s services?
•
•
•
•
•
25% of all A&E attendances at south west London hospitals are by children aged under 15 8
In five of our six boroughs, levels of obesity in children aged 10-11 are above the average
level nationally 9
In five of our six boroughs in south west London the number of children presenting at A&E
aged under four is higher than the national average 10
London has one of the highest rates of teenagers having unwanted pregnancies in the UK 11.
4 of our 5 acute providers have a short stay assessment model for children. These models
are variable and would benefit from review.
Figure 3: Local context for children’s services
The figures below show the mortality rates of infants in our boroughs per 1,000 live births in
2009/10. There is a significant variation between the boroughs and we need to understand the
reasons for this and how we can prevent deaths of children across south west London.
CCG
Croydon
Kingston
Merton
Richmond
Sutton
Wandsworth
1.7
1.8
3.9
Mortality rates per 1,000 live
3.7
4.7
3.7
births (09/10)
12
Table 1: Mortality rates per borough Source: Office for National statistics
The table below highlights the admissions of children aged up to 17 per 100,000 of the population
for in-patient stays of more than 3 days for mental health disorders in 2009/10. We want to
understand the significant variance between our boroughs and determine if these admissions are
avoidable.
CCG
Croydon
Kingston
Merton
Richmond
Sutton
Wandsworth
Admissions of >3 days for
3.6
7.4
11.3
8.8
11.3
11.2
MH disorders of children up
17 years, per 100,000 (09/10)
13
Table 2: Admissions for in-patient stays for mental health disorders more than 3 days per borough Source: Gov.uk
8
South West London Urgent Care Project, 2013
Child Health Profiles, Public Health England, 2014
10
Child Health Profiles, Public Health England, 2014
11
Transforming Primary Care in London, General Practice Transformation Programme, 2013
12
Office for National Statistics, http://www.ons.gov.uk/ons/index.html
13
https://www.gov.uk/government/publications/special-educational-needs-in-england-january-2013
9
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
47
Page 51
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
What are the key challenges for children’s services that we will address?
The key challenges for children’s services we will address through in this strategic plan are:
1. We need to ensure we have a full understanding of our current service provision in order to
target investment in children’s services in the most efficient way.
2. We need to ensure that improvements in the quality of children’s services are supported by
strong clinical leadership and collaboration with children and their families, local authorities
and public providers, to ensure consistent standards of care across south west London based
on a foundation of strong evidence.
3. We need to increase the number of children being treated in appropriate settings with more
of a focus on ill health prevention, and early intervention and care closer to home.
4. We need to achieve London Quality Standards and make improvements to the quality of
care in children’s acute and urgent services.
Figure 4 : Key challenges
1. We need to ensure we have a full understanding of our current service provision in order
to target investment in children’s services in the most efficient way
Between 2011 and 2021 it is predicted that the number of children resident in south west
London will increase by about 13,500. Peak numbers are in the 0-6 years age group. 14
There has been a general increase in the proportion of children living in poverty across south west
London. 15 Children born into poverty suffer an increased risk of mortality in the first year of life and
a shorter life expectancy once adults; they are more likely to be born early and small, and they face
more health problems in later life.16
Children born into poverty have worse educational outcomes and increased risk of mental and
behavioural disorders such as Attention Deficit Hyperactivity Disorder. 17 Diversity in socio-economic
status across south west London means that families are using children’s services in different ways
making a standardised approach to children’s services challenging. For example, children from
deprived households are more regular attendees at A&E departments, and are more likely to attend
A&E for minor illnesses and injuries rather than seek treatment in non-emergency settings, than
children from wealthier households. 18 In contrast there has been a faster decline in the uptake of
14
Children’s Clinical Working Group, Final clinical report, 2013
London Health Observatory Public Health Performance Report, Association of Public Health Observatories
2009 data from website 2008/09 Q4
16
Childhood development, education and health inequalities, Dyson A et al., 2009, Report of task group.
Submission to the Marmot Review. http://www.instituteofhealthequity.org/projects/ early-years-andeducation-task-groupreport (Accessed May 2012).
17
End Child Poverty, Health Consequences for Poverty for Children, 2012
18
The association between deprivation levels, attendance rate and triage category of children attending a
children's accident and emergency department, T.F. Beattie et al., Emergency Medicine Journal, April 2000
15
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
48
Page 52
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
Measles, Mumps and Rubella vaccinations among children from areas with a higher socio-economic
status 19. The table below shows the percentage of children routinely immunised by 2 years of age
and the variation in its uptake across South West London, particularly against PCV and
DtaP/IPV/Hib20. Our boroughs are not meeting the recommended World Health Organisation
immunisation targets.
Immunisation completion at
2 years by borough in
2009/10 in percentages)
Routine vaccinations against
diphtheria, tetanus, polio,
pertussis and Haemophilus
influenzae type b
(DtaP/IPV/Hib)
Routine vaccinations against
pneumococcal disease (PCV)
Croydon
Kingston
Merton
Richmond
Sutton
Wandsworth
94.40
94.50
85.71
92.26
85.71
86.91
76.48
82.21
71.48
77.99
71.48
82.12
Routine vaccinations against
83.72
85.09
82.90
80.03
82.90
measles, mumps and rubella
(MMR)
21
Table 3: Indicators of immunisation in children under 2 Source: NHS Atlas of variation in Healthcare
85.70
We are also seeing an increase in the number of morbidities resulting from family eating and
exercise behaviours. Childhood obesity is now a major public health issue, with around one in five
children in early adolescence being at risk of becoming obese with all the associated health
problems. 22 We must ensure that we are commissioning universal health interventions as well as
targeting particular groups with specific needs.
Commissioners of all children’s health and care as well as NHS and LA together should jointly
assess needs, plan and coordinate commissioning to create high quality, integrated pathways
of care of all children and young people out of maternity and right through into adult services. 23
Children’s services in south west London have been designed around a traditional acute model of
care. We want to commission and deliver an integrated children’s service model that is focused on
health promotion and early intervention as well as treating children in out of hospital settings
whenever possible. In order to achieve our aspiration we need to understand the current demand
for children’s services and what capacity there is to manage that demand. Assessing needs and
current provision must be completed in conjunction with other organisations involved in delivering
care for children in south west London. Effective commissioning takes a whole pathway approach
and will include joined up working with a number of organisations including Public Health England,
local authorities, adult mental health services, maternity services, Health and Wellbeing Boards,
educational representatives and the criminal justice system.
19
Impact of adverse publicity on MMR vaccine uptake: a population based analysis of vaccine uptake records
for one million children, born 1987-2004, Friederichs V, Cameron J, Robertson C, 2006
20
NHS Atlas of Variation in Healthcare Series: http://www.rightcare.nhs.uk/index.php/nhs-atlas/
21
Ibid.
22
Everyone Counts: Planning for patients 2014/15 to 2018/19, NHS England, 2013, London
23
Vision, Report on Children and Young People’s Health Outcomes Forum, 2012
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
49
Page 53
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
We also need to look at the way in which we collect and analyse data. One of the key
recommendations from the Report of the Children and Young People’s Health Outcomes Forum is
that, with immediate effect, all data about children and young people should be presented in 5 year
age bands through childhood and the teenage years. This will allow relevant local and national
comparisons of key outcomes as well as international comparisons at significant transition points,
such as joining secondary school and transition to adult life. 24
Only when we have undertaken a robust and comprehensive review of our existing services, and
carried out an analysis of population change and its impacts, will we be able to target investment in
the most effective way. We will know where to invest in prevention measures that will provide
improved outcomes and where we can strengthen community provision to achieve a higher yield on
investment. Activities to undertake this work will develop under our initiative ‘Establish baseline
provision and need.’
Figure 5: Summary of challenge 1
2. We need to ensure that improvements in the quality of children’s services are
supported by strong clinical leadership and collaboration with children and
families, local authorities and public health, to ensure consistent standards of care
across south west London based on a foundation of strong evidence
Clinicians are uniquely placed to identify their patients’ needs, the necessary standards of care,
skills, and outcomes which can drive change to services for the right reasons. 25
The Royal College of Paediatrics and Child Health (RCPCH) has clearly stated that children’s
networks, supported by strong clinical leadership and sound management, are fundamental to
improving the quality of paediatric care. Local clinicians working alongside other children’s services
professionals from local authorities, primary care and public health, are well placed to shape local
services and care pathways. A children’s network can bring the following benefits:
•
•
•
•
•
More consistent use of clinical guidelines and best practice management in all settings of
care, for example asthma
Improved workforce planning, for example, multidisciplinary teams based in community
settings
Better development of workforce to include maintenance of skills, development of new skills,
counter-balance for increasing specialisation by rotating staff through different settings and
services
Promotion of an integrated model of children’s care
Provides a forum for engagement with children and families about their services.
24
Children and Young People’s Health Outcomes Strategy, Report of the Children and Young People’s Health
Outcomes Forum, 2012.
25
Bringing Networks to Life, An RCPCH guide to implementing Clinical Network, 2012
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
50
Page 54
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
Despite well researched evidence of good and effective practice, guidelines for the management of
the more common conditions for children and young people in the UK are not being followed across
the entire pathway. For example, children presenting in acute settings for conditions such as asthma
are treated but often discharged with adequate information on how to further manage their
condition at home. The table below indicates the rates of unscheduled hospital attendances in
children with asthma and other common conditions between 2007-10. 26
Indicator (per 100,000
population)
Croydon
Kingston
Merton
Richmond
Sutton
Wandsworth
Emergency admission rate
(DSR) for children with
asthma aged 0–17 years by
borough, 2009/10
241.1
145.7
105.1
141.4
105.1
233.1
Rate of admissions for
bronchiolitis in children under
2 years of age by borough,
2007/08-2009/10
956.5
1,039.8
744.7
990.7
744.7
1,293.5
Emergency admission rate
(DSR) for children with
epilepsy aged 0–17 years by
borough, 2007/08Rate of elective tonsillectomy
in children per 100,000
population aged 0-17 years by
borough, 2007/08-2009/10
55.1
50.3
30.8
26.2
30.8
38.5
174.2
83.1
199.3
154.5
199.3
172.3
Table 4: Indicators around unscheduled attendances for children with asthma and other common conditions for SWL
27
Source: NHS atlas of variation in healthcare
A south west London children’s network is an opportunity to design services locally, improve clinical
quality, take forward evidence-based decisions about models of care, monitor outcomes collectively
and promote integrated services for children. The children’s network will also be able to collaborate
with and influence regional and national service models by connecting with other networks such as
the Strategic London Network, with local providers and with policy makers.
The network is also an opportunity to tackle workforce issues in collaboration across south west
London. As care shifts out of hospital, training needs for community staff should be identified,
specialists should be supported to work in this setting, and multi-disciplinary working are promoted.
The case study below highlights how a networked approach in London has facilitated the up-skilling
of GPs through the Learning Together Programme. The programme has been piloted over 4 sites in
south London and further funding has been granted to expand to 20 sites over 2014.
26
27
NHS Atlas of Variation in Healthcare Series: http://www.rightcare.nhs.uk/index.php/nhs-atlas/
NHS Atlas of Variation in Healthcare Series: http://www.rightcare.nhs.uk/index.php/nhs-atlas/
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
51
Page 55
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
The Learning Together programme
What is the Learning Together programme?
The Learning Together programme is an initiative developed to empower GPs in London to
manage children in the community, build relationships between hospital doctors and GPs, and
improve family and child health as well as chronic disease management.
What kind of activities are we undertaking?
•
•
•
The programme consists of joint clinics run in GP surgeries collaboratively by GP senior
trainees and paediatric senior registrars
Children with complex or chronic conditions or who are acutely unwell are seen with
their families and joint management plans devised.
Multidisciplinary team sessions are held after each clinic to involve other health care
workers in case based discussions and other educational opportunities.
What are the benefits of the model we have seen so far?
Along with up-skilling healthcare workers, children are managed in the community more
effectively and participants have reported they are less likely to refer children to hospital.
Parents have reported extremely high levels of satisfaction with the programme and we have
seen improved management of chronic illnesses such as asthma and constipation.
Figure 6: Learning together programme
The need for a forum for collaboration, clinical leadership, development of standard guidance
across entire patient pathways, and the challenges to workforce and service provision that a
shift to community settings will bring, strongly advocates the need for the ‘Establishment of a
south west London Children’s network.’
Figure 7: Summary of challenge 2
3. We need to increase the number of children being treated in appropriate settings
with more of a focus on ill health prevention, and early intervention and care closer
to home.
Reasons for shifting settings of care to community
There is a strong rationale for increasing the number of children being treated in community settings
and shifting care from acute services closer to home. Reasons include:
•
•
•
Admission to hospital can be stressful for children and their families
Hospital admissions are an expensive form of care
Our paediatric and emergency care consultants have stated that they continue to be
overwhelmed with cases that could and should be managed in the community and therefore
can reduce the availability of resources for emergency presentations
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
52
Agenda Item 5
Page 56
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
•
When high quality care is available in the community, carers and clinicians agree this will
result in better outcomes and patient experience and lead to a reduction in admissions and
re-admissions.
Challenges we must overcome to shift care into community
Currently, lack of consistent availability of appropriately skilled community workforce is a key
challenge in shifting settings of care. There is a shortage of community children’s nursing (CCN)
teams delivering care at home and in the community, who are able to manage children with longterm conditions and minor acute illnesses. 28 There is a significant deficit in the numbers of health
visitors, both locally and nationally, at a time when safeguarding caseloads for complex families are
rising. 29 This prompted ‘The National Health Visitors Plan’ response from the Department of Health
in 2011, as health visitor numbers reached critically low numbers. 30 Strengthening and expanding
our children’s community services also relies on increasing numbers of school nurses, nursery
nurses, children’s centre workers and social care staff. We also need to up-skill existing children’s
nurses and clinicians from acute settings so that they can deliver care and education in the
community.
We also need to reduce variability in access to general practice and other services which
complement a community based model of care in south west London. We acknowledge that our
boroughs contain a small cohort of children who are considered ‘hard to reach’ for various reasons
such as the issues of poverty and the increase in children from other countries migrating to south
west London, particularly in Croydon. Enabling these children and their parents to receive care
when appropriate in the community is likely to be more of a challenge, and focused efforts will be
required to improve health-seeking behaviour particularly for minor illnesses, and improving selfmanagement.
The table below indicates the variation in the expenditure on child community health services per
head across South west London in 2008-09 highlighting the need to be consistent in improving
access to funding and resources in order to meet the needs of children in community.
Indicator
Croydon
Kingston
Merton
Richmond
Sutton
Expenditure on child community
£122.69
£119.27
£85.15
£153.01
£85.15
health services per head of
population aged 0-17 years by
borough, 2008/09,
31
Table 5: Expenditure on child community services Source: NHS atlas of variation in healthcare
Wandsworth
£180.84
28
Defining staffing levels for children and young people’s services, Royal College of Nursing, 2013
A review of arrangements in the NHS for safeguarding children, Care Quality Commission, 2009
30
The National Health Visitor Plan, Department of Health, 2013
31
NHS Atlas of Variation in Healthcare Series: http://www.rightcare.nhs.uk/index.php/nhs-atlas/
29
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
53
Page 57
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
Early years interventions
To further improve outcomes, we need to increase the focus on early years interventions. There is
growing evidence that what happens in these early years of a child’s life has lifelong effects on many
aspects of health and well-being from obesity, heart disease and mental health, to educational
achievement and economic status. 32 This is particularly needed in the case of looked after children
of whom 45% are estimated to have a mental health disorder in childhood, and who are least likely
to achieve their true potential due to the disadvantages they have suffered in their childhood
years. 33
Health visitors in conjunction with midwives can support good outcomes by encouraging more
women to breastfeed. Evidence supports increased breastfeeding rates reduce childhood illnesses,
which in turn reduces hospital admissions in under infants 34. Infants who are not breast fed are likely
to become obese later in childhood, develop type 2 diabetes and have higher levels of blood
pressure and cholesterol as adults 35. The following table shows variation in breastfeeding rates at 6
weeks after birth in south west London.
Indicator in 2010-11
Croydon
Percentage of infants who are
67.26
totally or partially
breastfeeding at 6-8 weeks
36
Table 6: Indicators of infants who are breastfed
Kingston
72.13
Merton
60.95
Richmond
71.28
Sutton
60.95
Wandsworth
72.74
Preventions for young people
Groups of young people are also exposing themselves to rising levels of risky behaviours.37 The cost
of teenage pregnancy is estimated at approximately £231 million per annum and the cost of crime
against individuals and households estimated at £36.2 billion in 2003/04. Whilst it is not reasonable
to assume that all of these costs could be negated through investment in early years interventions,
this does show the scale of remedial spending incurred in some areas. If further investment were
directed towards the early years and ‘getting it right first time’ then some of the remedial costs later
in life (for example, in relation to truancy, teenage pregnancy, anti-social behaviour or crime) could
be alleviated 38.
There are high rates of undiagnosed mental illness 39, with 10% of boys and 13% of girls between the
ages of 11 and 16 suffering from a mental health problem. We have identified earlier and increased
access to mental health services and a better managed transition from CAMHS services to adult
mental health services as areas for improvement in south west London. We need to understand and
32
Fair Society Healthy Lives, The Marmot Review, 2010
st
Mental Capital and Wellbeing, Making the Most of Ourselves in the 21 Century, Government Office for
Science, 2013
34
https://www.gov.uk/government/publications/infant-feeding-profiles-2010-to-2011
35
http://www.cdc.gov/nccdphp/dnpa/nutrition/pdf/breastfeeding_r2p.pdf
36
NHS Atlas of Variation in Healthcare Series: http://www.rightcare.nhs.uk/index.php/nhs-atlas/
37
Young people in London: Abortion and repeat abortion, Department for children, schools, and families, 2012
38
Greater London Authority, Early years intervention to address health inequalities in London, 2011
39
Annual report of the Chief Medical Officer, Our children deserve better: prevention pays, chpt 10, 2012
33
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
54
Page 58
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
overcome these transition issues, including where young people leave and return to south west
London, to prevent destabilisation of their mental health and provide confidence in services as they
reach adulthood. It is also recognised that children and young people will benefit from early
screening, and peer support for mild depression, self-esteem or emotional issues and body-image
concerns. This will prevent more severe mental health problems, impacting social wellbeing and
educational achievements ensue.
To maximise educational achievement, early screening should be undertaken in partnership with
educational institutions where difficulties in learning met by a young person are often first picked
up. The table below highlights the percentage of children in state funded schools with a statement
of special education needs. We also need to factor in the implementation of the Special Education
Needs Code of Practice (as per the revised Children and Families Act) and consider the statutory role
that education authorities have to deliver better health outcomes in conjunction with health
commissioners such as school based counselling.
Indicator
Croydon
Kingston
Merton
Richmond
Percentage of primary school
1.2
1.8
1.5
1.9
children in state funded schools
with a statement of special
education needs by local
authority at January 2011
40
Table 7: Indicators of primary school children in state funded schools with a Special Education Need
Sutton
Wandsworth
2.2
2.0
We have an opportunity to commission innovatively and to tailor interventions to the and needs and
preferences of our children and young people.
An example of how technology was used to provide an information service to young people can be
found in Appendix 1A.
Supporting parents and carers
Supporting the needs of parents can in turn help the child make more progress, especially in cases
where a child has long term conditions. Services which are centred around children’s centres in
south west London, provide a family-based approach. Children’s centres provide a hub in the
community, where all services for children can be provided from or networked to, but this will
require an integrated approach between commissioners, providers of services and professionals.
The case study below highlights the work of the pilot programme ‘Family Nurse Partnership’ in
Merton which provides nurses to support first time mothers who are on low incomes. This is an
example how supporting parents has worked well.
40
Office for National Statistics, http://www.ons.gov.uk/ons/index.html
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
55
Page 59
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
What is the Family Nurse Partnership?
The programme provides nurses, who have participated in intensive training in working with and
coaching families from disadvantaged backgrounds, to visit families on a regular basis from early
on in the mother’s pregnancy until the child is two years old. By working with families and
providing support and coaching on health and other issues (for example nutrition, alcohol, drugs
and smoking, breast feeding, sexual health and safety at home), peer support networks are
developed ,increasing families internal resilience and confidence in their own abilities, and
empowering them to look after themselves both as a family unit and community. Rather than
reacting to demand (for example increased ill health), this initiative is designed to prevent needs
arising in the first place.
Figure 8: Family nurse programme
Community models of care
The use of integrated community models of care is increasing. In Warrington, a paediatric model
which allows children who present to their GP with specific conditions, such as simple febrile
illnesses, to be given follow up appointments by trained community children’s nurses who can visit
children at home, and prevent attendances in A&E. 41 Locally, in the borough of Richmond, an
emerging and innovative integrated children’s model has been implemented in stages and is starting
to show benefits including an increasing identification of young people with mental health needs.
This is one of the models of care we may wish to explore in more detail to ascertain where the
benefits of co-commissioning in selected areas might be derived. Details of the Richmond integrated
model can be found in Appendix 1B.
There is a compelling need to improve the outcomes for children in south west London to enable
them to fulfil their full potential and lead healthier lives into adulthood. In order to achieve this we
need to work in collaboration with other organisations and improve transitions to adult services.
This has led us to create an initiative ‘Build community capacity and resilience.’
Figure 9: Summary of challenge 3
4. We need to achieve London Quality Standards and make improvements to the
quality of care in children’s acute and urgent services.
In south west London we are committed to fully achieving the London Quality Standards across our
acute and urgent care children’s services by 2016/17, providing high quality care and maintaining
sufficient senior consultant presence on site. (The LQS are available in Appendix 1C.) We recognise
the current pressures on the acute children’s workforce, with rising demand for unplanned care. For
acute services, lack of senior clinician availability can result in less timely decisions made about
41
www.bridgewater.nhs.uk/warrington
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
56
Page 60
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
children’s care, ranging from discharge decisions to escalation of management. 42 Clinically
significant information can be lost during shift handovers between junior staff, which can lead to
adverse outcomes for patients 43. Consultant presence at handovers ensures that issues are flagged
up and addressed earlier. Over the next five years we need to ensure that we continue to attract
talented medical and nursing professionals to both acute and community children’s services.
In addition to the challenges of achieving LQS and developing the trained and specialised workforce
that the standards are dependent on, several key priorities exist to improve the quality of urgent and
emergency care for children. We have discussed in our initiative to ‘build community capacity and
resilience’ the need to improve community management of common childhood conditions (e.g.
asthma, constipation, diabetes) so that we reduce the frequency and severity of exacerbations of
these conditions. This will reduce the number of unplanned GP and emergency department
attendances and hospital admissions, reducing strain on acute services and improving quality of life
for patients and their families. The figures below highlight the diversity in the number of children
attending A&E across our boroughs.
Indicator (per 100,000
population)
Croydon
Kingston
Merton
Richmond
Sutton
Wandsworth
Rate of accident and emergency
(A&E) attendances under 5 years
by borough, 2009/10
624.65
597.95
733.51
501.67
733.51
762.86
Table 8 Rates of A+E attendances in under 5s, Source: NHS atlas of variation in healthcare
44
We need to review and signpost non-hospital based care and options for provision of urgent advice
for parents and young people including access to primary care services in and out-of-hours
(discussed in further detail in Chapter 4 Section 7), community pharmacies, NHS 111 and online
resources. In addition, we will work to improve the availability and quality of ambulatory care
provision in the community so that children can be discharged from hospital earlier and get better in
their own homes. We will review outputs from the Ambulatory Emergency Care Delivery Network
(developed to strengthen ambulatory care provision for patients with urgent conditions) through the
children’s network to understand the opportunities for further developing ambulatory emergency
care in children's urgent and emergency care pathways.
Sick children can deteriorate and become critically unwell swiftly, and prevention of rapid
deterioration and early identification of the sick child requires highly skilled staff to recognise and
respond early. We need to work with community healthcare workers in increasing training about
early recognition and management of sick children and by improving our signposting and navigation
of acute services so that children who do need to be seen urgently are identified and treated earlier
and are able to easily navigate the acute care system.
42
Seven days a week forum, Evidence base and clinical standards for the case and onward transfer of acute
inpatients, NHS Services, 2013
43
Adequacy of information transferred at resident sign-out (in-hospital handover of care), Quality and Safety
in Healthcare, Clarke et al, 2008
44
NHS Atlas of Variation in Healthcare Series: http://www.rightcare.nhs.uk/index.php/nhs-atlas/
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
57
Page 61
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
It is crucial that children who are seriously unwell are looked after by healthcare workers with the
time, training and expertise to provide excellent care. Emergency departments, paediatric wards
and high dependency care areas require senior and appropriately trained staff so that deteriorating
and unstable children who may require transfer to Paediatric Intensive Care Units (PICU) or Neonatal
Intensive Care Units (NICU) are identified and managed appropriately. Nationally, standards for
delivering high dependency care on general wards vary, including variation in nursing staff. 45 The
children's network (as discussed earlier) is an opportunity to address such variances and design
standard specifications and link with the London Strategic Clinical Networks to implement these.
4 out of 5 acute trusts in south west London currently offer short-stay models of care in the form of
‘paediatric assessment units’ (PAUs) or “short stay units” (SSUs). Such units encourage a more
proactive and dynamic approach to patient management and bed-flow, allow children to be seen
earlier by more senior paediatric staff and shorten length of stay for many patients, often reducing
the need for an overnight stay in hospital. It is acknowledged that addition of PAUs and change
inpatient capacity is likely to change the case mix of inpatient wards, while the number of inpatient
beds may be reduced, the complexity and acuity of inpatients will be increased resulting in higher
dependency care requirements and resultant workforce implications 46. In addition, effective PAUs
and SSUs will need high levels of staffing, but overall there is likely to be net reduction in acute
staffing levels 47. In south west London variation in the PAU models being delivered (e.g. hour of
opening and staffing level) warrants review in 2014/15, and the optimal combination of inpatient
wards and PAUs will be collaboratively agreed following this process. It is anticipated that this work
should facilitate achievement of the LQS.
Improving urgent care services for children is a key priority and we are aware of the need to reduce
the overall activity in this area while increasing and sustaining quality. We believe that by ‘building
community capacity and resilience’ and by exploring alternative and innovative models of care, we
will be able to shift care away from acute settings wherever appropriate, and reduce avoidable
admissions. The interdependency with other services, in particular our intentions to strengthen
whole system urgent care services for adults (see chapter 4 section 7), improve neonatal and
maternal services (discussed in Chapter 4 Section 3) is appreciated and will be explored and
developed during this work.
We have developed activities around an initiative to ‘Improve children’s urgent and acute provision’
in our five year strategy. We need to develop activities over the next five years to efficiently and
effectively manage acute services in south west London that are safe and of high quality.
Figure 10: Summary of challenge 4
45
Defining staffing levels for children and young people’s services, Royal College of Nursing, 2012
Short stay paediatric assessment units, Royal College of Paediatrics and Child Health, 2009
47
Seven days a week forum, Evidence base and clinical standards for the case and onward transfer of acute
inpatients, NHS Services, 2013
46
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
58
Agenda Item 5
Page 62
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
How we developed our initiatives for improving children’s services
As previously discussed, the children’s services CDG reviewed the previous work of the Clinical
Working Group from the Better Services Better Value programme in order to inform future thinking.
We recognise and support the principles from this previous work around shifting settings of care into
community, increasing the attention to the level and type of prevention and awareness work
community staff will be doing, and the issues of transition of children to adult services.
The development of the initiatives has been through the children’s services CDG which involves a
wide range of stakeholders including acute, community and mental health clinicians, CCG and LA
commissioners, providers of children’s services and public health representatives. A first draft of our
strategic plan, outlining key themes and challenges was submitted to NHS England on 4th April 2014.
The children’s services CDG met in April 2014 to agree what activities should be taken forward in
order to deliver our vision for children’s services. The CDG agreed that the following four key
initiatives should be would be prioritised:
1.
2.
3.
4.
Establish baseline provision and need
Establish SWL children’s network
Build community resilience and capacity
Improve children’s urgent and acute provision
The key challenges in re-designing children’s services highlighted by the CDG included:
•
•
•
Costs of running an enhanced community model alongside current acute service provision.
Sequencing of activities across the four initiatives and linking into other interdependent
areas of the plan to achieve best outcomes.
Understanding population risk over the next 5-10 years in south west London which has
significant demographic shifts across the patch and a changing demographic profile in each
borough.
Figure 11: Key challenges for improving children’s services
The group concluded that the following are key enablers for improving the services:
•
•
•
•
A key activity which will underpin the success of implementing all initiatives is the need to
establish an understanding of current service provision in each CCG.
As far as possible, for establishing the baseline provision and need the aim should be to
combine data sets, including access to local authority and community provider metrics.
There is a strong interdependency between each of the four initiatives. The sequencing of
planned activities will be crucial to the success of the implementation of the plan. Expected
benefits of the enhanced community model should be realised before changes to impacted
acute services are implemented, in order to ensure expected benefits are being achieved.
Implications of not achieving LQS must be understood and alternatives considered.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
59
Page 63
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
Figure 12: Enablers for improving children’s services
We held a stakeholder group on the 8th May 2014, which included patient and public
representatives, CCGs and providers. There was general consensus that the children’s services plan
are focusing on the right areas. The group raised the following points which we have taken into
account in the development of our initiatives:
•
•
•
We need to factor in the implementation of the Special Education Needs Code of Practice
and consider what the role of educational providers (schools) is in health. We need to work
closely with them as some are commissioning services for their school (such as counselling
and MH)
There are areas of both deprivation and poverty but also wealth across the boroughs in
south west London. Each brings different challenges for health commissioners and
providers. Therefore, Children’s services need to meet all needs for all across south west
London but different local needs too
Children’s model needs to deliver community level resilience but also a child/individual
resilience for the child’s life ahead of them.
What are the interdependencies with other workstreams?
We have highlighted throughout the chapter the links from children’s services to other parts of the
strategy. Children’s services are primarily interdependent with urgent care, primary care, maternity
services and adult mental health services.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
60
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
What are the initiatives that will address our challenges in children’s services?
1
Establish baseline provision and need
Benefits for patients:
• Early improvements in consistency, quality and transparency
of care
• Integrated approach to planning of community services
resulting in joined up care with better outcomes for patients.
Milestones and activity / finance impact:
Performance monitoring description:
Year
Milestones
2014/15
•
•
•
•
2015/16
• Detailed analysis of year 1 baseline data
• Community strategy developed
Plan for engagement with NHSE, LAs and HWB
Map of existing community services
Analysis of population data
Scorecard developed
The scorecard will be monitored through the children’s network which will
allow refinement of strategy through analysis of robust data.
2016/17
• Strategy refined based on year 1 and 2 results
2017/18
• Strategy refined based on year 3 results
How we will measure performance:
2018/19
• Implementation of further improvements based
on scorecard results
Develop local KPIs to support community
strategy
Target to be finalised year
one
Achievement of highlighted milestones to
include development of plan for collaborative
working, scorecard and baseline data agreed
with assessment of population risk over future
years.
Target to be finalised year
one
Page 64
Major activities over the five years :
• Establish plan and methods of working with NHSE, local authorities
and HWBs for development of community strategy and inclusion of
shared data sets for baseline exercise.
• Establish baseline provision and need across south west London for
population risk and capacity of provision.
• Assessment of population risk over the next 5-10 years.
• Carry out mapping exercise of existing children’s community
services.
• Define strategy for community based working in children’s services.
• Develop a shared scorecard to measure outcomes and efficiencies
that includes agreeing shared definitions for specific clinical
outcomes across SWL providers.
• Detailed analysis of year one baseline provision and need.
• Monitor impact on activity flows, outcome metrics and efficiency
through the SWL children’s services scorecard.
• Refinement of strategy based on collated data and analysis.
System risks:
• Potential reputational risk due to increasing transparency of
clinical performance through publications of outcomes.
• Unable to gain agreement on collaborative working and
community strategy amongst stakeholders
Figure 13: Establish baseline provision and need
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
61
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
2
Establish a south west London children’s network
Major activities over the five years :
Benefits for patients:
•
•
•
•
•
•
•
Early detection of problems through improved performance measuring.
Improved consistency of care across south west London with pathways
leading to improved outcomes and experience.
Increased sharing of best practice, collegiate working across providers and
reduced fragmentation leading to improved experience.
Milestones and activity / finance impact:
Year
Milestones
2014/15
•
•
•
Network established with agreed membership, function and
accountability
Programme of work for network agreed
Standard specification for pathways developed
•
•
Published scorecard and guidelines
Agreed and implemented schemes for early years
2016/17
•
•
Reviewed and evaluated results of schemes
Audit of compliance with guidelines
2017/18
•
Evaluated results of and impacts of implementations through
scorecard
2018/19
•
Evaluation of schemes and guidelines intervention to inform
next programme of work
Performance monitoring description:
Establishment and function of the network. Development of standard
specification and recommendation for services provided children
suffering from common conditions, improvements in early years
interventions and prevention of ill health.
How we will measure performance:
Network established with governance structure
and agreed plan for collaborative working
Target to be
finalised year one
Programme of work established
Target to be
finalised year one
Effectiveness of standard pathways and
interventions - (KPIs dependent on selected
Target to be
finalised year one
programmes of work following on from baseline provision
exercise)
h
System risks:
Target to be
finalised year one
•
•
Network members not being able to give sufficient bandwidth to the
network
Lack of agreement among stakeholders on governance and structure.
Agenda Item 5
Scorecard and guidelines published within
agreed timelines
2015/1625t
Page 65
•
•
Establish children’s network of clinicians and children’s experts
alongside local authorities, PHE and NHSE to take a population-wide
view of improving children’s health.
Agreed accountability for the network informed by baseline
provision and need data as well as governance and membership.
Agreed mandate and programme for network plan over years 2 and
3, focused on shifting care into the community and prevention of ill
health as well as agreeing consistency of pathways and models of
care.
Working with other networks , specifically focussing on SWL
maternity network on early years to facilitate transitions between
postnatal and early years care, improving immunisation and
breastfeeding rates.
Publication of dashboard and guidelines. for common conditions
Audit of compliance with guidelines for common conditions
Figure 14: Establish a south west London children’s network
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
62
3
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
Build community resilience and capacity
Benefits for patients:
• Children and their families will be treated in the community by resulting in less disruption to them
and their families and carers.
• Improved educational outcomes for children with mental health problems.
• Greater integration between mental health services resulting in a more consistent patient
experience.
System risks:
• Continued movement of clinical staff to community posts risks destabilising acute services.
• Lack of resources available to meet workforce demand
• Resistance to changes across workforce
• Losing expertise and tacit borough level knowledge through cross borough working
• Issues around service viability in providers with reducing volumes and inadequate funding
• Increasing birth rates creating pressures on the system
Milestones and activity / finance impact:
Year
Milestones
2014/15
•
•
•
•
Implement obligations identified in Children and
Families Act
Benchmarked current provision against best practice
models
Specified workforce and recruitment change plan
Agreed revenue investment in community nursing and
training and workforce changes
2015/16
•
•
•
Implement training programme
Implement pilot of enhanced community model
Define standard data sharing protocol
2016/17
•
•
Roll out integrated model implementations
Formalise transition to adult services
2017/18
•
Review impact of model
2018/19
•
Review community provider landscape
Page 66
Major activities over the five years :
• Implement initiatives resulting from statutory obligations identified in Children and Families Act
2014
• Carry out stocktake of existing community workforce and training programmes in order to establish
gaps in existing provision.
• Scoping exercise to establish ‘what good looks like’ in community based models of children’s care
and associated risks with those models.
• Work with HESL to scope out:
• Specifications for community based roles
• Workforce planning and specify training needs for community based working in children’s
services including analysis of potential transfers from inpatient services and ‘skill mix’ of
existing community working
• Community standards and specifications for community based working
• Agree revenue investment and implement children’s community nurses and retraining programme
with HESL and acute providers.
• Identify a pilot site(s) for investment in an integrated community model
• Scoping exercise to determine areas for transition planning from children’s to adult services
including CAMHS
• Work across trusts to enable 1 point of access for CAMHS in each borough
• Collaborative working to formalise and improve the transition process from CAMHS to adult mental
health services and any other transition areas identified
• Scoping of IT systems for data sharing across children’s services and joint data protocols
• Review impact of pilot investment in integrated model and identify funding for further sites /
services
• Agree full rollout of children’s integrated model by end of year three covering SWL-wide footprint
• Continued investment in children’s community nurses and retraining programme with HESL and
acute providers
• Review community provider landscape to determine activity, quality, efficiency and workforce
Performance monitoring description: Development of local metrics for
support activities required to implement integrated community model.
How we will measure performance:
Rates of training to up-skill
Target to be finalised in year one
Recruitment and retention rates
Target to be finalised in year one
Numbers of children shifted from
acute care to community care
pathway
Target to be finalised in year one
Numbers of children with a plan for
adult services
Target to be finalised in year one
Numbers of children with education
and health care plans
Target to be finalised in year one
Improvements in breast feeding rates
Target to be finalised in year one
Improvements in immunisation rates
Target to be finalised in year one
Borough level reductions in mortality
rates
Target to be finalised in year one
Figure 15: Build community resilience and capacity
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
63
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
4
Improve children’s urgent and acute provision
Major activities over the five years :
Benefits for patients:
•
•
•
•
•
•
•
•
Evaluate results of LQS audit and agree trajectory for achieving LQS
in all SWL providers.
Investigate implications and alternatives to not achieving LQS
Conduct evaluation of SGH PAU model of care and equivalents to
inform potential expansion of PAU model to DGH’s.
Review outcome of PAU evaluation and commission standard
model at other DGH’s.
Review viability of children’s inpatient units across all acute sites
given loss of activity to community services and workforce
challenge in meeting LQS.
Review impact of CQUIN investment in improving standards and
outcomes across all SWL providers.
Consult on consolidation of acute inpatient provision to ensure long
term clinical and financial viability, working closely with the SWL
children’s network to ensure system readiness and agree necessary
clinical gateways.
model is providing safer and improved quality of care.
How we will measure performance:
Milestones and activity / finance impact:
Year
Milestones
2014/15
•
2015/16
2016/17 25t
2017/18
Reduction in A&E attendances
Target to finalised in
year one
Reduction in LoS in acute services
Target to finalised in
year one
Yearly LQS audit
Target to finalised in
year one
Reduction in SUIs
Target to finalised in
year one
Reduction in inappropriate admissions
Target to finalised in
year one
PAU KPIs are met
Target to finalised in
year one
h
2018/19
•
Evaluate LQS audit and agreed timeline for
achievement
Evaluation of PAU model
•
•
Development of standard PAU model
Review progress towards LQS
•
•
Roll out of PAU model
Review viability of inpatient units
•
Review impact of CQUIN
•
Finalise plans for consolidation of inpatient provision
Page 67
Performance monitoring description: KPIs to demonstrate acute
•
Increased senior decision making through investment to meet LQS
reduces admissions and LoS as well as improving outcomes.
All providers meeting LQS means SWL providing consistent high quality
acute children’s services.
System risks:
•
•
•
Transition risks associated with reducing footprint of acute children’s
services
Interdependency of children’s services result in the need for
consolidation of additional clinical services and therefore increases
opposition and external scrutiny.
Increased financial pressure on either commissioners and providers due
to the ‘cost of quality’ associated with the delivery of LQS.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
Agenda Item 5
Figure 16: Improve children’s urgent and acute provision
64
Agenda Item 5
Page 68
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
When will we achieve the initiatives for children’s services?
Figure 16: Timeline for children’s services initiatives
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
65
Page 69
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
How does our work to improve children’s services address the outcomes in
Everyone Counts 48?
The vision for our children’s services will address the seven measureable outcomes 49set out in the
national planning guidance and the three key measures outlined below.
1. Additional years
of life
2. Health related
quality of life
• Earlier and
• Improved access to
increased diagnosis
psychological
of mental and
therapies.
physical health
• Further health
issues.
promotion
• Interventions for
initiatives.
tackling childhood • Increased health
obesity.
visitor support for
• Better uptake of
early years.
infant and child
immunisation
programmes.
5. Positive
experience of
hospital care
• More treatment of
children delivered
in children’s
facilities.
• More trained
children’s nurses
48
49
6. Positive
experience of care
outside hospital
• More care for
children in
community by
children’s
community nurses.
3. Time people
spend avoidably in
hospital
• Integrated care
approach for
children with long
term conditions,
reducing the need
for hospital
admissions.
• PAU model of care
as an alternative to
inpatient admission
for emergency care
for 70% of patients.
4. Proportion of
older people living
independently at
home
• n/a
7. Avoidable deaths
in our hospitals
• Increased presence
of consultant
paediatricians.
• Earlier involvement
of consultant
paediatricians in
care.
Everyone Counts: planning for patients 2014/15 to 2018/19. 2013. NHS England
Ibid.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
66
Agenda Item 5
Page 70
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
What are the investment implications of these initiatives?
The strategic plan outlines a bold and ambitious approach to improving the quality of care delivered
across acute, community, mental health and primary care services. In order to deliver these clinical
ambitions and achieve a financially sustainable health economy, south west London commissioners
will need to work together to prioritise how best to address the multiple challenges identified whilst
supporting the investment required to deliver transformational change.
The redesign of children’s services in south west London including increasing the capacity of
community based services will require both a shift of spending from acute provision to the
community and also a level of increased investment. At this point the financial implications of the
children’s strategy are not known in any detail, due to the need for the extensive baselining exercise
identified in Initiative 1 above. Once the financial implications and the proposed detailed model of
care are known, it will become possible to agree a more specific implementation plan. It is
important however to note that it is already clear that there is more investment required to deliver
the various initiatives identified in the overall strategic plan than can be financed from the available
financial resources; this will require there to be appropriate prioritisation by commissioners.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
67
Page 71
Agenda Item 5
Chapter 4: Clinical workstreams, Section 1: Children’s
Services
South West London Collaborative Commissioning
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
68
Agenda Item 5
Page 72
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
Integrated Care
Introduction: Why Integrated Care is important
In south west London we have recognised the importance of integration between health and social
care having listened to the experiences of our patients and service users. We understand that
historical silos between health and social care have created inefficient interfaces between services.
We know that our patients, services users, their carers and families want professionals to
understand their needs, without having to repeat their story each time, be empowered to take part
in how their care is delivered and be supported at the right time to remain healthy and independent.
We know that integrated care means working in multidisciplinary teams across health and social
care, involving primary care teams and specialists. We know that case management, involving
people in their care plan regularly and having a single person to contact is important. This all means
that a huge cultural change in the way we deliver care is required to address the challenge of
working across organisational boundaries and to prevent fragmentation of care for our patients.
In south west London we recognise that integrated care should be delivered according to the needs
of the local population, which varies across our boroughs. Whilst we have reflected a local approach
through each borough’s Better Care Fund (BCF) plans, we know we can work collectively on some
key areas to have a stronger impact together. We have collectively identified ten significant areas to
focus our collaborative efforts. These are:
•
•
•
•
•
•
•
•
•
•
better communication between commissioners, providers, other stakeholders and the public
shared integrated care quality standards
improved focus on prevention through services
improved approach to helping patients access the right services
improved approach to helping patients manage and development of structured education
for patients
improved approach to discharge planning relationships between shared acute providers,
local authorities and community providers
financial and activity modelling
planning and development of the workforce
implementation of improved IT systems
developing a joint response to information governance issues
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
69
Page 73
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
We know that planning, implementing and delivering integrated care is a national objective, and
there are significant challenges to achieving this successfully. We acknowledge that further
assurance and confidence is being sought around BCF plans nationally, as was announced in the
national media. This reflects the degree of the challenge, the emerging nature of integrated care and
that achieving the outcomes we want and need to achieve in south west London will require our
joint effort.
What does this section of the 5 year strategic plan cover?
This section describes all care which is delivered to adults in the community or outside hospital, and
is increasingly being delivered jointly between health and social care providers through the advent of
the BCF. The BCF is an enabler to integrated care, but the scope of integrated care includes all
services which improve and strengthen community-based adult care.
The section includes:
•
•
•
•
•
•
•
services supporting people with long term conditions (LTCs)
services supporting patients identified as being at high risk of a hospital admission
community-based rapid response services
services supporting patients in the community post discharge
outpatient consultations where the primary diagnosis is related to LTCs
planned medical day care
services to support patients with co-existing LTCs and mental health conditions.
It does not include services, such as housing services, which are provided by local authorities and are
not directly related to care delivered jointly with healthcare providers. It also does not include
services provided by primary care, which is considered in section 6 of chapter 4. Although the scope
does not directly include primary care or voluntary care services, integrated care overlaps with and
links with these services and the professionals providing such services. Therefore strategic
consideration of integrated care will include the relationships between integrated care, primary and
voluntary care services.
What is the vision for Integrated Care in south west London for 2018/19?
In south west London we have developed a vision for integrated care which combines the six CCGs’
local ambitions for community-based health and social care services. Our collaborative vision has
harnessed common areas of each CCG’s BCF plans, and other key planning stages such as
commissioning intentions and two-year operating plans.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
70
Agenda Item 5
Page 74
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
We aim to expand and improve services provided outside hospital, up-skill the workforce, increase
specialisation in the community and high quality care out of hospital whenever appropriate. We
want people to experience an uninterrupted journey through services, ensure that patients’ families
and carers receive education and support, and improve connections to the voluntary sector. In
addition, integrated services will make better provision for mental health care to enhance overall
wellbeing, independence and ‘social capital’.
In south west London we want to improve integrated care in line with our vision in Figure 1, and to
enhance patient experience and confidence in integrated care services as a consequence.
In south west London we believe that people should experience integrated care which:
• Helps people to self-manage their condition and helps understand how, when and who to
access care from when their condition deteriorates. This means that preventative advice is
given by their care coordinator and they can access structured education.
•
Helps to keep people with one or multiple LTCs and complex needs stable. This means that
patients at risk have been identified and assigned a care coordinator who intervenes when
appropriate. Helps people who are at risk of losing their independence to access services which
increase their ability to live independently and improve quality of life. When they are at risk,
their GP or practice nurse is able to signpost them to a care navigator (or equivalent) to help to
access services
•
Allows people to get timely and high quality access to care when they are ill, delivered in the
community where appropriate. Improved signposting to services will ensure people know
when and where to access the right services. Allows professionals to be familiar with the
patient’s circumstances, to support their preferences, and to provide continuity where agreed,
while including them in making choices about their care through a care which is reviewed each
time there is contact with their care coordinator
•
Supports people who are in hospital to be discharged back home as soon as they no longer
require hospital care, with appropriate plans in place for care to continue at home. People will
know how they will be looked after when they leave hospital and their care coordinator or
primary care team will contact them when they are discharged
•
People who are discharged from hospital with the right level of support delivered at home or in
the community to prevent readmission and promote independence. This means they receive
appropriate reablement therapy whether at home or in the community, professionals will
provide regular care until they are independent again. Where they suffer from mental health
issues, a mental health support worker will assess their needs and plan further mental health
care for them. They will also be actively connected up with voluntary sector services where
these can help them to becomes more independent and enjoy life
•
Supports and provides education to both family and carers to ensure their health and wellbeing needs are met, and includes support to maintain finances and staying in work, where
relevant.
•
Helps people requiring end of their life care to be supported to receive their care and to die in
their preferred place. People who are identified as being at the end of their lives are registered
on Coordinate My Care which will hold information about their preference of care and place of
death and prevent unnecessary admissions to hospital.
Figure 1: The vision for integrated care
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
71
Page 75
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
What is the national context for Integrated Care?
•
•
•
The government recognises that joint, integrated working is important to develop a
personalised health and care system that considers people’s health and care needs 1.
In order to enable collaborative working between health and social care, the government has
introduced a pooled funding arrangement known as the Better Care Fund 2 and the Care Bill 3
which places new duties on local authorities and was passed 14th May 2014
The integrated care ‘pioneers’ programme has been established to support sharing of best
practice to develop effective, ambitious and innovative approaches for integrated care
Figure 2: The national context
According to the King’s Fund 4, successful integration of health and social care has the potential to
offer three key benefits:
•
•
•
Improved outcomes for people, including increased independence with maximum choice
and control
Better use of existing resources, ensuring patients get the right care, in the right place, at
the right time
Increased access to and improved satisfaction with health and social care services.
Recognising the benefits of integrating health and social care, the Government introduced, as part of
the June 2013 Spending Round, the BCF 5; a pooled fund for health and social care services which will
be worth approximately £3.8bn in 2015/16.
The following principles of integrated care plans have been of national interest 6:
•
•
•
•
•
•
•
Reducing the complexity of services
Wrapping services around primary care to ensure groups of practices are supported by staff
with whom they are familiar and can develop shared ways of working
Creating multidisciplinary teams for people with complex needs, including social care,
mental health and other services
Providing specialist medical inputs to these teams and redesigning approaches to consultant
services, particularly for older people and those with LTCs
Developing services that provide an alternative to hospital stay
Creating an infrastructure to support the new model, including improving the ways in which
to measure and pay for services
Developing the capability that makes the power of the wider community more effective.
1
Department of Health/Department of Communities and Local Government 2010
HM Treasury, Spending Round 2013, June 2013
3
Care Bill [HL] 2013-14: http://services.parliament.uk/bills/2013-14/care.html
4
Humphries et al., Integrating health and social care? Where next? (March 2011), The King’s Fund
5
NHS England are due to provide CCGs and LAs with further information about the Better Care Fund to
respond to national concerns about the Fund’s ability to reduce the expected savings/shifts
6
Health Service Journal, Community Care and cost conundrum, May 2014
2
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
72
Agenda Item 5
Page 76
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
The BCF and other integrated care services will reinforce the role of public health and prevention
through the responsibilities of the Health and Wellbeing Boards (HWBs), playing an important role in
ensuring that health and social care systems work effectively together to promote health and
wellbeing and diminish local health inequalities.
The implications of the Care Bill 7 will be central to planning integrated services, reflecting the new
duties which social care providers will need to take on in the future. The Care Bill modernises the
way the current system will operate for adults eligible for care and their carers. The Bill is in the
process of being passed 8, and there are still some uncertainties about its full implications; however it
is likely that the Bill will require local authorities to make provision for safeguarding adults from
abuse or neglect, to make provision about care standards, to establish and make provision for Health
Education England and the Health Research Authority. The Bill is likely to introduce a cap on the
costs of care to protect people from catastrophic costs associated with long-term residential care
and introduce a new procedure for managing provider failure.
Although the government is promoting integrated care, it is recognised that more evidence about
effective approaches for delivering integrated care is required in order to encourage more ambition
and innovation. As a result fourteen areas were selected in November 2013 to take part in the
integrated care ‘pioneers’ programme which was established to rapidly progress the development of
efficient methods to deliver integrated care that includes local health, public health, social care and
voluntary services 9. The pioneer sites will act as exemplars, sharing learning about effective delivery
of integrated care and how to address local barriers.
What is the local context for Integrated Care?
•
•
•
The population in south west London is expecting to increase by 7.2% to 1.56 million between
2013 and 2018 and the proportion of older people over the age of 65 is expected to rise slowly
from 12.2% to 12.4%
As the population ages, more people are living with one or more LTCs, complex needs and
dementia. By 2018, it is predicted that three million people in the UK will have three or more
LTCs 10
There are additional local challenges around the workforce and the lack of competition in the
community provider landscape
Figure 3: The local context
With regard to the local population, there are a number of key challenges currently facing south
west London, for instance:
7
Ibid. 3
th
The Care Bill has been passed on May 14 2014
9
Fourteen sites: Barnsley, Cheshire, Cornwall and Isles of Scilly, Greenwich, Islington, Leeds, Kent, North West
London, North Staffordshire, South Devon and Torbay, Southend, South Tyneside, Waltham Forest and East
London and City, Worcestershire
10
NHS England, Transforming Primary Care, 2014
8
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
73
Page 77
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
1. In south west London the highest densities of deprivation are found in relatively small areas
of Croydon and in areas of Putney and Battersea in Wandsworth and Wallington in Sutton11.
Evidence suggests that people who live in deprived areas have higher rates of emergency
admissions. Cardiovascular disease is strongly related to deprivation, owing to increased
likelihood of smoking and unhealthy eating 12.
2. The population in south west London is expected to increase by 7.2% from 1.46 million in
2013 to 1.56 million 13 in 2018. At the same time, the proportion of older people is expected
to rise slowly from 12.2% to 12.4% . The number of people over 65 years is projected to
increase from 178,000 in 2013 to 194,000 in 2018, a growth of 8.9% 14 over 5 years.
3. As the population in south west London ages, it is expected that more people will be living
with multiple LTCs. The King’s Fund (2014) reports that for those over 65 years most people
have one LTC and for those over 75 most people have two or more 15. For those living with
chronic obstructive pulmonary disease (COPD), data from the World Health Organisation
show that death rates are almost double the EU average 16, and 40% of people with COPD
also have heart disease 17, increasing the complexity of management. Furthermore,
significant numbers have co-existing depression or an anxiety disorder 18. Studies show that
people with LTCs are twice to three times more likely to experience depression and
estimates suggest that 20% of people with LTCs have depression 19. It is recognised that the
presence of multiple LTCs significantly contributes to health inequalities and the inverse care
law 20, i.e. the people who most require medical care are the least likely to receive it.
4. For the frail elderly, falls are a significant cause of admission to hospital 21 and are the leading
cause of ambulance call-outs to the homes of people over 65 22. Falls prevention is also a
regional priority for the World Health Organisation23. Around one in three people over 65
and one in two over 80 fall each year 24. 1.7% of non-elective admissions for the over 65
in2013/14 was for a fall and 3.9% of admissions for the over 80s. In south west London
there are 178,406 people over the age of 65, and 50,728 25 over the age of 80, representing a
11
Integrated Impact Assessment, Better Services, Better Value: Pre-consultation scoping report, Mott
MacDonald, 2013
12
Ibid
13
Population Projections Unit, ONS (2012)
14
Ibid
15
Making our health and care system fit for an ageing population, Oliver, D. et al., 2014, London: King’s Fund
16
An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England,
Department of Health, London: Department of Health, 2011
17
Ibid.
18
19
Ibid. British Heart Foundation, Twice as likely: putting long term conditions and depression on the agenda,
April 2012
19
British Heart Foundation, Twice as likely: putting long term conditions and depression on the agenda, April
2012
20
Hart, J., The Inverse Care Law, The Lancet, 1971
21
Ibid. 15
22
Prevention package for older people resources, Department of Health, London: Department of Health 2009
23
Strategy and action plan for healthy ageing in Europe, 2012-2020, World Health Organization, Copenhagen:
World Health Organization Regional Office for Europe, 2012
24
Ibid. 15
25
ONS mid-year population estimates 2012, Published August 2013
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
74
Page 78
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
significant population at risk of a hospital admission owing to conditions related to frailty
and declining functionality.
Non-elective admissions in south west London
180,000
160,000
164,351
165,608
167,720
15%
16%
17%
17%
17%
18%
140,000
120,000
100,000
60-80
80,000
60,000
80+
Under 60
67%
67%
66%
2011/12
2012/13
2013/14
40,000
20,000
Source: SUS Data extracted May 2014
Figure 4: Non-elective admissions in south west London
We need to increase effective reablement which is associated with improved health outcomes,
greater independence, allows people to remain in their homes for longer 26 and is associated with
better health-related quality of life and social care outcomes. In 2012/13 510 people over the age of
65 in south west London were discharged from hospital and given some form of
reablement/rehabilitation. Of these 81.6% did not go back to hospital in the following 91 days
compared to the national average of 81.4% (this does not include data from private nursing homes
in south west London).
Non elective activity has grown slowly over the last 3 years, activity has grown at 1.0% per year.
Demographics have grown by 1.4% and non-demographic growth of health services have grown by a
further 2.2% over the same period. This implies that some of the activity growth over the last 3
years has already been offset by schemes in the community and A&E.
15% of admissions in south west London are classed as avoidable according to the NHS England
‘Everyone Counts’ definitions suggesting there is further opportunity to reduce admissions.
26
Reablement: A cost effective route to better outcomes (reviewed edition) Francis, J. et al., 2014, London:
Social Care Institute for Evidence
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
75
Page 79
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
Non-elective avoidable admissions in south
west London
100%
164,351
90%
165,608
Other NEL
167,720
Avoidable NEL
80%
70%
60%
50%
86%
85%
85%
14%
15%
15%
2011/12
2012/13
2013/14
40%
30%
20%
10%
0%
Source: SUS Data extracted May 2014, avoidable admissions defined
according to NHSE 'Everyone Counts' definitions
Figure 5: Non-elective avoidable admissions in south west London
With an increasing number of older people, the number of people living with dementia is also rising.
Nationally, there are estimated to be 670,000 living with dementia 27 (although prevalence is lower in
south west London than the national average). If someone with dementia is admitted to hospital in
south west London they are likely to have a length of stay longer than the national average, and they
are more likely to be readmitted to hospital after discharge. People with dementia in south west
London are also more likely to die in hospital than the national average 28. Figure 6 presents the local
highlights from each of the south west London boroughs from the State of the Nation Report13 which
outlines developments nationally since the Prime Minister’s Challenge was launched.
27
Dementia: A state of the nation report on dementia care and support in England Department of Health,
London: Department of Health, 2013
28
Putting dementia on the map (2013), online resource available from:
http://dementiachallenge.dh.gov.uk/map/
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
76
Agenda Item 5
Page 80
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
Figure 6: South west London dementia prevalence
All CCGs in south west London submitted their BCF plans to NHS England on 4th April outlining their
intentions for improving and enhancing joined up services in their local areas. Figure 7 outlines the
planned 2015/16 transfers from CCGs to the pooled budget and some of the key initiatives that will
be implemented through the local BCF plans. The schemes planned for south west London
collectively address all of the thirteen themes for integrated care that make the most effective use of
the BCF, as outlined by the King’s Fund 29.
29
Bennett, L. and Humphries, R., Making the best use of the Better Care Fund, The King’s Fund, 2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
77
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
Page 81
Agenda Item 5
Figure 7: South west London Better Care Fund summary
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
78
Agenda Item 5
Page 82
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
In order to implement planned changes to out of hospital services, it is acknowledged that the
workforce will need to be transformed to enable the transition from acute to community-based
settings. In south west London there are some specific challenges, for instance the high number of
staff nearing retirement. It is estimated over 2,500 of the local workforce 30 will be of retirement age
by 2017/18, which represents 16% of the total 31 workforce.
Furthermore providers of healthcare, south west London faces further challenges. The provider
landscape in south west London is complex with different CCGs sharing responsibilities for the same
provider, requiring commissioners to collaborate to commission services. Therefore exploring
different contracting and procurement models could stimulate a reorganisation of the current
community provider landscape to take advantage of economies of scale, workforce arrangements
and service models.
What are the key challenges that we will address?
The key challenges for integrated care we will address through this strategic plan are:
1
2
3
4
5
The burden and complexity of LTCs is rising, and patients and service users are experiencing
fragmented care which does not meet their needs appropriately
Implementation of local BCF plans and meeting outcomes at an aggregate level across south
west London
Non-elective (NEL) admissions and urgent care needs are rising, and with the redirection of
funds through the BCF, our current community-based provision will not meet this demand
We do not have the inter-organisational systems and infrastructure in place to enable
delivery of integrated services
We have a pressing community and social care workforce gap
30
This figure covers south west London and Surrey Downs
Better Services, Better Value Pre-consultation Business Case, Appendix K: Workforce, 2013, London: Better
Services, Better Value
31
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
79
Page 83
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
1. The burden and complexity of LTCs is rising, and patients and service users are
experiencing fragmented care which does not meet their needs appropriately
The number of people with multiple LTCs in the UK is projected to rise from 1.9 million in 2008 to
2.9 million in 2018 32
Historically, health and social care have not been well integrated, producing the effect of
fragmenting care for patients. The connections and shared working between different professionals
and services within community, primary care, acute and third sector services have been weak. This
can cause patients and service users, particularly those suffering with multiple LTCs, dementia or
frailty, to receive disjointed care and poor communications about their follow-up, leading to a lack of
confidence in services. In particular dementia needs timely diagnosis. When there are signs of early
cognitive decline, there is little support, care and signposting for patients, who currently do not
receive intensive mental health service support. Our plan for integrated care is to ensure that
patients and service users not only experience better single episodes of care, but a high quality
experience of overlapping parts of their care. Furthermore they are given the skills and empowered
to make informed decisions about their care.
Some of the specific challenges around providing care for people with LTCs, complex needs, frailty
and those nearing the end of their lives were addressed through the work of the Long Term
Conditions and End of Life Care clinical working groups which were conducted under the BSBV
programme. The recommendations (see Appendix 2A) have since been reviewed, and are considered
sound, still serving to provide guiding principles to be addressed through the Integrated Care Clinical
Design Group (CDG).
There are some clear recommendations around activities which are likely to transform care for those
with complex needs and provide a holistic approach to care. The following are recommended by the
King’s Fund 33:
•
•
•
•
•
•
Patients should be supported through care co-ordination
Risk stratification should be used to identify people at risk of hospital admissions
Case management should be provided through integrated locality-based teams, involving
patients, carers and families in the care planning
Personal care budgets and direct payments should be introduced
Telehealth should be used to improve self-care
Support and education should be provided for family and carers
Improving services and care for people with multiple LTCs or complex needs in times of resource
scarcity is difficult, and the evidence for successful interventions such as care co-ordination and case
32
33
Department of Health, 2012a
Oliver, D., Making our health system and care system fit for an ageing population, King’s Fund, 2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
80
Agenda Item 5
Page 84
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
management is dependent upon effective local implementation 34. Whilst commissioners in south
west London recognise the immense challenge, there is an opportunity to transform services
through a strategic and regional response, in particular for complex conditions such as dementia,
heart failure, COPD and frailty, where collective planning and pooling of resources may have a
greater impact on outcomes. Opportunities to collaborate encompass the entire spectrum from
planning individual end-to-end patient pathways with increased social care provision, to developing
innovative contracting arrangements to incentivise improved patient experience and quality. Recent
national examples have highlighted that, when implemented correctly, opportunities for both
improvements in clinical outcomes as well as reducing unnecessary hospital admission through early
intervention exist. Examples include the assessment unit in Abingdon Community Hospital in
Oxfordshire for frail patients requiring same day diagnostics and specialist care 35. Planning services
together across south west London will build on the achievements of the Out of Hospital Programme
Board 36.
According to the World Health Organisation (WHO) more than half of the burden of disease among
people over 60 could be avoidable through changes in lifestyle 37. This is no different for the
population of south west London and therefore a significant focus on primary prevention schemes
that promote healthy lifestyle and wellness, will be necessary for the first two years of this 5 year
strategic plan. A further focus will be improving secondary prevention to ensure services are in place
for timely assessments and intervention to prevent full symptoms from developing.
Promotion of self-care for people with multiple LTCs and complex needs is considered a key priority
by commissioners, and should extend from educating patients to self-manage their LTC, to enabling
them to be independent and addressing their functional and emotional needs. Promotion of selfcare is considered a fundamental component of providing services which are proactive, holistic and
patient-centred and is core to the ‘house of care’ model approach 38.
‘House of care’ model
Care planning is core to the ‘house of care’ model, which focusses on providing care that should be
proactive, holistic, preventative and patient-centred39; this is considered in further detail in the
Transforming Primary Care section (See chapter 4, section 6). The Royal College of General
Practitioners (2011) Care Planning, Improving the Lives of People with Long Term Conditions
describes care planning as an effective way of developing an environment which helps clinicians to
support patients with LTCs to better understand their conditions and confidently self-manage.
Figure 8: ‘House of care’ model
34
Goodwin et.al, Co-ordinated care for people with complex chronic condition – The lessons and markers for
success, King’s Fund 2013
35
Health Service Journal, Community care and the cost conundrum, May 2014, p 21
36
The Out of Hospital Programme Board was established in April 2013 and dissolved in March 2014
37
Ibid. 15
38
Delivering better services for people with long-term conditions: Building the house of care, Coulter, A. et al,
2013, London: King’s Fund
39
Ibid
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
81
Page 85
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
The case for supporting informal carers has never been stronger, with over 700,000 informal carers
in London; an estimated quarter from black and minority ethnic (BME) groups and a fifth being
pensionable age or older 40. Commissioners in south west London are working with providers to
implement a diverse range of schemes to meet the needs of people in their localities. The Care Bill
includes new provisions for carers, and the law specifies that carers should be treated as equal for
those they care for. In south west London some work has already taken place to make
improvements for carers, as outlined in Figure 9, We intend to take this work forward, particularly
improving education and support to carers, for instance supporting carers to manage their finances
and staying in work.
Carer Training and Support
Following the success of the dementia conference (see Figure 11), Health Education England
recognised the need to invest in raising the awareness of dementia across south west London,
specifically around Early Onset Dementia (EOD) and provided the programme with £75k to allocate
across south west London. Therefore, £25k was awarded to St George’s University Hospital to
deliver a training programme for those caring for sufferers of EOD, and the remaining £50k was
divided equally between the six CCGs to develop existing training, or to invest in new dementia
training programmes. Outcomes from these programmes will be sought later this year.
Figure 9: Carer Training and Support
A priority for self-care education and the management of LTCs is that patients carefully adhere to
prescribed medication regimes. Medicines optimisation is an approach to increasing the benefits
that patients receive from prescribed medications and has been highlighted as an ‘early adopter
intervention’ in the ‘Anytown Urban Health System 41’ as having the potential to significantly improve
clinical outcomes and reduce wastage. We intend to explore the use of community pharmacists to
deliver medicines optimisation programmes, allowing people and their carers to take more control
over their compliance with medications. Since the majority of prescribing occurs in primary care,
there will be some interdependencies with the Primary Care CDG.
Croydon Medicines Optimisation
About 50% of prescribed medication is not taken as intended, which leads to wasted resources (in
Croydon the waste is estimated at £500,000 per year) and poor outcomes. In Croydon it was been
agreed that the Croydon CCG, the Local Authority and Croydon University Hospital are to create a
Joint Medicines Policy to ensure safe standards of practice, maintaining independence and
collaborative working 42.
Figure 10: Croydon Medicines Optimisation
All CCGs and local authorities in south west London are committed to improving self-care
management. The following table illustrates a range of self-care schemes that are planned to be
implemented or expanded across south west London:
40
Greater London Authority: https://www.london.gov.uk/priorities/equalities/carers
NHS England, Any Town Health System, Urban CCG data, 2014
42
th
Croydon CCG and London Borough of Croydon, Better Care Fund Submission 2014-16, 4 April 2014
41
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
82
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
Page 86
Table 1: Self-care initiatives in south west London
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
83
Page 87
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
We want to create a greater emphasis on access to mental health services, and professionals trained
to provide support for co-existing mental health conditions, such as depression and anxiety. We
recognise that tackling mental health problems allows people to be more functional, improving their
ability to self-manage and access care appropriately when mental health issues are treated alongside
physical care 43. It is core to community professionals’ work to identify, manage and signpost patients
with mental health conditions. People with significant mental health problems will be assigned a
mental health worker, who will be part of the multidisciplinary team that supports them. Improving
access to mental health provision will be achieved through Improving Access to Psychological
Therapies (IAPT) (considered in more detail in Mental Health Chapter 4, Section 4) and we have
prioritised the need for implementing models such as Rapid Assessment, Interface and Discharge
(RAID) models (considered in Urgent and Emergency Care Chapter 4, Section 7). NHS England has
estimated that implementing a RAID service would have a financial benefit of up to £1.5m per CCG 44.
Providing early intervention through peer support schemes and voluntary sector befriending
schemes will also be required.
There will also be an increased focus on improving care for people with dementia. This will involve
ensuring timely assessments and diagnosis, and providing training and education to people with
dementia and their carers. An example of our effort and approach around dementia to date is
outlined in Figure 11.
South West London Dementia Conference
The South West London Dementia Conference in November 2013, which was attended by over 80
key stakeholders, shared local and national examples of best practice in dementia care. The event
engaged a range of providers including the third sector who were able to demonstrate how their
services could be incorporated into an integrated approach. Furthermore the event collated
stakeholder views, including those of carers of people with dementia, and produced ‘ten guiding
principles’ for commissioners to refer to in planning integrated dementia services locally (see
appendix 2B).
Figure 11: The south west London dementia conference
Across south west London the provision of end of life care needs to be improved allowing people
more choice to be managed and die in the location of their choice. Although approximately one
third (35%) of residents in south west London die in their usual place of residence, a London survey
found that nearly two thirds of people (63%) would prefer to die at home 45. The opportunity to
provide higher quality end of life care which is less costly is well recognised. For example, it is
estimated that the NHS could save over £160m if all appropriate end of life care were delivered at
home 46. Locally we are seeing the benefits for patients whose care is being coordinated by
43
The cost of co-morbidities, Naylor C, et.al, 2012, The King’s Fund
Any town health system: Urban CCG data, NHS England, 2014, Available from:
http://www.england.nhs.uk/wp-content/uploads/2014/01/at-urban-rep.pptx , Note: This figure refers to an
urban CCG, for a suburban CCG the net benefit is £1.2m
45
Better Services, Better Value, Pre Consultation Business Case – Chapter 2 The Case for Change, pg 13, 2013
46
Dr Foster Intelligence at Home, 2010
44
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
84
Agenda Item 5
Page 88
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
professionals on the Co-ordinate My Care (CMC) shared record system. Data from the Royal
Marsden NHS Foundation Trust (2014) shows that 80% of CMC patients have died in their preferred
place, whereas only 18% of patients with CMC records die in hospital, compared with 54%
nationally. We therefore need a consistent approach for end-of-life care in south west London and
commissioners are in agreement to encourage and incentivise the use of CMC locally.
2. Implementation of local BCF plans and meeting outcomes as an aggregate for south
west London
All CCGs and local authorities submitted their jointly agreed BCF plans to NHS England on 4th April
2014. The aggregate amount that will be transferred to the Fund in 2015/16 is £94m
A significant degree of service transformation is required to achieve the level of ambition outlined in
local BCF plans across south west London. In particular commissioners will need consistent
approaches to implementation, working with their shared acute providers and measuring outcomes
carefully. The degree of challenge for implementation of BCF plans and overall delivery of
operational plans for integrated care has not been underestimated by commissioners in south west
London. The aggregate amount of financial resource assigned to BCF schemes across south west
London in 2014/15 is £32m and in 2015/16 rises significantly to £94m. Investment, further expansion
and strengthening of community-based services and horizontal integration with other providers such
as primary care and the third sector is required, and is likely to lead to savings for the health
economy. Commissioners therefore recognise the continuing importance of careful transition
planning with acute providers, robust financial contingency planning, and maintaining effective joint
commissioning with local authorities.
Better Care Fund knowledge share and support
A preliminary approach to this has already been undertaken through the Out of Hospital programme,
and the subsequent collaboration undertaken to develop local BCF plans through weekly
teleconferences between CCG Directors of Commissioning and Integrated Care leads from all six
boroughs.
Figure 12: The Better Care Fund knowledge share and support
CCGs, local authorities and Health and Wellbeing Boards in south west London have all committed to
meeting a set of national conditions, including protection of adult social care services, by promoting
the new duties of the Care Bill, implementing 7 day services in health and social care to support
patients being discharged and prevent avoidable admissions to hospital and assigning a lead
accountable professional, responsible for co-ordinating care for older people and those with complex
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
85
Page 89
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
needs 47. This has been reflected in local BCF plans and through joint working through the Out of
Hospital programme. Commissioners in south west London have noted that meeting the national
conditions of the BCF, the introduction of the Care Bill and health and social care commissioners and
providers working closely together, will have significant impact on allocation of resources, workforce
and leadership within organisations. In addition, south west London commissioners have committed
to working collaboratively to consider contractual and financial mechanisms to enable this, including
how organisational boundaries can be overcome. It is also recognised that effective implementation
of the BCF schemes will include engagement with GPs and there will be some overlaps with the
Transforming Primary Care CDG.
Commissioners in south west London have reflected that given that the roll out of integrated care is
in its infancy, the strategic objective for integrated care will be to continue to review progress against
carefully considered and reliable outcomes, and for commissioners to utilise the functions of the
strategic planning unit to facilitate benchmarking and peer-review of progress between localities.
Several sources cite the inconsistent and differential success of integrated care and communitybased schemes, and careful implementation, evaluation methodology and timely refinement of
service design are key features of success 48. Commissioners across south west London are
committed to reviewing progress together. and appreciate that diverse approaches to schemes and
service models in fact provides an advantage to assessing ‘what works’ and ‘what doesn’t work so
well’. Therefore there will be an expected accumulative effect on reduction in acute activity. Coupled
with reviewing progress from national sources and pioneer sites, commissioners in south west
London expect to refine their strategic and operational approach to integrated care in 2015/16 and
again in 2016/17 as outcomes data becomes available. Commissioners are committed to invest
further resources and collaborate to achieve this. The south west London Collaborative
Commissioning (SWLCC) programme will be responsible for further disseminating best practice and
coordinating functions which allow knowledge sharing and co-commissioning.
In summary, in order to ensure we achieve the best possible impact of the BCF, we will need to
manage the risks of implementation, financial resource, workforce available and the fragmented
relationships between the organisations delivering integrated care.
47
NHS England, Annex to the NHS England Planning Guidance – Developing Plans for the Better Care Fund,
2013
48
Bardsley et. al, Evaluating integrated and community-based care – how do we know what works?, Nuffield
Trust, June 2013
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
86
Agenda Item 5
Page 90
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
3. NEL admissions and urgent and emergency care needs are rising, and with the
redirection of funds through the BC F our current community-based provision will not
meet this demand
There is a need to expand current provision of community services to manage the increasing
demand on the acute sector
Demand on health and social care services is rising as a result of:
1. Demographic growth of 1.4% per year. Resulting from high birth rates, increasing life
expectancy and migration
2. Increased use of health and care services growth 2.2% per year, due to increasing
complexity of care, increasing rates of multiple LTCs, medical advances and the rising
expectations of service users.
This also extends to demand on residential and nursing home placements as life expectancy rises
(between 2000 and 2010 male life expectancy in south west London rose from 77.0 to 80.4 and
females from 81.1 to 84.2).
In south west London we have been monitoring our progress through the ‘out of hospital tracking
tool’, in order to assist in making rational and evidence-based decisions about how to strengthen our
out of hospital strategy. Managing demand on acute services and providing more appropriate care in
the community will require strategic efforts from all angles. It will include commissioning a range of
proactive services which will help people to live well and manage their conditions before escalation
or crises arise. It will also include a range of reactive services which appropriately respond in times
of destabilisation, and equally services which are able to receive patients promptly back into the
community after hospital admission, preventing readmission. We know that currently our
community services capacity is unable to meet the expected demand over the next five years. In
addition, commissioners in south west London have made a clear commitment to achieve a 7-day
working service model, and develop schemes which respond ‘around the clock’ and including
weekends. This approach will require significant momentum, planning and resource, but is likely to
achieve significant long-term gains. Commissioners and community and social care providers will
need to work together in 2014/15 and 2015/16 as proposed in order to carry out a baselining and
gap-analysis process as a first-step in identifying the full extent of community capacity required.
We know that targeting our efforts on those people most at risk of A&E attendance, unplanned
admissions and preventable complications such as falls and exacerbations of LTCs makes economic
sense and will improve quality of life for this cohort. All localities in south west London have
committed to implementing risk stratification and multidisciplinary working to accelerate joined up
working between professionals providing intensive support to identified individuals. This is expected
to enhance relationships and communication between primary care, social care, community and care
home professionals and community-based specialists, as well as with services users and their carers.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
87
Page 91
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
The following case study from Merton demonstrates how risk profiling tools and MDT working are
being implemented:
Merton Risk profiling and Care Management Scheme
All our 25 GP practices in Merton are already undertaking risk-stratification profiling (through
engagement with Merton CCG) GP practices carry out risk profiling using the risk profiling tool
agreed by Merton CCG (SOLLIS/ ACG). Patients identified by these searches are sorted by predictive
relative cost weight which is calculated by the tool. Patients who are considered suitable for active
case management are identified for discussion at a multi-disciplinary team (MDT) meting. The
meetings occur on at least quarterly basis, in order to develop a personalised care plan. This care
plan should be created to ensure better quality of care and reduce the risk of the patient being
admitted to hospital. Within the MDT, a lead professional will be allocated responsibility for the
patient
Figure 13: Merton Risk Profiling and Care Management Scheme
Effective and expanded rapid response and urgent care services (the latter being considered in more
detail in Chapter 4, Section 7: Urgent and Emergency Care) are required to improve the quality and
expertise of community-based urgent care, reduce avoidable admissions to hospital and prevent
functional deterioration leading to subsequent permanent care home admission. Intermediary
reablement and rehabilitation services whether bed or home-based will need to compliment rapid
response services. Service reviews and schemes which support effective discharge from hospital and
post discharge support are vital for strengthening and expanding community based health and social
care. Although delayed transfers of care are lower across south west London than the national
average 49, we know that we could be doing better still, given that there is considerable variation in
the length of stay between the best and worst performing Boroughs.
Sharing the challenges of commissioning community and social care services, addressing the
complexities of implementation, understanding the workforce gap and blurring organisational
boundaries (between acute, community, social care and primary care providers) will need to be
strategically handled across existing networks (e.g. stroke network), between CCGs who share acute
and community providers and through the SWLCC. Shared principles for commissioning and
procurement, as well as new contracting models, will be fundamental to achieving the strategic
approach over the next five years and expanded community services.
Table 2 demonstrates the various schemes across south west London boroughs to manage
emergency activity, discharge planning and post discharge support:
49
Delayed transfer of care per 100,000 population (All delays) 2012/13, NHS England, 2013, updated 25/10/13,
available from: http://www.england.nhs.uk/statistics/statistical-work-areas/delayed-transfers-of-care/
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
88
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
Page 92
Table 2: The Managing emergency activity, discharge planning and post discharge support schemes in south west London
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
89
Page 93
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
4. We do not have the inter-organisational systems and infrastructure in place to enable
delivery of integrated services
We need to implement a shared IT system to ensure records are shared effectively across the
different services to ensure patients experience joined-up services
Planning the right infrastructure and ‘conditions’ for high quality integrated care in the local
healthcare economy requires strategic effort to be exercised, as well as strong partnerships with
enabling bodies such as the South London Commissioning Support Unit and the South West London
Academic Health and Social Care System. The challenges to create an appropriate ‘environment’ and
capability for integration cannot be managed at a local borough level. Commissioners in south west
London are committed to the following strategic objectives in order to develop the systems and
infrastructure to support integrated care:
•
As a result of historical arrangements, community providers have largely remained aligned to the
originating PCT, and then CCG. In some cases, vertical integration between acute and community
providers has evolved such as for Croydon Health Services NHS Trust and St. George’s Healthcare
NHS Trust. Commissioners recognise that in order to expand, raise the quality of and increase
the capability of community health and social care, ensuring its future sustainability, the
landscape of providers may change. Commissioners in south west London are particularly
interested in exploring outcomes-based commissioning and integrated service specifications,
creating new opportunities for providers, including partnerships between health and social care
providers. Commissioners in south west London aim to explore the collective impact of
commissioning services differently and providing opportunities for providers to work together
which will help to reduce organisational barriers.
•
Shared IT systems which allow multidisciplinary professionals to share records about care. This
will facilitate joined-up working across primary care, community and social care services and
specialty clinicians. South west London boroughs have commissioned the CSU to support this
work. This will also include managing the information governance issues that will need to be
addressed as organisations share information.
•
Whilst each locality has already devised governance arrangements and fostered relationships
between CCGs and LAs, as well as receiving overarching leadership from HWBs, further
development of strategic leadership will be required. This will necessitate further work of the
Integrated Care Clinical Design Group (CDG), wider stakeholder engagement and robust public
and patient engagement.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
90
Agenda Item 5
Page 94
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
•
Review of community estate is needed as premises need to be fit for purpose. Co-location of
services and professionals, including primary care, encourages integrated care to become a
workforce hub, supporting shared knowledge and multidisciplinary working
•
Challenges to dissemination of innovative practices, service design and commissioning levers is a
well-known issue. At a strategic level we will need to create a culture of innovation. Working
closely with the south west London Academic Health and Social Care System will be important in
to creating an environment where novel and progressive solutions can be diffused easily and
implemented quickly.
•
As described in the King’s Fund paper ‘Community Services’ 50,51 having many small, specific and
sometimes poorly co-ordinated services makes the system difficult to understand and navigate.
In south west London, it will be increasingly important to ensure that services provided out of
hospital are well connected. We will work with providers to ensure complexity is reduced, by
having integrated teams with diverse skills which would include more specialist knowledge. This
will require an advanced approach to commissioning of provider services and incentivising multiprofessional health and social care teams, whether through one provider, or providers working
in collaboration. Furthermore we will improve signposting, including improvements in navigation
to third sector services, for instance through generalist roles such as care navigators. Third
sector services play a significant role in providing holistic care to meet the needs of local
populations, and these will need a higher profile moving forward if we are to commit to person
and carer centric care.
5. We have a pressing community and social care workforce gap
A significant gap exists between the workforce currently available in south west London in
primary, community health and social care, and the workforce needed to support the shift to
integrated care provided out of hospital
In order to expand community-based health and social care services, an appropriately skilled
workforce will need to be in place. This will mean year-on-year growth in such professionals will be
required, with an opportunity to up-skill incoming members of the workforce as well incumbents,
create new roles to achieve integration and new ways of working between professionals. The new
ways of working will require new skills and also a culture change for the workforce working in
multidisciplinary teams, collaborating with professionals they may not previously have worked with.
Multidisciplinary working will be hosted by Primary Care and GPs will primarily have the role of lead
accountable professionals. There will therefore be overlaps with the Transforming Primary Care CDG.
50
51
Community Services, How They Transform Care, The King’s Fund, 2014
Ibid. 6
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
91
Page 95
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
A recent preliminary gap-analysis of the workforce has been undertaken by SWLCC 52 funded by
HESL, which has examined the workforce gap to meet the workforce numbers and ambitions of each
borough. The report estimated that around 570 (full-time equivalent) staff including 330 community
nurses, 90 Health Care Assistants, 40 GPs, 36 therapists, 35 support staff, and 15 practice nurses, will
be required over 5 years. It should be noted that these numbers are based on preliminary studies
and therefore should be treated as such, and are likely to be conservative estimates. Indeed, since
undertaking the research for this work, an upper estimate has been calculated, putting the total
number of staff at around 800. Despite being reasonably high-level at this stage, these workforce
requirements, although estimates help size the scale of change required across south west London.
Furthermore, south west London also faces additional workforce challenges, such as an ageing
workforce with an estimated 16% 53,54 of acute hospital staff reaching retirement age by 2017/18.
We will need to develop the social care workforce, including social workers, domiciliary carers in
homes and care homes and therapists, by increasing the level of recruitment and retention, upskilling the workforce, for instance promoting reablement skills for frontline staff, and encouraging
formal qualifications where relevant.
4,100
1,200
Nursing staff in acute
providers
Nursing staff in
community
300
Nursing staff in
general practice
Figure 14: Comparison of nurse FTEs across sectors
Conversely, it is expected that there will be a reduction in numbers of the workforce required in
acute care services, as community services expand and strengthen. Limited consideration of means
by which these workers can be retained in south west London has taken place as yet. Commissioners
and representatives from HESL working in close relationship, have recognised this major issue
previously working through the Out of Hospital programme workforce subgroup and have identified
the following priorities to be taken forward:
•
Workforce commissioning should reflect four key workstreams:
52
South West London Collaborative Commissioning, Implementing Integrated Care in south west London, 2014
This figure covers south west London and Surrey Downs
54
Ibid. 31
53
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
92
Agenda Item 5
Page 96
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
(a) Adapting to 7-day working in the community
(b) Integrated working across organisational boundaries
(c) Upskilling the incoming community workforce
(d) Adapting to transforming primary care
•
Community roles need to be made more attractive, and different rates of pay such as London
weighting across south west London need to be addressed
•
The unqualified workforce, such as healthcare assistants, formal and informal carers and
volunteers need training and valuing
•
IT systems to support improved communication between professionals needs to enable this
•
Training schemes and relationships with educational institutions especially those within
south west London and surrounding areas need to be strengthened
How we developed our initiatives for improving Integrated Care
The development of integrated care initiatives, associated activities and performance metrics, has
been through the Integrated Care CDG. As has been discussed previously the Integrated Care CDG
builds on the recommendations of the BSBV CWGs and also the work around out of hospital and
community-based services that culminated in the formation of the Out of Hospital Programme (see
appendix 2C).
The membership of the Integrated Care CDG includes health and social care commissioners and
representatives from acute trusts, primary care, community providers and third sector services.
Local commissioners and clinicians are committed to fully include patients in the design of pathways,
and therefore patient and public representatives from local HealthWatch and expert patient groups
are also active participants in the decision-making.
The Integrated Care CDG met for the first time in April 2014. A key outcome from the meeting was
an agreement about the areas for collaborative working where significant progress could be made
by working at a south west London level.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
93
Page 97
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
1
Better communication between commissioners, providers, other stakeholders and the wider
public
2 Shared integrated care quality standards
3 Improved focus on prevention through services
4 Approach to helping patients access the right services
5 Approach to helping patients manage and development of structured education for patients
6 Approach to discharge planning relationships between shared acute providers, local authorities
and community providers
7 Financial and activity modelling
8 Planning and development of the workforce
9 Implementation of improved IT systems
10 Joint response to information governance issues
Figure 15: Collaborative areas of working in south west London
In addition to the work of the Integrated Care CDG, some wider engagement has taken place
including a stakeholder event on the 8th May 2014. The main priorities identified at the stakeholder
event are outlined in Figure 16.
Priorities identified at the stakeholder event on the 8th May 2014
•
•
•
•
•
There is an opportunity for health and social care to work together to plan, commission and
deliver some services – i.e. dementia care is a good example of this. Community teams could
be co-located.
The complexity of the integrated care system needs to be reduced for patients, GP
commissioners and other partners, for instance through IT and Transport arrangements
We need to address workforce issues, particularly as specialist care will be carried out in a
community setting and the need to upskill the workforce to support care navigation
A big cultural change is needed in order to consider care as a whole, not health and social
care as separate
We need to address organisational boundaries and avoiding fragmentation of services
th
Figure 16: Priorities identified at the stakeholder event on the 8 of May 2014
The Integrated Care CDG developed five key initiatives on which the group wants to focus their
efforts over the next five years, to addres the identified challenges. This included consideration of
activities that will need to take place, key milestones, any risks and issues and performance metrics.
The agreed initiatives are:
1. Improving care for people with LTCs and complex needs (including frailty)
2. Review and implement BCF plans, and meet outcomes as an aggregate for south west
London
3. Expansion of community-based services
4. Improving system integration
5. Improved planning and development of the integrated care workforce
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
94
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
What are the initiatives that will address our challenges in Integrated Care?
The following figures contain detailed information about the five initiatives that will be implemented for integrated care
Page 98
Figure 17: Review and implement BCF plans, and meet outcomes as an aggregate for SWL
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
95
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
Page 99
Agenda Item 5
Figure 18: Improving care for people with LTCs, complex needs (including frailty) or mental health conditions
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
96
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
Page 100
Figure 19: Expansion of community-based services
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
97
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
Page 101
Agenda Item 5
Figure 20: Improving system integration
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
98
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
Page 102
Figure 21: Improved planning and development of the integrated care workforce
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
99
Page 103
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
When will we achieve the initiatives for Integrated Care?
Figure 22: Integrated care key milestones
How does our work to improve Integrated Care address the outcomes in
Everyone Counts 55?
Our integrated care section of the strategic plan will address most measureable outcomes from
Everyone Counts, with the exception of the outcome that specifically focuses on positive experience
of hospital care and avoidable deaths in out hospitals. However, by strengthening community and
primary care services, this should have an indirect impact on hospital care.
55
Everyone Counts: planning for patients 2014/15 to 2018/19. 2013. NHS England
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
100
Agenda Item 5
Page 104
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
Figure 23: How integrated care addresses the outcome measures in the Everyone Counts planning guidance
What are the interdependencies with other workstreams?
There are a number of interdependencies between integrated care and other clinical workstreams
within the SWLCC programme and with social care and the third sector that have been considered
during the development of this strategic plan.
There is an overlap with primary care, and the development of case management and promotion of
care coordination will require GPs to take part in multi-disciplinary teams focused around the needs
of the patient.
There are also overlaps with the Urgent and Emergency Care CDG, as community-based rapid
response services are considered within the scope of the Integrated Care CDG, however 111 and
other urgent care service, many of which may be based in the community, sit within the scope of the
Urgent and Emergency Care CDG.
Collaboration will also be required with the Mental Health CDG to ensure services are provided to
support people mental health conditions co-existing with LTCs, complex needs and dementia.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
101
Page 105
Agenda Item 5
Chapter 4: Clinical workstreams, Section 2: Integrated
Care
South West London Collaborative Commissioning
The Integrated Care CDG will also have interdependencies with social care and the third sector
especially for those with frailty or complex needs, and will need to establish approaches for
collaborating with these sectors.
What are the investment implications of these initiatives?
•
The Strategic Plan outlines a bold and ambitious approach to improving the quality of care
delivered across acute, community, mental health and primary care services. In order to
deliver these clinical ambitions and achieve a financially sustainable health economy, south
west London commissioners will need to work together to prioritise how best to address the
multiple challenges identified whilst supporting the investment required to deliver
transformational change.
•
For integrated care, investments will be required for:
o Staff (including recruitemnt and training)
o Information technology
o Double-running costs or project management associated with new services
o Estates upgrade
•
Preliminary estimates have been completed and calculate the staff costs for delivering
integrated care to be between £25m and £35m for community care, and up to £10m for
primary care. Any further cost of re-provision of outpatient appointments in community
settings or other costs, such as training, IT and estates improvement are not included in this
estimate. These estimates, stemming from the HESL gap-analysis work, were based on broad
models of care for the whole south west London area, meaning that individual CCG
investments will vary according to the integrated care models they adopt.
•
CCGs have committed to actively working together to identify how best to achieve the
strategic aims having regard to the limited nature of the funds available. However, it is clear
that there is more investment required to deliver the various initiatives identified in the
Strategic Plan than can be financed from the available financial resource.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
102
Agenda Item 5
Page 106
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
Maternity care
Introduction: why Maternity care is important
“High quality healthcare during pregnancy makes a crucially important contribution to the reduction
of health inequalities at birth, in infancy, throughout childhood and across the whole of an
individual's life course. We now know that the antecedents of many lifelong conditions and illnesses
in the middle and later years have their roots in the antenatal period.” 1
Giving birth for most women is a normal healthy experience. However, in south west London we are
not consistently delivering the best outcomes. There is wide variation in the uptake of antenatal
screening at 12 weeks 2 to identify women at higher risk of complications during pregnancy,
variation in the rates of normal vaginal births acoss the four units, and markedly different rates of
certain interventions such as unplanned caesarean sections. This is not just a problem in south west
London but in the UK as a whole. Against international standards there is serious cause for concern
in UK maternity services. Stillbirth rates in the UK were around 4.9 per 1,000 births in 2012 3
according to the Office of National Statistics, amongst the highest in Europe, with the rate in London
even higher than the national average.
The variation in outcomes both locally and against international benchmarks has led to an increased
focus in developing new quality standards for maternity. The London Quality Standards (LQS), based
on Royal College guidelines, have set a quality benchmark which clinical commissioners in the capital
expect to be achieved by all providers.
We need to make sure that local services are meeting LQS, particularly ensuring that women at
higher risk of complication have the support they need when they need it, but also that we have the
best services in place to support normal healthy women. We want all our women to have a positive
experience of maternity care thoughout their pregnancy, birth and post natal period.
Maternity is a key focus in the 5 year strategic plan because achieving the desired quality standards
across all our hospitals can only be done through strong collaboration amongst CCGs, it cannot be
achieved if each commissioner operates independently. The detailed set of initiatives contained
within this strategic plan will deliver safer services, focussed around the woman, where all providers
work together to provide continuity of care throughout the whole pregnancy ensuring that specialist
support is always available for those who need it.
What does this section of the 5 year strategic plan cover?
The maternity section of the 5 year strategic plan includes all services commissioned across south
west London to support women and their families through pregnancy, birth and the postnatal
1
The Scottish Government, 2010, Reducing Antenatal Health Inequalities: Outcome Focused Evidence into
Action Guidance. http://www.scotland.gov.uk/Publications/2011/01/13095621/1
2
2013-14 South west Maternity dashboard
3
Office for National Statistics, Characteristics of live birth 1, England and Wales 2012. London ONS, 2013
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
103
Page 107
Agenda Item 5
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
period, and the care of new borns. Other disciplines, (e.g. anaesthetics, mental health and social
care) may become involved if needed.
This section of the strategy does not include neonatal care of unwell babies which is covered in the
Children’s section of Chapter 4, nor does it include care for gynaecological conditions that could
affect conception and pregnancy or result from pregnancy.
Our approach to developing maternity services is to focus on the whole pathway of care for
individual women, rather than separately considering antenatal, intrapartum and postnatal care.
Care pathways will differ between women likely to have normal pregnancy and birth, women with
mild or moderate complications and women with highly complex pregnancies.
What is the vision for Maternity care in south west London for 2018/19?
In south west London we have developed a vision which responds to the challenges facing the
Maternity care services and the expected future needs of the local population. Our vision is to
strengthen the Maternity care whole-pathway service model through improving the quality of
maternity care services and ensuring that the provision of Maternity care services is timely and
robust.
Our vision for Maternity care in south west London is shown in Figure 1.
In south west London maternity services will be designed in a way that:
•
•
•
•
•
Prepares women for pregnancy and becoming a parent through education and up to date
evidence based information
Provides care to women as individuals, with a focus on their needs and preferences
Invests in improving continuity of care and carer, with a strong emphasis on midwifery led
care for normal pregnancy and birth
Provides care which meets the London quality standards for women with more complex
needs, where obstetric care will be provided in our hospitals, with enhanced on site
presence of consultant obstetricians and dedicated obstetric anaesthetists, supported by a
range of emergency services, should they be needed
Values and takes on board feedback from women we look after and their families in order to
drive continuous improvement in the quality of care
Figure 1: Our vision for maternity care in south west London
What is the national context for Maternity care?
National and London-wide standards have been developed which provide a benchmark for the level
of quality clinicians expect to see across local maternity services.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
104
Agenda Item 5
Page 108
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
•
•
•
•
In some areas the UK performs particularly badly in international comparisons. Stillbirth
rates are amongst the highest in the developed world
The London Quality Standards, based on Royal College guidance, set out a minimum level of
quality which clinical commissioners expect in maternity care
Birth complexity is increasing with rising maternal age and increasing prevalence of obesity
The Birthplace Study of 65,000 births across England found that midwife led care is just as
safe as obstetric led care for low risk pregnancies 4
Figure 2: National context for maternity care
What is the local context for Maternity care?
•
•
•
•
In 2012 there were just over 21,000 births to women living in south west London. Although
the number of births has increased over the last 5-10 years this increase is expected to slow
down over the next 5 years
Outcomes and intervention rates vary widely between maternity units
8 out of the 27 LQS maternity standards are not currently being met consistently by trusts in
south west London
No units are currently meeting the London Quality Standard of providing 24/7 hour
obstetrician presence on a labour ward
Figure 3: Local context for maternity care
What are the key challenges for Maternity care services that we will
address?
There are a number of challenges currently facing maternity services in south west London, which
we address in this strategic plan
1. Outcomes and intervention rates vary widely between our maternity units
2. Rising maternal age is leading to increasing complexity
3. Services are organisation focused rather than woman centred services
4. Key clinical staffing standards are not met, or not met consistently
5. Continuity of carer could be improved
6. Hospital and community postnatal care experience can be poor
7. Variation in quality and quantity of antenatal care provided by GPs
8. Screening programmes are not always well integrated into usual care, and there is
variation in uptake and follow up
Figure 4: Key challenges for maternity care
1) Outcomes and intervention rates vary widely between our maternity units
There is wide variation in a number of maternity outcomes across the four providers in south west
London. Figure 5 shows variation in the incidence of caesarean sections, induction of labour and
episiotomies. However, it should be noted that the measures should be interpreted with a degree of
caution as common definitions for measurement were not in place prior to November 2013.
4
https://www.npeu.ox.ac.uk/birthplace
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
105
Page 109
Agenda Item 5
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
Performance Measure
Normal vaginal births
Instrumental births
Caesarean section rate
Planned
Unplanned
Induction of labour
Episiotomy rates
3rd or 4th degree tears
of the perineum
South West London
Lowest
Highest
37%
46%
14%
17%
23%
27%
9%
13%
13%
14%
19%
26%
19%
25%
3%
3%
England Average
42.0%
13.0%
25.5%
12.7%
14.7%
12.8%
14.0%
3.1%
Figure 5: Types of delivery across SW London for 2013-14 Source: South West London & Surrey Downs Maternity
Dashboard. Note: we are awaiting the latest clinical data from Epsom & St. Helier NHS Trust
A ‘normal birth’ is defined by the south west London Maternity Network as one where there has
been ‘no induction, no augmentation, no artificial rupture of membranes, no epidural analgesia, no
use of instruments or caesarean section’. By this definition, these births should be able to take place
in midwife-led units or at home. The Pre-Consultation Business Case for BSBV suggested that we
should aim for a split of 60% obstetric-led births and 40% midwifery-led births, of which at least 4%
would be home births. This is regarded as an ambitious but desirable target, as between 10% and
21% of births currently take place in alongside midwifery-led units 5, and there is only a 1.9%
incidence of planned home births (national average is 2.4%).
Maternal choice plays a large part in where the birth takes place and there is the potential to
increase the numbers of normal healthy women giving birth in midwifery led settings. Better
education of these women and their GPs about their options for place of birth, and improvement in
the continuity of their midwife care throughout their pregnancy and birth could help to increase the
proportion choosing to deliver in a midwife-led setting. There will need to be excellent liaison
between midwifery-led and obstetric-led services so that women can easily move between services,
as dictated by the course of their pregnancy or labour.
5
South West London & Surrey Downs Maternity Dashboard 2013
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
106
Agenda Item 5
Page 110
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
Case Study: St George’s Healthcare NHS Trust
During 2011/12, clinician to clinician discussions were held, led by local commissioners, regarding
the pressures on maternity services at St George’s. Although the incident rates and staffing
establishments were not at variance with other acute providers, it was clear there were significant
opportunities for improvement.
The service was operating at a midwifery ratio of 1:33 with 73 consultant hours per week on the
labour ward and, due to increasing demand, the unit was operating above capacity. Working closely
with clinicians at the trust, commissioners saw an opportunity to use the contractual incentives at
their disposal in an innovative way. A 3-year phased investment was designed to move St George’s
from its current midwifery ratios and consultant numbers to published best practice standards. At
the same time, the trust capped deliveries at 5,100 per year to ensure the unit was operating within
a safe capacity. This investment allowed the trust to confidently invest in their Maternity services
and deliver more efficient services with better outcomes.
The unit now operates at a midwifery ratio of 1:27 and by the end of 14/15 it will have 24/7 (168
hours) of consultant obstetrician presence on the labour ward. As a result of this increased
investment by commissioners and the ongoing commitment of clinical staff within the hospital there
has been a significant improvement in outcomes for local women, with stillbirth rates reducing by
50% by 2013/14. The unit now has the lowest caesarean section rate in London (22.7%) and during
the latest CQC inspection the trust’s maternity services received an overall rating of ‘good’ by the
Care Quality Commission (CQC) in the areas of safety, effectiveness, responsiveness and ‘well led’
whilst receiving an ‘outstanding’ rating for its care.
Commissioners had previously considered the possibility of establishing a stand-alone midwifery-led
unit (SAMLU) and remain supportive of this model of care especially as a way to promote maternal
choice and increase the number of midwifery-led births. There are no current firm proposals to
establish a SAMLU but this does not preclude providers from further developing the business case
for one.
We know from the Birthplace study 6 that women planning birth in a midwifery-led unit and
multiparous women planning birth at home experience fewer interventions than those planning
birth in an obstetric unit and there is no negative impact on perinatal outcomes for these women or
the babies. By increasing the proportion of births in these settings, we can reduce interventions and
greatly improve experience for these groups of women.
2) Rising maternal age is leading to increasing birth complexity
There are a number of public health factors that increase the challenges and complexity of provision
of maternity services across south west London. One of the main factors is that more women are
6
‘Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the
Birthplace in England national prospective cohort study’ Birthplace in England Collaborative Group, 2011,
BMJ2011;343:d7400,
http://www.bmj.com/highwire/filestream/545014/field_highwire_article_pdf/0/bmj.d7400
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
107
Page 111
Agenda Item 5
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
giving birth when they are older. There is a likelihood that this trend will continue in the next decade
with the changing socio-economic status of women.
Figure 6: Live births across England and Wales by age group of mother, 1938-1912
Advanced maternal age defined in this context as 35 years or older at the expected date of delivery
(EDD) is associated with a range of adverse pregnancy outcomes with the risk remaining significantly
high despite adjustment for parity, socio-economic status and higher body mass index 7. The
prevalence of diabetes and hypertension also increases in older women which are independently
linked to negative pregnancy outcomes. Rising maternal age has also been linked with greater risk of
perinatal mortality, pre-term delivery, low birth weights, type 1 diabetes in childhood8, neonatal
death 9, and risk of multiple pregnancy 10.
With increasing complexity of pregnancy, there will be added pressures on maternity services
ranging from antenatal screening to identify the risk of complications as early in the process as
possible, to care in labour and the postnatal period. In addition we need to focus on preconception
care to prepare all women to enter pregnancy in the most healthy state possible.
3) Services are organisation focused rather than woman centred services
A significant component of the strategic plan for maternity is to commission whole pathways of care,
spanning home, community and hospital settings. Women and their families currently work around
the provision of services rather than the services being designed in a way that best supports them.
Their experiences during pregnancy could be greatly enhanced by a service that is designed around
7
Kenny LC, Lavender T, McNamee R, O’Neill SM, Mills T, et al. (2013) Advanced Maternal Age and Adverse
Pregnancy Outcome: Evidence from a Large Contemporary Cohort. PLoS ONE 8(2): e56583.
doi:10.1371/journal.pone.0056583
8
: Bingley P J, Douek I F, Rogers C A, and Gale E A M (2000): Influence of maternal age at delivery and birth
order on risk of type 1 diabetes in childhood: prospective population based family study, BMJ, 321:420
9
Jacobsson B, Ladfors L and Milsom I (2004): Advanced Maternal Age and Adverse Perinatal Outcome,
Obstetrics & Gynecology, 104 (4), pp 727-733
10
Tough S C, Greene C, Svenson L, Claro A and Belik J(1999): Maternal Age and Its Relationship to Multiple
Birth, Low Birth Weight and Preterm Delivery in In Vitro Fertilization(IVF)Pregnancies, Paediatric Research, 45,
257A–257A
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
108
Agenda Item 5
Page 112
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
their needs and preferences. Poor experiences can result in negative outcomes for the woman, her
baby and her family.
With support from local commissioners, women will define what is important for them in terms of
outcomes and experience and services will need to respond to those. Families need clear
information about local maternity services as well as education about lifestyle, pregnancy and
preparation for parenting. This will enable them to make informed choices about the type of care
they want for themselves and where they want that care to take place.
At varying times during pregnancy women may need access to a GP, community midwife, health
visitor, obstetrician, ultrasonographer, community psychiatric nurse, fetal medicine specialist,
neonatologist, geneticist, social worker, breast-feeding advisor and many other types of specialist.
They all work for different organisations, have different referral criteria and are not always very
good at communicating with each other. We want to commission care that suits the woman’s
needs, rather than the needs of the health and social care professionals or the organisations for
which they work. In particular, identification of risk of perinatal mental health problems in the
antenatal period with early involvement of specialist mental health services can make a notable
difference to maternal and infant outcomes 11.
4) Key clinical staffing standards are not met, or not met consistently
There is considerable variation in achievement of the London Quality Standards across the four main
providers of maternity. Of the 27 standards, there are currently eight that are reported as not being
consistently met across all trusts according to the self-assessment carried out at the end of 2013.
These relate to midwifery and obstetric staffing on the labour ward, optimal anaesthetic cover and
access to 24 hour interventional radiology services. A priority for this 5 year strategic plan is to
achieve all of the London Quality Standards by 2018/19 and the London Strategic Clinical Network in
Maternity has identified five standards that it would like to focus on over the next two years with
the overall aim of achieving at least 26 out of the 27 standards by the end of year two. The standard
that will the most difficult to achieve will be the 168 hour obstetric consultant presence on the
labour ward. This is not just due to the cost of the provision but lack of availability of consultant
obstetricians in the national workforce. Whilst recognising this is a challenge, local clinicians have
agreed that we need to set a clear trajectory towards achieving 168 hour presence. We recognise
that obstetric emergencies arise very quickly, at any time of day or night, and the lives of mothers
and babies can be saved by the prompt involvement of the most senior and experienced doctors.
Increasing complexity means that greater obstetric input will be needed with closer antenatal
monitoring. Social deprivation, maternal age and ethnicity are all important predictors of infant and
11
‘Whole-person care: from rhetoric to reality. Achieving parity between mental and physical health’ Royal
College of Psychiatrists, 2013, http://www.rcpsych.ac.uk/files/pdfversion/OP88xx.pdf
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
109
Page 113
Agenda Item 5
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
perinatal mortality 12 and need to be taken into account when caring for these women and planning
the services needed to support them safely.
There is the potential for moderately complicated pregnancies to be midwifery-led, but there will
need to be a succinct transfer policy in place if further complications arise. This will be
complemented by careful selection of women for midwife-led care and increasing midwife
confidence and experience. One-to-one midwifery care and continuous personal support throughout
labour can also reduce the demand for epidurals and is associated with lower interventions 13, and
can therefore reduce the number of women delivering in an obstetric-led unit.
5) Continuity of carer could be improved
Too often, there is little continuity in midwifery care during pregnancy and labour, with many
women meeting the midwife who will support them to give birth for the first time on arrival in the
maternity unit. There is a good correlation between continuity of care and maternal satisfaction,
associated with better outcomes for birth and for breast-feeding rates 14.
6) Hospital and community postnatal care experience can be poor
Postnatal care and liaison between hospital and community care is an essential component of the
maternity service, especially for women deemed to be socially vulnerable and requiring more
support from health visiting teams and social services. Postnatal and care in infancy provides the
greatest opportunity to influence the very early years of a child’s life and future health. Providing
more consistency of care across the whole health team and utilising systems such as family nurse
schemes for vulnerable families will improve support and education for parents and in turn improve
the child’s life.
Although Department of Health statistics suggest that the percentage of women breastfeeding in
south west London is better than England average, post-natal care and support is the area most
frequently criticised by women in feedback, and still has some of the greatest potential to
improve 15. It is also one of the London Maternity Strategic Clinical Network’s priorities.
7) Variation in quality and quantity of antenatal care provided by GPs
A number of women will choose to have shared antenatal care provided by their GP. Variation in the
quality and quantity of antenatal care being offered by GPs in south west London limits the choice
for these women. Providing more capacity and consistency of shared antenatal care by GPs will
improve the quality of antenatal care for women without identified complications in pregnancy. It is
12
‘What factors predict differences in infant and perinatal mortality in primary care trusts in England? A
prognostic model’ N Freemantle et al, 2009, BMJ 2009;339:b2892,
http://www.bmj.com/highwire/filestream/384425/field_highwire_article_pdf/0/bmj.b2892
13
‘One-to-one midwifery care in labour’ NCT position statement, 2011,
http://www.nct.org.uk/sites/default/files/One-to-one%20midwifery%20care%20in%20labour.pdf
14
‘Continuity of maternity carer for all women’ , Petra ten Hoope-Bender, 2013, The Lancet, Vol 382, Issue
9906, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61793-6/fulltext
15
‘Left to your own devices: the postnatal care experiences of 1260 first-time mothers’, V Bhavnani & M
Newburn, NCT 2010,
http://www.nct.org.uk/sites/default/files/related_documents/PostnatalCareSurveyReport5.pdf
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
110
Page 114
Agenda Item 5
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
recognised that this will require support and training for local GPs to ensure they fully understand
their roles and responsibilities.
8) Screening programmes are not always well integrated into usual care, and there is
variation in uptake and follow up
There is a well-established national antenatal screening programme currently in place with a clear
timeline for when women should receive screening and further appropriate action if needed. Timely
access to these services for all women will ensure that time-sensitive interventions or treatments
can occur as needed, improving outcomes and appropriately identifying woman at higher risk of
complications during pregnancy.
Trust
Croydon Health Services NHS Trust
Kingston Hospital NHS Foundation Trust
Epsom and St Helier University Hospitals NHS Trust
St George’s Healthcare NHS trust
Antenatal Assessment
by 12 weeks
78.32%
89.55%
70.15%
82.00%
Figure 7: Uptake of antenatal screening in SW London for year 2013-14
Figure 7 provides evidence of the uptake of antenatal screening by 12 weeks across south west
London. As indicated, this uptake is poor in Croydon and areas around Epsom & St Helier which
means maternal factors such as obesity, smoking, and pre-disposition to conditions such as diabetes,
hypertension and mental health problems are not likely to be picked up until much later leading to a
delay in provision of appropriate guidance and support to these women. In the future the screening
date will need to be shifted forward to 10 weeks given the number of other conditions which would
benefit from earlier interventions.
How we developed our initiatives for improving Maternity care
History of south west London wide work on maternity
There has been a long history of joint working in South-west London on maternity services. A
maternity clinical working group was established as part of the BSBV programme, chaired by
clinicians from primary care and secondary care, with a membership of clinicians representing SWL
commissioner and provider organisations, and patient and public representatives. The goal of the
CWG was to develop clinical models that would be implemented in south west London and as such
the group developed a series of recommendations which were endorsed by the CCGs. Some of these
recommendations are relevant to the current priorities identified by the Clinical Design Group:
•
•
•
There is a compelling case for increasing the number of obstetric consultants to be in
hospitals, on the labour ward 24 hours a day
Midwifery-led care should be the ‘norm’ for women and the default setting of care. Midwife
care is equally important for high risk women and / or those transferring to the obstetric
unit
Co-located midwifery-led units may care for up to 30% of the total number of births,
depending on the risk profile and preferences of the women
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
111
Page 115
Agenda Item 5
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
The previously agreed recommendations provided a vital platform on which to develop the 5 year
strategic plan, and it has been important to build on the clinical consensus established in the clinical
working group when developing current proposals to ensure as much of this agreement as possible
is carried forwards.
The south west London Maternity Network (SWLMN)
The SWLMN in its current form was established in April 2013 and includes clinical leads from local
providers, women and family representatives and public health representatives.
The objectives of the network are to:
1. Inform and lead a programme of maternity service improvement across SW London, to
agreed commissioning and Pan London priorities for maternity services.
2. Improve the overall quality and outcomes of maternity services across SW London
3. Coordinate and share best practice across the network to help develop capacity and
capability across the network
4. Identify cross boundary opportunities and co-ordinate service delivery to meet the needs of
women and their families
5. Work collaboratively to operationalise agreed SWL and Pan London priorities for maternity
and newborn services
6. Share information and audit outcomes to enhance understanding, monitoring and provision
of maternity care across SWL and beyond.
The development of a maternity network in south west London is a major step forward for local
services and demonstrates a shared commitment across providers to improve quality and safety.
The work programme developed by the network is therefore closely aligned to much of the work
that will be taken forward in the five year strategic plan. Proposals articulated in this strategy have
been reviewed by members of the network in order to ensure that priorities are aligned and that
there has been appropriate engagement from a wide group of clinicians. This feedback was used to
develop the strategy and it will continue to do so as the process shifts to implementation.
South West London Collaborative Commissioning
As part of the SWL Collaborative Commissioning programme a number of Clinical Design Groups
(CDGs) were formed, of which one was the Maternity CDG. The CDG met in March and April and will
continue to meet throughout implementation. Its immediate task has been to agree on a set of
initiatives, building on the work that has already taken place to develop maternity recommendations
locally, and linking in with the work and priorities of the network. In addition to the work of the CDG
wider engagement has taken place through a number of focus groups, but most importantly at a
stakeholder event on the 8th May 2014. There were two separate maternity discussions at this event
where additional priorities were identified:
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
112
Agenda Item 5
Page 116
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
Priorities identified at the stakeholder event on the 8th May 2014
• Education for women should be a priority so that they can make informed choices about the
care they wish to receive
• Continuity of care, to reduce the number of repeated interventions
• There should be a focus on outcomes for women and less focus on inputs
• We need to involve pregnant women/mums in our discussion much more
• Pre-conception care – providing health advice to mums-to-be and families.
• ‘Post’ postnatal care – up to 12 months – opportunity to influence very early years of a
child’s life and health
• The role of community based groups - outreach groups to provide support to women.
These priorities have been incorporated into the initatives which have been prioritised for the group.
The initiatives which have been set out by the Maternity CDG for implementation are as follows:
1.
2.
3.
4.
5.
6.
Improve the utilisation of women’s experience and outcomes data to influence
commissioning decisions
Improve the availability & quality of Midwifery-led care for normal women
Improve the quality of Obstetric and Specialist care for women with complex needs
Improve continuity of carer and care throughout the maternity pathway
Improve the quality of care throughout pregnancy and childbirth and into infancy
Review and develop out of hospital provision of antenatal and postnatal care to improve
access, consistency and range of care provision
Each of these initiatives is explored in further detail in the following section, showing the detailed
activites, milestones, and performance indicators which will be used to track progress.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
113
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
What are the initiatives that will address our challenges in Maternity care?
Page 117
Agenda Item 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
114
Agenda Item 5
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
Page 118
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
115
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
Page 119
Agenda Item 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
116
Agenda Item 5
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
Page 120
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
117
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
Page 121
Agenda Item 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
118
Agenda Item 5
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
Page 122
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
119
Page 123
Agenda Item 5
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
When will we achieve the initiatives for Maternity care?
Figure 8 shows the high level milestones underpinning the implementation of the initiatives set out
in the previous section:
Figure 8: Timeline for Maternity care initiatives
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
120
Agenda Item 5
Page 124
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
How does our work to improve Maternity care address the outcomes in
Everyone Counts 16?
Figure 9 outlines how the Maternity initiatives developed will address the seven measureable
outcomes and three key measures set out in the national planning guidance 17.
Figure 9: How our vision for Maternity care aligns to national outcome measures and key measurements
What are the interdependencies with other workstreams?
We need to be aware of the impact on other clinical areas of any changes in maternity care.
Examples of this include the transition to children’s services, highlighted by the work expressed in
initiative six around care into infancy and ensuring high breastfeeding rates in the first six months of
a child’s life.
Urgent and Emergency care is another CDG which may have important interdependencies with
Maternity. Local clinicians have recommended that given the number of shared support services
needed to safely run an obstetric unit and an A&E department. It is important therefore that any
future changes to services reflect a desire to co-locate obstetric led units and A&E departments.
Similarly there is a cross over with mental health care. Initiative three highlights the intention to
develop appropriate perinatal mental health services to support women, and the Mental Health CDG
16
17
Everyone Counts: planning for patients 2014/15 to 2018/19. 2013. NHS England
Ibid.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
121
Page 125
Agenda Item 5
Chapter 4: Clinical workstreams, Section 3: Maternity
care
South West London Collaborative Commissioning
has expressed an intention to establish oversight over the mental health services offered to mothers
to ensure that these services are integrated into the full spectrum of mental health care that is
available across south west London. It will be important to work closely with the Mental Health CDG
to ensure the range of perinatal mental health services are appropriately linked in with the full range
of other mental health services available across south west London.
What are the investment implications of these initiatives?
The Strategic Plan outlines a bold and ambitious approach to improving the quality of care delivered
across acute, community, mental health and primary care services. In order to deliver these clinical
ambitions and achieve a financially sustainable health economy, south west London commissioners
will need to work together to prioritise how best to address the multiple challenges identified whilst
supporting the investment required to deliver transformational change.
Currently approximately £70m is spent by CCGs on maternity services across south west London.
The level of investment required to achieve 168 hour consultant presence at all four sites is
estimated to be around £4m, based on WTE data and adjusted to take into account the estimated
movement towards the target throughout 2013/14. In addition a number of the proposed initiatives
have investment implications which have not yet been costed, for example the cost to provide
consultant midwives at the level specified. So the overall cost of the proposed initiatives will be
higher. On the other hand, there may be an offsetting cost saving due to the expected improvement
in the quality of care resulting in a reduction in the cost of Trust litigation insurance, which is heavily
dependent on maternity related outcomes.
For many of the initiatives the funding mechanism has not currently been identified. CCGs have
committed to actively working together to identify how best to achieve the strategic aims having
regard to the limited nature of the funds available. However, it is clear that there is more investment
required to deliver the various initiatives identified in the Strategic Plan than can be financed from
the available financial resources.
How will our workforce and estates need to be developed to deliver the
strategy?
As described under “challenges” earlier in this section there are a number of particular standards
which require significant investment in workforce, notably the LQS to have 168 hour consultant
obstetrician presence on a labour ward, meeting the midwife staffing ratios and achieving sufficient
neonatology cover. Clear feedback has been given by clinicians during the strategy development
process that we need to develop a trajectory to meeting the 168 hour objective. This will require the
use of commissioning levers to establish a minimum level of presence of 98 hours across all units as
soon as possible, ideally by the end of 2014/15. This will then be translated into phased targets
encouraging all units to move towards 168 and achieve it at the least by the end of the 5 year
period.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
122
Agenda Item 5
Page 126
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
Mental Health services
Introduction: why mental health services are important
Mental ill health is the single largest cause of disability in the UK, impacting on health from birth to
end of life, contributing up to 22.8% of the total cost of ill health, compared to 15.9% for cancer and
16.2% for cardiovascular disease 1. As such the treatment of mental health problems is a major
priority for the NHS and the principle of “Parity of Esteem” – established in the Everyone Counts 2
planning guidance released in December 2013 – highlights the need for mental health services to be
given equal status with physical health services in the development of NHS plans and strategies.
The principle of “Parity of Esteem” has ensured mental health is addressed throughout the strategic
plan, but this section will deal with specific mental health needs of adults and older people. The
policy document Closing the Gap 3 outlined 25 priority areas which need to be tackled jointly by
public services, particularly the NHS and social care and is a major influence on the development of
our strategy.
This strategic plan addresses the need to develop a more joined up mental and physical healthcare
system where, no matter in which setting a patient is treated, their needs can be assessed and staff
are aware and can signpost them to the most appropriate service available.
Developing integrated mental health and social care model is a major priority and a number of crosscutting changes will need to take place to manage the delivery of this objective and to extend this
work to a wider range of service providers currently caring for patients. To do this we need to
challenge assumptions about the existing models of care and enhance the role of patients, famillies
and carers in the development of this work.
We will also seek to engage members of the population that do not access mental health services.
To facilitate this work, services will take into consideration the cultural needs and social differences
of black and minority ethnic groups (BME) groups and how they respond to the mental health
system. Some progress has been made but further work will be done on developing services that
promotehealth and well being for groups that may be socially and economically disadvantaged and
have difficulty with accessing psychological interventions.
We set out in this plan an ambition to respond to and implement the policies outlined in the Crisis
Concordat 4 and the Schizophrenia Commission, whilst maintaining a focus on wellness and quality
of life. Mental health problems remain a stigma which affect people’s willingness to seek help, and
1
No Health without Mental Health, Department of Health, 2013
Everyone Counts: planning for patients 2014/15 to 2018/19, NHS England, 2013. Retrieved from:
http://www.england.nhs.uk/everyonecounts/
3
https://www.gov.uk/government/publications/mental-health-priorities-for-change
4
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/281242/36353_Mental_He
alth_Crisis_accessible.pdf
2
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
123
Page 127
Agenda Item 5
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
much of the work will be focused on ensuring we move away from this attitude and work towards
the early identification of people with mental health needs.
Mental health has not previously been addressed by a south west London-wide strategy. Much of
the sector-wide development work which has taken place focussed on acute services, however the
opportunity presented by the Everyone Counts guidance, and NHS England’s A Call To Action 5, allows
us to bring mental health to the forefront of our planning for the first time.
What does this section of the 5 year strategic plan cover?
In the context of parity of esteem it is essential that mental health issues are addressed across the
whole of the 5 year strategic plan. The CDGs therefore have a responsibilities to ensure the
interdependencies between the different clinical areas are addressed particularly at the transition
with physical health services and in relation to social care needs .
The Mental Health CDG has a specific focus on adults and older people with functional mental health
needs. It will link in closely to the other CDGs to ensure that the development of all mental health
services across south west London is joined up. We will pay particular attention to the interface
between the different mental health areas to minimise the possibility of service users being
disengaged at critical points in their life course.
Figure 1 highlights some key areas where specific responsibilities for developing mental health
services lie with different CDGs. Examples include dementia, which is within the remit of the
Integrated Care CDG, Child and Adolescent Mental Health Services (CAMHS), covered by the
Children’s CDG, and perinatal mental health, covered by the Maternity CDG.
Figure 1: How the full range of mental health services are addressed by south west London’s clinical design groups
5
http://www.england.nhs.uk/2013/07/11/call-to-action/
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
124
Agenda Item 5
Page 128
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
Some responsibilities for commissioning mental health services lie with other organisations. Local
authorities have wide ranging responsibilities for commissioning social care services whilst NHS
England (Direct Commissioning) commissions specialised mental health services within the definition
of the Manual for Prescribed Specialist Services 6,7. These services fall outside the scope of this
strategic plan. The Strategic Commissioning Board (SCB) will ensure alignment between our
respective strategic plans.
What is the vision for mental health services in south west London for
2018/19?
People who need to use mental health services in south west London will experience:
•
•
•
•
•
•
•
•
•
•
6
7
Patients are at the forefront of developing and shaping the way services are delivered
Action being taken to address inequalities in mental health services and improvements
made, which reflect the needs of BME communities, the socially disadvantaged and
vulnerable groups
Better support being provided to Carers and more work being done to ensure their views
are taken into consideration and they are treated like partners during the care planning
process of a family member
Community mental health services that reflect what patients want and are in a wider
range of locations
Services focus on evidence based recovery models with a greater emphasis placed on
peer-led interventions
Community pharmacist patients and GPs working collaboratively to improve the
management of psychotropic medication
Resources provided to facilitate a the use of personalised budgets and a greater emphasis
placed on delivering services that have successful recovery outcomes and patient
experience.
The effective management of physical health care, particularly with people that have
severe and enduring mental illness to improve the disparity in mortality rates.
Improved crisis services that are based on the recommendations set out in the crisis
concordate
Developing services that take into account the recommendations set by the Schzophrenia
Commission
Manual for Prescribed Specialist Services, NHS Specialised Services Commissioning Transition Team, Nov 2012
Securing equity and excellence in commissioning specialised services. NHS England, 2012
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
125
Page 129
Agenda Item 5
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
What is the national context for mental health services?
•
•
•
•
•
•
The Health and Social Care Act 2012 set out the legal framework for reducing the divide
between how mental health is treated compared physical health problems. “Parity of
Esteem” is a key priority for mental health services set out in the ‘Everyone Counts’ planning
guidance
The Department of Health document ‘Closing the Gap’, published in January 2014, sets out
25 priorities for change in mental health services. It details how changes in local service
planning and delivery will make a difference to the lives of people with mental health
problems in the next 2 or 3 years. ‘Closing the Gap’ supports the government’s mental
health strategy ‘No Health without Mental Health’.
Patient choice applies from 1st April 2014. Patients will have more choice about how and
where they get treated for their condition in the NHS on equal parity with choice for physical
conditions.
The Better Care Fund allocated money to support the integration of social care and adult
mental health and the transfer of health budgets to the local authority.
There are currently no mental health standards for London however services will need to
adapt as these standards are developed
There is a planned nationwide reduction in the amount of money available for secondary
mental health care
Figure 2: National context for mental health services
What is the local context for mental health services?
•
•
•
•
•
Current services need to continually focus on providing community based care wherever
possible and ensuring patients are treated in the least restrictive setting possible
Mental health pathways are not integrated with physical health and social care
Access to psychological services routinely exceeds the target waiting time of one month
Services that are interdependent with mental health do not have definite working
arrangements and developed service protocols
There are two main mental health providers delivering inpatient care for SWL residents, with
an increasingly mixed economy of care provided overall. The models of care in place across
the different boroughs of south west London vary in the way they adopt a whole system
approach to designing mental health services
Figure 3: Local context for mental health services
What are the key challenges for mental health services that we will
address?
The key challenges for mental health services we will address in this strategic plan are:
1. We need to ensure pathways are integrated to respond to both physical and mental health
needs
2. We need to reduce inequalities in access to mental health care
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
126
Agenda Item 5
Page 130
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
3. We need to increase the amount of care delivered outside hospitals and improve access to
community based services
4. We need to ensure that more patients suffering from mental health problems are
identified earlier
5. We need to improve the wellbeing and quality of life for all patients suffering from mental
health conditions, and promote recovery
6. We need to integrate the mental health model of care with the entire patient pathway
1. We need to ensure pathways are integrated to respond to both physical and mental
health needs.
Mental ill health is the single largest cause of disability in the UK 8.
People with mental health problems have worse physical outcomes than those without mental
health problems, as well as reduced life expectancy. In the UK men and women without mental
health problems have life expectancies of 79 and 83 respectively; for patients with mental health
problems this life expectancy is reduced to 68 and 73 respectively 9.
People with a chronic physical illness have a two to threefold increased risk of depression in
comparison with people in good physical health, and this increases to a sevenfold increased risk in
those with two or more chronic physical illnesses 10. One in two people with advanced cancer also
develop mental health problems 11. The health consequences of mental illness are most extreme for
people with a psychosis (schizophrenia or bipolar disorder). Men with schizophrenia living in the
community live on average 20.5 years fewer, with the comparable number for women being 16.4
years fewer. 12 The main cause of deaths is cardiovascular disease, which suggests that many of
these deaths may be preventable.
There is a strong relationship between mental health and physical health, and that influence works
in both directions. ’Parity of Esteem’ is needed to ensure that patients are treated with a holistic
‘whole person’ approach which gives people’s mental health equal status to their physical health
needs. Treating mental and physical health conditions in a coordinated way, without duplication, is
essential to supporting recovery. This drive to create parity of esteem for mental health is reflected
in the Department of Health’s ‘Closing the Gap’ which highlights the following priorities:
1. Mental health care and physical health care will be better integrated at every level
2. We will change the way frontline health services respond to self-harm
3. No-one experiencing a mental health crisis should ever be turned away from services
including A&E.
8
How mental illness loses out in the NHS, Centre for Performance, London School of Economics and Political
Science, 2012
9
A call to action: achieving parity of esteem; transformative ideas for commissioners. NHS England, 2014
10
Depression with a chronic physical health problem; the treatment and management of depression in adults
with chronic physical health problems, NICE, Clinical Guidance, 2009
11
Psychiatric disorders in advanced cancer, Miovic M, Block, S , 2007
12
Twenty-five year mortality of a community cohort with schizophrenia, British Journal of Psychiatry 196, pp
116-21, 2010
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
127
Page 131
Agenda Item 5
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
Any changes made to mental health services cannot take place without working with patients and
their carers in order to establish what currently works well and where gaps exist in the current
service provision. Each patient must be treated an individual and given choice about the type of
service they want to use. There should be increased use of self-directed support which allows
patients and their carers to take control over their mental health care.
Currently not enough services are co-ordinated around the patient, and the required integration
between physical and mental health services does not exist. Many patients struggle to access
mental health services, and can often fail to be treated until their condition worsens and they suffer
a crisis. Staff in many services do not have the awareness or ability to recognise mental health
symptoms and more work needs to be done to upskill both physical and mental health clinicians to
be able to give patients more holistic support.
2. We need to reduce inequalities in access to mental health care
National and local evidence show people from BME groups have difficulty accessing treatment and
these services may not be culturally sensitive to the needs of specific communities. There is a higher
degree of stigma associated with receiving mental support from some ethnic communities and this
result in people engaging with services at a much later stage, which may result in them receiving
inpatient treatment for longer periods and a higher proportion of these groups are admitted to
hospital under the Mental Health Act.
Evidence suggests further work needs to be undertaken to understand the broader social context
and cultural nuances of ethnic groups and the social inequalities and disadvantages faced by some
groups and the management of refugees from war and torture. We must acknowledge work that
has taken place with providers to address these issues and a wider range of planned to elicit the
early access of BME groups in health and well being activities and psychological interventions.
3. We need to increase the amount of care delivered outside hospitals and improve
access to community based services
Many people want to be treated for mental health conditions in their own home or local community.
It is recognised that being admitted to hospital can, at times, be a frightening and daunting
experience for patients. People admitted to hospital should be admitted for the shortest possible
time and treated in a way which causes the least disruption to their lives and allows them to return
to their families and carers as quickly as possible. We need to increase access to a greater range of
services offered in the community in order to give mental health patients and their carers more
choice about their care. This can be done by working collaboratively with community services.
Community mental health services are provided through a variety of social, health and mental health
agencies, each with its own eligibility criteria and application and monitoring processes. Gaining
access to the right agency is often a frustrating and time-consuming task, especially for people with
mental illness 13. This can lead to increased numbers of people not seeking help until they are at
13
Community based treatment for severe mental illness: What are benefits and costs?, Mental Health
eJournal, 2007
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
128
Agenda Item 5
Page 132
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
crisis point and often having to be admitted to hospital. We need to work with other agencies to
understand the existing service provision and develop peer-led resources that navigate patients to
the most appropriate services.
One in five people in the UK with severe mental illness are waiting more than a year to access
psychological therapies. We would rightly never accept this state of affairs for people with physical
health problems - it should be no different for people with mental illness 14. Part of developing
equality between mental and physical health will be to improve the numbers of people who can
access help and reduce waiting times across mental health services.
The Crisis Concordat released by the Department of Health (2014) states that every community
should have plans in place to ensure that no one in crisis will be turned away and services for people
in crisis should be ‘the most community-based, closest to home, least restrictive option available,
and should be the most appropriate to the particular needs of the individual’. 15 A key aim of this
strategy is to develop better crisis services to meet the ambitions of the Concordat, but also to
improve access to psychological therapies and treatment outside of hospital. This means ensuring
that patients are not sent to hospital as a default location for crisis care but are directed to the
services that are most appropriate to them.
We will also place a greater emphasis on rehabilitation and supporting people to achieve recovery
by developing programmes of work that focus on step-down and peer supported initiatives that
have proven to be successful with helping people maintain good health and well being. We will also
invest in services which improve patient experience based on feedback from service users and
carers.
4. We need to ensure that more patients suffering from mental health problems are
identified earlier.
Nearly half of all ill health among people under 65 is owing to mental health problems, yet only a
quarter of them get any treatment 16.
Nationally, evidence suggests that services are not accessible to all groups and this can result in
people from certain communities being reluctant to seek help from mental health services and may
delay contact until a situation has reached a crisis point 17. As an example, Afro-Caribbean people
are twice as likely as white people to be diagnosed with a mental health problem, but they are less
likely to access treatment and care 18.
14
We still need to talk, A report on access to talking therapies, Rethink, 2013
Mental Health Crisis Care Condordat, Improving Outcomes for People Experiencing Mental Health Crisis,
Department of Health, 2014
16
Ibid. 8
17
Mental health of Chinese and Vietnamese people in Britain, Reid-Galloway, C. and Gillam S, 2006
18
‘Safe passage’, Community Care, Hill, N. 30.10.03, pp36–37 , 2003
15
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
129
Page 133
Agenda Item 5
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
One in three GP consultations has a mental health element to it, and 90 per cent of mental health
disorders are treated in primary care 19.
Many people will try to access mental health services through visits to their local GP. Often the
sheer volume of work means that there are not sufficient resources available to identify all these
patients. The expansion of psychological services such as Improving Access to Psychological
Therapies (IAPT) coupled with the ability to self refer to this service will address some of these
issues. These services can be made available in locations that are easy to access without the same
barriers in place as statutory services.
We need to integrate the diagnosis of mental health problems with physical health interventions.
People with physical conditions which they cannot manage or control can be a indicator of
undiagnosed mental health issues and work should be developed to support patients and health
workers in understanding the interrationship between mental and phyiscal health and screening
available, which support this process. As part of this work we will review the treatment pathways
for managing medically unexplained symptoms and long-term conditions by working collaboratively
with our medical partners to develop joint protocols and improve communication as services move
towards integration. The signposting of mental health conditions from primary care and also from
other physical health services is a major priority in this strategy, and becomes increasingly pertinent
for people who are more likely to be isolated such older people or those with language barriers.
Stigma is a further reason why people are often not identified early enough. There is evidence that
stigma has a toxic effect by preventing people seeking help, given a profound reluctance to be ‘a
mental health patient’. This can mean people will put off seeing a doctor for months, years, or even
at all, which in turn delays their recovery. 20 Patients have cited concerns around disclosing mental
health conditions in primary care and confidentiality issues.
We need to work to reduce the stigma surrounding mental health and identify groups that are at
particular risk of not seeking and identify service need and design services that are culturally
appropriate.
There is a compelling case to be made for investing more in treating mental health problems at an
earlier stage. This strategy highlights a focus on early intervention and a significant emphasis on
increasing access across primary and community care services. This increasing access will avoid the
dependence on secondary care services and increase the proportion of people with mental health
issues who can be managed in their communities and homes.
19
20
Greater support for GPs to help diagnose common mental health disorders, NICE, 2011
Stigma ‘key deterrent’ in accessing mental health care, Kings College London, 2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
130
Agenda Item 5
Page 134
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
5. We need to improve the wellbeing and quality of life for all patients suffering from
mental health conditions, and promote recovery
People with mental health problems often have fewer qualifications, find it harder to both obtain
and stay in work, have lower incomes, are more likely to be homeless or insecurely housed, and are
more likely to live in areas of high social deprivation 21.
These five essential elements of wellbeing are:
•
•
•
•
•
The first element is about how you occupy your time or simply liking what you do every day:
your Career Wellbeing.
The second element is about having strong relationships and love in your life: your Social
Wellbeing.
The third element is about effectively managing your economic life: your Financial
Wellbeing.
The fourth element is about having good health and enough energy to get things done on a
daily basis: your Physical Wellbeing.
The fifth element is about the sense of engagement you have with the area where you live:
your Community Wellbeing 22.
When people are struggling with any elements of wellbeing they can often be more susceptible to
mental health problems or a relapse in mental health problems. Equally, if someone is suffering
from mental health problems it may also impact on all areas of people’s lives including employment,
housing, education, leisure and recreation, family life and relationships as well as criminal justice.
There is a great deal of evidence that interesting and fulfilling work can be beneficial for mental
health, and that measures to help people with mental health problems into work offer high returns.
Supported employment schemes such as Individual Placement and Support have been shown to
deliver both long-lasting economic benefits and clinical improvements. 23 We know that having
settled accommodation can be invaluable for people living with a long-term mental health problem.
Further work is planned on how we can work with our partners in housing to influence this priority
within Health and Wellbeing Boards (HWBs).
When people live in a place that helps them feel safe and secure, it can support recovery and reduce
the likelihood of further episodes of mental illness. It can also help safeguard their physical health.
Achieving improvements in quality of life for people with mental health conditions will necessitate
CCGs, local authorities, providers, voluntary sector partners and patients and their carers to work
together to promote and sustain good mental health for people in south west London. This will
include linking with Public Health England to gather information about mental health and wellbeing.
21
No health without mental health, A cross government mental health outcomes strategy for people of all
ages, Department of Health, 2011
22
The five essential elements of wellbeing, Gallop Business Journal, 2010
23
Making the most of ourselves in the 21st century, Mental Capital and Wellbeing, Government Office for
Science, 2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
131
Page 135
Agenda Item 5
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
South west London has demographic factors such as a transient population, and large numbers of
ethnic minotirity groups that are more vulnerable to mental health problems, and we need to be
aware of this when developing the strategic plan.
6. We need to integrate the mental health model of care with the entire patient
pathway
A final area on which we need to focus is ensuring that the mental health components of many
physical health conditions are adequately identified and addressed as part of their normal physical
health care. Primary Care is ideally placed to ensure this but the way this service is currently
delivered will need to change. The interface with patient is based on high volume and short
consultations and in the future patients presenting with co-morbidities may require more time for
assessments and planning with a range of community services.
We need to treat patients holistically and avoid setting up services which only provide care for a
certain problem or condition without addressing the wider needs of the individual. Examples of this
include children’s IAPT. Getting mental health services right for the younger population is essential
in preventing serious mental health issues developing in later life; however it is currently the case
that much of the support that was available to children is lost during the transition period to adults.
Often they may not meet the adult referral criteria for some services and have difficulties with
accessing psychological services.
This strategy specifically focuses on these transitions and ensuring that a mental health model is as
far as possible developed across a whole patient pathway, making the right services available at all
times no matter by which team the patient is currently being treated.
How we developed our initiatives for mental health services
Mental health commissioning has historically been divided in south west London. There are two
major mental health providers, South West London & St George’s Mental Health NHS Trust (SWLStG)
and South London and Maudsley NHS Foundation Trust (SLAM). Kingston CCG is currently the lead
commissioner for SWLStG, working on behalf of Merton, Richmond, Sutton and Wandsworth, whilst
Croydon is one of four commissioners for SLAM, working closely with Lambeth, Lewisham and
Southwark CCGs in this context.
In developing the strategic plan we have worked closely with both providers and commissioners to
review current commissioning intentions and trust transformation plans. This work has allowed us
to start with a set of shared priorities recognised by all organisations.
Following the creation of SWL Commissioning Collaborative a Mental Health CDG was formed to
develop the priorities into a number of detailed initiatives. The CDG met formally on the 22nd April
and since then further engagement has taken place with commissioners and providers to ensure as
many views as possible have been captured. In addition to the work of the CDG wider engagement
has taken place through a number of focus groups, but most importantly at a stakeholder event on
the 8th May. There were four separate mental health discussions at this event and the priorities
identified are outlined below.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
132
Agenda Item 5
Page 136
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
Priorities identified at the stakeholder event on the 8th May 2014
• Availability of supportive housing
• Care navigation for patients with MH issues ensuring they are linked appropriately into
physical health services
• Developing the provider landscape and working together with voluntary organisations
• Integration of mental health and physical health
• Services to work with and support carers
• Transitional arrangements for children moving into adulthood
• Self-directed support – move away from rehabilitation to recovery
• Appropriate training for all NHS staff in mental health issues
• Support and care planning for patients with dementia
• Employment opportunities for those with mental health issues to provide purposeful
employment. This is broader than the NHS and should include private sector and other
employers
The engagement and work of the CDG has resulted in a set of six initiatives being developed, as
below:
1.
2.
3.
4.
5.
6.
Improving mental health and wellbeing
Reducing avoidable admission and readmission rates
Improving crisis services
Integrating physical and mental health services, including with wider social care network
Measuring and improving the quality of life for people with mental health problems
Improving access to community-based mental health services including IAPT
In addition to the identified initiatives the Mental Health CDG was clear that a number of crosscutting themes needed to be identified which would apply across the whole spectrum of mental
health care. These included not limiting any services to patients because of their age, having a
continuing focus on recovery and addressing health and access inequalities. The full set of cross
cutting themes, alongside the strategic initiatives, is shown in the diagram below summarising the
content of the strategic plan.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
133
Page 137
Agenda Item 5
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
Figure 4: Overview of the south west London mental health strategy
The following pages provide detail around each of the identified intiatives.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
134
Agenda Item 5
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
What are the initiatives that will address our challenges in mental health services?
Page 138
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
135
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
Page 139
Agenda Item 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
136
Agenda Item 5
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
Page 140
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
137
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
Page 141
Agenda Item 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
138
Agenda Item 5
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
Page 142
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
139
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
Page 143
Agenda Item 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
140
Agenda Item 5
Page 144
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
When will we achieve the initiatives for mental health services?
Figure 5 shows the high level milestones underpinning the implementation of the initiatives set out
in the previous section:
Figure 5: Timeline for mental health initiatives
How does our work to improve mental health services address the
outcomes in Everyone Counts 24?
The vision for mental health services will address the seven measureable outcomes set out in the
national planning guidance 25 and the three key measures as outlined in 13.
24
25
Ibid. 2
Ibid. 2
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
141
Page 145
Agenda Item 5
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
How will the five year strategic plan address the seven measurable outcomes?
1. Additional years
of life
2. Health related
quality of life
• Improving
mental health
outcomes will
reduce the life
expectancy gap
between
patients with
and without
mental health
problems
• We will
implement
personal
health budgets
- these have
been shown to
improve
quality of life
for patients
with mental
health
problems
3. Time people
spend avoidably in
hospital
• Our strategy is
focussed on
reducing our
reliance on
inpatient
mental health
care and a
greater focus
on prevention
and care
outside of
hospital
settings
4. Proportion of
older people living
independently at
home
• We are looking
at investing
more in
independent
living services
5. Positive
experience of
hospital care
6. Positive
experience of care
outside hospital
• We are looking
at innovative
CQUINs that
reward positive
patient
experience
• We will
implement
patient choice
from April
2014
• Improved
discharge
planning and
better
coordination
between
health and
social care will
improve
patient
experience
outside of
hospital
7. Avoidable deaths
in our hospitals
• We will review
the impact of
better mental
health care on
reducing the
demand on
acute trusts,
particularly
A&E
departments
How will the five year strategic plan address the three key measures?
Improving health
Reducing health inequalities
Parity of esteem
• We are already contracting using CQUINs and
to support us achieving the priorities in
Closing the Gap, we will explore outcome
based commissioning for mental health
• We recognise there is inappropriate variation
in mental health care, with inpatient service
users disproportionately coming from a BME
background. We will work with voluntary
sector partners to identify the issues driving
this and potential alternative service
provision
• We will implement the 25 national priorities
in the DH’s Closing the Gap
• We will commission services that are patientcentric not provider-centric
Figure 6: How our vision for mental health services aligns to national outcome measures and key measurements
What are the interdependencies with other work streams?
We need to be aware of the impact on other clinical areas of any changes in mental health care. As
discussed at the beginning of this strategy there are a number of other clinical design groups which
are developing proposals to help patients with mental health problems.
Social care
Local agencies must work together to deliver the comprehensive mental health services that meet
the needs of their local populations. In the development and provision of community mental health
services a framework must be established to identify how health and social services are jointly
commissioned and coordinated.
Local joint planning will include, health boards and joint agreements , which clearly set out the plans
for the commissioning health and social care for people with mental health needs. To achieve this
health boards and local authorities will have coordinating arrangements in place for the delegation
of authority and resources to support the delivery of mental health services.
The remit of this work will include:
• Supporting vulnerable adults with learning, physical and sensory impairment
• Complex mental health
• Personalisation and budget accounts
• Supported Housing
• Older people care
• End of Life Care.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
142
Agenda Item 5
Page 146
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
Primary care
The delivery of mental health services is changing with a greater emphasis being placed on shifting
services from a hospital based model to the development of community mental health services. To
achieve this objective there must be a close alignment between secondary and primary care
services. It is therefore crucial that the Mental Health CDG is closely involved in work to develop
primary care and the responsibilities between the groups are clearly established.
Children’s services
The Mental Health CDG needs to link in very closely with the Children’s CDG. There is an intention as
the strategy progresses to do more around the development of CAMHS services, Children’s IAPT and
ensuring the tranistions from children’s to adults’ services are appropriately handled. These are all
areas in which the CDGs will need to work closely together. In addition, it will be important to
reflect jointly on the impact of the Children and Families Act.
Integrated care
The Integrated Care CDG has separately developed several initiatives to respond the the needs of
patients with dementia, including the implementation of the joint dementia strategy, improving
information and education for those with dementia, and developing psychiatric liaison services. The
Mental Health CDG will ensure that it is closely aligned with this work to ensure services are
developed within a set of joined up mental and physical health services. As the development of the
strategy progresses both groups will need to have a joint focus on patients with co-morbid mental
and physical health conditions. This will be a key priority for the development of services out of
hospital.
There are a number of different services which are vital to the effective delivery of community
mental health:
Community pharmacists have a role in:
•
•
•
•
•
Collaboration with GPs, mental health teams, services users and carers
The early identification of people with mental health concerns and signposting to services
Medication compliance and risk management
Medication optimisation
Identification of physical health complaints.
Substance misuse teams have a role in:
•
•
•
•
Co-morbid alcohol and substance misuse
Management of risk and risky behaviours
Self-harming
Supporting the management of cross cutting workstreams.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
143
Page 147
Agenda Item 5
Chapter 4: Clinical workstreams, Section 4: Mental
Health
South West London Collaborative Commissioning
Urgent and emergency services
From an urgent care perspective, the Urgent and Emergency CDG has proposed a review of Urgent
and Emergency Care for people experiencing a mental health crisis and, separately, a review of
psychiatric liaison services, recognising a level of inconsistency between the services currently
available to patients across south west London. The Mental Health CDG will work closely with the
group to assist in this review and will be particularly careful to be joined up in the development of
crisis services.
Maternity services
Finally, there is a considerable mental health component to the work being developed by the
Maternity CDG. Perinatal mental health care is included within this strategy, and the mental health
CDG will link in with this group to make sure women are adequately supported and directed to the
most appropriate services.
What are the investment implications of these initiatives?
The Strategic Plan outlines a bold and ambitious approach to improving the quality of care delivered
across acute, community, mental health and primary care services. In order to deliver these clinical
ambitions and achieve a financially sustainable health economy, south west London commissioners
will need to work together to prioritise how best to address the multiple challenges identified whilst
supporting the investment required to deliver transformational change.
The initiatives set out in this plan will require upfront investment, particularly to expand access to
existing community teams and to improve crisis services. Current combined spending by south west
London commissioners is around £193m in 2014/15, which is anticipated to rise by around 8% over
the next five years. This represents approximately 12% of total CCG spend.
The intention is to work closely with providers over the coming months to identify specific
programmes of work and investment implications to ensure that a fully costed programme of work
can be developed. Once the financial implications are known, it will become possible to agree a
more specific implementation plan. It is important however to note that it is already clear that there
is more investment required to deliver the various initiatives identified in the overall Strategic Plan
than can be financed from the available financial resources; this will require there to be appropriate
prioritisation by commissioners.
What are the workforce implications of these initiatives?
This strategy sets out a clear mandate to improve the integration of physical and mental health
services.Significant workforce development is required in order to do meet these objectives,
specifically to improve the competencies of physical health staff in identifying and treating patients
with mental health problems. Similarly it will become increasingly vital to ensure mental health staff
have appropriate competencies to direct patients with co-morbid physical health problems to the
appropriate services.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
144
Agenda Item 5
Page 148
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
Planned Care
Introduction: why Planned Care is important
We know that patients rightly expect to receive high quality Planned Care. We also know that some
Planned Care can be subject to long waiting times, cancellations for non-clinical reasons and
unnecessary treatment delays. Planned Care is therefore an essential area of focus in our strategic
plan. We are committed to improving local Planned Care services so we better meet patient needs
and ensure patients receive high quality, personalised, care safely and efficiently.
Improving Planned Care services is directly aligned to one of the six characteristics of high quality
and sustainable health and care systems; ‘a step-change in the productivity of elective care 1’. This
characteristic refers to the need for Planned Care services across the health system to be ‘designed
and managed from start to finish to remove error, maximise quality, and achieve a major stepchange in productivity’1. There is an expectation that centres will be able to deliver high quality
treatment, develop expertise, and use the most modern equipment available.
In south west London, the Elective Orthopaedic Centre (EOC) is an example of best practice in
Planned Care. The EOC operates from a single site to provide a regional Orthopaedic service which is
separated from non-elective surgery services. Though some patients may have to travel further,
lessons from the EOC indicate that patients are willing to do so for shorter waiting times, lower
instances of cancellations and delays and better outcomes.
Given the success of the EOC, a single inpatient multi-specialty elective centre (MSEC) is our
preferred clinical model for inpatient Planned Care in south west London. We recognise that moving
to this model of care represents a significant change and we are therefore looking to develop the
MSEC using a staged approach; developing a local Urology centre before expanding to include other
specialties. Successfully implementing a MSEC cannot be achieved in isolation by individual CCGs or
providers, as it requires close collaboration and effective partnership across the south west London
health economy to guarantee a critical mass of the right categories of work. This can only be done if
there is a regional agreement to centralise into a single centre for maximum efficiency, as is the case
for the EOC. Failure to collaborate across the south west London health economy could result in
underutilisation and a reduction in productivity.
What does this section of the 5 year strategic plan cover?
The Planned Care section of the 5 year strategic plan covers planned inpatient routine elective
surgery. Day case procedures are out of scope (except where there is a significant financial and/or
clinical benefit in centralisation), and routine medical outpatient appointments will be considered as
part of the Integrated care section (see chapter 4, section 2).
1
Everyone counts: Planning for patients 2014/15 to 2018/19, NHS England, 2013. Retrieved from:
http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
145
Page 149
Agenda Item 5
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
What is the vision for Planned Care in south west London for 2018/19?
Clinicians in south west London have developed a vision for a future model of care that responds to
regional challenges and meets the needs of people in the area for the years ahead. In south west
London we believe that the separation of Planned Care and non-elective care provided as part of an
end-to-end pathway, with Planned Care being delivered in a MSEC, will provide safer, higher quality
and more convenient care for patients.
The Planned Care service in south West London will:
• Separate elective and non-elective surgery, reducing the rate of cancellation for non-clinical
reasons due to peaks in demand for non-elective surgery
• Be delivered in a single MSEC for south west London by 2018/19
• Improve efficiency, quality and safety for patients through the centralisation of routine
inpatient procedures in a centre of excellence
• Improve patient experience through use of efficient surgical care pathways, which are
predictable, uninterrupted and encourage greater continuity of care
• Optimise post-operative care for the condition provided by senior decision-makers and
specialist nurses
• Reduce length of stay in hospital with highly coordinated discharge and after-care delivered
in the community where possible
• Build easier access to enabling or recovery services such as therapy, pain management,
oncology, reablement and mental health services into the care pathway, providing
continuous and integrated support through the entire patient journey
• Utilise existing estate to maximum effect, with any capital investment focussed on building
technology-enabled care pathways
Figure 1: Our vision for Planned Care in south west London
We know that we also need to address the care patients receive before, and after, their planned
surgery; we will only improve patient experience and patient outcomes if we look at end-to-end
pathways. The end-to- end care pathway is summarised in Figure 2.
Setting
Community
Community
Community
Elective Centre
Pathway
step
Initial
presentation
at GP
Investigation
of all
alternatives
to surgery
Preoperative
assessment
Check-in at
Elective
Centre
Screening to
ensure
appropriate and
safe casemix
On day of
procedure in
Procedure
Carried out at a
‘centre of
excellence’ with
no non-elective
procedures
Postoperative
recovery
Provided by
specialist
nurses,
overseen by
senior decisionmakers
Community
Community
After care
Follow-up
Supported by
technological
advances
Minimising length of stay
Figure 2: Planned Care pathway
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
146
Agenda Item 5
Page 150
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
What is the national context for Planned Care?
•
•
•
•
Where operating lists are run in parallel in the same department, Planned Care surgical
procedures are frequently cancelled to create capacity for non-elective surgery. This has the
potential to increase discomfort and complications in patients leading to dissatisfaction, lead
to longer referral to treatment times and increase length of stay.
The Royal College of Surgeons (RCS) advocates the separation of non-elective and Planned
Care services, to improve patient experience and quality of care 2. The RCS has also recently
highlighted their support for the concentration of emergency, elective and specialist surgery
onto few, larger and separate sites 3 to address increasing demand, changing clinical needs,
poor coordination of care and out-of-hours cover as well as concerns over workforce supply.
A step-change in the productivity of elective care is one of the six characteristics of high
quality and sustainable health and care systems 4. Greater productivity is important given
projections of greater demand for planned surgery as a result of population growth and
advances in surgical techniques.
Delayed discharge occurs when a patient is medically fit for discharge from care and is still
occupying a bed 5. Delayed discharges exacerbate patients’ exposure to hospital-acquired
infections and reduce providers’ functional capacity 6. Evidence shows that these delays can
happen for a number of reasons however the availability of social care and rehabilitation
services can be a factor5, particularly with patients who have complex care needs 7. There is
a national requirement for better end-to-end pathway planning and for social, rehabilitation
and Planned Care services to work more closely together to minimise instances of delayed
discharge. Seven-day working may have a positive impact on the availability of required
post-operative services 8.
Figure 3: National context for Planned Care
2
Emergency surgery: Standards for unscheduled surgical care, Royal College of Surgeons, 2011
Reshaping surgical services: principles for change, Royal College of Surgeons, 2013
4
Ibid. 1
5
Statistical press notice: Monthly delayed transfers of care data, England, March 2014, Government Statistical
Service, 2014. Retrieved from: http://www.england.nhs.uk/statistics/wpcontent/uploads/sites/2/2013/05/March-14-DTOC-SPN.pdf
6
In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience, Clinical Medicine
2012, Vol 12, No 4: 320–3, 2012. Retrieved from:
http://www.clinmed.rcpjournal.org/content/12/4/320.full.pdf
7
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_to
ols/discharge_planning.html
8
NHS Services, Seven Days a Week Forum: Summary of Initial Findings, NHS England, 2013. Retrieved from:
http://www.england.nhs.uk/wp-content/uploads/2013/12/forum-summary-report.pdf
3
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
147
Page 151
Agenda Item 5
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
What is the local context for Planned Care?
•
•
•
Although average length of stay for elective admissions is lower than the national and
London averages, the variation we see locally demonstrates there is room for further
efficiencies. With improved working with other health and social care services, such as
community rehabilitation services, we can further reduce the time patients spend in hospital
The average cancellation rate for Planned Care surgery is above the national and London
averages, leading to poorer patient experience. This is a contributory factor to increased
referral to treatment times and the number of patients on the waiting list 9.
The average level of healthcare acquired infection (HCAI) is above national average. HCAIs
can complicate patients’ underlying conditions, be challenging to treat and lead to a sevenfold increase in the risk of dying in hospital 10.
Figure 4: Local context for Planned Care
There is scope to reduce the variability in length of stay across south west London
In 2012/13 the average length of stay for elective inpatient admissions for all of the acute providers
in south west London was lower than the national average, as well as the average for London 11 (see
Figure 5). However, as the graph shows, there is some variability in length of stay across south west
London, indicating scope for further improvement through sharing best practice and making
efficiencies. Reducing the variability in length of stay across south west London could result in a
number of benefits including lower risk of (HCAI) as well as more efficient use of staff and bed
utilisation.
Average length of stay for elective procedures in south west
London compared to London and national average, 2012/13
3.5
3.0
2.5
National Average
2.0
London Average
1.5
1.0
0.5
0.0
Croydon
Epsom & St.
Helier
Kingston
St George's SWL Average
9
A new pathway for elective surgery to reduce cancellation rates, BMC Health Services Research 12:154, 2012.
Retrieved from: http://www.biomedcentral.com/1472-6963/12/154
10
GO-Science Review of the Department of Health, Annex 5 - Healthcare Associated Infection - Case Study,
Government Office for Science, 2007.
11
Average refers to the mean. Source: https://www.nhscomparators.nhs.uk
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
148
Agenda Item 5
Page 152
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
Figure 5: Average length of stay for elective inpatient procedures in south west London compared to London and
national averages, 2012/13
Length of stay for elective inpatient admissions may be improved through:
•
•
•
•
Robust patient selection criteria to ensure appropriate patients go forward to have an
elective procedure.
Improvement in surgical outcome due to development of centres of excellence.
Improvements to internal processes to ensure an efficient patient pathway.
Effective post-operative care through effective discharge planning and co-ordinated working
with Community and Rehabilitation services to get people back into a home environment
sooner and avoid re-admissions 12.
Higher than national average cancellation rates are recorded in Planned Care at some
providers in south west London
Where operating lists are run in parallel in the same department, planned surgical procedures are
sometimes cancelled to create capacity for non-elective surgery. Across south west London
hospitals, over 1,000 Planned Care procedures were cancelled at the last minute for non-clinical
reasons in 2012/13 13. Following the cancellations, 20 patients were not seen within 28 days. In
Croydon and Epson & St Helier, rates for planned elective procedures not carried out exceed the
national average of 2.8% and a London-wide average of 2.6% 14 (see Table 1). The variation in
Planned Care cancellation rates in south west London suggests there is a need to work with
providers to better understand the details and local context behind the figures.
% Not carried out
NATIONAL
London SHA
Croydon
Epsom & St Helier
Kingston
St George's
SWL Average (Median) 15
2.80
2.62
3.73
3.45
2.19
0.40
2.82
Table 1: Percentage Elective Procedures Not Carried Out
16
Total Not carried
out
202,987
28,165
1,172
1,461
473
138
-
- 2012/13
Total count
7,251,510
1,074,657
31,386
42,326
21,557
34,739
-
17
12
Enhanced recovery program in total hip arthroplasty, Indian J Orthopaedics, Jul-Aug; 46(4): 407–412, 2012
http://www.england.nhs.uk/statistics/statistical-work-areas/cancelled-elective-operations/cancelled-opsdata/
14
Average refers to the median. Source: https://www.nhscomparators.nhs.uk
15
SWL average assumes that all activity going to Epsom and St Helier is from south west London
16
Not carried out is the percentage of elective admission where HRG = Planned procedures not carried out (S22
or WA14Z). Denominator data: Count of completed spells
17
https://www.nhscomparators.nhs.uk
13
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
149
Page 153
Agenda Item 5
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
Cancelling Planned Care in order to create capacity for non-elective surgery and emergency medical
admissions has adverse implications for patient experience and outcomes. The interruption of the
Planned Care surgical pathway also causes inefficiencies elsewhere in the system, resulting in
backlogs and unmanageable waiting lists for Planned Care 18. Overall this results in a poor experience
for patients and carers and can be frustrating for local clinicians, who are trying to balance a
commitment to treating their patients within a clinically appropriate and reasonable timeframe with
having to attend to emergencies admitted through local A&Es 19.
The effects of cancelled planned procedures are outlined in Figure 6.
The effects of cancelled planned procedures
We know that there are a number of negative consequences associated with the delay and
cancellation of elective procedures for non-clinical reasons. These include:
• Prolonged duration of pain associated with the patient’s condition(s) and/or anxiety whilst
waiting for surgical treatment
• Prolonged duration of ‘prepared state’ before surgery e.g. patients may have to be ‘nil-bymouth’ or off specific medications prior to the surgery for longer than is strictly necessary.
Patients may also have to go through a repeat pre-assessment or surgical preparation
process
• Prolonged state of being ‘bed-bound’, increasing risk of clinical complications
• Increased risk of pressure sores through prolonged state of being ‘bed-bound’
• Increased risk of escalation of the condition where emergency or urgent care may be
required
• Significant waste of resource as the costs of theatre time, the surgical and nursing team and
the administrative processes relating to the patient have to be replicated at a later date
• Increase in the overall length of stay in a hospital leading to wastage and poor use of
stretched provider resources
• Increased risk of contracting a HCAI
• Burden to patients in re-arranging, for instance, time off work, transport to and from
healthcare services and carer provision
Figure 6: Effects of cancelled planned procedures
The NHS England Any Town data packs, cite elective specialty centres as a way for centres to
decrease waiting times and post-surgery complications, as well as provide significant cost
improvements 20.
18
Better Services Better Value Planned Care Clinical Working Group Final Clinical Report, Better Services Better
Value, 2012. Retrieved from: http://www.bsbv.swlondon.nhs.uk/wp-content/uploads/2012/09/2012-03-01Report-Final-Clinical-Report-Planned-Care.pdf
19
Ibid. 2
20
Any town health system: Urban CCG data, NHS England, 2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
150
Page 154
Agenda Item 5
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
Higher than national average levels of HCAIs are recorded in Planned Care in south west
London
All providers, bar Kingston, had higher Methicillin-resistant Staphylococcus Aureus (MRSA) rates per
100,000 bed days than the national average in 2012-13 (see Figure 7) 21. Contracting an HCAI
generally results in further complicating a patient’s underlying condition, can be challenging to treat
and leads to a seven-fold increase in the risk of dying in hospital 22. Even if the patient experiences no
lasting ill-effects of the infection, their length of stay will increase by three to ten days 23 and they are
likely to be in distress or discomfort during the period of infection.
MRSA bacteraemia rate per 100,000 bed days, April 2012- March 2013
National Average
2.6
Croydon Health Services
2.9
St. George's Healthcare
Kingston Hospital
4.6
1.4
Epsom & St Helier
University Hospitals
6.2
Figure 7: MRSA bacteraemia rate per 100,000 bed days, 2012-13
HCAI rates can be reduced through improved infection control protocols including hand hygiene and
environmental cleaning, screening and rapid testing on emergency surgery patients, prudent
antibiotic prescribing, isolation of infected patients, and use of personal protective equipment 24. The
early identification and management of patients is critical to reducing incidence; conversely,
inefficiencies in bed management, delays in the transfer of patients, and increasing bed occupancy
levels all contribute to higher incidences 25. Many of these predisposing circumstances, such as
infection control between planned and emergency theatres sessions and patients, can be addressed
through clear separation of planned and unplanned cases. As an example, since opening in 2004, the
EOC has had no incidence of MRSA cross infection 26.
21
http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1233906819629
Ibid. 10
23
Ibid. 10
24
Editorial, BMJ, 2007
25
Implementing guidelines for the control and prevention of methicillin-resistant Staphylococcus aureus and
vancomycin-resistant Enterococci: how valid are international comparisons of success? Royal College of
Surgeons, 2005
26
NHS Specialist Orthopaedic Alliance: The south west London Elective Orthopaedic Centre. Retrieved 2014,
from: http://www.specialistorthopaedicalliance.co.uk/Membership/Epsom
22
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
151
Page 155
Agenda Item 5
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
What are the key challenges for Planned Care that we will address?
The key challenges that we need to address are:
• The lack of sufficient end-to-end Planned Care pathways, for specific conditions, on an
integrated networked basis
• Improvable patient experiences and health outcomes for patients undergoing planned
procedures
• The disruption caused to Planned Care services by non-elective activity
Figure 8: Key challenges for Planned Care
We need to develop end-to-end care pathways, for specific conditions, on an integrated
networked basis
End-to-end Planned Care ‘pathways’ should be developed for specific conditions on an integrated
networked basis to maximise access, convenience and safety for patients and overall pathway
efficiency. These pathways need to cover the whole ‘patient journey’ from initial presentation
through diagnosis, pre-operative assessment and patient information, discharge planning before
admission, minimising hospital stay, effective information transfer and the necessary community
back-up to ensure safe discharge. Systems need to be in place to ensure that those patients who join
the pathway later or from unusual routes such as via Emergency Departments (EDs) or Consultantto-Consultant referrals receive the same high quality care.
We need to further improve the experience and health outcomes for patients undergoing
planned procedures
There is evidence that patient satisfaction rates across different Planned Care specialties vary
around a number of factors when using Planned Care services 27. These include, but are not limited
to:
• Poor co-ordination between acute and community services providers negatively affecting
length of stay, patient experiences and health outcomes
• Incidence of HCAI
• Lack of information on existing services and unclear access guidelines for users
• Longer waiting times and cancellation of planned procedures
• Few services on offer
• Fragmented step-down services
Addressing these factors will help to improve patient experience. Outcomes can also be improved
by aspiring to upper quartile performance benchmarks. Where upper quartile is already being
achieved the aspiration should be to reach top decile.
27
Ibid. 18
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
152
Agenda Item 5
Page 156
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
We need to ring-fence Planned Care theatres, beds and staff to avoid disruption from
emergency activity
Planned Care must be ring-fenced to avoid disruption from emergency activity and create an
environment in which standardisation of care processes and their systematic audit is promoted.
Delivering Planned Care through an elective centre would help achieve this. The EOC provides proof
of concept; with its ring-fenced theatres, beds and staff for planned orthopaedic surgery, the EOC
records lower cancellation rates than other local providers 28 and significantly improved outcomes
(see Figure 9).
Proof of concept: elective orthopaedic surgery in south west London
In 1998 consultant orthopaedic surgeons from across south west London came together to consider
the sustainability of the service across the area. At the time, elective orthopaedic procedures were
carried out at all trusts in the area (Croydon [formerly Mayday], Epsom [part of Epsom & St Helier
University Hospitals Trust], Kingston, St George’s, and St Helier). The service was characterised by
relatively poor outcomes, a lack of training opportunities, and with questions around the overall
clinical sustainability 29.
Following a period of detailed planning and implementation, led by consultant orthopaedic surgeons
and drawing on national and international best practice, the EOC was opened on the Epsom Hospital
site in 2004. Since then it has become a ‘Centre of Excellence’ in orthopaedic surgery and has
gradually increased the number and range of procedures that it offers, and has become a national
example of the model of care. It has also developed a successful research centre, and provides
training opportunities for the specialty. The clinical outcomes and complication rates are some of
the best in the country and between April and August 2013; over 97% of patients would be ‘likely’ or
‘extremely likely’ to recommend the centre to friends and family (see Figure 10).
Fundamentally, it has been recognised that clinical appetite and leadership, the opportunity to
provide better outcomes for patients and the strength of commissioning has allowed this service to
become a success, and pave the way for the future of elective care across multiple surgical
specialties across south west London.
Despite initial concerns over extended travel times the service has become extremely popular with
patients, which has gradually increased both the volume and range of offers. It has developed a
strong ‘brand’ and is the first choice for elective orthopaedics care across the area.
Figure 9: Proof of concept; the EOC
28
29
Planned Care Clinical Working Group Final Clinical Report, NHS South West London, 2012
Source: Meeting with the Elective Orthopaedic Centre Leadership Team, July 2013
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
153
Page 157
Agenda Item 5
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
800
Patient Responses
700
EOC Friends and Family Test, Apr-Aug 2013
670
600
500
400
300
200
63
100
0
Extremely
likely
Likely
8
1
5
6
Neither likely
nor unlikely
unlikely
Extremely
unlikely
Don’t Know
Figure 10: EOC Friends and Family Test results, 2013
The majority of Planned Care can be delivered in an elective centre where activity is consolidated in
order to drive up productivity and quality of outcomes; whilst single-specialty elective centres are
possible, a multi-specialist elective centre would benefit from economies of scale in addition to the
clinical benefits detailed by the RCS 30,31.
How we developed our initiative for improving Planned Care:
A significant amount of work has been undertaken to develop our initiative for improving Planned
Care. In October 2013, 45 clinicians working in six different specialties (breast and endocrine,
colorectal, gynaecology, hepatobiliary and upper GI, orthopaedics and urology) attended a workshop
to explore the best way to deliver Planned Care across south west London. This work has continued
to be developed and refined through Clinical Design and Advisory Group meetings.
Numerous public engagement events have also been held to provide local residents, patients,
councillors and voluntary groups with the opportunity to explore the challenges facing the NHS and
to discuss the initiatives being considered. During the events, local doctors and nurses leading the
review tested clinical discussions with members of the public and local stakeholders: this included
recommendations for improving the quality of services in Planned Care.
At the event in May, attendees discussed:
1. The benefits of having physical separation of Planned Care and emergency surgery in terms
of reducing appointment waiting times and cancellations
2. The benefits of consolidating the number of Planned Care centres in terms of patient
experience and clinical outcomes. There was support for having a MSEC if it is proven to
lead to better quality care and health outcomes. Attendees believed most people would not
mind travelling further to access care, if the benefits of doing so are clearly communicated.
However they felt that there would be a requirement to make special provisions for
vulnerable patients who are the least mobile, e.g. ensuring that assessments prior to their
30
Ibid. 3
Ibid. 2
31
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
154
Agenda Item 5
Page 158
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
operations can be carried out nearer to home and providing transport links to the centre.
Attendees also called for greater investment in aftercare support for people who are
recovering from surgery at home, especially older people and those living alone.
In order to test the organisational and clinical implications of the proposed initiative across the local
health economy, it is envisaged that there will be a phased approach to implementation, assessed
on a specialty-by-specialty basis. Changes to the clinical model and patient pathway will only take
place following readiness assessments and development of detailed mobilisation plans. Urology was
considered to be the specialty in the most advanced state of readiness to move to this new model of
working within a single, centralised ‘Centre of Excellence’.
Urology has been identified locally as a suitable ‘pilot’ specialty, due to the overwhelming clinical
appetite for transformation, which emanates from plans for a single South West London Department
of Urology (SWLDU) originally proposed as early as 2008 by local consultant urologists. The strategy
for redesign of urology services has therefore been clinically led throughout, working in partnership
with commissioners to identify the specific clinical and service experience benefits for patients, their
carers and families. Local commissioners recognise that facilitating this clinical leadership is
paramount to the effective and safe transition of services.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
155
Page 159
Agenda Item 5
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
What is the initiative that will address our challenges in Planned Care?
Figure 11 outlines the initiative that will address the challenges in Planned Care; the creation of a
south west London multi-specialty elective care centre (MSEC).
Figure 11: Planned Care initiative
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
156
Agenda Item 5
Page 160
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
When will we achieve the initiative for Planned Care?
The timeline for achieving the Planned Care initiative is outlined in Figure 12.
Figure 12: Timeline for achieving the Planned Care initiative
How does our work to improve Planned Care address the outcomes in
Everyone Counts 32?
The vision for urgent and emergency care will address the seven measureable outcomes set out in
the national planning guidance and the three key measures as outlined in Figure 13.
Figure 13: Alignment to the seven measurable objectives
32
Ibid. 1
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
157
Page 161
Agenda Item 5
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
What are the interdependencies with other workstreams?
There are three key interdependencies for Planned Care:
1. Primary Care: A number of changes are planned for both primary care and Planed Care.
Given the overlap between these care provisions, it is important that proposed changes are
shared and implications discussed between services
2. Integrated Care: The future model will require health and social care to work closely
together to provide effective care across the health and social care boundaries. Additionally,
although the preferred model for Planned Care is a MSEC, rehabilitation services will
continue to be provided close to patients’ homes. It is vital that there is a seamless transfer
of care between Planned Care and all rehabilitation services
3. Urgent and Emergency Care: The future model will require the workforce, especially
surgeons, to cover both planned and non-elective rotas. Providers will outline the workforce
and rota arrangements in the business case, taking into account the geographical location of
the MSEC and non-elective sites and staff training requirements. The services will need to
work together to ensure viable staffing arrangements are implemented
What are the investment implications of this initiative?
The Planned Care initiative will require investment in a number of areas, including but not limited to:
• Workforce; financing transition support requirements and ensuring all MSEC staff are
appropriately trained
• Estates; providing a suitable site for the MSEC
• Technology; ensuring the centre has access to required systems and specialist equipment
• Infrastructure; providing necessary provisions for the MSEC, including telecoms and
transportation links to connect the MSEC to localities closer to patients' homes
• Aftercare support; providing care for people who are recovering from surgery at home
In 2014/15, we will work with providers to develop a costed business case for the Planned Care
initiative. South west London providers will be the source of investment for the Planned Care
initiative. For this reason, the business case will be subject to provider approval. There will also be a
requirement for providers to agree on profit-share arrangements, accounting for the level of
providers’ initial investments.
How will our workforce and estates need to be developed to deliver the
strategy?
Moving towards an MSEC model will have positive implications for the workforce in south west
London; it is an attractive model for nurses as it caters for nurses who want to specialise in
emergency, elective or a mixture, providing excellent training opportunities. In addition, by seeing
higher volumes of patients and working in a MSEC, the workforce will develop more quickly and this
will ultimately lead to higher quality care. Some initial workforce development and training may be
required; to ensure that staff are involved in the changes and that they are appropriately trained.
The business case will outline the arrangements for on-call consultant cover across planned and nonelective rotas.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
158
Agenda Item 5
Page 162
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
The business case also will provide a detailed assessment of estate needs, which will be dependent
upon where the MSEC is finally built and developed.
What work is already underway in boroughs to deliver our vision for
Planned Care?
In all south west London CCGs, work is already underway to ensure that patients receive the right
care in the right time and place. In Croydon and Wandsworth CCGs, work is being done to
strengthen referral routes and the links between planned and community care. This work
contributes towards our aim of developing end-to-end patient pathways that maximise access,
convenience and safety for patients and overall pathway efficiency.
The next step in delivering our vision for Planned Care is to ring-fence Planned Care theatres, beds
and staff through the implementation of the MSEC model, starting with the Urology service.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
159
Page 163
Agenda Item 5
Chapter 4: Clinical workstreams, Section 5: Planned Care
South West London Collaborative Commissioning
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
160
Agenda Item 5
Page 164
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Transforming Primary Care
Introduction: Why Transforming Primary Care is important
We as lead commissioners recognise the importance of transforming primary care in order to
strengthen our local healthcare economy. We have also listened to the needs of our communities
and wider stakeholders, and they want increased access to high quality primary care and in particular
to general practice professionals. We have therefore designed a dedicated Transforming Primary
Care Clinical Design Group (CDG) through our programme, which will work collaboratively with NHS
England’s London Area Team to improve the commissioning of primary care in south west London.
We know that our primary care teams, including wider primary care professionals, are working under
increasing pressures and demand for their time. Primary care has been a key contributor to
efficiency in the NHS and our local healthcare economy, and we need to ensure that we continue to
promote this. We know that general practitioners and their teams will work differently in the future
if we are to achieve the best outcomes for our local populations, and therefore we need to support
general practices and wider primary care providers to adapt and innovate.
Primary care has received both national and London-wide attention, as an area where increasing
focus and investment is likely to relieve significant pressure in the health and social care system.
Primary care commissioning is also under the spotlight and in the near future we will need to
consider what is appropriate in south west London, in collaboration with our primary care providers.
Co-commissioning as a whole for south west London is a significant opportunity to improve services
for patients, but does not come without some obvious challenges. This 5 year strategy describes our
plans for primary care, whilst recognising that on a London-wide and national level there is
significant transformation emerging. We have considered this and believe that our strategy
compliments the wider changes and plans for primary care, including meeting London-wide primary
care standards which are to be made available later this year.
What does this section of the 5 year strategic plan cover?
Transforming primary care includes all services delivered by primary care including routine, urgent
and any other services delivered in primary care. It does not include the provision of specialist care
by GPs with a specialist interest where this is not commissioned directly by NHSE; however it would
include specialist care as enhanced services or local incentive schemes.
What is the vision for Transforming Primary Care in south west London for
2018/19?
In south west London, CCG commissioners together with local primary care professionals have
developed a vision for primary care which addresses the imminent and expected future pressures
facing primary care. The vision has been developed with consideration of the draft Primary Care
standards for London. Achieving high quality, good outcomes and access in general practice is
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
161
Page 165
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
becoming increasingly challenging. CCG commissioners in south west London recognise in common
with NHS England that, for general practice to be sustainable and future-proof, primary care services
need to change. CCG commissioners also agree that general practice can no longer be commissioned
in isolation from other parts of the health economy in south west London.
The transformation of general practice in south west London is a key strategic priority because
improvements will enable the full implementation of each borough’s Better Care Fund (BCF) plan and
agenda for delivering integrated care. In addition, high quality and accessible primary care can
enable reductions in A&E attendances and non-elective admissions, as well as deliver holistic care
planning, co-ordination and continuity which are founding principles for general practice in the UK.
We believe that people in south west London deserve and expect a primary care service which is
accessible and responsive:
•
For times when they need to consult for routine medical problems and concerns
•
For times when they need urgent advice and care
•
To keep their condition from progressing or escalating to a situation of emergency, where
possible
•
To help people to stay healthy
In addition, it is a primary care service which:
•
Gives people the confidence that their general practice can offer the level of continuity
which enables them to receive high quality routine care
•
Allocates the right amount of time, attention and skill to all patients including those who
are most vulnerable in society or at risk of losing their independence
•
Allocates the right amount of time, attention and skill to those who have significant health
and/or mental health conditions
•
Takes responsibility for co-ordinating holistic care of people suffering with multiple LTCs,
and includes helping people to identify and seek further help for associated mental health
conditions or accessing services which will increase their social welfare
•
Utilises care co-ordination, case management, risk stratification process and
multidisciplinary working, joining community teams, social care professionals and
specialists to deliver joined up care for people with long term conditions and complex
needs
•
Allocates the right amount of time, attention and skill to helping people to self-manage
their condition or to improve their health and wellbeing overall
•
Delivers frontline care in premises which are safe, suitable and facilitate multidisciplinary
working between health and social care professionals where possible, a physical space in
the community associated with health and wellbeing
•
Provides increased uptake and equity of access to immunisation and health screening
•
Signposts and provides opportunities for people to learn and be empowered to manage
their condition, where appropriate, from self-limiting or minor illness to chronic conditions
impacting on long long-term quality of life
CONFIDENTIAL:
DRAFT
Figure 1: The vision
for Transforming Primary
Care FOR CCG GOVERNING BODY DISCUSSIONS
162
Agenda Item 5
Page 166
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Therefore in south west London we intend to enable the transformation of primary care in
collaboration with NHS England, concentrating our efforts on the following three areas for
improvement:
•
Accessible care – care which is timely and responsive to the person’s needs and access to
care is not limited to consultations in the surgery
•
Coordinated care – care which is holistic, provides continuity and reassurance for patients
and delivers care alongside a multidisciplinary team for those whose condition, complexity
of care or preference requires this
•
Proactive care – care which focusses on preventing ill-health, encourages patients to selfmanage and supports the overall health and wellbeing of the population.
What is the national context for Transforming Primary Care?
•
•
•
Transforming Primary Care is a national priority and aspires to deliver a number of key
changes, for example:
- Introduction of the Proactive Care programme 1
- Changes to the GMS contract that require practices to allocate a named GPs to people
over 75 2
- The Better Care Fund 3, a pooled funding arrangement between CCGs and local
authorities, has been introduced as part of the integrated care agenda to enable closer
working between health and social care
- Local pilots to be set up to explore how to improve access to primary care 4
- Requirement of CCGs to provide £5 per head of population to commission services that
support practices in transforming the care of patients aged 75 or older as outlined in
Everyone Counts planning for patients 2014-15 to 2018/19 5
‘A Call to Action – Tranforming Primary Care in London’ highlighted the scale of the
challenge in relation to London 6
Co-commissioning proprosals between NHSE and CCGs were announced on 1st May 2014,
and CCGs are able to make expressions of interest for delegated responsibilties by 20th June
2014
Figure 2: The national context
1
Williams, L., Transforming Primary Care – Safe, proactive, personalised care for those who need it most (April
2014), Department of Health
2
NHS England, Gateway reference: 00698, 2014/15 GMS Contract Negotiations, November 2013
3
NHS England, http://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/
4
NHS England, The Prime Minister’s Challenge Fund: http://www.england.nhs.uk/ourwork/qual-clinlead/calltoaction/pm-ext-access/ (accessed 8 May 2014)
5
NHS England, Everyone Counts planning for patients 2014/15 to 2018/19 , 2013
6
NHS England, Transforming Primary Care in London: General Practice A Call to action, Jemma Gilbert, 2013,
London
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
163
Page 167
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Primary care in the UK has for a long time consisted of independent primary care providers offering
internationally recognised family medicine, while being ‘gatekeepers’ to expensive secondary care
services. However, without undermining the historical impact of primary care, it is recognised
nationally that general practice can no longer be commissioned in isolation from other parts of the
health economy.
The transformation of primary care is considered a national priority owing to pressures on the
system caused by an ageing population and the need to provide better and more accessible services
to people who have complex health and care needs 7. In order to keep the population healthy,
independent and out of hospital, health and social care services need to provide increasingly
personalised and proactive care. Last year the ‘A Call to Action – Transforming Primary Care in
London’ 8 led by NHS England London opened the debate about why and how to transform primary
care in London, and in April 2014 the Department of Health released the paper ‘Transforming
Primary Care’ 9 which describes primary care as a new national area of focus, stating that this is only
the start of increasing investment into primary care. The report highlights intentions to promote a
shift from a reactive focus to a prevention focus for those who have high needs.
A number of changes are planned to improve primary care services nationally:
•
From September 2014, the Proactive Care Programme will be introduced, ensuring over
800,000 people with complex needs will experience a change to their care, with GPs
delivering more proactive and personalised care, tailored to support their needs 10
•
As part of the changes to the 2014/15 General Medical Services contract, all practices will be
required to allocate a named GP to all people over 75 years. The named GP will have overall
responsibility for and oversight of their care, providing greater continuity 11
•
The Care Quality Commission (CQC) has developed a new method to regulate and inspect
NHS GPs and out of hours services to assure the quality of services 12. This work has
commenced and the first of ten inspection reports from new GP out of hours inspections was
released in April 2014 13
7
Ibid. 1
Ibid. 6
9
Ibid. 1
10
Ibid. 1
11
Ibid. 2
12
Care Quality Commission, A fresh start for the regulation and inspection of GP practices and GP out-of-hours
services, December 2013
13
Care Quality Commission, http://www.cqc.org.uk/public/news/first-10-inspection-reports-new-gp-outhours-inspections (accessed 8 May 2014)
8
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
164
Agenda Item 5
Page 168
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
•
IT systems will be improved to support people to access their own medical information, book
appointments online and order repeat prescriptions in a simpler way than at present 14
•
Employers, professional bodies and education providers will receive support from Health
Education England (HEE) to ensure the workforce has the required skills to care for older
people and people with LTCs or complex needs 15
•
From 2014/15, the Better Care Fund will support the integration of health and care services
by introducing a single pooled budget and enabling the integrated care agenda 16. NHS
England are due to provide CCGs and local authorities with further information following
some concerns about the Fund’s ability to deliver the expected savings 17.
•
Over the coming year, local pilots will explore new ways to improve access to GP services,
supported by the £50m Prime Minister’s Challenge Fund 18. A wide range of innovative ideas
are being tested, such as opening 8am-8pm on weekdays and weekends, improving the use
of telehealth and telecare, new ways to book appointments such as e-mail and Skype and
new services such as care co-ordinators
•
In 2014, CCGs will be required to pay £5 per head of registered practice population to
commission services that ensure tailored care for vulnerable and older people aged 75 years
and above to reduce avoidable admissions 19
•
2014/15 GMS contract changes also reflect a reduction in focus on Quality and Outcomes
Framework (QOF) points completion, attempting to allow general practice teams to refocus
their efforts on people over 75 years and others with complex needs 20
•
Area teams are encouraged to reflect the appropriate General Medical Services (GMS)
contract changes in local Personal Medical Services (PMS) agreements to endorse a
reasonable approach across all practices 21.
The ‘A Call to Action – Transforming Primary Care in London’ highlights the scale of the challenge
with reference to London. London suffers from a high level of health inequalities, a mobile and
changing population which requires highly accessible and responsive primary care services,
compounded by issues of increasingly constrained resources and a workforce under immense
pressure to be more and more productive. In particular, the ‘Transforming Primary Care in London’
case clearly articulates that incremental changes and ‘tweaking around the edges’ will no longer be
enough to relieve pressures for both general practice and where primary care links with other
services, including social care and unplanned care services. A transformational approach to strategic
14
Ibid. 1
Ibid. 1
16
Ibid. 3
17
The Guardian: http://www.theguardian.com/society/2014/may/06/nhs-better-care-fund-policy-haltedwhitehall-review (accessed 8th May 2014)
18
Ibid. 4
19
Ibid. 5
20
NHS England Gateway reference: 01264, 2014/15 General Medical
21
Ibid. 2
15
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
165
Page 169
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
change is required, and CCG commissioners in south west London are committed to enabling such a
transformation.
The increase in demand for primary care services will lead to increasing pressure on NHS financial
resources. Currently primary care receives 9% of the overall NHS budget. The Royal College of
General Practitioners is campaigning for a 2% increase 22.
Investment in Primary Care services can lead to more cost effective delivery of health services as well
as improved patient experience:
• GP consultations are estimated to cost between £19 23 and £30 24, while an attendance in A&E for
a minor conditions is estimated at £57 25 to £73 26. Therefore a patient diverted from A&E to
primary care could cost £27-54 less to the overall health economy
• A review of international studies found that increased availability of primary health care spending
was associated with higher patient satisfaction and reduced aggregate health care spending as
well as improved population health outcomes. 27
In addition, the general practice workforce is under pressure. Specific challenges include significant
cohorts of GPs approaching retirement, GPs reducing their clinical practice for commissioning and
other roles, the salaried workforce choosing to do fewer sessions or more locum work, and a greater
reliance on GP locums. Difficulties in recruiting practice nurses are also reported 28.
Owing to the national challenges facing general practice, NHS England’s London Area Team is
currently working to create a set of standards that outline what all Londoners can expect to receive
from general practice. The draft standards have been circulated for consultation to the Clinical
Senate Forum for London and it is intended that these will later proceed to public consultation later
in the year. The standards are designed to reduce variation in the quality and accessibility of general
practice.
22
Royal College of General Practitioners: Patient care under threat in General Practice:
http://www.rcgp.org.uk/policy/~/media/Files/Policy/Fair%20Funding%20for%20General%20Practice/Fair%20F
unding%20for%20General%20Practice.ashx
23
Calculated from extended hours costs for a 10 minute GP consultation
24
Personal Social Services Research Unit (2009) Unit Costs in Health and Social Care – based on 10 minute GP
consultation, 2008/09 pricing
25
Based on A&E minors charge
26
Personal Social Services Research Unit (2009) Unit Costs in Health and Social Care – based on the lower
quartile cost of A&E attendances not leading to admission
27
WHO Regional Office for Europe’s Health Evidence Network (HEN) January 2004 What are the advantages
and disadvantages of restructuring a health care system to be more focused on primary care services?
http://www.nhsalliance.org/wp-content/uploads/2013/06/Jan-2004-What-are-the-advantages-anddisadvantages-of-restructuring-a-health-care-system.pdf
28
South west London Collaborative Commissioning, Implementing Integrated Care in south west London, 2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
166
Agenda Item 5
Page 170
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
In addition, on the 1st May 2014 the NHS’s new Chief Executive Simon Stevens announced intentions
to delegate some responsibilities for the commissioning of general practice to CCGs and has called
for CCGs to put forward expressions of interest in June 2014 29.
What is the local context for Transforming Primary Care?
In line with the challenges for London as a whole, commissioners in south west London recognise the
following specific challenges in their area:
•
There is a diverse population with a large variation in socioeconomic status and ethnicity in
differing parts of the geographical area
•
There is an ageing population, which suffers a greater degree of complexity of LTCs, with a
higher prevalence in some specific conditions, such as cancer, diabetes and atrial fibrillation 30
•
The prevalence of conditions affecting the ageing population is increasing, including dementia
and falls
•
General practice and multidisciplinary teams are taking on more responsibilities for care coordination, such as risk stratification and multidisciplinary care planning
•
General practice teams are being required to be more productive overall, with consultation
rates growing year-on-year 31. The crude rate of consultation per person increased from 3.91
consultations per year in 1995/6 to 5.53 consultations per year in 2008/9, an increase of
41.5% 32.
•
There is a significant group of GPs expected to retire fully or partially in the near future. Within
south west London, a fifth of GP practice partners are aged 60 or more. 33
•
There is variability in primary care estate and its suitability to meet the growing demands in
general practice is unclear
•
The uptake of technology-enabling solutions in primary care is slow and requires systematic
commissioning support, momentum and diffusion
Figure 3: The local context: key points for consideration
29
NHS England, Publications gateway reference number 01599, Letter to CCG Clinical Leads and Area
Directors, NHS England, Co-commissioning of primary care services, 9 May 2014
30
NHS England, South west London SGP, 2013
31
NHS England Analytical Service, Improving General Practice – A Call To Action, Evidence pack, 2013/14
32
Health and Social Care Information Centre, Trends in Consultation Rates in General Practice – 1995-2009,
published September 2009
33
Health and Social Care Information Centre 2014a
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
167
Page 171
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Figure 4: General practice in south west London
34
Figure 5: Variation in clinical outcomes across south west London in some long term conditions and public health
measures
34
Sources: Office of National Statistics (2012 population estimates), My health London (number of GP
practices) and GP Patient Survey (Published December 2013)
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
168
Agenda Item 5
Page 172
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Figure 5 demonstrates the variation in clinical outcomes for common LTCs and key public health
measures across south west London.
South west London is a mixture of urban and suburban areas, even within each borough, with
distinct areas of deprivation. There are communities with high and diverse health needs with
variable access to high quality primary care, interspersed with areas of relative affluence. Across
south west London there are variances in health indicators as shown in Figure 5. For instance, in
Croydon, Sutton and Wandsworth there is a higher prevalence of substance misuse 35. Binge drinking
is highest in Wandsworth and Richmond 36. In contrast, prevalence for those with long term
conditions varies less across the boroughs. For example, the prevalence of older dementia in older
adults ranges from 0.56% in Wandsworth to 1.1% in Sutton37.
The QOF results for 2012/13 38 demonstrate moderate variances in the quality of care delivered by
practices across south west London, both for the clinical and organisational domains. However,
there are several indicators for which practices in south west London performed below the national
average (highlighted blue figures 6 and 7). For instance, five out of the six CCGs in south west
London score below the England average for diabetes, chronic obstructive pulmonary disease (COPD)
and Chronic Kidney Disease (CKD) care. All CCGs in south west London score below the national
average for education and training.
Figure 6: Quality Outcomes Framework – clinical domain – south west London 2012-13
35
Hay et al, Estimates in the prevalence of opiate and/or crack cocaine use (2010/11), Public Health England,
2013
36
Public Health England:
http://www.localhealth.org.uk/#sly=msoa_2011_DR;i=t1.l_term_ill;z=516042,189660,33002,22228;sid=788;v=
map4;l=en
37
Department of Health, Dementia: A state of the nation report on dementia care and support in England,
2013
38
Health and Social Care Information Centre, Quality and Outcomes Framework 2012-13
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
169
Page 173
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Figure 7: Quality and Outcomes Framework – organisational domain – south west London 2012-13
Patient expectations of services are rising including how patients wish to access services outside
working hours and ‘on the go’. In south west London, the results from the GP survey 2013
demonstrate that patients’ overall satisfaction with primary care on average is slightly below the
national average (85% versus 86%). In addition, on average 72% of patients said they found it easy to
get through to someone at their GP surgery on the phone which is close to the national average of
74%, and 76.6% of patients are satisfied with the opening hours of their GP practices which is slightly
lower than the national average of 79%.
An additional £8.0 million will be invested into primary care from secondary care budgets in 2014/15
through provision in Every Counts for £5 per person aged over 75 years. The table below sets out
the approaches taken by each CCG for this funding. 39
39
Ibid. 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
170
2014/15 (£'000)
Kingston CCG
Merton CCG
Richmond CCG
Sutton CCG
Wandsworth CCG
£2.0m
£1.0m
£1.1m
£1.0m
£1.0m
£1.9m
Funding nonrecurrently in
2014/15
£1m pre-existing investment
£1m new recurrent investment
Non-recurrent
Non-recurrent
Non-recurrent
Non-recurrent
Wandsworth CCG is meeting the
requirements via the Planning All
Care Together contract.
Are funds being
invested with
practices or
centrally by CCG?
Practices
In discussion but likely to be a
mixed approach
Mixed approach
Mixed approach
CCG
Funds are being invested
through a direct contract with GP
practices (the Planning All Care
Together PACT) contract,
previously a LES
This equates to circa £7 per
head.
How are
investments being
used to support
over 75s?
The CCG is placing significant
investment into the development
of a Practice Development and
Delivery Scheme that supports
practices to develop robust plans
supporting Over 75s. The CCG has
also invested in a Transforming
Community Services which has
involved substantial investments
into Community Services that
supports better care for those at
risk of unplanned admissions
including Over 75s
In discussion. Possible
emphasis on (a) patient level
care coordination for those
requiring multidisciplinary
care package, and (b) practice
level coordination for wider
group of lower need >75s
The £5 per head is being
incorporated in to a Locally
Commissioned Service that as
one of its core aims will be to
manage the over 75’s; other
areas include providing longer
appointment times for those
identified through risk
stratification; better
integration of patient
management with other key
Community Service Providers;
with the core outcomes being
reductions in admissions,
readmissions and length of
stay within acute settings.
The £5 per head is being
incorporated in to a Locally
Commissioned Service that as
one of its core aims will be to
manage the over 75’s; other
areas include providing longer
appointment times for those
identified through risk
stratification; better
integration of patient
management with other key
Community Service Providers;
with the core outcomes being
reductions in admissions,
readmissions and length of
stay within acute settings.
• The establishment of a GP
engagement scheme which
pays member Practices £1 per
head (list size) to use to
support practice plans for
improving services for older
people.
• Redesigned older peoples
pathway – a CCG investment
of £750k as part of £1.2million
multi agency investment
including the CCG, acute trust,
community services provider
and voluntary sector. The
investment includes the
Community Services
Prevention of Admission Team
(advance nurse practitioners /
therapists), physiotherapists,
occupational therapists,
rehabilitation and healthcare
assistants, and Age UK
providing home visits with
support.
• Investment in new risk
stratification tool of £75k
• Investment in COPD health
coaching of £100k
The PACT contract with GP
practices covers the risk
stratified population with
significant cross over for the over
75s population. The PACT
contract covers 27 different
preventative initiatives to deliver
a comprehensive package that
supports greater self
management, carer support and
early intervention and focuses on
patient functionality and
independence.
£5 per head calculation
(based on 14/15
registered population)
Page 174
Croydon CCG
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
The £5 per head total is calculated based on the NHS England estimated registered population for each CCG in 2014/15 (source: NHS England, Total Allocations 2014/15 & 2015/16, December 2013).
Figure 8: South west London CCGs’ approaches for funding £5 per head
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
171
Page 175
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Figure 9: NHS England GP Survey results south west London - 2013
Owing to the diversity and historical growth in primary care, the delivery of general practice and
each organisation’s form, and relationships with other practices, and the wider health and social care
economy, varies. For example it can range from small practices to large training practices that may be
part of a network of practices working together on shared objectives. As well as demand pressures,
variation in health and quality of care is a key driver for practices to work in networks providing
opportunities to improve outcomes 40.
Figure 10: Diagram to show spectrum of organisational form for primary care services
Locally we have recognised that integral to transformational redesign of services, a carefully planned
and implemented change management process is required. Following our successful application to
NHSIQ we have initiated a programme of workshops over six months to address transformation of
primary care. Workshops commenced in March 2014 and have begun to deliver the change
management process required for change efforts ‘to stick’ and allow local primary care stakeholders
to work through the most challenging problems, devising solutions together. A key outcome of the
workshops will be to identify how practices can work more collaboratively with each other. The
40
Addicott, R, Commissioning and funding general practice – Making the care for family care networks, The
King’s Fund (2014)
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
172
Agenda Item 5
Page 176
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
workshops aim to allow participants to deliver their own solutions to networking across practices,
and do not endeavour to be prescriptive about the formation that groups of practices will take.
Progression through the workshops will be facilitated through the provision of evidence-based and
experiential examples of innovative or more productive ways of delivering primary care.
What are the key challenges that we will address?
1. Primary care is under increasing pressure and individual practices are unlikely to be
able to cope with increased demands working independently
“79% of people believe that GPs are best placed to understand what services their patients
need. This rises to 90% for over 75s” 41
There is consensus that general practice teams can no longer work in isolation to meet the increasing
demands on primary care 42. Many practices are coping with unprecedented demand on services,
unable to provide the level of access which patients request. This has downstream consequences
with unmanageable demand on emergency and urgent care services, as well as greater requirements
for specialist input as prevalence and complexity of LTCs increase. For example, local data suggests
that there has been a 12% increase in A&E attendances as well as admissions through A&E between
2009/10 and 2012/13 43.
Being the gatekeeper, primary care has a significant opportunity to affect demand on planned and
unplanned care, as well as being able to strengthen local implementation of integrated care plans.
Furthermore, by practices working together, and taking on shared responsibility for population
health outcomes, variation in quality can be reduced, and average quality and accessibility can be
increased 44. General practice networks will provide, whether in the form of federations or other
functional partnerships between practices, a transformational approach taking collective
responsibility for the combined local population. With a commitment to 7-day services in the
community, extended opening in general practice and strengthened urgent care services (such as 111
and out-of-hours services), practices will need to support each other to deliver these and improve
consistent access to primary care. The importance of continuity of care and improved access for
patients and their families and carers cannot be underestimated 45. Patient and public
representatives have highlighted that transformation of primary care in south west London should
deliver improved access to care. Groups of practices working together are an opportunity to bridge
the gap between primary and secondary care, bringing more specialists into primary care, and to
41
Williamson, L., Transforming Primary Care, Department of Health, 2014
The Kings Fund and Nuffield Trust, Securing the Future of General Practice, New Models of Primary Care,
Judith Smith et. al., 2013
43
Local SUS data for South West London
44
Thorlby, R., Reclaiming a population health perspective, Nuffield Trust, April 2013
45
th
Stakeholder engagement event, 8 May 2014
42
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
173
Page 177
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
make collective decisions, for example about technology, such as shared systems (see initiative 6 –
technology-enabled care). Practice networks can also deliver wider connections with other providers
of primary care such as community pharmacists, optometry and dentistry. Improved utilisation of
community pharmacy services including medication reviews and medicines optimisation approaches
on a population basis can be effective.
Different models of networked general practices have been demonstrated in London, nationally and
internationally and have shown good outcomes 46. Activities and accountability between groups of
practices range from sharing best practice and joint agreed outcomes, to sharing specialist skills and
support, to providing cover for extended hours or other service arrangements. As outlined in
‘Commissioning and funding general practice –Making the case for family care networks 47’
federations have the opportunity to retain what is good about primary care including the level of
cost efficiency in comparison with other services in the health system, but also to enable further
development of increased quality at scale. CCG leads are aware that the extent to which groups of
practices may want to explore benefits and contractual models of networked arrangements will vary.
Each set of practices will need to decide the level of collaboration and commitment that they have to
each other, and how this may be taken forward. However this is an emerging area, and showcasing
examples of how this can occur will be important. The overall objective however is that practices
harness their collective influence, expertise, access and facilities and independent provider status to
achieve best outcomes for the area population.
South west London CCGs are committed to supporting NHSE and local practices in achieving the
formation of practice networks. Together with NHSE, South West London Commissioning
Collaborative (SWLCC) intends to provide strategic support to localities in exploring networked
primary care models, enable good organisational development and governance structures to support
relationships between practices, support engagement with stakeholders including the public and
develop commissioning incentives for collaboration. In addition, south west London commissioners
will pay attention to recommendations from other stakeholder organisations such as the LMC, RCGP
and Health Education for South London (HESL), and engage with CCG members to provide support
for the formation of practice networks.
Moving forward clear advice will need to be taken around relationships between practices and
shared extended services, which groups of practices may wish to provide between them, adhering to
national guidelines. Given that there is a significant degree of uncertainty around future proposals
for co-commissioning relationships between NHSE and CCGs for commissioning core primary care
services, commissioning leads are committed to working with NHSE in 2014/15 to develop these
further. This also includes extended functions of primary care which will promote the integrated care
agenda, and link primary care more closely with community, social and third sector services.
Furthermore, commissioners are committed to supporting primary care providers to meet the
London primary care standards once these have been agreed. Following the NHSIQ programme,
46
Ibid. 44
The King’s Fund, Commissioning and Funding General Practice, Making the Case for Family Care Networks,
Rachael Addicott and Chris Ham, 2014, London
47
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
174
Agenda Item 5
Page 178
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
commissioners in south west London, in alliance with NHSE and local primary care providers, will
need to establish a programme of work to implement recommendations developed.
2. Patients with multiple LTCs or complex needs experience fragmented care between
primary care and other community and hospital-based care
More than 15 million people in England have a long term condition. This figure is expected to rise
over the next 10 years, particularly those people who have 3 or more conditions 48
The future development of primary care and the emphasis on hosting and leading the co-ordination
of care for patients with LTCs or complex needs is embedded in the integrated care approach for
south west London. Our integrated care plans (see section 2 of chapter 4) seek to overcome
organisational boundaries between health and social care providers, including those which interface
with primary care.
Historically general practice teams have always relied on good relationships with other multidisciplinary professionals such as district nurses, midwives, health visitors, community pharmacists,
social workers and specialists to name but a few, in order to deliver holistic and high quality care.
However, with capacity in primary care and community care being overstretched, and a more flexible
and sessional workforce in place, these relationships and interactions have become diluted over
time, and patients often receive disjointed care with needs escalating until emergency admission
becomes inevitable. For people over 75 years emergency admissions have increased by 31% over
the last decade, with 23% of older people being discharged after an overnight stay in hospital
reporting feeling vulnerable 49. One way to alleviate this, and core to our approach in the strategic
plan across primary care and integrated care, is multidisciplinary working, risk stratification and case
management.
Multidisciplinary working involving GPs who in many cases will lead and host case management and
care planning for patients identified at risk of admission, has been included in BCF plans for all
localities. Transformation of primary care will therefore involve absorbing these responsibilities
across networks of practices, where relationships and communication with community and social
care professionals will strengthen. We anticipate that effective multidisciplinary working will
inevitably take time and resources to develop. Resources will include the technology and
infrastructure to enable MDT working; that is shared IT systems, resolved information governance
issues and different workforce roles. Practices and commissioners will need to carefully plan this into
service models and workforce plans. Professionals’ accountability across overlapping responsibilities
will need to be managed, particularly as services move to a seven-day model. The requirement for a
named GP for people aged 75 years and over will go some way to tackling problems with the coordination of care 50. There is however strong evidence that co-ordination of care ‘wrapped around’
patients with appropriate input from specialists, can achieve the desired improvement in
48
Department of Health: https://www.gov.uk/government/policies/improving-quality-of-life-for-people-withlong-term-conditions (accessed 8 May 2014)
49
Ibid. 1
50
NHS England Gateway reference: 01347, General Medical Services Contract 2014/15, March 2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
175
Page 179
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
outcomes 51. Care co-ordination and a dedicated point of contact is likely to improve the quality of
care being delivered, improve patient’s taking responsibility for self-management and increase
productivity of primary care. It relies on care coordination from a dedicated professional, delivered
expertly. Innovative roles will need to be considered, for example, from primary care-based ‘care
navigators’ to GPs and nurse practitioners with a specialist interest in long term conditions
management and care coordination.
Additionally, we intend to strengthen the input of mental health care through strong links to mental
health key workers for concurrent mental health diagnoses. In particular, multidisciplinary
professionals will be encouraged to include screening for mental health conditions such as
depression, anxiety and alcohol-related dependency, co-existing with other physical health
conditions when care planning, recognising ‘parity of esteem’ and its inherent relationship with
quality of life and ability to self-manage care.
Another focus for improving capacity in primary care is to help patients to self-manage their multiple
LTCs. As the ‘Building of the House of Care’ model 52 indicates, developing patients’ skills in managing
their condition actively is a key element to achieving good health outcomes, and reducing costs
associated with unplanned care. Transformation of primary care will need to include additional
structured interventions to support patients to self-manage, including expert-patient programmes,
carer support and more focussed training for primary and community professionals.
There is considerable system fragmentation for patients receiving care between secondary and
primary care. Often this extends from delayed communications about care delivered in hospital), to
issues with shared prescribing and monitoring of medications. As suggested in the Future Hospital
Commission Report 53, it will be unsustainable to deliver all specialist care in hospital, and some
specialists will need to work in the community integrated with MDTs. For the frail elderly and those
with complex needs, this will improve access to timely specialist care and has the potential to up-skill
general practitioners. Community-based specialist may include geriatricians, older person’s
psychiatrists, general paediatricians, specialist nurses in heart failure, COPD, diabetes, dementia and
specialist pharmacists, who should become integral to the multidisciplinary team. We therefore
intend to commission services which bring specialist care, including diagnostics, into primary care
and the community,. We are starting to see good examples of this in south west London, such as the
Surbiton Health Centre in Kingston, Purley War Memorial Hospital in Croydon, Jubilee Health Centre
in Sutton and the Nelson Health Centre which will open shortly in Merton. Networks of practices
working together will have an opportunity to collaborate on the specialist input and diagnostics they
receive collectively.
Management of long term conditions, will need to use resources from wider primary care
professionals. In particular, it has been noted that community pharmacy could play a stronger role. In
our plans for integrated care (in Chapter 4, Section 2) we have discussed medication optimisation as
51
The King’s Fund, Delivering Better Services for People with Long Term Conditions, Building the House of Care,
Angela Coulter et.al., 2013
52
Ibid.
53
Royal College of Physicians, Future Hospital: Caring for medical patients, 2012, London
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
176
Agenda Item 5
Page 180
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
a key method to improve the quality and cost-efficiency.. This will fundamentally overlap with
general practice prescribing, and we will need to define a strategy locally around this.
In summary we intend to promote multidisciplinary working, proactive case management, care
planning, medicines optimisation and self-management universally across practices and take
advantage of the use of commissioning incentives to help promote this further. This is expected to
improve the quality of care delivered to those with high needs and improve variation in clinical and
public health outcomes (secondary prevention focussed).
3. Increasing pressure on health and social care services calls for a greater focus on early
intervention, prevention and proactive approach to primary care services
Primary care nationally delivers overs 300 million consultations per year 54 with the greatest
opportunity to ‘make every contact count’
NHS England’s A Call To Action – Transforming Primary Care in London 55 defines proactive care as
being care that supports the health and wellbeing of the population and keeps people healthy 56. This
involves identifying high-risk groups to ensure better uptake of preventative services, promoting selfcare and referring people to services that can assist with improving health and wellbeing.
Primary care teams are uniquely positioned to deliver public health advice and health promotion.
Frustratingly the introduction of QOF payment incentives, which include incentivising primary care
teams to give key public health advice, has shown limited impact on outcomes, despite uptake by
GPs and nurses 57. It is thought that incentivising through QOF may have ‘mechanised’ the approach
taken by clinicians, therefore not resulting in changes in patient behaviour 58. Nevertheless
commissioning for prevention and placing more emphasis and resource to deliver public health and
prevention-focussed activities, is key to achieving year-on-year reductions in spending in health. In
terms of disability adjusted life years (DALYs) ‘A Call to Action – commissioning for prevention 59’
highlights that effective prevention for ischaemic heart disease, stroke, lung cancer, COPD and lower
back pain is likely to deliver the greatest gains. Primary care has a significant opportunity to target
secondary prevention in these areas and promote effective self-management when appropriate
following diagnosis as an early-intervention approach.
54
Department of Health, GP Contract Changes 2014/15 Equality Analysis, March 2014
Gilbert, J., A Call to Action: Transforming Primary Care in London, NHS England, November 2013, p6
56
There are some variances in the definition of proactive care. The Department of Health (2014) Transforming
Primary Care refers to proactive care as co-ordination of care for people with long term conditions, including
providing personal care plans, allocating a named accountable GP, having personal care coordinators and
same-day telephone consultations if required. NHS England (2013) Transforming Primary Care in London
defines proactive care as ‘supporting the health and wellness of the population and keeping people healthy’. In
this document our definition of proactive care aligns with the London definition
57
Dixon, A. et. al, Impact of Quality and Outcomes Framework on health inequalities, April 2011
58
King’s Fund, Incentivising public health in primary care: learning from the QOF, 2011,
http://www.kingsfund.org.uk/blog/2011/04/incentivising-public-health-primary-care-learning-qof
59
NHS England, A Call To Action: Commissioning for Prevention, 2013
55
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
177
Page 181
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Commissioners, including GP commissioners in south west London, see that primary care teams will
become part of delivering care in their communities, taking a more proactive approach to wellbeing,
public health and interventions to promote prevention. There is a particular role for primary care
clinicians to engage in primary prevention 60 and pressing primary problems such as obesity 61. We
will support primary care teams to improve overall health and wellbeing of their population, in
particular through consistent and evidence-based public health activities, meeting local intentions as
outlined in each Health Wellbeing strategy. Formation of networks of practices will help primary
care to scale up and undertake health promotion activities between practices. We intend to
reinforce key public health messages through coordination of primary care with community care,
social care and voluntary services, improving outcomes including for those most at risk such as
deprived or black and minority ethnic (BME) populations. Moreover we intend to incentivise general
practice professionals to deliver health promotion to their local population beyond the confines of
their building. This could include health prevention in schools, community groups and collaboration
with the third sector.
A key risk to delivering proactive care is that there is not enough resource available. There are
significant workforce challenges in south west London and we will need to develop innovative roles
in order to successfully deliver more outreach to the population However this is likely to be high
impact for hard-to-reach populations. For instance, if we work with public health to deliver more
consistent outreach of sexual health advice to teenagers and improve access for youth, we can drive
down the number of unplanned pregnancies and sexually transmitted diseases and thereby reduce
the number of GP appointments, need for care and associated costs.
4. There is an expected shortage of primary care professionals with the right skills who
will be able to meet the rising demand on primary care services
Overall there has been an estimated 76% rise in hospital doctors nationally, with overwhelmingly
lower growth in GPs at 21% 62
Nationally primary care is facing its biggest workforce challenge to date. This year has seen the
lowest rate of applications to general practice since 2009. A retirement ‘bubble’ is approaching with
many GPs coming towards the end of their careers, compounded by high numbers of GPs leaving
the profession before retirement 63. More specifically the following local challenges to the primary
care workforce are noted:
•
Significant cohorts of GPs approaching retirement
•
GPs reducing clinical practice for commissioning roles
•
Changing salaried workforce, choosing to do less sessions or more locum work
60
Ibid. 59
Royal College of Physicians, Action on obesity: Comprehensive care for all, January 2013
62
O’Dowd, A., Balance between GP and hospital doctors numbers may need to shift, says new NHS chief, April
2014: http://careers.bmj.com/careers/advice/view-article.html?id=20017402
63
Rimmer, A., Evidence on GP workforce “crisis” is presented to BMA, April 2014:
http://careers.bmj.com/careers/advice/view-article.html?id=20017343
61
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
178
Agenda Item 5
Page 182
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
•
Greater reliance on the locum GP workforce
•
Difficulties in recruiting practice nurses
•
A potential gap in the incoming GP workforce related to the extension of GP training from 3
years to 4 years
•
Increasing demand for routine and urgent primary care, requiring a higher degree of skill mix
in teams with more advanced skills and knowledge
•
The recruitment of considerable numbers of healthcare assistants to enhance productivity,
with unknown or inconsistent levels of skills and competencies
•
The potential of community pharmacy has not been fully exploited, there is limited
integration with other community and primary care services.
The workload in primary care is widely recognised as increasing at a rate that poses a significant
challenge to the existing workforce. An increase in out of hospital activity will inevitably impact on
the workload of primary care staff and workforce numbers across the six CCG populations vary 64,
with some areas being better resourced with staffing than others. Moreover, integrated care
schemes and multi-disciplinary working will require working in different ways, taking on new
responsibilities such as the supervision of teams, higher degrees of skill mix, and differing levels of
generalist skills contrasting with specialist competencies. The majority of London GP
respondents(83%) agreed that their workload was unsustainable, according to a survey of GP
workload 65. The survey also found that 90% of respondents would like more staff in their practice
and 87% identified funding as the main barrier to achieving this. We recognise however that for
future-proof primary care, there is also a significant bottleneck in the numbers of workforce,
including those taking up general practice training.
South west London is well served for GPs when compared with the London area as a whole. The
numbers of GPs per 100,000 population is equal to or, more often, higher, in south west London
than the London area average – see Figure 11.
Where average full time equivalent (FTE) per 100,000 population are shown. This is calculated from
raw FTE data using CCG populations that are weighted for health needs (GP practice shares- NHS
England, Gateway Reference Number: 00337. Information correct as of August 2013)
64
65
London-wide LMCs (2013). GP workload survey results. Available at:
http://www.lmc.org.uk/visageimages/Campaigns/GPs_care/Workload%20Survey%20v2.pdf (accessed on 1
April 2014).
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
179
Page 183
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
90
76
77
74
69
65
CCG
London average
Croydon CCG
Kingston CCG
Merton CCG
Richmond CCG
Figure 11: GP (FTE) numbers per weighted 100,000 population
Sutton CCG
W'worth CCG
66
Yet the data also shows that the areas in south west London with the highest need to do not have
highest number of GPs.
Any plans for the development and recruitment into primary care, need to take account of the
numbers of GPs likely to exit the workforce in coming years. Within south west London, a fifth of GP
practice partners are aged 60 or more 67. The proportion of GPs nationally who are expected to stop
delivering patient care in the next five years increased from 6% in 2010 to 9% in 2012 in GPs under
50 years of age, and from 42% to 54% in GPs aged over 50 for the same time period 68.
There are also great variations in practice nursing numbers, with particular issues around
recruitment. A number of national initiatives are underway to strengthen the primary care and
community nursing workforce. A project to develop a community nursing strategy in support of
Transforming Primary Care 69 will look at the transition of nurses from hospital to out of hospital
settings. This includes developing a career framework for general practice nurses, developing
national standards for education, and guidance for education commissioning for these nurses 70. A
competence framework for general practice nurses has already been developed 71.
There is greater variation in practice nursing staff across the six CCG areas when compared with the
London area average. Figure 12 shows that Merton and Wandsworth are better served than the
66
Health Education England (2014a). Broadening the Foundation programme. Available at:
http://hee.nhs.uk/2014/02/26/broadening-the-foundation-programme-report/ (accessed on 4 April 2014).
67
Ibid.
68
Hann M, McDonald J, Checkland K, Coleman A, Gravelle H, Sibbald B, Sutton M (2013). Seventh National GP
Worklife Survey. Manchester: University of Manchester. Available at: http://www.populationhealth.manchester.ac.uk/healtheconomics/research/FinalReportofthe7thNationalGPWorklifeSurvey.pdf
(accessed on 1 April 2014).
69
Ibid. 1
70
Moger A (2014). Personal communication.
71
Royal College of General Practitioners General Practice Foundation (2012). General Practice Nurse
competencies. Available at: http://www.rcgp.org.uk/membership/practice-teams-nurses-andmanagers/~/media/Files/Membership/GPF/RCGP-GPF-Nurse-Competencies.ashx (accessed on 24 April 2014).
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
180
Page 184
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
London area average, while the data indicates that Sutton and Richmond may be less well provided
for.
22
23
26
25
18
19
CCG
London average
Croydon CCG Kingston CCG
Merton CCG Richmond CCG Sutton CCG
Figure 12: GP practice nursing staff (FTE) per 100,000 weighted population
W'worth CCG
72
There is wide variation in the use of advanced 73 and extended 74 nurses across south west London.
As shown in figure 11, Richmond has half the number of advanced nurses per population than
Croydon.
In south west London we have already identified that planning and developing the workforce is a key
and urgent priority for achieving sustainable services. This is a clear priority for primary care as well
and will require strategic direction and leadership which can be delivered from the SWLCC. Over the
past six months the Out of Hospital Programme has concentrated efforts upon understanding the
gaps in the development of the out of hospital and primary care workforce for south west London.
In particular an extensive piece of work funded by HESL has been undertaken to establish the
workforce gap across community and primary care over the next 5 years 75.
The analysis for the HESL gap-analysis estimates that an additional 40 WTE GPs and 15 WTE practicebased nurses will be required over 5 years in South West London, in order to manage the planned
shifts from secondary to primary care and meet the aspirations of the Clinical Design Group and
commissioners 76. In actual fact, these estimates are likely to be conservative and latest calculations
show that the staff numbers could be up to 62 GPs and 25 practice-based nurses. These estimates
are based on extending and scaling up existing models of care, and within the current skills and
72
Health Education England (2014b). HEE launches first national consultation on a NHS bands 1-4 workforce
strategy. Press release. Available at: http://hee.nhs.uk/2014/02/04/hee-launches-first-national-consultationon-a-nhs-bands-1-4-workforce-strategy/ (accessed on 29 April 2014).
73
E.g. advanced nurse practitioner, prescribing nurse, nurse clinician, nurse manager, practice development
nurse, physician associate and assistant practitioner.
74
E.g. extended role nurses and practice nurses who have received additional training in a specialist area such
as diabetes or asthma. Practice employed community nurses, midwives, health visitors, and school nurses.
75
South west London Collaborative Commissioning, Implementing Integrated Care in south west London - The
workforce challenge, May 2014
76
These estimates are higher than those in the published report, which are more conservative and do not take
into account aspirations in improved quality or practice in primary care.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
181
Page 185
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
staffing mix. As the majority of primary care services are commissioned through NHS England rather
than CCGs presently, and funding is unlikely to cover these increases, different models of care and
alternative skills mixes need to be explored as a means of providing the desired primary care service
levels. This will ensure that the workforce is used more productively.
In addition to up-skilling the existing and incoming workforce we will need to ensure that systematic
education and training is available. Through HESL we are seeing emerging models of how to quickly
disseminate and accelerate this kind of training through Community Education Provider Networks,
where four pilot networks are in place.
Community Provider Education Networks77
‘CEPNs are designed to improve the quality and localisation of education for health professionals.
They aim to empower community organisations to work with higher educational institutions to
assess workforce training needs, expand capacity for training in the community, innovate in the field
of training and deliver multi-professional training.
A review into early progress shows that stakeholders are positive about their potential. Although the
four CEPN pilots each have a different focus and structure, the perceived benefits of community
based networks are common and include a more localised approach to training needs assessment
and education provision and shifting the focus from acute to community- based education and care.
Four prototype CEPNs were established to test the concept during the summer looking at a number
of different areas such as: addressing community nursing capacity; interprofessional learning in child
health; supporting multi-professional training in GP practices; and creating a network to assess the
training needs for staff caring for patients with dementia in community settings.’
Figure 13: Community Provider Education Networks
Variations across south west London as described will also need to be addressed through a south
west London -wide community workforce plan, to ensure that communities with high health
inequalities and individuals most at risk of deterioration and hospital admissions, withe complex
conditions, have timely access to appropriately skilled professionals.
5. Primary care estates and facilities are in many cases no longer fit for purpose and need
to be further adapted or relocated
It is estimated that there is currently circa £1bn of healthcare estate in London that is not fit for
purpose 78
It is recognised that owing to historical reasons, some primary care estate has been established and
further adapted on sites not specifically designed to deliver healthcare, and is now either prone to
77
Health Education South London: http://southlondon.hee.nhs.uk/2013/12/28/community-educationth
provider-networks-cepns-in-south-london/ (accessed 15 May 2014)
78
London Health Board, Agenda Item 5, 17 March 2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
182
Agenda Item 5
Page 186
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
access problems, unsuitable or even unsafe. In addition, the cost of estate in south west London is
above national average given high land values. Nationally to transform primary care, capital
investment in estates and facilities is required 79.
As primary care transforms, it will take on a new role overlapping with integrated care services, and
this will require physical community-based space. Adaptations, refurbishment and procurement of
new estate needs to be future-proof and sustainable, which means designing estate and allocating
capacity in line with expected future growth of primary and community care. A review of the
suitability of individual estates will in part be delivered through CQC inspections, but review may
only assess the minimum requirements of estate and will not collectively inform of whether estate is
fit-for-purpose for the future. Together with NHSE 80, strategic CCG-led review of local primary care
estate will ensure that local commissioners are clear where opportunities to co-locate services exist,
as well as gathering information for where further investment is required to existing premises.
Consolidation of some existing estate for multi-purpose community health and social care service
use or for expansion of shared services between proposed practice networks, such as phlebotomy or
diagnostic suites, may also be desirable. We will need to ensure that primary care is delivered in
premises that are safe, high quality and suitable for core general practice and its extended
relationship with other services and professionals. Furthermore estate will need to be able to house
the technology required to improve general practice, be accessible to all members of the population
and promote an atmosphere of wellbeing. The review of primary care estate and the resulting
recommendations and actions, is intended to help prevent the former isolation of primary care from
other services. In some cases investment in new estate will be appropriate as well as co-location of
primary care services alongside other health and social care services. For example, co-location of GP
practices could involve having shared receptions, administration, diagnostics and multidisciplinary
teams, and networked practices may host specialist working in the community.
Co-located services
In south west London we have already seen the establishment of multidisciplinary health centres
such as Surbiton Health Centre in Kingston, the Jubilee Health Centre in Sutton and the Nelson
Health Centre in Merton (to be opened). These examples showcase how care can be brought closer
to home, and fundamentally integrate primary care professionals with a wider team. It is recognised
that productivity for extended functions of primary care such as case management and
multidisciplinary working is a challenge for primary care, and that co-location may be an enabler to
increase efficiency in primary care. Sharing the delivery of improved outcomes such as patient
satisfaction and a higher degree of coordinated care from co-located services will be important
moving forward.
Figure 14: Multidisciplinary health centres in London
79
Rowan, T et.al., “Improving General Practice – A Call To Action” – Analysis of responses to the NHS England
consultation, CIPFA Research, January 2014
80
Dyson, B., Improving General Practice – A Call To Action Phase 1 Report, NHS England, March 2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
183
Page 187
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Commissioners in south west London, NHSE and providers, will need to find new solutions to the
critical issue of estates, where opportunity for capital investment will be challenged. This may range
from exploring collaborations with foundation trusts to host primary care in their estate to working
with local authorities to establish community estates and hubs. In the future, estate across health
and social care will need to be used very differently and multi-purpose spaces may be desirable. The
time-utilisation of estate will also change as we shift services to a 7-day and 24-7 model, and estates
review should address this as this will ensure that premises are more productive through sharing
space.
Some of the challenges facing estates across South West London are explored further in the provider
section of the sustainability chapter.
6. Increasing pressure on primary care services means that opportunities to implement
new technology solutions should be taken up to improve access and care
Carefully designed and implemented technology-enabled services such as online booking, econsultations, electronic prescription requests, data sharing or care planning applications can
all increase the capacity and efficiency of primary care delivery
The timely and effective uptake of technology solutions in primary care is likely to provide several
benefits for both patients and health system, including improving access; quality of services; coordination of care from multi-professional teams; and providing health information and outcomes
data to improve population health. Critically NHS England have delegated operational responsibility
to CCGs allowing local commissioners together with primary care providers to adopt local solutions
to online patient services and information sharing solutions 81. Later this year local commissioners
will look to NHSE’s guidance on ‘Securing excellence in general practice information technology’ in
order to further support local general practice providers in taking up improved IT solutions, including
online patient services which are a requirement of the 2014/15 GMS contract change 82.
In south west London we will ensure that the uptake of technology-enabled services in primary care
is a key priority. In addition, it is recognised that the preference for timely access to GP services and
assistance may supersede a patient’s preference for a face-to-face consultation. The uptake of
alternative methods of consultation for patients in general practice in the UK is not new. Between
1995 and 2009, the percentage of telephone consultation rates is estimated to have risen from 3% of
all consultations, to 12% 83. Despite its increase, the uptake of telephone consultation systems by
practices is not consistent, and the methods by which practices implement and are supported to
deliver safe telephone consultations is highly variable. Achieving a systematic approach to telephone
consultations in general practice has been highlighted as an ‘early adopter intervention’ in the
‘Anytown Urban Health System’ recommendations for CCGs which is likely to show an impact on the
81
Dyson, B, Improving Primary Care – A Call To Action, Phase 1 report, NHS England, March 2014
Ibid. 2
83
BMJ Quality Improvements Report, Telephone Consultation in Primary Care, How to Improve Their Safety,
Effectiveness and Quality, Muhammad Naseer Babar Khan, 2013
82
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
184
Agenda Item 5
Page 188
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
efficiency of primary care 84. The same implementation lessons will need to be taken forward as
more diversification in access channels become available to patients.
The uptake of innovative technology is typically slow, particularly when new technology involves
significant investment, adoption barriers, changes to the functions provided and elements of risk for
clinicians and patients. In addition, there is significant upfront investment and resource in terms of
the technology itself, but also for training, ongoing management of the technology (service level
agreements and upgrades) and interoperability with existing systems. Therefore implementation of
technology changes can be immensely challenging. We recognise that although technology can
provide innovative solutions which may promise increased productivity, until use of technology
promotes a different way of working (as opposed to an added layer of activity and responsibility),
technology-enabled care is unlikely to impact improved outcomes in primary care. Furthermore
information governance issues have become key barriers to shared IT systems and sharing
information across organisations and providers. South west London will need a robust approach in
collaboration with South London CSU to manage this early on.
In south west London we intend to provide the commissioning support to promote the systematic
uptake of technology-enabled solutions. This will include taking advantage of expertise and
innovation from international and national sources which have shown convincing benefits. We will
also look to learn from innovative technology solutions to access being funded through the PM
challenge fund 85. We will therefore transform the way in which patients experience frontline care
and improve patient satisfaction with the access to general practice. As commissioners we will need
to champion innovation in order to facilitate faster uptake of technology. In the first instance,
alongside plans for integrated care, we will work with the South London Commissioning Support Unit
(SLCSU) to implement care planning by sharing information across services, similar to the way in
which ‘Coordinate My Care’ patients care plans are being used in south west London for sharing for
end-of-life care plans. Additionally, we intend to work alongside and collaborate with the south west
London Academic Health and Social Care System to bring innovations to primary care services which
will deliver more convenient and timely access to primary care. Commissioners and providers in
south west London will also need to leverage their collective influence to work with technology
providers to ensure that technology solutions as problem-focussed, as opposed organically
developed by opportunity or industry trends.
How we developed our initiatives for Transforming Primary Care
The urgency to transform primary care has never been greater. At the point of formation of the
SWLCC, lead commissioners from all six CCGs recognised that significant review and transformation
of primary care is required locally, despite CCGs (at the time) having limited direct commissioning
delegation for primary care under the 2012 Health and Social Care Act. CCG leads recognised that
the transformation of primary care in the local health economy is pivotal to achieving sustainability
and improved clinical, public health and social care outcomes for the people of south west London.
84
NHS England, Any Town Health System, Urban CCG data, 2014
NHS England, Prime Minister’s Challenge Fund: http://www.england.nhs.uk/wpcontent/uploads/2013/11/gms-contr-let-at113.pdf (accessed 7 May 2014)
85
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
185
Page 189
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Therefore ‘Transforming Primary Care’ has been set up as a distinct workstream, and the 5 year
strategic plan and corresponding initiatives for primary care have been developed by the Primary
Care Clinical Design Group (PC CDG). This CDG is led by Eleanor Brown (chief officer of Merton CCG)
and the clinical chair Dr Nicola Jones (chair of Wandsworth CCG).As discussed above, the NHSIQ was
initiated under the Out of Hospital programme and has subsequently been absorbed as a clinical
design group because of the benefits that the NHSIQ process can bring, including external
facilitation, support and funding. Three workshops have been conducted to date taking local
primary care leads and stakeholders, including representatives of the public, through the process to
recognise the challenges, design the interventions and activities, and work through the appropriate
outcomes to be achieved taking into consideration associated risks. These are discussed below.
In addition, there have been some wider engagements, including a stakeholder event on the 8th of
May. The key outcomes from the stakeholder event are outlined in Figure 15.
Priorities identified at the stakeholder event on the 8th of May 2014
•
•
•
•
•
•
•
•
Clearer and better ‘signposting’ is required, as it can sometimes be very confusing for the public
to know where to go for the right services
We need to consider the balance between continuity of care and provision.
Workforce planning need to be a priority, including making sure the public are aware of the
range of workforce within primary care setting.
Federation of practices and practices grouping together to achieve economies of scale were
discussed
We need to consider if problems with access to primary care impact on people’s choice to
access emergency and urgent care instead
We need to importance of the role of the community pharmacist and how they can better
support the public
The use of the risk stratification tool needs to be considered
We should explore the possibility of co-commissioning primary care
th
Figure 15: Priorities from stakeholder event 8 May 2014
Through the NHS IQ process, six initiatives have been identified as the key priorities for transforming
primary key. These are as follows:
1.
2.
3.
4.
5.
6.
Development of practice networks
Proactive care
Coordination of care
Primary care estate review
Primary care workforce
Technology-enabled care
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
186
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
What are the initiatives that will address our challenges in Transforming Primary Care?
Page 190
Figure 16: The Transforming Primary Care initiatives
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
187
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Page 191
Agenda Item 5
Figure 17: Detailed description of integrated care initiatives – Development of practice networks
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
188
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Page 192
Figure 18: Detailed description of integrated care initiatives – Coordination of care
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
189
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Page 193
Agenda Item 5
Figure 19: Detailed description of integrated care initiatives – Proactive care
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
190
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Page 194
Figure 20: Detailed description of integrated care initiatives – Review of primary care estates
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
191
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Page 195
Agenda Item 5
Figure 21: Detailed description of integrated care initiatives – Primary care workforce
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
192
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Page 196
Figure 22: Detailed description of integrated care initiatives – Technology-enabled care
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
193
Page 197
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
When will we achieve the initiatives for Transforming Primary Care?
Figure 23: Transforming Primary Care key milestones
How does our work to improve Transforming Primary Care address the
outcome in Everyone Counts 86?
The vision for Transforming Primary Care will address all of the measureable outcomes set out in the
national planning guidance, with exception of the one focusing on positive experience of hospital
care and avoidable deaths in hospital. The vision will address all of the three key measures.
86
Ibid. 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
194
Agenda Item 5
Page 198
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Figure 24: How Transforming Primary Care addresses the outcome measures in the Everyone Counts planning guidance
What are the interdependencies with other workstreams?
Although direct provision has been limited in the preceding health reform, CCGs recognise their role
in the commissioning and development of high quality general practice. The interdependencies
between CCGs’ roles (in commissioning acute services and community-based services, and now the
additional co-commissioning with social care through the Better Care Fund) and the commissioning
of primary care are apparent. Therefore commissioners in south west London intend to establish
ways of working and co-commissioning with NHSE London Area Team to coordinate transformation
efforts and to help incentivise primary care teams to adopt new models of care.
There are a number of interdependencies between primary care and other clinical workstreams that
have been considered in the development of this strategic plan and require robust working
arrangements to be developed with the relevant Clinical Design Groups and health care
professionals. There are, for instance, overlaps with the Urgent and Emergency Care CDGs as urgent
care access in primary care including community pharmacy links with GP out of hours, 111 and
Urgent Care Centres, as well as demand on A&E services.
Furthermore, there are overlaps with the Integrated Care CDG and community and social care
professionals who will work together in multidisciplinary teams, and referrals for planned care
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
195
Page 199
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
(medical or surgical) are initiated in primary care. There are overlaps with the Maternity CDG, as
shared antenatal care is provided by GPs. Close working relationships will also need to be developed
with health visitors and public health.
Moreover, there are major overlaps with mental health, given that diagnosis and screening takes
place in primary care, and stable mental health cases are looked after by GPs and some patients
access psychotherapy access in general practice as well.
Additionally, there are interdependencies with cancer services, as diagnosis takes place in primary
care.
What are the investment implications of these initiatives?
The Strategic Plan outlines a bold and ambitious approach to improving the quality of care delivered
across acute, community, mental health and primary care services. In order to deliver these clinical
ambitions and achieve a financially sustainable health economy, south west London commissioners
will need to work together to prioritise how best to address the multiple challenges identified whilst
supporting the investment required to deliver transformational change.
There are likely to be four key areas in which we believe investments or additional resources will be
needed in primary care over the next 5 years. These are
•
•
•
•
Capacity to absorb activity shifted from acute settings
Capacity to meet underlying growth rates in demand for primary care
IT systems
Primary care estates
Some indicative costing of the workforce has been undertaken for absorbing activity shifts from the
acute sector into primary care. As discussed earlier, extensive modelling 87 has identified a workforce
gap for these shifts in Primary Care of around 62 GPs and 25 practice-nurses (WTE) plus, where
required, administration staff. This is estimated to cost up to an additional £10 million per year.
However, this is based on the assumption that the necessary services must be delivered using
current models of care and current staff and skills mixes. Further work is therefore needed to
explore the potential for alternative care models or staffing mixes. The cost and workforce
implications of shifting activity are considered further in the Integrated Care Chapter.
87
Ibid. 77
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
196
Agenda Item 5
Page 200
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
Additional workforce capacity will be needed to meet additional demand and demographic growth,
with the cumulative growth in demand likely to be 12-19% by 2018/19 88. Capacity may be built
through additions to the workforce, or through training and upskilling existing primary care staff.
The combined impact of increasing underlying demand and shifts in activity from hospital settings
are likely to put current primary care provision under significant strain without additional
investment.
Substantial investment is also needed in new technology and systems for primary care, particularly
in the context of the increasing pressure on current models and processes. There are currently no
planned investments in IT through the CCGs. The challenges facing the primary care estate in South
West London are explored in the provider section of the sustainability chapter.
The majority of primary care commissioning sits with NHS England and significant increases in
available funding are not expected. South West London CCGs will work as co-commissioners with
NHS England, to prioritise how to support the investment and funding needs in primary care,
particularly as the scale of investment need exceeds the likely available resources. Discussions on
the potential transfer of additional commissioning responsibility to CCGs are on-going, and until
these are ultimately resolved, some incremental investments may fall to CCGs.
88
CCG finance templates submitted to NHS England on 04/04/2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
197
Page 201
Agenda Item 5
Chapter 4: Clinical workstreams, Section 6:
Transforming Primary Care
South West London Collaborative Commissioning
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
198
Agenda Item 5
Page 202
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
Urgent and emergency care
Introduction: why urgent and emergency care is important
The spotlight on urgent and emergency care has never been stronger. NHS England’s Medical
Director, Sir Bruce Keogh, is reviewing the urgent and emergency care system. Urgent care services
have been recommended as the first that should move towards seven day working. Urgent Care
Working Groups (UCWGs) have been set up across the country and NHS 111 is now fully operational.
We recognise that urgent and emergency care services provide care for patients when they are at
their most vulnerable. There is now a broader range of services available to patients requiring urgent
and emergency care than ever before. The range of services available is often not easily recognised
or understood by patients or carers and this combined with the success of the 4-hour emergency
department target and an ageing population, is leading to increased pressure on our emergency
departments with A&E attendances projected to grow by 18.8% 1.
Despite our local success in south west London with 4-hour waiting times in 2013/14, our hospitals
will not be able to cope without changing the way urgent and emergency care is provided. This
imperative for change applies across primary, community and hospital settings of care. We know
that, to provide higher quality care for our patients, and to reduce the demands on our emergency
departments we must change the urgent and emergency care system in south west London to
enable more urgent care to be delivered in primary and community settings. We expect patients to
receive a timely same day response their urgent care needs and understand that primary and
community facilities will need to be developed to achieve this. We also recognise the role that NHS
111 can play in supporting patients and carers through the urgent care system; a single, memorable
number that can provide urgent clinical advice as well as an up to date view of the full range of
services in south west London.
We are already seeing change; in south west London we have four UCWGs, one based around each
of our acute hospitals. Last year, each UCWG developed and implemented a plan to meet the 4hour emergency department target in 2013/14 and each of the UCWGs achieved this.
Previous efforts to change the urgent and emergency care system have focussed too much on either
care provided in hospitals or care provided in the community, without delivering changes across
both. The scale of the challenge means that the issues cannot be addressed by a single hospital, CCG
or borough; we must work together as a health economy: commissioners, providers, local
authorities, health and wellbeing boards, patients and the voluntary sector.
Our approach is to develop a south west London urgent and emergency care network that to lead
the changes across the urgent and emergency care system. We expect national guidance about this
during 2014/15 but with our Urgent and Emergency Care clinical design group (CDG) and the four
1
Unify activity projections
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
199
Page 203
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
UCWGs we already have the foundations in place. By working together as a network, and focussing
on the health economy as a whole, we will deliver our vision for urgent and emergency care and
provide better care for our patients when they need it most.
What does this section of the 5 year strategic plan cover?
This section considers all care delivered to patients with urgent and emergency needs in all settings
whether general practice, primary and community care, pharmacy, 111, paramedic services
provided through London Ambulance Service (LAS), other urgent care services and the links between
the services.
The scope includes the relationship between these urgent care services and emergency
departments; however it excludes the day to day running and management of emergency
departments.
The scope excludes emergency mental health services and rapid response services, which have been
considered as part of the mental health and integrated care chapters respectively.
What is the vision for urgent and emergency care in south west London for
2018/19?
In south west London we have developed a vision which responds to the challenges facing the
urgent and emergency care system and the expected future needs of the local population. Our vision
is to strengthen the urgent and emergency care whole-system service model through improving the
quality of urgent care services and ensuring that the provision of integrated urgent care services is
timely and robust.
Our vision for urgent and emergency care in south west London is shown in Figure 1.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
200
Agenda Item 5
Page 204
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
In south west London we believe that the urgent and emergency system service model needs to be
transformed so people are:
•
•
•
•
•
•
•
•
•
•
Supported to manage their conditions in their own homes through improved self-care and
shared decision making
Aware of the different parts of the urgent care system and when and where to access the
care they need
Provided with improved access to a well-connected and clearly defined urgent care system
including Urgent Care Centres 2 (UCCs), primary care, GP out of hours, 111, social care,
London Ambulance Service, and other health professionals such as pharmacists and dentists
Diagnosed, treated and able to go home on the same day through wide-scale
implementation of Ambulatory Emergency Care Services as part of our work to improve the
overall urgent and emergency care pathway
Treated in high quality and safe emergency departments that meet the recommended levels
of senior staffing and access to specialist equipment, as per London Quality Standards (LQS)
with pathways designed to improve patient flow; meaning patients who access urgent or
emergency care are not caught in bottlenecks as they move between services
Supported with their health and social care needs in the community, enabled through Better
Care Fund schemes, such as community nursing, reablement and rehabilitation services and
investment in social workers 3
Able to access emergency departments that deliver high quality specialist care; this will be
achieved by implementing the recommendations in the Keogh report (to be published in
2014) and taking into account any national guidance on standards for urgent and emergency
care services and consistency in the naming of such services
Able to access alternative forms of high quality urgent care services which meet LQS and
other nominated best practice standards, to alleviate pressure on hospital emergency
departments and expedite diagnosis and treatment
Given access to seven-day services in hospitals, complemented by seven-day services in
primary care and the community to enable timely discharge
Able to benefit from strengthened links between urgent and emergency care services and
mental health psychiatric liaison services
Figure 1: Our vision for Urgent and emergency care in south west London
We will achieve this vision by working through a network to deliver change across the urgent and
emergency care system.
2
UCCs are facilities providing access to urgent care for a population, sometimes co-located with an emergency
department, sometimes based in the community. The National Urgent Care board are planning to publish
guidance on UCCs during 2014/15
3
Further detail is in the Integrated Care chapter
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
201
Page 205
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
What is the national context for urgent and emergency care?
•
•
•
•
The NHS Medical Director, Professor Sir Bruce Keogh, is reviewing urgent and emergency
care as a national priority. The first stage of this report was published in November 2013 4
Keogh’s report notes “40% of patients who attend emergency departments in England are
discharged requiring no treatment 5” (in this report, “no treatment” also includes patients
who receive advice and guidance only) and locally the figure is 45% 6 (16% who received no
treatment and 29% who received minor treatments (e.g. wound dressings) or guidance
The LQS services represent the minimum level of quality patients should expect to receive 7
Emergency care networks were highlighted in a recent NHS Confederation report as one of
the fundamental changes required to create a sustainable high-quality system 8
Figure 2: National context for Urgent and emergency care
South west London’s vision for urgent and emergency care has been developed with careful
consideration of the national evidence around the challenges facing urgent and emergency care
services. The recent report by Professor Sir Bruce Keogh 9 is a comprehensive review of the NHS
Urgent and Emergency Care system, highlighting the issues for urgent and emergency services as a
national priority. The report concludes that a system-wide approach for transforming urgent and
emergency care services is required quickly so that patients can continue to receive high quality
emergency care in the future.
Keogh recommends that the key requirements for successful transformation of services are:
•
•
•
•
•
Providing better support for people to self-care
Helping people with urgent care needs to get the right advice in the right place, first time
Providing highly responsive urgent care services outside of hospital so people no longer
choose to queue in A&E
Ensuring people with more serious or life threatening emergency needs receive treatment
in centres with the right facilities and expertise in order to maximise chances of survival and
good recovery
Connecting all urgent and emergency care services together so the overall system becomes
more than just the sum of its parts.10
The NHS Confederation’s paper Ripping off the sticking plaster 11 also highlights some fundamental
changes required to create a sustainable and high-quality urgent and emergency care system to
4
Keogh (2014) Transforming Urgent and Emergency Care, NHS England
Ibid.
6
2013/14 SUS data for south west London
7
London Health Programmes (February 2013) Quality and Safety Programme Acute Emergency and Maternity
Services London Quality Standards
8
NHS Confederation and Urgent and Emergency Care Forum (2014) Ripping off the sticking plaster
9
Transforming urgent and emergency care services in England – Urgent and Emergency Care Review,
NHS England 2013
10
NHS England (2013): Transforming Urgent and Emergency Care Services in England, pp7-8
5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
202
Agenda Item 5
Page 206
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
meet the needs of patients. The paper emphasises the importance of having emergency care
networks that are innovative and bold in developing solutions. Furthermore it recommends that an
effective triage approach is consistently applied to ensure people with both physical and mental
health needs are referred to the right part of the system 12. We expect our patients, and their carers,
to be consistently signposted to the correct part of the urgent and emergency care system every
time. It is proposed that emergency care networks should play a role in organising the deployment
of scarce specialist resources, such as emergency medical consultants and that Health Education
England should continue to support the advances of community-based services, for instance by
enhancing the role of paramedics 13.
What is the local context for urgent and emergency care?
•
•
•
•
Between 2009/10 and 2012/13, A&E attendances in south west London’s four acute
providers increased by 12% 14. During the same period, the number of A&E attendances for
patients aged over 80 years increased by 16% 15 and the number of patients admitted to
hospital from emergency departments increased by 12% 16.
The pressure on emergency departments is expected to continue to rise as people live
longer with increasingly complex and multiple long term conditions. A&E attendances are
projected to grow by 18.8% over the five years of the strategy 17
NHS 111 is fully operational, working as a ‘gateway’ to urgent and emergency service with
up to date information about local services as well as clinical advice
Urgent care centres (UCCs) have been established at St George’s, Croydon and St Helier
Hospitals to treat patients with minor injuries/illnesses
Figure 3: Local context for urgent and emergency care
Figure 4 illustrates what the urgent and emergency care system looks like in south west London. We
must ensure that services are strengthened and well connected, that referrals are appropriate and
information is shared in a timely way.
11
Ibid. 8
Ibid. 8
13
Ibid. 8
14
A&E attendances statistics by provider 2009/10 and 2012/13, Health and Social Care Information Centre.
Note: This includes Epsom hospital. 2012/13 figures include the Croydon Urgent Care centre
15
A&E attendances statistics by provider 2008/09 and 2012/13, Health and Social Care Information Centre.
Note: This includes Epsom hospital
16
SUS data
17
Unify activity projections
12
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
203
Page 207
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
Public
health
services
Emergency
department
Pharmacy
Urgent
Care
Centres
Community
health
services
Mental
health
services
Out of
hours
Home care
General
Practice
Public and patients
111
Ambulance
Service
Adult Social
Services
Residential
and nursing
homes
Figure 4: The urgent and emergency care system in south west London CD change to adult sco care
Clear progress has already been made in south west London in relation to urgent and emergency
care. NHS 111 is well established and by January 2014:
•
•
•
95.5% of calls were answered in 60 seconds
10% of calls led to ambulance dispatches
7% of callers were recommended to attend an emergency department, 54% were
recommended to attend primary and community care and 28% did not need to access other
services 18.
We recognise the valuable role that community pharmacists can play in the urgent care system.
Every year in England, 438 million visits are made to community pharmacy for health related reasons
– more than in any other NHS care setting 19. We need to ensure that we maximise the opportunity
for community pharmacists to play a greater role in the urgent care system.
18
NHS 111 Minimum data set – data to January 2014 http://www.england.nhs.uk/statistics/2014/03/07/nhs111-statistics-january-2014/
19
NHS England. Improving health and patient care through community pharmacy – a call to action. 2013
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
204
Agenda Item 5
Page 208
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
What are the key challenges for urgent and emergency care that we will
address?
The key challenges for urgent and emergency care we will address in this strategic plan are:
1. We need to enable and empower patients, carers and professionals to access the right
care, in the right place, first time
2. We need to meet our own minimum standards for quality
3. We need to reduce the projected workforce gaps we require to deliver LQS and ensure
that our workforce is sufficiently trained to deliver new models of care
4. We need to work together more innovatively to maximise the benefits of ambulatory
emergency care
Figure 5: Key challenges for urgent and emergency care
1. We need to enable and empower patients, carers and professionals to access the
right care, in the right place, first time
We need to work together as a south west London health economy to ensure patients have
access to networked urgent care services
Clinicians across London recognised the importance of a networked approach to Urgent Care
Services: the LQS 20 for Urgent Care Services that specified:
“All urgent care services are to be within an urgent and emergency care network with
integrated governance structures.”
We are already seeing the benefits of taking a whole health economy approach. Four UCWGs have
been set up in south west London, one for each of the acute providers. They include representation
from patients, acute and community providers, commissioners, HealthWatch, local authorities and
the voluntary sector. UCWGs were formed in May 2013 to develop Urgent Care Improvement Plans
(UCIP), indicating how the 4-hour emergency department target would be achieved and
subsequently maintained.
On the face of it, the UCWGs’ focus on the 4-hour emergency department target may appear to be a
narrow remit. This 4-hour target is, however, a reliable indicator of how effectively a hospital
manages the patient journey from A&E through to discharge and how effectively primary, secondary
care and social care are working together; it is a single measure that provides an insight into the
journey for a range of patients from those who are discharged without requiring any treatment or
with advice only to those who require an unplanned admission and complex discharge involving
social services. We see UCWGs as essential to delivering the quality of urgent and emergency care
that our patients expect. Figure 6 as an exemplar describes the work undertaken through the
Kingston UCWG. Information on the other three SWL UCWGs can be found in the “What work is
20
London Health Programmes (February 2013) Quality and Safety Programme Acute Emergency and Maternity
Services London Quality Standards
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
205
Page 209
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
already underway in boroughs to deliver our vision for urgent and emergency care?” section at the
end of this chapter.
Kingston UCWG included representatives from the following organisations:
•
•
•
•
•
•
•
•
•
•
•
CCGs: Kingston, Richmond and Surrey Downs
Acute Trust: Kingston Hospital Foundation Trust
Community Providers: Your Healthcare, Hounslow and Richmond Community Trust
Ambulance provider: LAS
Local Authority: Royal Borough of Kingston and London Borough of Richmond upon Thames
Mental Health Trust: South West London & St George’s
Voluntary sector: Age Concern Kingston
Out of hours provider: Harmoni NHS 111
HealthWatch: Kingston HealthWatch
Commissioning support: SWL Commissioning Support Unit
Primary care commissioner: NHSE – Primary Care Services
The UCWG agreed a plan to invest in three areas:
1. Acute: Improvements to systems flow through 7 day working, increased bed capacity, and
senior decision-making and redirection in delayed transfers of care (DTOCs). This included:
• Providing acute assessment beds 24/7
• Increased support in ED, therapy support &discharge coordinators
• Paediatric Nursing and additional Paediatric Consultant support to A&E
• Increased workforce capacity and senior decision making to cover the escalation beds
2. Community: Improvements to systems flow through 7 day working and patient flows to
reduce DTOCs and enhancement of admission avoidance services’ capacity. This included:
• Increased community nursing workforce
• Increased community therapies workforce
3. Primary Care: Improving access to primary care services. This included:
• Same day access to primary care in Kingston & Richmond CCGs
Key findings:
•
•
•
Weekend and 7-day working, across all providers enabled discharge planning to be
undertaken more effectively, allowing patients to be discharged earlier in the week.
KHFT schemes put additional medical staff in place to allow for greater senior decision
making to take place, increase frequency of ward rounds to review patients’ conditions
and expedite investigations and treatment.
Community admission avoidance schemes supported a reduction in the number of A&E
attendances and admissions, enabling KHFT to achieve the 95% A&E target across all
types throughout the winter.
Figure 6: Kingston Urgent Care Working Group winter wash up report
21
The NHS Confederation report 22 proposes that NHS England should consider how senior clinicians
could be involved in NHS 111 and that an online counterpart to the service should be developed. In
21
Kingston Urgent Care Working Group Winter Wash up report May 2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
206
Agenda Item 5
Page 210
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
south west London, we know that much more can be done to improve the role of GPs and to
strengthen the urgent care system, to provide patients with care in alternative settings out of
hospital. We want to align the key performance indicators to include measures that are important to
our patients such as the number of abandoned calls and patient satisfaction. We know that we will
be more successful if we address these issues across all of south west London rather than by
individual borough.
In south west London, we know that more care can be shifted to alternative settings such as primary
care, community services and other urgent care services such as NHS 111. This will not only match
the type of care to the patient’s acuity, but also enable patients to be seen as quickly as possible and
often closer to, or in, their own home.
UCCs are now well established at St George’s, Croydon and St Helier, co-located with the emergency
departments. These UCCs are able to treat patients with minor injuries and illnesses, reducing the
pressure on the emergency departments. Kingston currently does not have an UCC.
St George’s – care navigators
When patients attend the emergency department at St George’s they are triaged by a nurse.
Patients are directed to the emergency department, the urgent care centre, the co-located out of
hours service or to a care navigator.
Care navigators:
• assist patients by booking alternative appointments (eg with a GP Practice, out of hours or
other community service)
• help register unregistered patients
• educate patients and carers about appropriate services available in the community.
Figure 7: Care navigators at St George’s
In Croydon, the total number of attendances at emergency departments in 2011/12 was 115,204. In
2012/13, with the establishment of the co-located UCC, the total number of attendances at the
emergency department and UCC was 118,672, of which 44% were seen in the UCC 2324. At St Helier
hospital there were approximately 82,000 A&E attendances in 2012-13, of which 22,000 (27%) were
UCC attendances 25,26. At St George’s there were 140,000 A&E attendances and 43,000 27 UCC (30%)
attendances 28 in 2012/13.
22
Ibid. 8
Urgent and Emergency Care Strategy 2013/14 – 2016/7 , Croydon Clinical Commissioning Group,
24
HSCIC data for 2013/13 suggests 137,428 attendances, 38% of which were in the UCC
25
Provider data, 09/07/2013 ESUH All data FY 2012-13
26
Note: some of the UCC attendees will have subsequently been sent to the ED department
27
Provider data, 24/06/2013 and 08/07/2013
28
Attendances were the patient was recorded as staying on UCC. (The UCC was created on weekend 10/11
June)
23
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
207
Page 211
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
We recognise the importance of patient and carers' understanding about which services are
available and where and when to access them. As we develop the urgent and emergency care
system in south west London we will ensure that our changes are recognised and understood by
patients and their carers. We know that there will be national guidance in 2014/15 about consistent
naming, and definitions, of services and any local changes to the urgent and emergency care system
will incorporate these recommendations. This will ensure that the local urgent and emergency care
system in south west London is easily understood by all.
2. We need to meet our own minimum standards for quality
People with serious or life-threatening conditions need to be treated in emergency
departments with the highest quality skills and facilities and we are not meeting all the
minimum clinical quality standards we have defined
In south west London, urgent and emergency care services are expected to provide high quality care
and it is the intention of the commissioners to have services that meet the London Quality Standards
(LQS) by 2016/17.
At present, none of the hospitals in south west London meet all of the LQS. All hospitals in London
recently completed a self assessment of their progress towards achieving full LQS. The results are
available on the NHS England website 29. A number of the standards are particularly challenging to
achieve, notably:
1. Consultant presence in the emergency department for a minimum of 16 hours per day
(standard 2 in Figure 8)
2. 24/7 access to diagnostics (standard 3 in Figure 8) and
3. 24/7 nursing shift cover (standard 6 in Figure 9)
29
http://www.england.nhs.uk/london/quality-standards/
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
208
Agenda Item 5
Page 212
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
Figure 8: April 2013 Hospital LQS self-assessments - emergency care standards 1-3
Figure 9: April 2014 Hospital LQS self-assessments - emergency care standards 4-7
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
209
Page 213
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
3. We need to reduce the projected workforce gaps to deliver LQS and ensure that our
workforce is sufficiently trained to deliver new models of care
There is a shortage of the emergency care workforce needed to deliver LQS and we need to
train our workforce to deliver our vision for care in 2018/19
Urgent and emergency care services require access to senior, specialist clinicians who are able to
make swift decisions in order to ensure patients get the best possible care and experience. Although
all hospitals have reported progress towards achieving LQS, we know from detailed modelling and
scenario testing that due to competition between providers for staff, national shortages in the
emergency care workforce, financial constraints and the increasing demand it will not be possible for
all four of our providers to meet all LQS without significant changes to the way in which care is
delivered.
Across south west London we know that in the next four years we will need a significant number of
additional consultants across a number of specialties. Previous modelling estimated that a further 16
A&E consultants, 16 emergency medicine consultants and 16 emergency general surgeons 30 are
required and that Croydon, Epsom and St Helier and Kingston each have a shortfall of five
interventional radiologists needed to provide the one hour diagnostics required under LQS 31.
Nationally there are shortages and recruitment issues for all of these specialties 32. In particular there
is a shortage of A&E consultants with nearly one in five posts not filled and only half of these with
locum cover 33.
In addition to addressing the gaps for consultant level staff, we anticipate needing more staff of
other grades and clinical disciplines to strengthen the urgent care system, and increase the level of
care provided in the community, and enable rapid response 7-days a week. These challenges mean
we need to attract more skilled people as our providers will not all successfully recruit sufficient
numbers from the same limited pool of talent.
We expect the four acute providers in south west London to develop a plan to meet the LQS across
all providers and to quantify and address the workforce challenges.
4. We need to work together more innovatively to maximise the benefits of ambulatory
emergency care as part of improving the flow of patients through the hospital
30
BSBV modelling
London Health Programme (2012) Audit of Acute Hospitals
32
Emergency Medicine: Background to HEE proposals to address workforce shortages. Health Education.
England. 2013 (8% of consultant posts in emergency departments vacant and 9% were filled by locums in
2011/12)
33
House of Commons Committee of Public Accounts. Emergency admissions to hospital. 2014
31
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
210
Agenda Item 5
Page 214
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
Ambulatory emergency care (AEC) has the potential to convert 20-30% of emergency
admissions to same day care
Ambulatory emergency care (AEC) is defined as “clinical care which may include diagnosis,
observation, treatment and rehabilitation, not provided within the traditional hospital bed base or
within the traditional outpatient services that can be provided across the primary/secondary care
interface. In the context of acute medicine, it is care of a condition that is perceived either by the
patient or by the referring practitioner as urgent, and that requires prompt clinical assessment,
undertaken by a competent clinical decision maker”. 34
We know AEC can have significant impact on the flow of patients through a hospital, enabling
patients to be seen, treated and discharged without requiring an admission into hospital.
In 2007, the NHS Institute for Innovation and Improvement developed the Directory of Ambulatory
Emergency Care. This directory outlined 49 emergency conditions suitable for ambulatory
treatment. When these protocols are followed, many patients can be treated and discharged on the
same day, avoiding the need for them to be admitted into hospital.
The approach to AEC has been developed further with a greater emphasis on early senior review of
patients; this provides the opportunity for a consultant to ‘review a patient for discharge’ rather
than reviewing them for an admission. The Royal Derby Hospital implemented Ambulatory
Emergency Care (AEC), with a focus on a consultant’s physiological assessment of the patient rather
than an AEC pathways approach. They were able to 35:
•
•
•
Reduce overnight admissions by 39%
decrease the average emergency department waiting time for medical patients by 30
minutes
increase patient satisfaction: moving from a model of care that generated three complaints
per week to one that only generated one complaint in the following eight months.
The AEC Delivery Network has been set up to support trusts who want to implement the approach;
their experience is that emergency 20-30% of patients who would have required an emergency
admission can be discharged on the same day 36. The AEC Delivery Network offer an improvement
programme to that includes workshops, virtual visits, webinars, and individual support.
34
Acute Medicine Taskforce. Acute medical care. The right person, in the right setting – first time. Report of
the Acute Medicine Task Force. London: RCP, 2007.
35
Staples, D. Medical Admissions Reduction at the Royal Derby Hospital. 2013. Presentation to NHS
Confederation
36
Ambulatory Emergency Care: a solution to manage emergency demand, improve outcomes and reduce
waits. Ambulatory Emergency Care Delivery Network.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
211
Page 215
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
How we developed our initiatives for improving urgent and emergency
care
The six CCGs in south west London and NHS England are working together, in partnership with the
four south west London acute hospitals and two mental health trusts, to produce a 5 year strategic
plan in response to NHS England’s Everyone Counts 37planning guidance. Further information about
our governance and how we work together can be found in chapters six (How we will work together)
and seven (Governance).
The new approach is CCG and NHS England led, will engage with the public, health and wellbeing
boards, providers and local authorities. We will focus on the whole health economy. It is agreed that
the excellent clinical engagement will be continued through a number of Clinical Design Groups
(CDGs) chaired by a local clinician, including a CDG for urgent and emergency care. The detail of the
governance arrangements for this new approach is explained in the Governance chapter.
Further details about our plans for urgent care in the community can be found in the Integrated Care
and Transforming Primary Care chapters.
The development of the initiatives has been through the urgent and emergency care CDG. A first
draft of our strategic plan, outlining key themes and challenges was submitted to NHS England on 4th
April 2014.
The urgent and emergency care CDG met in April 2014 to agree what initiatives should be prioritised
in order to deliver our vision for urgent and emergency care.
In May, the south west London CCGs ran a stakeholder event, attended by over 100 patients,
members of voluntary sectors, political parties, providers and carers. Attendees were asked for their
views on the development of this 5-year strategic plan. The stakeholder group were keen that the
following issues were taken into account for urgent and emergency care:
1. Patients in need of acute mental health care should have access to crisis teams, and, should
they attend the emergency department, there should be appropriate psychiatric liaison
services
2. The ‘navigator role’ is important and emergency department reception and triage staff must
be skilled in directing patients to the right place
3. We must consider the needs of patients with sensory impairments – the reception or ‘front
of house’ areas are often confusing and inaccessible for these patients
4. Young people – although there is an understandable focus on the elderly, there is an
increase in the use of the London Ambulance Service and emergency care in 20-30 year olds
so we need to look into this in more detail and respond to their needs differently
5. Understand the impact on travel times for patients when accessing different types of urgent
and emergency care in different types of emergencies.
37
Everyone Counts: planning for patients 2014/15 to 2018/19. 2013. NHS England
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
212
Page 216
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
Based on this south west London CCGs have agreed that the following four initiatives should be
prioritised38:
1.
2.
3.
4.
Strengthen the urgent and emergency care system through a networked approach
Improve the quality of emergency departments
Improve workforce planning and development
Develop the urgent and emergency care pathway
Challenge
Initiative
1. We need to enable
and empower
patients, carers and
professionals to
access the right care,
in the right place,
first time
1. Strengthen the
urgent and
emergency care
system through a
networked
approach
2. We need to meet our
own minimum
standards for quality
2. Improve the
quality of
emergency
departments
Rationale and progress
To address the challenges faced in south west London, we need to
be transformational in the way we deliver urgent and emergency
care. In line with recommendations from the King’s Fund
39
Transforming our health care system . It is recognised that some
of the specific actions required to effectively redesign the urgent
and emergency care system could be to:
• Clearly signpost services to patients – we see 111 and care
navigators as key to achieving this
• Ensure hospital and community services adjust their service
levels in response to changes in demand
• Ensure A&E departments use best practice for handling
patients with major illnesses or injuries including early senior
review
• Ensure hospital and local authority social services and housing
departments are well co-ordinated to avoid delayed discharges
and reduce length of stay, and
• Consider patient flows around the system to find bottlenecks
and opportunities for changing pathways
We recognise that the Keogh report will recommend national
changes to the urgent and emergency care system. We also know
that our providers may develop a different model of care to meet
the challenges facing our urgent and emergency care system. We
will develop a communication strategy, alongside our patients and
health and wellbeing boards and UCWGs, so that our patients
know where and when they should access which service.
We will build on the progress made by UCWGs and develop an
urgent and emergency care network across south west London.
The Urgent and Emergency Care CDG will provide strategic
leadership and the four UCWGs will deliver the operational aspects
of our changes. As we develop this network we will also build links
with the relevant regional and national bodies.
People with serious or life-threatening conditions need to be
treated in emergency departments with the highest quality skills
and facilities in order to reduce risk and maximise their chances of
survival and good recovery. In south west London we will achieve
all LQS by 2016/17 – we know that this is a change in the way we
work and that UCWGs can lead a networked approach to delivering
LQS.
We expect providers to play a greater role in LQS audits and in
2014/15 we propose an open and transparent peer review process
for the south west London acute providers to monitor LQS.
38
39
Further information about how the strategic plan was developed can be found in the governance chapter
Transforming our health care system, Ten priorities for commissioners, The King’s Fund, 2013, p12
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
213
Page 217
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
Challenge
Initiative
Rationale and progress
We will deliver the recommendations in Professor Sir Bruce
Keogh’s report due to be published later this year. We recognise
that this will be focused on addressing variation in urgent and
emergency services by creating a new classification of Emergency
40
Centre and Major Emergency Centres .
To deliver the quality of urgent and emergency care our patients
expect will not be possible without a coordinated approach to
recruiting and training the workforce we need to address the
challenges our ageing population will face in 2018/19.
3. We need to reduce
the projected
workforce gaps to
deliver LQS and
ensure that our
workforce is
sufficiently trained to
deliver new models
of care
4. We need to work
together more
innovatively to
maximise the
benefits of
ambulatory
emergency care
3. Improve workforce
planning and
development
Previous LQS audits projected significant consultant workforce gaps
over the next five years. From 2016/17 we expect all our providers
to deliver full LQS for urgent and emergency care and during
2014/15 we will review workforce proposals and plans from our all
our providers to meet these standards.
Given the likely staff shortages across a range of grades and
disciplines, we will need to explore innovative solutions that could
include: reviewing the skill mix within different urgent and
emergency care, looking at integrated governance arrangements
for rotas across more than one organisation and engaging with
Health Education South London (HESL) and the Royal Colleges
about training programmes and rotations.
We will develop pathways that improve patient flow through the
urgent and emergency care services, including a better transfer
through to specialist departments and subsequent discharge
4. Develop the urgent
and emergency
care pathway
We will initially focus on Ambulatory Emergency Care (AEC). All
providers and CCGs in south west London have joined the AEC
network, recognising the opportunity that improving Ambulatory
Emergency Care can make to patient outcomes and experience.
Since joining the network, approximately 25% of patients who
would have been admitted to Epsom & St Helier have been treated
41
with ambulatory emergency care .
Work is ongoing to evaluate the impact of the changes and to
further develop the AEC model to include surgical patients.
Croydon University Hospital is now seeing 15-20 patients per day in
42
AEC and has invested in additional nursing support . Kingston
Hospital is currently focussing on a small number of AEC pathways,
and the Trust is considering how to improve AEC services. Estates
development is underway at Kingston and the Trust are looking at
how this could be developed to further improve Ambulatory
43
Emergency Care .
Table 1: Linking our challenges and initiatives
40
Transforming Urgent and Emergency Care Services in England – Urgent and Emergency Care Review, End of
Phase 1 report, NHS England, 2013
41
AECDN Provider status report. April 2014
42
Ibid.
43
Ibid.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
214
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
What are the initiatives that will address our challenges in Urgent and emergency care?
We have identified four initiatives that will enable us to address our challenges and these are outlined in Figure 8 to Figure 11.
1
Strengthen the urgent and emergency care system through a networked approach
Benefits for patients:
Major activities over the five years :
Performance monitoring description:
When a patient has urgent, but not life threatening needs,
highly responsive, effective and person-centred services will
be delivered outside of the emergency departments, often
closer to the patient’s home
•
Key milestones:
Year
Milestones
2014/15
• Agree links between UCWGs, CDG & London Urgent
and Emergency Care Board
• Urgent care services, incl. primary care, GP out of
hours, 111, LAS, pharmacies etc. reviewed &
specified
• Plan for changes required developed
• Equality impact assessment completed
2015/16
• Post-Keogh review communications strategy
published
• Service specification and outcome measures agreed
• 7 day working in community to compliment acute
services implemented
• Urgent care centres meet the LQS
2016/17
• Implementation of changes required to services and
new, innovative technology
2017/18
• Services reviewed and evaluated
2018/19
• Ongoing review and evaluation of services
Service specifications and performance outcomes need to be agreed
System risks:
How we will measure performance:
•
LQS peer review of audits
From 2014/15
KPIs for community pharmacy contacts/minor ailments
From 2015/16
KPIs for 111 service incl. abandoned calls, patient
satisfaction
From 2016/17
KPIs for out of hours incl. cost, quality, outcomes,
patient satisfaction
From 2016/17
Page 218
• Develop a networked approach to urgent and emergency care, building on the success of the
four SWL UCWGs
• Review urgent care services across SWL in light of Keogh recommendations, ranging from
strengthening urgent care access in primary care to specification of co-located UCCs
• Agree a communications strategy following publication of the Keogh recommendations
• Decide on the approach for improving patient and public education & for assessing the role of
care homes in the urgent care system
• Undertake an equality impact assessment for changes to urgent care system, including the
impact on carers, patients with learning disabilities and sensory impairment
• Ensure the services have appropriate workforce arrangements and integrated IT systems
• Ensure urgent care services support patients to register with GPs and educate patients/carers
on how to make the best use of urgent care services
• Review and evaluate inappropriate use of emergency services, e.g. emergency departments
and ambulance services
• Review 111 services and services provided by LAS
• Review community pharmacy services and evaluate how to increase capacity and capability
of pharmacists to support patients with minor ailments
• Review and standardise the specification for out of hours services
• Review the effectiveness of the Better Care Fund initiatives
• Implement the changes required to transform the urgent care whole-system
• Explore advances in technology-enabled care , and the evidence base, to understand the
opportunity provide an alternative to face-to-face care and enable improved self-care
management
• Implement advances in technology enabled care, including systems to allow efficient
communication and sharing of information between urgent care services across SWL
Complexity of the urgent and emergency whole-system service
model not reduced
Workforce implications:
•
Workforce gaps to be identified by providers and workforce
plans to be agreed in 2014/15
Finance and activity implications:
•
Finance and activity implications to be quantified in 2014/15
Figure 10: Strengthening the urgent and emergency care whole-system approach
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
215
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
2
Improve the quality of emergency departments
Major activities over the five years :
Benefits for patients:
•
•
•
•
•
•
•
•
•
Patients with serious, life threatening conditions receive care in emergency
departments with high quality skills and facilities
Reduced variation of the urgent care services provided through the
introduction of Keogh recommendations
Improved patient flow
Key milestones:
Year
Milestones
2014/15
• Develop new model of acute liaison for MH patients
• Gap analysis performed
• Agree links between UCWGs, CDG & London Urgent and
Emergency Care Board
• Plan for introduction of Keogh recommendations developed by
providers
• Plan for emergency care workforce developed by providers
2015/16
• Local quality measures added to provider contracts
2016/17
• LQS is met across all emergency departments in SWL
2017/18
• Two levels of emergency departments introduced (pending
further guidance)
2018/19
• Emergency department workforce organisation reviewed based
on changes in demand and the effectiveness of services provided
out of hospital
25th
Performance monitoring description:
Commissioners in SWL are committed to meet the London Quality Standards in
emergency. Other performance measures and outcomes will be considered.
How we will measure performance*:
LQS audits
From 2014/15
Total time in the emergency department improved to
national upper quartile
By 2018/19
Time to initial assessment improved to national upper
quartile
By 2018/19
Time to treatment improved to national upper quartile (TBA)
By 2018/19
Unplanned re-attendance rate1 improved to national upper
quartile
By 2018/19
System risks:
•
•
•
Significant workforce challenges to meet the LQS
Transforming urgent care services, leading to reduced demand for
emergency care must be done in a way that does not compromise clinical and
financial sustainability
Implications of second Keogh report not yet fully known
Workforce implications:
•
Workforce gaps to be identified by providers and workforce plans to be
agreed in 2014/15
Finance and activity implications:
•
•
Agenda Item 5
*to be agreed through urgent & emergency care network. Other metrics could include:
Senior sign off, time to decision maker and initial assessment, HSMR / SHMI,
ambulance turn around times
1. Patients who return to same ED/UCC site within 7 days of original attendance
Page 219
•
•
Agree the Urgent Care Clinical Design (CDG) Group’s relationship and links to
Urgent Care Working Groups & the London Urgent and Emergency Care Board
who are working to implement the Acute and Emergency Standards across
London as well as considering the impact of the Keogh report
Explore acute liaison services
Share learning eg Rapid Assessment and Treatment (RAT) (early senior review
of patients) vs traditional triage systems to ensure there is a focus on patient
experience and patient flow
Review current services at emergency departments and perform a gap
analysis to determine what needs to be done to achieve the LQS
Review and plan for specialist emergency care workforce particularly senior
consultant presence in line with the LQS at all emergency departments
Following further national recommendations, plan for the introduction of two
levels of emergency departments (Major Emergency Centre and Emergency
Centre) to reduce current inconsistency in types of services provided
Implement the changes required to achieve the LQS
Introduce two levels of emergency departments in line with national (Keogh)
recommendations
Cost of implementing LQS is estimated at £14m
Finance and activity implications to be quantified in 2014/15
Figure 11: Improving the quality of emergency departments
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
216
3
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
Improve workforce planning and development
Major activities over the five years :
Benefits for patients:
•
•
•
•
•
•
Key milestones:
Year
Milestones
2014/15
•
•
•
•
Provider peer review of LQS
Providers to submit plans to 7 day working
Review of provider workforce plans and skills completed and
suitable approach agreed to ensure Keogh recommendations and
LQS are met
Work with HESL, to develop training programmes
2015/16
•
•
Workforce training facilitated
7 day working implemented
2016/17
•
Workforce planning and development reviewed and evaluated
taking into account changes to the workforce, demand etc.
25th
2017/18
•
Ongoing review and evaluation of workforce requirements
2018/19
•
Ongoing review and evaluation of workforce requirements
System risks:
•
•
Performance monitoring description:
Patients will access urgent care services 7 days a week in their communities and
hospitals. Services will be staffed to appropriate levels with locally developed
training programmes
Page 220
•
Implement a provider LQS peer review process that involves relevant
consultants
Review provider workforce plans and skills required to provide
appropriate urgent care services across SWL. This will include
establishing a suitable approach for organising the workforce across
the urgent and emergency system (including GP access and out of
hours) to ensure services move towards achieving the LQS in
emergency departments and in urgent care services
Work with HESL to develop appropriate training to upskill the
workforce, review skill mix and develop new roles as required within
different parts of the urgent care system in light of the Keogh
recommendations and/or agreed pathway models AEC / “See and
treat” / Rapid Assessment and Treatment (RAT)
Urgent Care CDG will evaluate and revise the way the workforce is
planned and organised, taking into account the workforce changes,
population and demand trends, the effectiveness of the Better Care
Fund in reducing non-elective admission and changes resulting from
the adoption of primary care transformation
Work with HESL to undertake co-ordination and planning of the
workforce to adapt to seven-day working, implementing integrated
working across boundaries, upskilling the incoming community
workforce and adapting to the primary care transformation
Engagement with other relevant stakeholders, e.g. Royal Colleges to
develop new training models to address longer term shortages in
certain specialties
KPIs and performance outcomes will need to be developed
Providers compete for the same staff leading to continued workforce shortages
across the system
Difference in salary weighting between inner and outer London providers may
lead to recruitment challenges to outer London providers
Workforce implications:
How we will measure performance:
Sufficient staff recruited to meeting the LQS and 7
day working at all acute providers
By 2016/17
Staff turnover/attrition rate improved to national
upper quartile*
By 2018/19
Completion of mandatory Training Programmes
By 2018/19
*to be agreed through urgent & emergency care network
•
•
•
Workforce gaps to be identified by providers and workforce plans to be agreed
in 2014/15
Workforce development and training to be co-developed with HESL
New training models may be needed to increase numbers of trainees in certain
specialties
Finance and activity implications:
•
Finance and activity implications to be quantified in 2014/15
Figure 12: Improving workforce planning and development
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
217
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
4
Develop the urgent and emergency care pathway
Major activities over the five years :
Benefits for patients:
•
•
•
•
•
•
•
•
•
Ambulatory Emergency Care will enable more patients to be treated the
same day, and thereby not require full admission
More care provided closer to home
•
Key milestones:
Year
Milestones
2014/15
• Current AEC models reviewed
• AEC implemented across SWL
• Improved methodologies established through the AEC
network
• Suitable KPIs and performance standards agreed
2015/16
• AEC models reviewed and evaluated
2016/17
• Suitable links with community models established and
workforce skills and training evaluated
2017/18
• Changes required to the model implemented
2018/19
• Ongoing review and evaluation of AEC services
25th
Page 221
•
Initial pathway focus will be on Ambulatory Emergency Care (AEC)
Explore current AEC models and evidence base to support
development of SWL-wide approach
Establish a model suitable for south west London by identifying
appropriate conditions for AEC and develop AEC pathways
Continue to work with the CCG-funded Ambulatory Emergency
Care network to share best practice and improvement of
methodologies
AEC Network event in July 2014 to consider the development of
standards, recommendations, capacity, evaluation, pathways and
models of AEC and tariffs
Implement AEC and establish suitable KPIs and performance
standards
Review and evaluate AEC models and identify opportunities for
strengthening the service
Establish suitable links with community models and ensure the
workforce has appropriate skills and training
Develop best practice guidance/specification for certain conditions
Performance monitoring description:
Suitable KPIs and performance measures will need to be established
How we will measure performance*:
A&E attendances reduced by TBA%
By 2018/19
System risks:
Activity shift from NEL to AEC of 30% at all
providers
By 2016/17
•
•
Prevention of readmission/re-attendance
By 2018/19
Patient satisfaction (F&F test) improved to
national upper quartile (TBA)
By 2018/19
Community AEC workforce trained &
recruited
By 2018/19
Workforce shortages
Provider engagement
Workforce implications:
•
Workforce gaps to be identified by providers and workforce plans to be
agreed in 2014/15
Finance and activity implications:
Finance and activity implications to be quantified in 2014/15
Agenda Item 5
•
*to be agreed through urgent & emergency care network
Figure 13: Developing the urgent and emergency care pathway
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
218
Agenda Item 5
Page 222
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
When will we achieve the initiatives for Urgent and emergency care?
2014/15
2015/16
2016/17
2017/18
2018/19
• SWL urgent and emergency care network developed
• Provider peer review of LQS and gap analysis completed
• Plan to addresses the short term (five year) workforce challenges for urgent and emergency care across SWL urgent and emergency care network
developed and reviewed by commissioners
• Local implications of Keogh report reviewed and implementation & communication plans agreed
• AEC models reviewed by SWL urgent and emergency care network & consideration given as to how far to extend AEC
• IT requirements of the urgent & emergency care system agreed & implementation plan developed by SWL urgent and emergency care network
• 7-day working implemented across the urgent and emergency care system in SWL
• AEC implemented across SWL
• New AEC model evaluated by SWL urgent and emergency care network
• SWL urgent and emergency care network to develop a plan to strengthen LAS, community pharmacy, 111 and out of hours services
• Training for mental health services in emergency departments including acute liaison services and the workforce delivery model developed
• All LQS met across all emergency departments in SWL
• Additional quality metrics added to provider contracts
• Appropriately skilled emergency and urgent care workforce in place
• Implemented innovative technology-enabled solutions and apps, including IT systems
• Reviewed LQS
• Long term workforce planning and development taking into account the workforce changes, inputs from public health around population health and
demand trends, the effectiveness of the Better Care Fund in reducing non-elective admissions and changes resulting from primary care transformation
Figure 14: Milestones for urgent and emergency care initiatives by year
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
219
Page 223
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
How does our work to improve Urgent and emergency care address the
outcomes in Everyone Counts 44?
The vision for urgent and emergency care will address the seven measureable outcomes set out in
the national planning guidance 45 and the three key measures as outlined in Figure 13.
Figure 15: How our vision for Urgent and emergency care aligns to national outcome measures and key measurements
What are the interdependencies with other workstreams?
As our approach to urgent and emergency care is a whole system one, there are, naturally, a number
of important interdependencies with the workstreams within this strategic plan. The key
interdependencies are highlighted below and further information is included in the relevant section
of the strategic plan:
Integrated care
We will implement new and enhanced health and social care schemes planned as part of the Better
Care Fund, such as rapid response and other CCG admission avoidance schemes (this is considered
as part of Integrated Care in section 2), reablement, rehabilitation and self-care management
schemes. NHS contributions will begin in 2014/15 and in many areas will triple by 2015/16. This will
require collaborative decision-making with local authorities and is expected to have an impact on
both acute and community providers. Another challenge will be the implementation of the Care
Bill 46 for local authorities.
44
Ibid.37
Ibid.
46
Care Bill [HL] 2013-14: http://services.parliament.uk/bills/2013-14/care.html
45
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
220
Agenda Item 5
Page 224
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
Mental health
In addition, we want to ensure parity of esteem, making sure we focus on improving mental health
as well as physical health, including improving care for mentally ill people in crisis and parity of
access to urgent care This will involve ensuring urgent care services are linked with mental health
liaison services and ensure the Rapid, Assessment, Interface and Discharge (RAID) services provide a
high-quality services by multi-specialist teams that are well-connected to acute hospital clinicians, as
well as psychologists and alcohol practitioners. Better links with mental health services could
support early intervention and treatment of people with mental health problems ensuring reduced
avoidable admissions to hospitals.
Transforming Primary Care
The GP Patient Survey (GPPS) identified that demand on the wider system could be reduced if GP
hours were extended in the evenings and on Saturdays. Across south west London some CCGs have
put in place plans to increase out of hours services. However, there are further improvements that
could be made to extend opening hours. This could, for instance, involve federations of general
practices coming together to share responsibility for developing new forms of out of hours care.
Reduction in avoidable admissions to hospital will also be enabled through improving patient and
public education to ensure more focus on prevention and self-care management in south west
London. This can be delivered through:
•
•
•
•
•
Patient education by GPs and other primary care clinicians, e.g. community pharmacists,
with advice on smoking cessation, weight loss and alcohol intake
Referrals to suitable services
A systematic approach to changing health-seeking patient behaviour and accessing services
when a patient has urgent care needs through a south west London wide plan.
Promoting use of technology to help patients self-manage effectively
Providing patients with appropriate information and access to support networks for their
conditions.
We will aim to further reduce non-elective admissions by implementing improved technology
enabled care for instance to provide an alternative to face-to-face care and enable improved selfcare management. We will also consider implementing urgent care dashboards in primary care.
To enable a whole-system integrated urgent care service, it will be important that all parts of the
system are able to communicate and share information. We will therefore consider building
electronic patient records into common standards, providing details about treatment and care of the
individual patient.
The Urgent Care CDG will also be reviewing technology delivered care used in other parts of the
country and consider introducing such technology enabled care across south west London.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
221
Page 225
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
Children’s Services
We know that 25% of all A&E attendances at south west London hospitals are by children aged
under 15 47. We are investing in more community care for children. In addition, when children
require urgent or emergency care in hospitals, frontline care will be delivered by consultant
paediatricians and trained children’s nurses. The Urgent and Emergency Care needs of children are
covered in the Children’s services chapter.
Further information on clinical interdependencies is included in the Chapter 5.
What are the investment implications of these initiatives?
The cost of meeting LQS in urgent & emergency care at all our four providers has been estimated to
be £14 million 48. In 2014/15, we will work with providers to develop an updated view on this cost as
well as the costs for all our initiatives. As a general approach, we expect the initiatives identified in
this chapter to be delivered within tariff. However, additional non-recurrent support is being
considered as a transitional measure, through sources such as CQUINS. NHS England, Monitor and
the Trust Development Agency will provide a view on the triangulation between commissioner,
acute and community provider finances in summer 2014 and we will use this information to support
our local development of business cases for investment and contracting in 2014/15. These issues are
explored further in the sustainability chapter.
How will our workforce and estates need to be developed to deliver the
strategy?
We want to ensure we continue to improve quality of services through effective workforce planning
and development. Locally there are specific workforce challenges such as an ageing workforce,
leading to increasing numbers of retirements and adopting to new care models where more services
are delivered out of hospitals. In south west London, the staff groups within the acute workforce
that will have the greatest proportion of staff close to retirement age are estates and ancillary (29%
aged over 60 by 2017-18), administrative and clerical (25%) and additional clinical services (20%) 49.
In order to ensure we attract new skills and maintain high quality staff across the whole-system
urgent and emergency care service, we need to ensure we develop appealing training and
development programmes.
Importantly, it will be providers, during 2014/15, who will develop a plans to address the challenges
of rising demand, LQS, seven day working and recruitment that will deliver quality standards we
expect at all of our providers in south west London. Health Education South London (HESL) and the
will be a key partner for workforce planning both in the short term to meet deliver the Keogh
recommendations and in the long term to address shortages of consultants in a number of
specialties
47
South West London Urgent Care Project, 2013
Based on costs in BSBV model – provisional estimate only
49
Electronic Staff Register (ESR), updated February 2013
48
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
222
Agenda Item 5
Page 226
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
Once we and our providers have agreed the changes required to the urgent and emergency care
system we will develop robust business cases that detail the estates requirements of the new urgent
and emergency care system.
What work is already underway in boroughs to deliver our vision for
urgent and emergency care?
This strategic plan work covers the work that we are planning to undertake across south west
London over the next five years but work is already underway in every borough in south west
London to address our challenges. Figure 14 provides an overview of the urgent and emergency care
work that is underway in each of our boroughs.
Richmond:
• Part of Kingston UCWG
• Developing admission avoidance strategies eg
GP consultation for A&E regular attenders &
Care home training & rapid response
• Developing of the ambulatory care model
• Pharmacist medicines reviews in patients’
homes
• NHS 111 to ensure urgent care services are
easier to navigate for patients and carers
• Improving access to out of hours services & 24/7
working
• Developing a comprehensive older peoples
assessment with Kingston
Kingston:
• Part of Kingston UCWG
• NHS 111 to ensure urgent care services are
easier to navigate for patients and carers
• Investigating of ways to develop and
implement local alternatives to A&E
attendance
• Developing estates, AEC pathways and urgent
care services
• Developing plans to manage pressures
throughout the year
• Developing a comprehensive older peoples
assessment with Richmond
Wandsworth:
• Part of Wandsworth UCWG
• Vision is to improve access, quality, innovation and
value of care
• UCC, out of hours service and care navigators at St
George’s
• “Yellow man” campaign to signpost alternatives to A&E
in communities
• notalwaysaande.co.uk website to support patients and
carers, providing information about nearby services in
based on patient symptoms (website pages were
viewed over 30,000 times)
• NHS 111 to ensure urgent care services are easier to
navigate for patients and carers
Richmond
Wandsworth
Kingston
Merton
Sutton:
• Part of Merton & Sutton UCWG
• Urgent care centre in place with 50% of attendances being treated in this
setting including paediatrics
• Exploring of ways to optimise urgent care at home
• Commissioned an Urgent Care Dashboard for 12 practices that will enable
GPs to manage patients’ care in a planned way
• NHS 111 to ensure urgent care services are easier to navigate for patients
and carers
• Improving access to out of hours services
Sutton
Croydon
Merton:
• Part of Merton & Sutton UCWG
• Developed an urgent care strategy
• Implemented of single point of
access and NHS 111 to ensure urgent
care services are easier to navigate
for patients and carers
• COPD screening to prevent
admissions and pulmonary rehab to
prevent readmission
• Lead on information sharing
between UCWGs to facilitate the
process of a more joined up
approach
• Developing admission avoidance
strategies
• Investing in community nursing and
rehabilitation services
• Focussing on patient /carer
education and social marketing of
urgent care strategies
• Developed an urgent care strategy
Croydon:
• Part of Croydon UCWG
• Development of ambulatory
emergency care
• Development and implementation of
an urgent care centre strategy
• Implemented single point of access
and NHS 111 to ensure urgent care
services are easier to navigate for
patients and carers
• Focussing on patient /carer
education and social marketing of
appropriate use of services
• Developed an urgent care strategy
Figure 16: Borough-based work on urgent and emergency care across south west London
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
223
Page 227
Agenda Item 5
Chapter 4: Clinical workstreams, Section 7: Urgent and
emergency care
South West London Collaborative Commissioning
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
224
Agenda Item 5
Page 228
Chapter 4: Clinical workstreams, Section 8: Cancer care
South West London Collaborative Commissioning
Cancer Care
What does this section of the 5 year strategic plan cover?
The cancer section of the 5 year strategic plan covers all aspects of care for cancer patients, from
prevention and screening through to diagnosis, treatment and, where necessary, end of life care.
This care will be provided by both primary and secondary services together with community services
and voluntary groups.
What is the vision for cancer care in south west London for 2018/19?
South west London cancer services will focus on prevention of disease, early diagnosis and patient
experience of treatment with an emphasis on patient choice and care provision in the community
during active treatment, recovery, and, where necessary, the end of life phase. Every patient will be
treated as an individual and offered the full support of the healthcare professionals involved.
Figure 1: Our vision for cancer care in south west London
How our work aligns with national priorities
The cancer section of the strategic plan will address all of the measureable outcomes from Everyone
Counts.
Figure 2: How our vision for cancer care aligns to national outcome measures and key measurements
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
225
Page 229
Agenda Item 5
Chapter 4: Clinical workstreams, Section 8: Cancer care
South West London Collaborative Commissioning
What are the key challenges for cancer services that we will address?
There are a number of challenges facing cancer services in south west London which we will address
in this strategic plan:
•
•
•
•
•
•
•
•
Increasing the focus on primary prevention
Improving early diagnosis through promotion of patient awareness and screening uptake
Addressing the variation in outcomes and patient satisfaction across secondary care
providers
Delivery of chemotherapy in more convenient settings for patients
Improving utilisation of radiotherapy technology
Improving access to support for patients living with and beyond cancer
Optimising delivery of end of life care based around the lives of patients and cases
Improving patient experience
Increasing the focus on primary prevention
43% of cancers are thought to be due to lifestyle choices 1 (smoking, obesity, excess alcohol
consumption, exposure to UV light) and environmental pollution and tackling these issues will help
to prevent a significant proportion of cancers, in addition to improving the general health of the
south west London population.
Improving early diagnosis through promotion of patient awareness and screening uptake
There are a number of cancer screening programmes available nationally with variable rates of
uptake. The remainder of referrals rely on patient awareness of symptoms and presentation to their
GP or opportunistic diagnosis as a result of attendance at A&E often resulting in a late diagnosis.
Promotion of self-awareness, as well as increasing education of GPs and other primary carers, will
increase the proportion of cancers that are detected early and thus improve outcomes.
Addressing the variation in secondary care providers
There are variations in terms of patient outcomes, experience and waiting times between local
secondary care providers. All patients in south west London need to be assured that they will receive
the same quality of care in the shortest possible time, regardless of where they live and where they
are treated.
Location of chemotherapy services in more convenient settings for patients
Chemotherapy treatment often requires patients to spend a considerable time in hospital which
could be avoided through delivery of appropriate chemotherapy elsewhere, including in the
patient’s home.
1
Cancer Research UK http://www.cancerresearchuk.org/cancer-info/cancerstats/causes/comparing-causes-ofcancer/results/
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
226
Agenda Item 5
Page 230
Chapter 4: Clinical workstreams, Section 8: Cancer care
South West London Collaborative Commissioning
Improving utilisation of radiotherapy technology
New developments in radiotherapy delivery can offer better outcomes and fewer side effects. The
introduction of new technology is expensive, and will need to be carefully planned and co-ordinated
to avoid unnecessary duplication and that cost effective treatments are available.
Improving access to support for patients living with and beyond cancer
Currently, this support is provided by several different bodies (acute trusts, primary care, individual
carers, the voluntary sector) and commissioned by different agencies (NHSE, CCGs and local
authorities). These disparate groups need to be better integrated in order to meet the needs of each
patient, as defined by their Recovery Package. This will include a holistic needs assessment, an
individual care plan and a treatment summary.
End of life care needs to be optimised and patient focused
Patients have the right to decide where they would like to die and must be supported in their
decision and allowed to die with dignity in their location of choice.
Improving patient experience
Efforts to improve patient experience should be integral to every area of cancer service delivery:
prevention, diagnosis, treatment and aftercare. Concerns regularly raised by service users include
travel and parking, delays in the patient journey, staff attitude, staffing levels and handoffs between
settings of care. Patient experience surveys report lower scores in south west London than the rest
of the UK.
What we will achieve in years one and two (2014/15 and 2015/16)
Each CCG is submitting a two year operational plan for 2014-16 and improvements to cancer
services and end of life care have featured in some of these. A number of key themes have arisen
which correspond with our strategic plan and those of note are a focus on prevention of disease
through lifestyle interventions, early detection of disease through screening and improved public
awareness, improvement of patient experience, increased use of Coordinate My Care and an
increase in the number of patients dying in their location of choice.
Our specific strategic goals for years one and two are to:
•
•
•
•
•
•
Increase the number of people referred to smoking cessation clinics
Increase the percentage population uptake of screening (bowel, breast and cervical cancer)
Increase the percentage of cancer diagnosed through two week wait referrals versus those
presenting through other routes
Increase the percentage of patients with a Recovery Package
Increase the percentage of terminally ill patients registered on Coordinate My Care
Improve the results of the patient satisfaction surveys
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
227
Page 231
Agenda Item 5
Chapter 4: Clinical workstreams, Section 8: Cancer care
South West London Collaborative Commissioning
How we will achieve our objectives in years one and two (2014/15 and
2015/16)
We will:
•
•
•
•
•
•
•
•
•
•
Ensure secondary care providers implement NICE guidelines on smoking cessation
Commission primary prevention programmes focussed on smoking, obesity, excess alcohol
consumption and exposure to UV light
Ensure that ensure screening is a priority in local Joint Strategic Needs Assessments and
Health and Wellbeing Board strategies
Support the age extension of the bowel cancer screening programme, commissioning extra
endoscopy services from JAG accredited suppliers
Use commissioning levers to increase the uptake of screening in primary care and work with
local community groups and Health and Wellbeing Boards to target hard to reach groups
Work with Public Health to invest in the Be Clear on Cancer Campaign to raise public
awareness of symptoms of cancer through signposting and messaging in pharmacies, GP
surgeries and other appropriate locations
Invest in Cancer Leads to coordinate early diagnosis strategies, including educational
activities for GPs to recognise symptoms associated with a cancer diagnosis.
Use commissioning levers to ensure secondary care providers meet access and treatment
targets for patients with suspected or proven cancer
Support patients and their carers to allow patients to die with dignity in their location of
choice (home, hospice, nursing home or hospital). This will be achieved by a south west
London wide roll-out of Coordinate My Care
Specify priority areas for improvement and request plans from secondary care providers for
improvements
What we will achieve in years three to five and how we will achieve it
(2016/17 to 2018/19)
•
•
•
•
•
Reduce local rates of obesity
Increase the percentage of early stage versus late stage cancers diagnosed
Increase the percentage of people receiving chemotherapy out of hospital
Utilise new technologies in radiotherapy provision
Increase the percentage of patients dying at their chosen location
To do this we will:
•
•
Focus on reducing the rates of obesity in south west London through commissioning and
public health initiatives.
Focus on screening and promotion of public awareness of symptoms and the importance of
early presentation to increase the percentage of early stage cancers diagnosed.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
228
Agenda Item 5
Page 232
Chapter 4: Clinical workstreams, Section 8: Cancer care
South West London Collaborative Commissioning
•
•
Wherever possible, deliver chemotherapy in satellite units, community settings or the
patient’s home, thus reducing the amount of time patients have to spend at the hospital,
and improving their experience and quality of life. Links with the central units will oversee
this and ensure quality and safety and newer forms of chemotherapy (oral agents and
subcutaneous delivery systems) will be used whenever clinically indicated to facilitate local
treatment.
Establish a south west London-wide roll-out of Coordinate My Care and increase the
percentage of patients dying in their preferred location.
What are the enablers which will help us to achieve these objectives?
Technology
Improving technology for radiotherapy has the potential to improve outcomes and reduce side
effects for patients.
Medication access
Availability of medications that will be suitable to administer in out of hospital setting plus the
availability of adequately trained staff will enable more patients to have their chemotherapy
treatment in community settings including their own homes. In addition we will ensure that patients
have access to the appropriate treatments available through the £200m National Cancer Drugs
fund 2.
2
http://www.england.nhs.uk/2014/02/03/cdf-drug-release/
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
229
Page 233
Agenda Item 5
Chapter 4: Clinical workstreams, Section 8: Cancer care
South West London Collaborative Commissioning
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
230
Page 234
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
Chapter 5: Sustainability
5 Year Strategic Plan
23rd May 2014 Draft Submission
Version 2.00
This chapter contains financial projections based on information available at 15
May 2014 and is subject to change as a result of ongoing work to further
improve the alignment of assumptions and outputs between Commissioners and
Providers
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
231
Page 235
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
Contents
1.
Clinical and operational sustainability in south west London ......................................................... 233
Providers are required to deliver higher quality and patient safety in an environment of increasing
pressure to make financial savings ..................................................................................................... 233
There are a number of short-term and medium-term risks associated with the delivery of the fiveyear strategic plan............................................................................................................................... 233
Challenges to operational sustainability ............................................................................................. 234
Operational targets ......................................................................................................................... 234
Infrastructure .................................................................................................................................. 234
Developing a systemic approach to identifying and addressing risks to clinical and operational
sustainability ....................................................................................................................................... 235
2.
Financial sustainability .................................................................................................................... 236
What are the challenges to financial sustainability in 2018/19? .................................................... 236
Commissioner sustainability: .............................................................................................................. 237
Commissioner sustainability – 2013/14 position............................................................................ 237
CCGs allocation and pace of change payments – 2014/15 to 2018/19 .......................................... 237
Allocations and distance from target – 2015/16 benchmarking .................................................... 239
3.
Estates capacity ............................................................................................................................. .251
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
232
Agenda Item 5
Page 236
Chapter 5: Sustainability
South West London Collaborative Commissioning
1. Clinical and operational sustainability in south west London
Providers are required to deliver higher quality and patient safety in an
environment of increasing pressure to make financial savings
Delivering the highest quality services in a clinically sustainable way is the number one priority for
CCGs. In the wake of the Francis report, published in 2013, there has been fresh momentum to drive
up clinical quality and safety throughout NHS hospitals, and make certain that the failings found at
Mid Staffordshire Trust can never happen again.
In developing a clinically sustainable health economy there are obvious interdependencies between
clinical, operational and financial sustainability. CCGs have stated a clear intention to deliver a shift
in the location of care from secondary acute and mental health settings to the community,
improving integrated care and making more services available to patients outside hospital. This shift
of care and increasing focus on integrated care is reinforced by the Better Care Fund (BCF), which
mandates a minimum level of investment in services that support delivery outside of hospital and
greater integration of care.
In addition to the BCF and CCG QIPP programmes, which require significant savings at acute trusts,
CCGs are setting out intentions, across the full range of clinical services, to improve quality. This is
signified by the commitment to achieving seven-day working and the London Quality Standards
(LQS), alongside the development of new primary care standards through the NHS Improving Quality
programme.
CCGs want to work with providers to help them achieve these improvements in quality, and have set
out a clear approach to delivering improvements based on the use of commissioning levers to
incentivise delivery of the required standards. The use of tactical levers will be aimed at encouraging
providers to work with each other and with CCGs to meet the challenges they collectively face. There
is a risk that the short-term pressure associated with achieving improved quality, whilst undergoing
a shift of the amount of care delivered from acute settings, may have unintended consequences for
the quality of care delivered in hospital. CCGs need to work with providers to identify the risks to
clinical sustainability inherent within this environment in order to ensure the appropriate systems
are in place to identify, and militate against, any deterioration in quality.
There are a number of short-term and medium-term risks associated with
the delivery of the five-year strategic plan
The approach set out above has a number of risks that CCGs need to make sure are mitigated as the
ambitious goals set out in this document are delivered:
•
The achievement of seven-day working will require changes to ways of working both in
acute trusts and in the community. This will mean the workforce needs to adapt and
support services, such as patient transport, need to be established 24/7. Achieving these
standards may stretch local services in the short run and the changes to working practices
could affect the overall quality of these services for a period of time
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
233
Page 237
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
•
•
Where a trust is struggling to meet both clinical and financial challenges it may fall into a
vicious circle where an actual or perceived problem can impact on the organisation’s ability
to recruit permanent staff, leading to higher expenditure on temporary staff which in turn
can create additional financial and clinical problems. CCGs need to work with providers to
identify these problems early and ensure that system-wide solutions are developed
Achieving the LQS, which remains the objective for all south west London CCGs, will be an
added pressure, over and above that required to achieve seven-day working. There are a
number of standards which local trusts are all struggling to meet, and there is recognition
that in their current form it will not be possible to meet the full LQS at every south west
London hospital. There are insufficient consultants available to achieve this even if the
financial resource were available. Managing this situation and encouraging providers to
work together to achieve the standards across south west London will be vital to achieving
clinical sustainability in the long term.
Challenges to operational sustainability
Alongside specific risks to the ability of providers to deliver safe high quality clinical services, it is also
important to identify operational risks associated with the delivery of the five-year strategic plan.
Operational sustainability is a broad definition yet there is a need to focus on certain specific areas,
such as performance against operational targets and the maintenance of appropriate infrastructure
such as IT and estates.
Operational targets
Hospitals in south west London are currently below average in performance against the four-hour
A&E target (although overall this target is being met) and are in the bottom quartile nationally when
looking at the median time from arrival to treatment, suggesting that A&Es are already coming
under pressure from high demand. 1 Trusts are in the 3rd quartile in performance against the 18
weeks target, and in other areas, such as the 2 weeks referral to first out-patient target for patients
with suspected breast cancer, performance is in the below average. Some of the areas this five-year
strategic plan will address, such as centralising some planned care services and developing
ambulatory care services, will help trusts to achieve these targets across south west London in the
longer term. However CCGs need to be mindful of the risks to the achievement of these targets
whilst undergoing significant change.
Infrastructure
It is vital that buildings and IT infrastructure are fit for purpose to achieve the goals set out in the
five-year strategic plan. Much of this will hinge around improving access to technology enabled
services, although the challenges vary by care setting.
A focus for primary and community care is to develop up to date IT infrastructure allowing access to
patient health information from multiple services, enhancing patient-centred care. Examples of this
could include allowing mothers access to real time information about their health, using telemonitoring by GPs or community nurses to identify exacerbations in patients with long-term
1
South west London SPG data pack – March 2014
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
234
Agenda Item 5
Page 238
Chapter 5: Sustainability
South West London Collaborative Commissioning
conditions, or finding alternatives to face to face urgent care. These services require different teams
to access patient information and it is vital that systems are connected together to allow this
information to be available without compromising confidentiality. Developing the systems that are
able to do this is vital to operational sustainability.
In primary care south west London has lower than average numbers of small practices (1-2 GPs), and
much work has already taken place locally to develop GP premises, particularly in areas such as
Merton. This needs to be further developed to ensure that every practice has the capability to
provide the core range of integrated services in the community, particularly to develop the capacity
to manage the overheads associated with more advanced IT infrastructure and integration with
other key services.
In larger hospitals there is a need to address maintenance concerns but also to develop the right
level of capacity in the right places to meet the needs of patients. Given the increasing specialisation
of hospital care, and the desire to develop services that achieve the required levels of medical and
nursing support, CCGs and providers need to work together to ensure that capital planning and
funding is available for existing hospital sites where development is required.
Developing a systemic approach to identifying and addressing risks to
clinical and operational sustainability
The foundation of the approach CCGs have set out is close collaboration with partners and provider
organisations to develop the five-year strategic plan and respond to the case for change. CCGs will
use a range of levers to incentivise this closer working, and will work closely with other organisations
in the health system, such as Monitor and the NHS Trust Development Authority (NTDA) to develop
a stable healthcare landscape.
Some examples of ways CCGs will work to identify and militate against any deteriorations in clinical
quality are outlined below:
•
•
•
Transparent communication on the standards they expect providers to deliver. Setting
these expectations early will allow time to prepare for the changes to service delivery and
this process has already begun by setting out a requirement in the 2014/15 contracts to
develop plans to move towards seven-day working
Use of investment to encourage the development of services. An example of this could be
setting aside a section of CQUIN funding to incentivise improvements in quality across all
trusts for particular services. CCGs will also be prepared to use transitional funding to
ensure providers do not have to suffer abrupt decreases in income following changes to
services
Developing extensive oversight over clinical services. This will be achieved through further
development of pre-existing networks such as the maternity or children’s networks. There
will also be regular assessments against local quality standards such as LQS.
Working together with providers, CCGs will manage the healthcare economy to identify and respond
to any risks to the sustainability of clinical services over the next five years. Given the difficulty of
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
235
Page 239
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
meeting the required quality standards CCGs will support providers through transition periods and
will ensure that there will be high quality healthcare for everyone in south west London by 2018/19.
2. Financial sustainability
What are the challenges to financial sustainability in 2018/19?
NHS England London set out in ‘A Call to Action’ the financial challenges facing London’s providers
and commissioners. ‘A Call to Action’ estimated that London needs to save ~£4 billion between 2015
and 2020 to meet the forecast national funding gap of £30 billion. 2
Commissioners and providers in south west London are not isolated from the financial pressures
being faced nationally by the NHS. Delivering on the ambitions for services set out in the previous
chapters whilst ensuring that south west London has a financially sustainable local health economy
will be extremely challenging.
‘Everyone Counts’ requires explicit plans on how commissioners intend to work together and with
key partners and stakeholders in the local health economy to close the funding gap ‘whilst
maintaining or enhancing the quality of services provided to patients’. 3 This section sets out the
scale of the financial challenge for commissioners and providers in south west London, and the
approaches commissioners are taking to deliver financial sustainability across south west London.
The initiatives for improving quality agreed during the Clinical Design Group process have financial
implications for both providers and commissioners. Provisional modelling indicates that substantial
investments from commissioners and providers are required to deliver the initiatives outlined by
each of the Clinical Design Groups. It is likely that there are additional costs above and beyond those
identified to date. Notwithstanding, it is clear from the provisional estimates that more investment
is required to support the implementation of the strategy than is available to local commissioners.
The Better Care Fund (BCF) is a significant new dimension that commissioners and providers have
had to consider in the development of five year strategic plans. As outlined in the letter from Sir
David Nicholson to commissioners in October 2013, the BCF is a ‘game changer’. The ring-fenced
budget for investment in integration across health and social care requires at a national level £2
billion of savings from existing spending in acute services 4. Commissioners in south west London are
proposing considerable reductions in the proportion of care that is delivered in acute settings, with
significant implications for the cost reductions acute providers will need to make over the period.
Likewise, substantial investments are proposed in out-of-hospital care, notably in community health
services.
The work required to meet the challenges outlined in detail in the remainder of this chapter will
require close working between commissioners – including NHS England as a direct commissioner
2
NHS England London, ‘A Call to Action’ (14 October 2013), p.25.
NHS England, ‘Everyone Counts: Planning for Patients 2014/15 to 2018/19’ (December 2013), p. 23.
4
Sir David Nicholson letter to CCG leaders, ‘Planning for a sustainable NHS: responding to the ‘call to action’
(10 October 2013)
3
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
236
Page 240
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
facing considerable financial sustainability challenges – and with provider organisations across the
local health economy. To ensure that funds are available to make the necessary medium- and longterm investments required to deliver high-quality, sustainable health care, south west London CCGs
recognise the need to continue to work closely together. This section of the strategy sets out in
financial terms the areas this collaborative working will need to continue to address.
Commissioner sustainability:
Commissioner sustainability – 2013/14 position
The six south west London CCGs had combined programme resources of £1,610 million in 2013/14,
and commitments of £1,632 million. Collectively, south west London CCGs delivered a surplus of
£0.3 million in 2013/14 after allowing for the return of previous year surpluses, with a remaining
challenge to 1% surplus of £16.1 million. 5
Five of the six CCGs met the NHS England business rules for 2013/14, delivering a surplus of 1% or
more (following the return of previous year surpluses).
6
Figure 1: SWL CCGs surplus / (deficit) position in 2013/14 after the return of previous year surpluses (£’millions) :
CCG
£’m
%
Croydon
(19.9) 7
(4.9%)
Kingston
2.0
1.0%
Merton
2.1
1.0%
Richmond
6.7
3.2%
Sutton
2.1
1.0%
Wandsworth
7.4
1.9%
Total
0.3
0.0%
Croydon CCG had a deficit of -£19.9 million. 8 The challenge faced by Croydon CCG is the starkest
example of the financial sustainability challenge faced by CCGs in the south west London Strategic
Planning Group. Four of the six south west London CCGs are below target allocation in 2014/15. If
Croydon CCG was funded at target allocation in 2014/15, the CCG alone would be able to pay down
the 2013/14 deficit and also break-even in year one of the strategy (all other things being equal).
CCGs allocation and pace of change payments – 2014/15 to 2018/19
In aggregate, south west London CCGs are 3.0% below target allocation n 2014/15, equivalent to
£48.3 million in the first year of the strategy. 9
Figure 2: Closing distance from target in 2014/15:
10
CCG
Croydon
Kingston
Merton
Richmond
Sutton
Wandsworth
TOTAL
2014/15
(9.5%)
(2.3%)
(7.7%)
0.5%
(7.5%)
6.6%
(3.0%)
5
SWL CCG Commissioning Model v0.20 (based on CCG finance template submissions to NHS England on 4 April
2014, updated at 21/05/2014)
6
Ibid.
7
Croydon CCG has reported an £18.2m (-4.5%) deficit in 2013/14, against a plan of £19.9m (displayed in the
table). In delivering this improved position, the CCG has delivered £14.0m (3.5%) savings and made no
commitments against the 2% headroom (£8m).
8
Ibid. 5
9
NHS England Allocation (December 2013)
10
Ibid.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
237
Page 241
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
Distance
to target
(£’m)
(38.5)
(4.5)
(16.0)
0.1
(15.5)
25.4
(48.3)
NHS England’s pace of change strategy addresses some but not all of the funding gap in south west
London, as shown in Figure 3 below. In particular, Croydon CCG remains -5.0% under target
allocation in 2018/19.
Closing Distance from Target (%)
Figure 3: Movement to target allocation – closing distance to target 2014/15 to 2018/19 (%):
11
10%
8%
6%
6.6%
4.1%
4%
2%
0%
0.5%
2014/15
-2%
2015/16
2016/17
0.0%
2018/19
2017/18
-2.5%
-3.1%
-2.3%
-4%
-6%
-8%
-10%
-4.2%
-5.0%
-7.5%
-7.7%
-9.5%
Croydon CCG
Kingston CCG
Merton CCG
Richmond CCG
Sutton CCG
Wandsworth CCG
Collectively, the South West London Strategic Planning Group remains £29.7 million below target
allocation in 2018/19. Croydon CCG’s closing distance to target allocation is £23.4 million. Despite
this, Croydon CCG is projecting a break-even in-year position in 2018/19. 12
Figure 4: Closing distance from target in 2018/19:
13
CCG
Croydon
Kingston
Merton
Richmond
Sutton
Wandsworth
TOTAL
2018/19
(5.0%)
(2.5%)
(3.1%)
0.0%
(4.2%)
4.1%
(1.6%)
11
NHS England Allocations (December 2013) and NHS England Indicative Allocations (February 2014). Model:
140331 SWL SPG – CCG distance from target v0.7. Note: Indicative allocations adjusted from 2016/17 for
Kingston CCG and Richmond CCG so that there is no drift below target.
12
Ibid.
13
Ibid.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
238
Page 242
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
Distance
to target
(£’m)
(23.4)
(5.6)
(7.6)
0.0
(10.1)
16.9
(29.7)
Allocations and distance from target – 2015/16 benchmarking
The South West London Strategic Planning Group is the furthest below target allocation in London.
Figure 5: SWL Strategic Planning Group Closing Distance from Target (as a percentage of Target Allocation) compared to
14
London SPGs (2015/16): (%):
South west London commissioners have to consider the options available for financial sustainability
in the context of a tighter overall financial envelope than some other London SPGs. The challenges
faced by CCGs in south west London, and by Croydon CCG in particular, are sensitive to a change in
allocations policy for 2016/17 onwards.
“Do nothing” position in 2018/19 and planned QIPP savings
In 2018/19, south west London CCGs have a combined projected expenditure of £2,064 million.
Without any improvements in productivity, commissioners would be faced with an in-year challenge
in 2018/19 of £209 million to deliver a 1% surplus. 15
Figure 6: SWL CCGs income and expenditure in 2018/19 before the return of previous year surpluses (£’millions):
16
14
NHS England Indicative Allocations (February 2014). Model: 140331 SWL SPG – CCG distance from target
v0.7.
15
Ibid. 5
16
Ibid. 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
239
Page 243
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
In order to address this challenge, south west London CCGs are planning to deliver £190 million in
QIPP savings between 2014/15 and 2018/19.
Figure 7: SWL CCGs’ run-rate QIPP savings in 2018/19 and percentage of expenditure:
CCG
£m
%
Croydon
45.0 18
9.4%
Kingston
20.7
9.0%
Merton
31.0 19
12.2%
Richmond
19.3
8.1%
17
Sutton
23.7
9.6%
Wandsworth
50.7
11.9%
Total
190.3
10.2%
Savings in acute services account for £126.6 million of the planned QIPP savings over the five years,
representing 67% of total net savings.
CCGs in south west London are planning to reduce the proportion of spend in acute services from
61% of commissioning spend in 2013/14 to 56% of spend in 2018/19, in order invest in greater
17
The QIPP savings displayed are on a run-rate basis for 2018/19 (i.e., the cumulative planned QIPP figure for
2014/15 through 2018/19 adjusted for growth and tariff effects). The non-adjusted cumulative QIPP for SWL
CCGs between 2014/15 and 2018/19 is as follows: Croydon CCG (£41.3m), Kingston CCG (£18.9m), Merton
CCG (£29.1m), Richmond CCG (£18.0m), Sutton CCG (£21.7m), Wandsworth CCG (£46.6m), South West London
CCGs (£175.5m). Source: SWL CCG Commissioning Model v0.20 (based on CCG finance template submissions
to NHS England on 4 April 2014, updated at 21/05/2014).
18
Croydon CCG has run-rate net QIPP savings in 2018/19 of £45.0m. On a non-adjusted basis, Croydon CCG is
planning £41.3m of net savings through QIPP and outcome based commissioning between 2014/15 and
2018/19. Planned net QIPP savings are £34.6m and outcome based commissioning savings are £6.7m over the
period (both figures are presented on a non-adjusted basis).
19
Note: Figure for Merton CCG is not directly comparable, as based on gross rather than net QIPP savings for
2016/17 onwards.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
240
Page 244
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
integration across primary, community and acute services as well as deliver on the commitments of
the Better Care Fund. 20
Better Care Fund
The Better Care Fund represents a significant investment for south west London CCGs.
The Better Care Fund is intended to be a significant enabler in delivering a transformation in the
integration of care across providers, especially in out-of-hospital settings. South west London CCGs
will transfer a minimum of £85 million to the BCF in 2015/16.
Figure 8: CCG minimum transfers to the Better Care Fund in 2015/16 (£’m):
CCG
2015/16
Croydon
21.5
Kingston
9.9
Merton
11.3
21
Richmond
10.7
Sutton
11.1
Wandsworth
20.0
Total
84.5
As the annex to the BCF in ‘Everyone Counts’ outlines, the BCF represents a ‘significant catalyst for
change.’ 22 The Fund clearly has implications for acute providers, represented in part by the scale of
the acute QIPP challenge outlined above.
Opportunity in south west London to deliver further savings?
CCGs in south west London could find it challenging to deliver any savings above and beyond the
planned QIPP outlined above.
Benchmarking indicates that south west London CCGs already perform well both for non-elective
and elective admission rates compared with the England average. For example, five of the south
west London CCGs are in the bottom quartile for avoidable emergency admissions. Furthermore,
four of the six south west London CCGs rank in the top fifteen CCGs for having low rates of
emergency admission (all six CCGs have emergency admissions below the 2012/13 age standardised
rate for England).
Figure 9: Composite of all avoidable admissions for CCGs across England (2012/13):
23
20
Ibid. 5. Note: the amount transferred to the Better Care Fund by SWL CCGs is included in the commissioning
spend for 2018/19.
21
NHS England, ‘Everyone Counts’ (December 2013), p.73.
22
Ibid.
23
NHS England Ambition Atlas Tool.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
241
Page 245
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
Avoidable Emergency Admissions
Metric
Composite of all avoidable emergency admissions for CCGs across England
2012/13
Croydon
Sutton
Wandsworth
Merton
Kingston
Richmond
CCGs Across England
Figure 10: Emergency admissions per 1,000 registered patients (2012-/13 age-standardised rate):
24
The above age-standardised comparison suggests that commissioners are already performing well
on demand management within the local health economy. This is reflected in NHS England’s target
allocation calculation: the South West London Strategic Planning Group has the lowest target
allocation per head in London.
Figure 11: SWL Strategic Planning Group Allocation per head compared to London SPGs (2015/16):
25
24
National Audit Office (October 2013)
NHS England Indicative Allocations (February 2014). Model: 140331 SWL SPG – CCG distance from target
v0.7.
25
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
242
Agenda Item 5
Page 246
Chapter 5: Sustainability
South West London Collaborative Commissioning
Therefore, south west London CCGs are not only the furthest below target allocation of London’s
SPGs, but also have the lowest target allocation as well.
Commissioner sustainability – 2018/19 position
Collectively, south west London CCGs will break even in 2018/19, with five of the six commissioners
planning to deliver a 1% surplus as required by NHS England business rules.
Croydon CCG is planning significant improvements to its in-year position across all five years of the
strategic planning period in order to deliver financial balance at the end of the five years. 26
Figure 12: Croydon CCG – in-year and cumulative surplus / (deficit) and closing distance from target – 2014/15 to 2018/19
27
(£’millions):
26
27
Ibid. 5
Ibid. 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
243
Page 247
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
244
Agenda Item 5
Page 248
Chapter 5: Sustainability
South West London Collaborative Commissioning
Collectively, south west London CCGs show considerable improvement on an in-year basis, reflecting
the improvements in Croydon CCGs position throughout the five year planning process.
Figure 13: SWL CCGs – in-year and cumulative surplus / (deficit) – 2013/14 to 2018/19:
28
However, despite the improvements to the aggregate in-year position, the South West London
Strategic Planning Group will not have addressed the cumulative deficit which is projected to grow
to £49.4 million by 2018/19. 29
Financial sustainability – Funding transformational change
The Strategic Plan outlines a bold and ambitious approach to improving the quality of care delivered
across acute, community, mental health and primary care services. In order to deliver these clinical
ambitions and achieve a financially sustainable health economy, south west London commissioners
will need to work together to prioritise how best to address the multiple challenges identified whilst
supporting the investment required to deliver transformational change.
CCGs have committed to actively working together to identify how best to achieve the strategic aims
having regard to the limited nature of the funds available. However, it is clear that there is more
investment required to deliver the various initiatives identified in the Strategic Plan than can be
financed from the available financial resources.
28
29
Ibid. 5
Ibid. 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
245
Page 249
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
Commissioners have reasonably well developed estimates, based on the significant amount of work
previously undertaken, for the costs associated with the additional consultants required to deliver
the London Quality Standards across south west London’s acute providers. However other
initiatives, including the non-consultant staff costs of delivering the full London Quality Standards,
have not been fully costed at this point in the planning process.
In the case of some of the Clinical Design Groups – notably Children’s and Mental Health – where the
scope of the initiatives extends across multiple service areas, significant work is required to
determine the investment and recurrent expenditure implications of the recommendations. South
west London CCGs need to develop as a matter of priority better estimates for the initiatives that
have not yet been sufficiently costed.
This information will support south west London commissioner’s assessment of the affordability of
the Strategic Plan.
Figure 18 below shows the sources of funds for south west London CCGs that could potentially be
applied to support the Strategic Plan.
Figure 14: Potential sources of funds in south west London (2014/15 to 2018/19):
Potential sources of funds (£m)
Non-recurrent funding
0.5% risk share
SWL transformation programme
Other non-recurrent funding
Transformation Fund
Brought forward surplus
Quality Premium
Total
30
Total - 2014/15 to 2018/19
Total - 2015/16 to 2018/19
42.8
20.8
30.1
16.1
17.0
16.5
143.3
34.8
17.4
17.4
17.0
16.5
103.1
In addition to the funds outlined above, CCGs in south west London are also discussing how other
sources of funds, such as CQUIN, could be used collectively to support the commissioning aims
outlined in this Strategic Plan. Notwithstanding this, south west London’s commissioners do not
anticipate having sufficient funds available to support the full implementation of all the Strategic
initiatives identified.
South west London CCGs are continuing to work closely together to detail the implementation costs
of the Strategy so that a financial implementation plan can be produced, covering both sources and
application of transformation funds.
30
Ibid. 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
246
Page 250
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
Provider sustainability
A key concern for the South West London health economy is the financial sustainability of the main
service providers. Without financially strong providers, health services are vulnerable to services
failing to be delivered to the quality required and it being challenging or impossible to achieve the
improvement in service quality that this 5 year strategy is targeting.
All providers are operating in the same challenging financial environment as commissioners, which
requires providers to deliver a high level of efficiency improvements (effectively cost savings) while
at the same time making significant improvements in the quality of care. The Acute sector faces the
greatest degree of challenge as a result of:
•
•
•
Ongoing efficiency requirements built into the national tariff of 4-4.5% p.a.
The need to meet the London Quality Standards which impose minimum service levels
necessitating the hiring of additional consultants and other clinical staff
Potential loss of income as a result of activity shifts to other settings of care notably as a
result of the Better Care Fund initiative
The Acute providers have each projected their 5 year Income and Expenditure to be aligned with
commissioners stated commissioning intentions and with specific activity projections shared by CCGs
with the acute Trusts 31. The Acute Trust projections are set out in Figure 19 below.
Figure 19: Acute Trust Normalised surplus – historic, current year plan and 5 year projection
Normalised surplus 32 (£m)
Trust
2013/14
2014/15
2018/19 projected
Croydon
(16.7)
(17.9)
0.5
Epsom & St Helier
(7.4)
(2.6) 33
2.9
Kingston
2.3
2.2
1.9
St George’s
0.9
4.3
7.1
(20.9)
(14.1)
12.4
Total
31
The Acute provider financial projections used as the basis of this analysis were those available at 7 May 2015
and did not fully align with commissioning intentions; a further iteration of provider 5 year projections is being
completed – any changes are expected to be limited and not affect the conclusions presented in this section
32
Normalised surplus is after adjusting for any non-recurrent items (one-off factors or provisions)
33
Epsom & St Helier are projecting a break-even position for 2014-15 including non-recurrent items
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
247
Page 251
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
In order to assess the financial sustainability of providers, the Commissioning Collaborative has
undertaken a review of provider’s own 5 year projections to test the extent that they are aligned
with commissioning intentions such as activity growth and quality improvements.
The review highlighted the following important assumptions/challenges within provider plans:
•
•
•
•
•
Income growth in excess of commissioners’ forecast expenditure on acute services
A collective need for cost savings of £360m over 5 years equivalent to 24% of the cost base
or average savings of 4.8% p.a. (see Figure 20 below)
Individual trust Cost Improvement Plans (CIPs) targets ranging from an average of 4.4% p.a.
to 5.7% p.a.
Market share gains that cannot be collectively achievable due to the zero sum nature of such
income gains
The cost of achieving London Quality Standards not fully reflected in provider plans
Cost Improvement Plans are required by trusts because the amount of income they are paid each
year is insufficient to allow them to cover their costs of providing the services in an unchanged
manner; in particular the national tariff is amended each year so that there is a significant gap
between the expected cost inflation faced by hospitals and the tariff increase 34
Figure 20: Acute Trust Planned CIPs 2014/15 to 2018/19
CIPs value
(£m)
Trust
Average CIPs
(% p.a.)
74.7
5.7%
83.1
4.5%
Kingston
47.2
4.4%
St George’s
154.8
4.4%
Total
359.8
4.8%
Croydon
Epsom & St
Helier
Comment
• Based on April 2014 model which is not
fully aligned to commissioners planned
activity
• Based on LTFM for whole Trust (both acute
sites)
• May not allow explicitly for the full cost of
achieving LQS – to be confirmed
Commissioners are also mindful of the substantial body of opinion led by system management
organisations such as Monitor that the relatively high level of cost efficiency improvements
34
Monitor, who set the tariff each year, deliberately target efficiency improvements of 4-4.5% p.a. in setting
the tariff; there are also other cost pressures faced by providers in addition such as the fact that providers are
only paid at the rate of 30% of tariff for non-elective admissions above an agreed baseline
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
248
Agenda Item 5
Page 252
Chapter 5: Sustainability
South West London Collaborative Commissioning
delivered in recent years by providers will not be capable of being replicated in future years. For
example:
Monitor and the National Audit Office both report that CIPs delivery by acute
providers is on a downward trend as the “easy” savings have already been made 35
Monitor in its recent guidance is suggesting that only a modest ~2% p.a. of CIPs
savings from provider efficiency is realistic 36
The Foundation Trust Network is arguing for efficiency assumptions of no more than
2% p.a. 37
Providers have also themselves indicated that notwithstanding their own financial projections, it is
becoming increasingly hard to identify potential savings at the level required, let alone deliver those
savings.
In reviewing the financial projections from the acute providers, the CCGs are mindful that while it
may be probable that each individual provider could achieve the very ambitious efficiency savings
assumed, the probability of all 4 Trusts achieving this simultaneously will be considerably lower. As
an illustration, if it is assumed that any individual trust has a 2/3 probability of delivering on its
forecast (i.e. is significantly more likely than not to be in surplus in 2018/19), the probability of all 4
trusts doing so reduces to less than 20% 38.
Commissioners have therefore concluded that In light of the evidence (on a provisional basis) that it
must be regarded as highly unlikely that all providers will be able individually and collectively to
achieve the level of savings and hence financial performance being projected. Accordingly, given the
negative potential service and financial implications for the SW London health economy,
Commissioners believe it appropriate that there should be proactive planning to deliver a more
financially robust health economy (and hence better and more secure services for patients). In
particular there is a need to consider how service changes can be made across the provider
landscape which will deliver financial savings whilst also making it easier to deliver the improved
services that Commissioners want to achieve for patients.
Recognising the significance of this conclusion, additional work is being undertaken at a Trust level
to assess the likely deliverability of the forecast CIPs savings/income gains that Trusts have included
in their financial projections. It is not the intention to apply any assessment at an individual trust
level but rather at the collective provider level.
Community Providers
35
NAO, Progress in making NHS efficiency savings, December 2012
Monitor, Guidance for the Annual Planning Review 2014/15, December 2013
37
Foundation Trust Network, How to make the NHS payment and pricing system work more effectively in
2015/16, May 2015
38
4
(2/3) = 0.1975
36
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
249
Page 253
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
Community providers have a key role in the delivery of the overall strategy and so it is important
that they should be financially sustainable. Preliminary modelling suggests that community
providers should be able to operate at breakeven on any incremental activity they receive in future.
This is based on the following assumptions:
•
•
•
•
Additional activity is reflected in additional income to providers “at tariff”
Growth in activity averages ~5-6% p.a.
CIPs of ~3.5% p.a. can be delivered
Underlying growth of ~3% is boosted by BCF related community shifts to provide 5%+
activity growth
However, this positive scenario for providers is dependent on the recruitment of a suitable trained
workforce to be able to deliver the required care, which is a recognised challenge.
It should be noted that two of the Community providers face some corporate challenges, noting that
Your Healthcare is relatively small with a turnover of ~£30m and Hounslow and Richmond
Community Health is facing uncertainty due to a lack of clarity regarding Richmond ‘s intentions as
regards community provision arrangements.
Mental Health Providers
There are two main providers of mental health services in SW London, being SW London and St
George’s Mental Health NHS Trust and South London and Maudsley NHS Foundation Trust. As
mental health has been commissioned using block contracts, both have been able to manage their
finances effectively and achieve financial surpluses. SW London and St George’s Mental Health NHS
Trust is projecting yearly surpluses to 2018/19. A fuller assessment of mental health provider
financial sustainability is dependent on more work being completed to detail the implementation
plans for mental health in SW London with its consequent implications for services and the change in
the level of activity.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
250
Agenda Item 5
Page 254
Chapter 5: Sustainability
South West London Collaborative Commissioning
3. Estates capacity
ALL OF THIS SECTION IS PROVISIONAL AND ALL NUMBERS ARE SUBJECT TO CHANGE
Introduction
A high-level review of provider estates and capacity in South West London has been undertaken to
ensure that there will be sufficient capacity to deliver this Strategy. The main health service areas
that have been considered are acute provision, community outpatients, community services and
primary care.
Review of the estates of the South West London acute providers
Croydon
Croydon is continuing with its site infrastructure improvements and in particular is progressing with
developing its 5 year plan to reconfigure the main site and rationalise areas with significant backlog
maintenance with a view to potential partial site disposal. These plans are being developed in
conjunction with all stakeholders within the trust including clinical leads, the Board and estates.
A three year Capital Plan has been produced which outlines short term measures to improve the
estate and deliver significant improvements in service provision including the provision of a
refurbished and extended Emergency Department, for which a planning application has already
been submitted.
The Estate Strategy will has an initial 5 year prevue with the scope to allow further development in
the longer term within a master plan for the London Road site that could provide space for new
development in the region of 400,000 sq ft on the retained core of the Hospital site.
The strategy has identified opportunities to relocate existing services from the underused northern
end of the site which could allow the disposal of land for other uses in the region of 1.85ha. This
would require the relocation of a number of core activities, principally Maternity Services, to a site in
the retained heart of the Hospital Campus.
The review of the London Road main site is being undertaken in conjunction with a review of the
outlying Hospital Estate and the vision is to consolidate the existing 15 sites across the Borough into
a smaller number of hubs to ensure provision of outpatient services across the Borough. This will
free up a number of existing sites for disposal to reduce capital expenditure.
Epsom and St Helier
The Trust has significant improvement works required to the St Helier site which were previously
part of a hospital redevelopment business case. The Trust has detailed plans for reconfiguring
services and recent in-depth reviews have resulted in a variety of potential scenarios being prepared
in Strategic Outline Case format.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
251
Page 255
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
The Trust has confirmed that it is progressing with its major backlog maintenance and investment
plans for improving the St Helier site and removing or reducing significantly the liability from the
underinvestment following the delay to the site redevelopment.
The Trust is also progressing the decant of the Sutton site services into St Helier and Epsom sites and
is committed to vacating and disposing of the Sutton site, the proceeds from which, subject to
approval, will part fund the improvement programme.
A clear updated Estates strategy 2014-2019 sets out the Trust plans and builds on those previously
prepared as part of previous reviews.
Kingston
The Kingston hospital site has a mixture of modern newly constructed estate and older estate in
reasonable condition, with two particular areas of the site in need of investment, these being the
former nurses home and the central storage buildings in the middle of the site.
This Trusts has an updated 5 year estates strategy and is progressing with plans where funding from
forecast activity from commissioning strategies is not required. The planned maternity extension
and modernisation is an example of a development project currently on hold pending commitment
by commissioners to future activity increases.
The Trust is therefore progressing with a large capital programme and is forecasting a £15 million, 5
year investment programme. This includes works to the A&E unit and a refurbishment of the former
nursing home building for alternative use. Once complete it is expected that the vacation of the
hospitals central blocks in poor condition can be completed ready for part demolition and
refurbishment.
The Trust is committed to investment of £5.7 million in medical equipment and £16 million in IT
infrastructure and assets.
St George's
St George's site is a fit for purpose site also with buildings of a range of ages the majority of which
are modern and well presented. The Trust has numerous plans and options in development
including the relocation of 18 neuro rehab beds to Queen Mary's Roehampton. It has confirmed
plans to redevelop the buildings housing its women’s and children’s services to improve the
infrastructure. Overall in the next 5 -10 years St George’s estate is likely to have the following
features:
•
•
•
•
•
A higher number of beds
A move towards higher acuity services
Less outpatient space on the Tooting site
Enhanced, better utilised community facilities
Improved facilities for children, women, renal, cancer , trauma and critical care
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
252
Agenda Item 5
Page 256
Chapter 5: Sustainability
South West London Collaborative Commissioning
•
•
•
A coherent approach to the use of space in collaboration with St George's University of
London
A rationalised estate with fewer peripheral buildings on the Tooting campus
Benefits from commercial developments such as greater provision for private patients
Acute provider capacity requirements over 5 years
A review of the estates requirements to support service delivery assuming no service reconfiguration
in South West London has been completed. Areas investigated included:
•
•
•
Capacity within acute hospitals, including beds, theatres and maternity capacity
Capacity within the community to service outpatient appointments
A high-level overview of capacity requirements for a multi-specialist elective centre
Scenarios modelled
Scenarios modelled as part of the analysis were:
1. A base-case scenario, assuming all CCG activity targets are achieved and 3% reduction in
ALOS
2. Downside scenario 1, assuming only 50% of the activity shifts are achieved
3. Downside scenario 2, assuming only 50% of the activity shifts are achieved, underlying
growth is 1% higher than assumed and ALOS decreases by only 2% per year
4. Upside scenario 1, assuming all CCG activity targets are achieved and an underlying growth is
1% lower than assumed in base-case
Scenario 1 – base-case scenario
The base-case scenario suggests that acute capacity requirements across all trusts will reduce over
the 5 years if CCGs achieve their activity shifts. Reduction in bed occupancy will be smaller at
Croydon and St. George’s where the occupancy is already high. Epsom/St. Helier and Kingston could
afford to reduce bed stock.
The scenario also suggests maternity capacity requirements will also reduce. The greatest reduction
is also at Epsom/St. Helier, where there is already a very low be occupancy
Model assumptions:
- Activity growth as unify assumptions
- Activity shifts as unify assumptions
- ALOS is expected to reduce by 3% per year
- Bed occupancy is taken from NHSE Statistics for bed occupancy rates
- No market share moves between providers
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
253
Page 257
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
General and Acute Bed Modelling 2013/14 to 2018/19
Epsom & St.
Croydon
Kingston
Helier
2013/14 Bed Occupancy
91%
85%
86%
91%
2018/19 Bed Occupancy (Model)
82%
73%
76%
82%
5 Year change
-9%
-14%
-12%
-10%
Croydon
St. Helier
Kingston
St. George’s
-45
**
5 Year change in beds
**
ǂ
-62
Maternity Bed Modelling 2013/14 to 2018/19
Epsom & St.
Croydon
Kingston
Helier
2013/14 Bed Occupancy
60%
43%
76%
St. George’s
60%
2018/19 Bed Occupancy (Model)
56%
39%
71%
56%
5 Year change
-7%
-9%
-7%
-7%
Croydon
St. Helier
Kingston
St. George’s
-4
**
5 Year change in beds
Note:
**
ǂ
St. George’s
**
-5
ǂ
Bed occupancy calculated from NHSE quarterly bed occupancy taking a full year occupancy
from Jan 2013 to December 2013 as 2013/14
Still waiting for up-to-date numbers from providers
Assuming St. Helier bed occupancy is the same as Epsom & St. Helier Trust bed occupancy
Scenario 2 – Downside 1: assuming only 50% of the activity shifts are achieved, underlying
growth is 1% higher than assumed and ALOS decreases by only 2% per year
With only 50% of the CCG target shifts successful the capacity requirements the model suggests
capacity requirements will be approximately the same in the acutes over 5 years. Maternity shows
the same picture as the base scenario.
Model assumptions:
- Activity shifts 50% of unify assumptions
- All other parameters as base-case
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
254
Agenda Item 5
Page 258
Chapter 5: Sustainability
South West London Collaborative Commissioning
General and Acute Bed Modelling 2013/14 to 2018/19
Epsom & St.
Croydon
Kingston
Helier
2013/14 Bed Occupancy
91%
85%
86%
91%
2018/19 Bed Occupancy (Model)
88%
79%
82%
88%
5 Year change
-3%
-6%
-4%
-3%
Croydon
St. Helier
Kingston
St. George’s
-16
**
5 Year change in beds
**
ǂ
-28
Maternity Bed Modelling 2013/14 to 2018/19
Epsom & St.
Croydon
Kingston
Helier
2013/14 Bed Occupancy
60%
43%
76%
St. George’s
60%
2018/19 Bed Occupancy (Model)
56%
39%
71%
56%
5 Year change
-7%
-9%
-7%
-7%
Croydon
St. Helier
Kingston
St. George’s
-4
**
5 Year change in beds
Note:
**
ǂ
St. George’s
**
-5
ǂ
Bed occupancy calculated from NHSE quarterly bed occupancy taking a full year occupancy
from Jan 2013 to December 2013 as 2013/14
Still waiting for up-to-date numbers from providers
Assuming St. Helier bed occupancy is the same as Epsom & St. Helier Trust bed occupancy
Scenario 3 – Downside 2: assuming only 50% of activity shifts are achieved
The more challenging of the 2 downside scenarios shows that with a combination of CCGs achieving
50% of their activity shifts, providers not quite finding the ALOS reduction and a greater than
expected underlying growth rate, suggests a 5% increase in capacity would be needed across the
providers. The greatest increase in capacity is needed at St. George’s and Croydon.
No additional capacity would be needed in maternity through this scenario.
Model assumptions:
- Activity shifts 50% of unify assumptions
- Growth rate is 25% more than unify assumptions (from an average of 4% to 5%)
- ALOS is only 2% rather than 3% in base scenario
- All other parameters as base-case
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
255
Page 259
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
General and Acute Bed Modelling 2013/14 to 2018/19
Epsom & St.
Croydon
Kingston
Helier
2013/14 Bed Occupancy
91%
85%
86%
91%
2018/19 Bed Occupancy (Model)
97%
87%
91%
97%
5 Year change
7%
3%
5%
7%
Croydon
St. Helier
Kingston
St. George’s
20
**
5 Year change in beds
**
ǂ
12
Maternity Bed Modelling 2013/14 to 2018/19
Epsom & St.
Croydon
Kingston
Helier
2013/14 Bed Occupancy
60%
43%
76%
St. George’s
60%
2018/19 Bed Occupancy (Model)
60%
42%
76%
60%
5 Year change
0%
-3%
0%
0%
Croydon
St. Helier
Kingston
St. George’s
0
**
5 Year change in beds
Note:
**
ǂ
St. George’s
**
-2
ǂ
Bed occupancy calculated from NHSE quarterly bed occupancy taking a full year occupancy
from Jan 2013 to December 2013 as 2013/14
Still waiting for up-to-date numbers from providers
Assuming St. Helier bed occupancy is the same as Epsom & St. Helier Trust bed occupancy
In scenarios where additional beds are required, the greatest number of beds will be required at St.
George’s. St. George’s had a number of schemes in various levels of preparation and could increase
its capacity by a maximum of 200 beds if required. Financial evaluation of these potential schemes
has not been undertaken.
Scenario 4 – Upside: assuming all CCG activity targets are achieved and an underlying
growth is 1% lower than assumed in base-case
The upside scenario, which is the base-case with additional ALOS improvement, suggests up to 20%
of bed capacity could be removed from acute providers in both general and maternity.
Model assumptions:
- Growth rate is 25% less than Unify assumptions (from an average of 4% to 3%)
- All other parameters as base-case
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
256
Agenda Item 5
Page 260
Chapter 5: Sustainability
South West London Collaborative Commissioning
General and Acute Bed Modelling 2013/14 to 2018/19
Epsom & St.
Croydon
Kingston
Helier
2013/14 Bed Occupancy
91%
85%
86%
91%
2018/19 Bed Occupancy (Model)
79%
70%
72%
79%
5 Year change
-14%
-18%
-16%
-14%
Croydon
St. Helier
Kingston
St. George’s
-60
**
5 Year change in beds
**
ǂ
-78
Maternity Bed Modelling 2013/14 to 2018/19
Epsom & St.
Croydon
Kingston
Helier
2013/14 Bed Occupancy
60%
43%
76%
St. George’s
60%
2018/19 Bed Occupancy (Model)
55%
39%
69%
55%
5 Year change
-9%
-11%
-9%
-9%
Croydon
St. Helier
Kingston
St. George’s
-5
**
5 Year change in beds
Note:
**
ǂ
St. George’s
**
-5
ǂ
Bed occupancy calculated from NHSE quarterly bed occupancy taking a full year occupancy
from Jan 2013 to December 2013 as 2013/14
Still waiting for up-to-date numbers from providers
Assuming St. Helier bed occupancy is the same as Epsom & St. Helier Trust bed occupancy
Capacity requirements for a multi-specialist elective centre
The Planned Care chapter of this strategy calls for the elective surgery activity for certain specialties
to be provided from a single multi-specialist elective centre at a location to be determined. The
options for such a centre are for it to be located on an existing acute hospital site but “ring-fenced”
from other hospital activity or to be located on a site which does not undertake any non-elective
activity. A number of locations have been proposed for the centre (in addition to current Acute
hospital sites) including Sutton hospital, Queen Mary’s Hospital, Roehampton and an extension the
Elective Orthopaedic Centre at Epsom, which serves SW London patients.
High level reviews of the feasibility of these alternatives are currently being undertaken. Queen
Mary’s Roehampton is a PFI financed site on a 30 year contract expiring in 2036. It potentially could
provide capacity for the number of beds envisaged for the MSEC, but has very limited theatre
capacity (1 day case theatre only). For Queen Mary’s Roehampton to be a viable option, it would be
necessary to successfully address the considerable complexities associated with the conversion of
the existing facility to a MSEC on a cost effective basis.
[To be further developed– will not be complete until end May/early June]
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
257
Page 261
Agenda Item 5
Chapter 5: Sustainability
South West London Collaborative Commissioning
Community Outpatients
Sutton CCG and Merton CCG have plans to shift outpatient appointments from acute hospital
settings to community settings. There are three local care centres (LCCs) planned across these two
CCGs:
• The Jubilee Centre (Sutton, open already)
• The Nelson (Merton, opening 2015-16)
• Mitcham (planned for 2018-19)
The total outpatient capacity of these three locations totals approximately 175,000 appointments
and CCG plans shift around half of this capacity in the coming 5 years.
Therefore, in terms of outpatient appointments, the available estate capacity is more than enough
to handle currently planned outpatient shifts.
Community Services
A significant amount of activity currently at Acute providers is expected to shift into the community
over the next 5 years. To meet this demand community workforce is expected to grow and also the
space they require, preliminary modelling suggests this could be around 20%.
At present no community provider has demonstrated a working “virtual base” model, so it is
expected that the additional community workforce needed to support the acute activity shift will
require additional space. Technology and new ways of working can offset some of the capacity
needed. Additionally these workers do not need to be housed in clinical buildings, which will reduce
the cost and complexity of the space needed.
Therefore it is expected that the maximum additional space required is in proportion to the growth
in the size of the workforce at approximately 20%. However technology should offset some of that
so the minimum requirement may be 10% additional space.
[To be further developed – info requested from providers and CCGs]
Primary Care Capacity
Analysis completed for Richmond PCT indicated that 32% of their GP practices had Gross Internal
Areas (GIA) 40% below the NHS Property target GIA. The implied additional recurrent revenue costs
of meeting the expected standard would be £797,000 if these premises were reimbursed at the
maximum target rent. Scaled over the whole of South West London this figure would be
approximately £5.9 million.
[To be further developed – info requested from CCGs and NHS England and will be included in a later
version of this document]
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
ALL NUMBERS HIGHLIGHTED YELLOW ARE PROVISIONAL
258
Agenda Item 5
Page 262
Chapter 6: How we will work together
South West London Collaborative Commissioning
Chapter 6: How we will work together
5 Year Strategic Plan
23rd May 2014 Draft Submission
Version 2.00
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
259
Page 263
Agenda Item 5
Chapter 6: How we will work together
South West London Collaborative Commissioning
Contents
1.
Introduction .................................................................................................................................... 261
2.
Collaborative agreement - principles for working together and shared behaviours.......................261
3.
Working with Providers ................................................................................................................... 262
4. Working with Local Authorities.......................................................................................................... 262
5. Challenged Health Economy Work .................................................................................................... 263
6. How the strategic planning unit will engage with other stakeholders ...............................................263
Building on past engagement activities .......................................................................................... 264
Patients & carers, and HealthWatch............................................................................................... 264
7. Approach to engagement .............................................................................................................. 264
8. Planned engagement activities ....................................................................................................... 265
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
260
Agenda Item 5
Page 264
Chapter 6: How we will work together
South West London Collaborative Commissioning
1. Introduction
The south west London health economy has some significant challenges that none of the CCGs will
be able to successfully address alone. For example, in Chapter 5, which discusses the financial and
clinical sustainability of local services, it is demonstrated that the four acute providers can only
generate a surplus by all forecasting growth, and that this level of growth is incompatible with each
other’s plans and with our plans as commissioners to deliver more care in the community. Alongside
these incompatible expectations, the average cost improvement that the acute providers would
have to achieve every year is of the order of 4.8% across the five years of the strategic plan, which is
higher than is considered to be realistic by the sector regulator.
These financial pressures make it much harder for providers to continue to improve the services
they provide for patients, a situation made even more difficult by shortfalls in the number of senior
clinicians required to meet minimum safety standards such as LQS. While the providers have not yet
had the chance to tell us how they are planning to recruit and retain the numbers of additional
senior clinicians that will be needed, it would be unrealistic to assume that they could not only find
the necessary number of clinicians to recruit (given national shortages in many areas) but they could
afford the additional costs given the level of financial pressures within the timescales suggested.
All the CCGs share this understanding of the nature and scale of challenge, and recognise that given
the level of interdependencies we can no longer think in terms of making changes in discrete parts
of the health system. Rather, a whole health economy solution with a focus on improving services
for the entire population is required to achieve high quality, safe and sustainable services. In the
first instance, our approach to this has been to establish the South West London Collaborative
Commissioning programme in February 2014.
2. Collaborative agreement - principles for working together and
shared behaviours
In order to underpin the joint working which will govern the delivery of the 5 year strategic plan
CCGs have agreed to a number of principles for collective behaviour. CCGs have agreed to:
•
Recognise the sovereignty of the six CCGs, that each is a membership organisation which
needs to conduct its business according to its constitution.
•
Build relationships and trust so CCGs have confidence in each other’s ability to deliver on
their behalf.
•
Have a clear and transparent framework by which they can hold each other to account.
•
Work together to understand each other’s clinical commissioning and service re-design
priorities and where possible align and agree collective strategies to support the
achievement of better outcomes, improved quality and value for money.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
261
Page 265
Agenda Item 5
Chapter 6: How we will work together
South West London Collaborative Commissioning
•
Co-ordinate dialogue with providers to maximise impact by ensuring CCGs speak with one
voice.
•
Ensure regular opportunities for dialogue between clinical and executive leaders and local
provider trusts.
•
Seek to co-ordinate and combine efforts to manage relationships with both NHS England
and South London Commissioning Support Unit (CSU).
•
Deploy clinical capacity where it is most needed, in a timely way.
•
Learn from existing experience and make time together to reflect on and build ‘what good
looks like’ as we develop.
3. Working with Providers
Analysis conducted during the development of this plan suggests local providers will face significant
financial and clinical challenges over the next five years. Provider sustainability impacts on their
ability to continue to deliver high quality services to our residents and as such, is a key consideration
for local CCGs. As such, CCGs intend to collaborate closely with providers on developing innovative
solutions to addressing some of the long-standing issues in our health economy. Providers have
agreed to engage fully in this process, and CCGs have set a number of expectations for them in
designing and delivering the strategic plan. Providers will, within the context of this engagement and
in line with competition guidance:
•
Contribute to the debate and development of the 5 year strategic plan through clinical
engagement
•
Drive realistic solutions that will deliver the commissioner outcomes
•
Share responsibility for delivering sector wide solutions
•
Engage with commissioners around realistic options.
The outputs of this collaborative work will help determine the options for implementing this
strategic plan for consideration by individual CCG Governing Bodies later in 2014.
4. Working with Local Authorities
The six CCGs are committed to working in partnership with local government and this relationship
has been enhanced through joint working at a local level on the use of the Better Care Fund. Local
authorities, working through Health and Wellbeing Boards, have been key partners in the
development of a more joined up relationship between health and social care. These Boards will
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
262
Agenda Item 5
Page 266
Chapter 6: How we will work together
South West London Collaborative Commissioning
have a crucial role to ensure local multi-agency input to the development, design and
implementation of the SW London strategic plan and monitoring its impact at a borough level.
The clinical and financial case for change has been, and will continue to be, widely shared and
discussed with our local authority partners, to ensure full ownership of both the challenges faced by
the NHS in south west London and the options for resolving them.
5. Challenged Health Economy Work
Following the publication of the Strategic Planning Guidance, Everyone Counts: Planning for Patients,
South West London was identified as one of eleven ‘Challenged Health Economies’ nationally in need
of additional intensive support to help deliver aligned, whole-system plans for delivering change that
are financially sound, built on the latest clinical evidence and most importantly, deliver a high
quality, sustainable health system for local residents. This work is ongoing but is expected to result
in a number of recommendations for how commissioners can work more effectively with each other
and with providers. The interim findings of the intensive support team are as follows:
•
•
•
The case for change is stronger than ever, and indeed the financial and workforce challenges
are likely to be even greater than is currently assumed. The commissioner funding gap in
2018/19 has been confirmed at over £200m;
Assessment of the initial financial plans produced by providers across the LHE indicates that
their strategies are not yet aligned with those of commissioners (and some indeed point in
the opposite direction by assuming growth in activity);
It is now clear that providers are very unlikely to be able to bridge their forecast funding gap
of £360m by 2018/19 through efficiencies alone. Providers will financially unviable unless
changes are made to the way they are organised across the system.
The challenged health economy work will conclude at the end of June, but work on detailed
implementation planning by local commissioners and providers will carry on over the rest of the
summer to ensure the overall objectives of the intensive support are met.
6. How the strategic planning unit will engage with other
stakeholders
There has been a significant amount of engagement already in south west London as a result of the
Better Services, Better Value (BSBV) programme, and much of the learning from this engagement has
been drawn into the development of this 5 year strategic plan. There is already strong clinician and
patient support for the clinical standards to which CCGs wish to commission, and we have continued
to draw on this engagement in developing our current programme of work.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
263
Page 267
Agenda Item 5
Chapter 6: How we will work together
South West London Collaborative Commissioning
Building on past engagement activities
Best practice public, patient and stakeholder engagement is a principle which has underpinned the
development of the 5 year strategic plan. A number of key groups have been involved:
Patients & carers, and HealthWatch
The BSBV programme was advised on best practice engagement by the Consultation Institute and
the guidance received has informed the future approach. Public and patient engagement on BSBV
was widely praised by the Office of Government Commerce, the National Clinical Advisory team and
NHS London. The advice of the Consultation Institute on engagement to develop the 5 year strategic
plan is that engagement should focus on sharing and confirming what we have learned from nearly
three years of engagement on the BSBV case for change and more recently the Call to Action.
The following principles, based on the engagement principles set out by NHS England in
Transforming Patient Participation in Health and Care will be upheld throughout our engagement
activities:
•
•
•
•
•
•
•
Early engagement – discuss the need for change early and base future reconfiguration
proposals on these early discussions
Provision of good quality information to ensure that the local community understands
commissioning plans and opportunities for participation in their development
Provision of a range of participation options, including face-to-face and social media
Proactively engage with diverse communities (those who experience greatest health
inequalities)
Build upon existing work with key partner organisations including the voluntary community
sector, local HealthWatch organisations and patient participation groups
Feedback to communities about the impact of their involvement.
On the 8th May the programme held a major engagement event to capture the views of stakeholders
on the ideas being developed for the strategic plan. Around 90 invited participants joined groups
representing each of the clinical areas being covered in the plan to give feedback and help to shape
the plans. This feedback was then taken back to each CDG to be incorporated into the strategic plan,
and the summary of the key messages is contained within each separate clinical section of Chapter
4.
7. Approach to engagement
The engagement approach for delivering the 5 year strategic plan will be built on the principles set
out in section 4.1 above. CCGs will continue to seek and follow best practice advice from the
Consultation Institute and to ensure that all feedback gathered through engagement is fed into the
decision-making process.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
264
Agenda Item 5
Page 268
Chapter 6: How we will work together
South West London Collaborative Commissioning
Engagement with a wide range of groups has been built into the south west London collaborative
commissioning programme governance. The following groups in particular will ensure wide ranging
engagement across patients, the public, clinicians, local authorities and other stakeholders:
•
Engagement with a wider group of stakeholders is achieved through the South West London
Forum. The Forum is comprised of CCG Chairs and COs, patient and public representatives,
Local Authority representatives, Provider CEs and representatives from the National Trust
Development Agency (NTDA), NHSE, London Ambulance Service (LAS), Public Health, Health
Education South London (HESL), the South west London Academic Health Science Network
and South West London System. The Forum’s primary purpose is to provide advice and
challenge to plans proposed by the SCB.
•
The Clinical Advisory Group’s primary role is to provide clinical advice to the SCB. It will also
challenge and develop clinical pathways and models of care developed by the work-streams,
and identify interdependencies between these plans which need to be addressed
collectively. It will be formed of the GP clinical leads of each CDG, provider medical directors
and directors of nursing.
•
The Patient and Public Steering Group will ensure patient and public engagement in the
development and implementation of the 5 year strategic plan. To ensure that there is lay
involvement/engagement in the strategic direction of the programme, there will be a core
lay group comprising patient/public reps from key stakeholder organisations. It is suggested
that the group elect a Chair who will represent them within the programme’s governance
structure. The Chair will be provided with additional support and training as required to
enable them to effectively carry out their role.
•
Seven Clinical Design Groups (CDGs) will have the primary role of developing a clinical vision
work programme for each clinical area. Each CDG will have a nominated CCG accountable
lead, clinical lead, nominated provider clinical representatives, patient and public
representation and representation from social care where appropriate.
•
Patient and Public Reference Groups will be formed, linked to clinical design groups. It is
essential that there is constructive patient and public engagement in each of the developing
work stream areas. These PPRGs will need to strike a balance between providing
independent and insightful lay perspective whilst avoiding becoming professionalised
committees. This value will be in bringing together lay and community representatives with
experience in specific clinical areas and who can contribute this perspective.
8. Planned engagement activities
Outside of the formal governance of the programme there are a number of ways in which CCGs will
collectively engage with as wide a group of stakeholders as possible to inform and feedback on the
plans being developed:
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
265
Page 269
Agenda Item 5
Chapter 6: How we will work together
South West London Collaborative Commissioning
•
Public and patient engagement will continue, with CCGs leading on engagement with their
local stakeholders and the South West London Collaborative Commissioning programme
team building on relationships developed during the extensive engagement carried out as
part of BSBV and latterly the Call to Action. As set out above, much of the engagement work
in the next period will be an ‘inform and confirm’ exercise, reflecting what we have already
learned from prior public engagement. Once the 5 year strategic plan is developed, a more
detailed forward engagement plan will be developed for discussing the plan and the next
steps with local people. A public-facing version of the case for change will be produced to
ensure the key messages are widely circulated and understood by local residents.
•
Political engagement with local MPs and councilors will continue to be important. Much
political engagement is to be handled locally at CCG level, using a jointly agreed message, to
ensure that all key stakeholders receive the same information. Of course local relationships
differ and our joint approach will need to recognise the nuances of differing local
relationships
•
The programme will continue to use social media, recognising its growing importance in
reaching members of the public who may not engage through more traditional routes.
Twitter chats with workstream clinical leads will continue to be used to promote and explain
the 5 year strategic plan.
•
A dedicated South West London Collaborative Commissioning website will host all key
documents and information about the programme in order to ensure maximum
transparency and accountability.
In summary, there has been significant engagement over the past few years to understand the views
of patients and the public. Providers have been engaged consistently on the case for change and the
clinical models. This engagement has been fundamental to the development of the 5 year strategic
plan.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
266
Page 270
Agenda Item 5
Chapter 7: Governance
South West London Collaborative Commissioning
Chapter 7: Governance
5 Year Strategic Plan
23rd May 2014 Draft Submission
Version 2.00
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
267
Page 271
Agenda Item 5
Chapter 7: Governance
South West London Collaborative Commissioning
Contents
1.
Introduction .................................................................................................................................... 269
2.
South west London Collaborative Commissioning.......................................................................... 269
3.
Key risks ........................................................................................................................................... 271
4.
Performance monitoring ................................................................................................................. 272
5.
Moving towards implementation ................................................................................................... 273
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
268
Agenda Item 5
Page 272
Chapter 7: Governance
South West London Collaborative Commissioning
Introduction
A collaborative approach to addressing the case for change in south west London is at the heart of
the five year strategy, and the governance put in place around the south west London strategic
planning unit underpins this.
Working together with providers, patients and the public, clinicians, local authorities and other NHS
bodies we are ensuring that we have the structure in place to effectively lead the programme,
ensuring comprehensive engagement with the widest possible group of people. The governance
goes hand in hand with a broad engagement plan, discussed in more detail in Chapter 6.
South west London Collaborative Commissioning
The six CCGs, alongside NHS England, have clearly stated an intention to continue to work
collaboratively to address the case for change in south west London. The strategic planning unit was
formed in response to the Everyone Counts guidance, issued in December 2013, and since then CCGs
have worked closely to define and ensure appropriate leadership of the new programme.
It is important to note that many south west London-wide groups existed across the area prior to the
formation of South West London Collaborative Commissioning, many of which had been formed to
discuss and review the recommendations of the Better Services Better Value programme, which
ended in February 2014. Where possible the knowledge and expertise of existing groups and bodies
have been transferred into the new governance structure in order to maintain continuity and
organisational memory in south west London, avoiding the need to redo much of the excellent work
which had already taken place to develop the case for change and clinical models of care.
CCGs remain the statutory decision making bodies in south west London and they will each work to
involve their membership to shape the programme, in line with each of their constitutions. Close
working with local authorities will be a key feature of the new governance, achieved predominantly
through the Health and Wellbeing Boards (HWBs). HWBs will oversee the development and delivery
of the strategic delivery plans pertaining to their population. With changes to legislation anticipated
to become effective in the autumn of 2014, it should become possible to have a single top-level
governance body with delegated powers to represent all six CCGs.
The South West London Collaborative Commissioning governance structure is shown below:
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
269
Page 273
Agenda Item 5
Chapter 7: Governance
South West London Collaborative Commissioning
CCG Governing Bodies will continue to exercise overall leadership, however the strategic direction
for the planning unit is set by the Strategic Commissioning Board (SCB). This board comprises CCG
chief officers and chairs, NHS England commissioning leads, patient, public and local authority
representation. Its overall role is to develop the five-year strategy and oversee the delivery of the
work programme. It is recognised that in due course, the SCB may need to be reconstituted to
include provider chief executive officers to facilitate more effective implementation, but that the
current governance will prevail during this transitional period. This is further discussed in section 5
of this chapter.
The other major groups established under South West London Collaborative Commissioning are as
follows:
•
The Joint Commissioning Group (JCG): A group for CCG Chief Officers to discuss and
resolve ongoing operational and governance issues.
•
The South West London Forum: Brings together stakeholders from across south west
London to provide advice, input and challenge to plans developed by the SCB.
•
The Clinical Advisory Group (CAG): A clinically led group charged with challenging and
developing clinical pathways and models of care developed by the design groups.
•
The Patient and Public Steering Group (PPSG): Its role is to help secure patient and
public engagement in the development and implementation of the commissioning
strategy.
•
Clinical Design Groups (CDGs): Primary role to develop a clinical vision, strategy and
work programme for each clinical area. On each CDG there is a nominated CCG
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
270
Page 274
Agenda Item 5
Chapter 7: Governance
South West London Collaborative Commissioning
accountable lead, a clinical lead, nominated provider clinical representatives, patient
and public representation and representation from social care.
•
Patient and Public Reference Groups (PPRGs): Local patient and public engagement is
secured through the PPRGs, one of which is linked to each clinical design group
•
The Enablers group, which interfaces with the CDGs and the SCB to ensure the
appropriate workforce, estates and IT infrastructure is in place to support the delivery
of the SPG strategy.
The collaborative commissioning programme is being supported by a jointly funded programme
team and implementation planning, particularly around contracting and performance management,
is also supported by South London Commissioning Support Unit. For more information on how the
CCGs will engage with a wide range of stakeholders please see chapter 6.
Key risks
Risk
Impact
Mitigations
Financial sustainability:
New service models in primary
care and community services
put significant financial
pressure on acute providers
Destabilisation of services
presenting risks to patient
safety and quality of care
Provider engagement:
One or more service providers
is insufficiently engaged
Full consequences of change in
the local health system are not
properly understood by all
involved parties leading to lack
of commitment to any
proposed service changes
Workforce requirements of
new models of services cannot
be met in timely fashion,
impeding delivery and creating
excess costs
The Strategic Commissioning
Group has a responsibility to
review all draft service models
as a whole to ensure that any
proposed changes to the health
system are effectively balanced
In the event that provider
failure becomes a risk further
steps may need to be taken by
commissioners to ensure that a
plan is in place to manage any
required changes to services
CCGs to work closely with
providers through the SWL
Forum and through their
involvement in Clinical Design
Groups and the Clinical
Advisory Group
A dedicated workforce enabling
workstream will be created,
with input from HESL to identify
workforce impacts of proposed
changes and develop plans for
resolution. Work will be taken
forward with providers to
ensure that workforce issues
Workforce:
Proposed services changes are
unable to be implemented due
to lack of available workforce
or lack of re-training for parts
of existing workforce
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
271
Page 275
Agenda Item 5
Chapter 7: Governance
South West London Collaborative Commissioning
Local support:
If partners and stakeholders are
not sufficiently engaged
throughout the development of
the 5 year strategic plan any
proposed service change could
be subject to significant local
opposition
Information systems:
Lack of integrated information
systems undermines ability to
integrate services across the
health system in South West
London
Stakeholder commitment:
Insufficient stakeholder
commitment to meeting to
workshops
Increased cost and delay to the
implementation of the strategy,
and considerable local
opposition in the event that
proposed changes are
controversial
Duplication of system, process
or information, resulting in
poorer patient experience,
poor quality of services across
integrated pathways and
additional cost
Strategy not able to move
forward at required pace or
level of quality / completeness
are identified in advance and
appropriate training put in
place
Engagement activities will be
undertaken with a broad range
of partners and stakeholders
throughout the development
and implementation of the
strategy. Further steps may
need to be taken by CCGs to
An Information Systems
enabling workstream will be
established to identify and
support improvements
required to enable the new
clinical models
Stakeholder meetings already
arranged, building on the first
meeting of the Forum on the
20th March. A full stakeholder
meeting is planned for the 8th
May with focus groups due to
be held throughout April.
Performance monitoring
CCGs are individually and collectively responsible for the delivery of the strategic plan, and all
progress will be fed back centrally to the SCB and individual governing bodies. It is crucial that this
delivery is informed by a timely and accurate flow of information relating to delivery and identified
risks, and the planning unit has begun to put in place mechanisms to ensure this information is
available.
Since 2013 CCGs have been collectively monitoring key information relating to the delivery of a
shared Out of Hospital programme, specifically reviewing trends in unplanned admissions and A&E
attendances. This information is used to inform the debate around the impact of OOH initiatives in
each borough and has proved highly useful in identifying trends.
Following the completion of the strategic plan each CDG will develop a specific work programme,
focused on the implementation of the set of initiatives it has identified. Performance monitoring of
this set of initiatives will be primarily achieved through the agreement of a set of metrics and
milestones agreed by each CDG. The CDG-specific sets of milestones have been developed and are
described in each relevant section of this document.
The CCGs will continue to develop this work as the implementation of the strategy develops, and
overall performance against the milestones and metrics will be fed back regularly to the Joint
Commissioning Group, with high level progress monitored by the Strategic Commissioning Board.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
272
Agenda Item 5
Page 276
Chapter 7: Governance
South West London Collaborative Commissioning
These groups will provide oversight and develop mitigating actions in the event of non-delivery
against the proscribed measures.
Moving towards implementation
Following the development of the strategic plan commissioners and providers in south west London
need to move quickly towards implementation. It is clear that the governance developed to oversee
the design of the strategic plan will need to be further adapted to ensure that it is appropriate for
the more practical task of implementation. Work will be undertaken over the next few months to
develop a new governance structure to involve providers more thoroughly in the development of a
work programme and to ensure that work is coordinated and centralised with appropriate oversight
to ensure success. It is envisaged that this work will be completed by the summer with new
governance in place by August 2014.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
273
Page 277
Agenda Item 5
Chapter 7: Governance
South West London Collaborative Commissioning
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
274
Agenda Item 5
Page 278
Appendices
South West London Collaborative Commissioning
Appendices
5 Year Strategic Plan
23rd May 2014 Draft Submission
Version 2.00
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
275
Page 279
Agenda Item 5
Appendices
South West London Collaborative Commissioning
Contents
Appendix 1: Children’s Services .............................................................................................................. 277
Appendix 2: Integrated Care ................................................................................................................... 281
Appendix 3: Performance against NHS Outcomes Framework Domains ............................................... 285
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
276
Agenda Item 5
Page 280
Appendix 1:Children’s Services
South West London Collaborative Commissioning
Appendix 1A: The WellHappy App
What is the WellHappy App?
WellHappy is a free app designed by a young person who has had contact with mental health
services since teenage years. It allows young people to search for local support services in and
around London including mental health, sexual health, drugs, alcohol and stop smoking services.
The app allows people to search for services by area or postcode and view results on a map to
find a range of services that they can chose from. It empowers young people to take control of
their health and includes useful features such as FAQs, jargon busters and information about
rights and advocacy.
The app also links to the WellHappy website which contains news, information and blogs for
young Londoners.
What are the plans to develop the app in future?
• The developers of the app have been connecting with young people and professionals in
order to make additions to the app.
• The app is currently only available in London but there are plans to launch it in other cities
throughout the UK.
• The team also has plans to add some more interactive features such as mood tracker and a
medication reminder.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
277
Page 281
Agenda Item 5
Appendix 1:Children’s Services
South West London Collaborative Commissioning
Appendix 1B: Richmond Integrated Children’s Model
What is our integrated children’s model?
An integrated child development team for children aged under 19 years working together to
improve outcomes for children in Richmond. This model involves local authorities and clinical
commissioning groups working together to align resources and understand needs.
What kind of activities are we undertaking?
•
•
•
•
•
•
•
•
We are working with local authorities to pool our budget for speech and language
therapy and jointly commission services.
A single point of access is being developed for CAMHS to ensure the right services are in
place as early as possible with the aim of preventing conditions becoming worse before a
service is provided.
We are piloting key areas of the Special Educational Needs Code of Practice including:
o The single assessment process
o Education, health and care plans
o Piloting personal budgets
o Developing a financial model for expenditure for CCG’s, LA’s and providers
o Engagement and involvement of children, families and parents
Increasingly using Family and Friends Test and the communication framework to ensure
that children and families voices are central to the development of services
Investment into community paediatrics to enable development of prescribing in and
CAMHS for children with ASD sleep disorders and ADHD.
Public Health and the CCG jointly performance manage the community provided services,
working together to ensure seamless service provision
Primary Mental Health Workers (PMHW) is a pooled budget and jointly commissioned –
we are working to join up with Kingston FASS service.
We are developing paediatric ambulatory pathways to prevent children and young
people attending A&E, this will include modelling and finding out what is needed for the
future.
What are the benefits of the model we have seen so far?
All developments have been built incrementally starting with a needs assessment led by the
public health team, taking each area at a time, learning and then applying the learning to other
areas. We have seen improved access to CAMHS PMHW and more efficient use of resources
through alignment of our plans. We are expecting further improved outcomes as the model
develops.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
278
Agenda Item 5
Page 282
Appendix 1:Children’s Services
South West London Collaborative Commissioning
Appendix 1C: London Quality Standards
Paediatric Emergency Standards
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
279
Page 283
Agenda Item 5
Appendix 1:Children’s Services
South West London Collaborative Commissioning
Consultant-delivered care: admissions, patient review and theatre
Training
Patient Experience
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
280
Agenda Item 5
Page 284
Appendix 2: Integrated Care
South West London Collaborative Commissioning
Appendix 2A: Clinical recommendations made as a part of BSBV
Long Term Conditions Clinical Working Group
1. The group recommends that the generic long-term conditions model is adopted and
implemented across south west London. This would require each primary care trust to
develop a care programme approach for Chronic Obstructive Pulmonary Disease (COPD),
diabetes and heart failure that encapsulates the key principles of prevention, early
diagnosis, patient education, risk stratification and management. It is essential that a
systematic programme to identify people with diabetes, heart failure and COPD is in place
by 2012/13 in order to improve the care of people with long-term conditions and reduce
unscheduled hospital admissions. This would help ensure south west London achieved the
outcomes set out in the National QIPP programme locally by 2013/14.
2. The characteristics of an effective integrated long-term conditions care pathway are
endorsed and recommended by the clinical working group. Each PCT should develop a
work programme that works with colleagues in hospitals, social care, primary care
(including Community Pharmacy), and the voluntary sector that focuses on better
management of the frail elderly.
3. The clinical working group recommends that improved access to psychological therapies
(IAPT) and Liaison Psychiatry services for the treatment of long-term conditions and
medically unexplained symptoms should be part of an integrated care pathway across
physical and mental health care
4. The clinical working group recommends self-care models are commissioned and
developed as part of any long-term conditions care pathway. Therefore the group
recommends each primary care trust commissions a comprehensive evidence based
patient education programme for COPD, diabetes and heart failure.
5. As evidence becomes available, the group would recommend Telecare and Telehealth is
used, where appropriate, in the management of people with long-term conditions.
End of Life Care Clinical Working Group
1. Among patients who have been identified as likely to be in the last year of life and who
have expressed a preference about where they would prefer to die, 75% of this group
should be able to die in that preferred setting.
2. A single electronic end of life care register should be implemented which would be
accessible to all health and social care across south west London.
3. Better co-ordination and co-operation is required across all parts of health and social
services, to deliver high quality integrated services, with access to 24/7 services.
4. Resources must be used appropriately across all settings to support patient preferences.
5. Education for carers, patients and institutions must be prioritised, as it is key to effecting
change.
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
281
Appendix 2: Integrated Care
South West London Collaborative Commissioning
Appendix 2B: Dementia 10 Point Plan
The 10 Point Plan is intended to be used by commissioners of dementia services to inform their action plans and future commissioning intentions. The ten
points relate to those patients who have already established diagnosis (not those undiagnosed requiring memory assessment, where principles may be
prioritised differently). The principles draw together best practice and the latest guidance to promote the improvement of locally, and regionally, provided
services.
Dementia services should be person-centred, needs-focussed and integrated
The Better Care Fund should be used to jointly commission dementia services.
The commissioning and provision of dementia services should be ‘ageless’ taking into account other co-morbidities and enabling independence.
The commissioning and provision of services to those with dementia should be flexible and responsive, including in times of crisis or where specialist
care is required.
5 A single point of access to services and a dementia care coordinator is a way of achieving seamless care for people with dementia and provides support
for their carers.
6 Improvements in dementia care must also improve care in hospital, including for those receiving a diagnosis in hospital.
7 The dissemination of existing good working practices in south west London is key to improving dementia services.
8 Multidisciplinary case management is a good way to ensure integrated working.
9 Commissioners should use local and national examples of best practice to design innovative and improved services that will fit their locality and ensure
that communities are dementia-friendly.
10 The creation of dementia-friendly communities involves engaging not only with health and social care providers, but also wider community
stakeholders
Agenda Item 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
Page 285
1
2
3
4
282
Agenda Item 5
Appendix 2: Integrated Care
South West London Collaborative Commissioning
Appendix 2C: Timelines of Achievements
Timeline of our achievements – formation of the OOH Programme
Page 286
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
283
Appendix 2: Integrated Care
South West London Collaborative Commissioning
Timeline of our achievements – delivering change locally
Page 287
Agenda Item 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
284
Agenda Item 5
Appendix 3: Performance against NHS Outcomes Framework Domains
South West London Collaborative Commissioning
Appendix 3: Performance against NHS Outcomes Framework Domains
The NHS Outcomes Framework contains five different domains, against which to assess the progress made in achieving the goals in the strategic plan:
Domain 1: Preventing people dying prematurely
Page 288
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
285
Appendix 3: Performance against NHS Outcomes Framework Domains
South West London Collaborative Commissioning
Domain 2: Enhancing quality of life for people with long-term conditions
Page 289
Agenda Item 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
286
Agenda Item 5
Appendix 3: Performance against NHS Outcomes Framework Domains
South West London Collaborative Commissioning
Domain 3: Helping people to recover from episodes of ill health or following injuries
Page 290
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
287
Appendix 3: Performance against NHS Outcomes Framework Domains
South West London Collaborative Commissioning
Domain 4: Ensuring that people have a positive experience of care
Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm
Page 291
Key for abbreviations and sources
Agenda Item 5
DRAFT FOR CCG GOVERNING BODY DISCUSSIONS
288
This page is intentionally left blank