Waltham Forest CCG meeting
Wednesday, 26 November 2014
Part 1: 14:30-16:30
Part 2: 16:30-17:30 - Confidential
Boardroom, Ground Floor, Kirkdale House, 7 Kirkdale Road, Leytonstone, E11 1HP
Waltham Forest Clinical Commissioning Group Governing Body Board Wednesday 26 November 2014
BOARDROOM, Ground Floor, Kirkdale House, Leytonstone
AGENDA
1 General Business – Part 1 (IN PUBLIC) Lead Action Clinical Page Officer(s) required Lead No.
To 1.1 Apologies and announcements Dr Anwar Khan - discuss
Declarations of interest To 1.2 All - (register on public view) declare
1.3 Matters Arising To note 1
1.4 Chair’s update To note -
Questions from Members and 1.5 To note - Public
2 Governance
Peter Helen 2.1 Board Assurance Framework To note 2 Brokenshire Davenport
To Helen 2.2 Communications Annual Report Alan Wells 25 approve Davenport
3 Performance and Quality
Les Borrett & Dr Dinesh 3.1 Performance & Quality Report To note Helen 36 Kapoor Davenport
Annual Safeguarding Children To Dr Dinesh Helen 3.2 52 Report approve Kapoor Davenport
4 Finance and QIPP
To 4.1 Finance Report - Les Borrett 62 approve
4.2 First draft 2015/16 Budget To note - Les Borrett 78
To 4.3 Better Care Fund – Section 75 - Les Borrett 88 discuss
5 Strategy and Planning
Final Transforming Services To Neil Kennett- 5.1 Changing Lives Case for Jane Mehta 100 approve Brown Change
Sharon Yepes- 5.2 Five Year Forward Plan For Info Jane Mehta 262 Mora
6 For information
Minutes of Audit Committee Peter 6.1 For info Les Borrett 315 (November) Brokenshire
Minutes of CCG Reference Helen 6.2 For info Alan Wells 322 Group (November) Davenport
Helen Minutes of Performance and Dr Dinesh 6.3 For info Davenport & 326 Quality Committee (October) Kapoor Les Borrett
Minutes of Medicines Dr Mayank Helen 6.4 Management Committee For info 334 Shah Davenport (October)
Minutes of Planning and 6.5 For info Alan Wells Jane Mehta 341 Innovation Committee (October)
Minutes of Finance and QIPP Peter 6.6 For info Les Borrett 345 Committee (October) Brokenshire
Minutes of IT Committee 6.7 For info Dr Mayank Les Borrett 349 (October) Shah
Dr Abdul 6.8 Summary of Walthamstow For info Jane Mehta 357 Sheikh Locality Meeting (October)
Summary of Leyton/Leytonstone Dr John 6.9 For info Jane Mehta 358 Locality Meeting (November) Samuel
Summary of Chingford Locality 6.10 For info Dr Anwar Khan Jane Mehta 359 Meeting (add November)
7 AOB
7.1 AOB ALL -
8 Forward plan
8.1 Forward plan ALL 360 9 Date of next meetings
28 January 2015 Formal Board 1400-1800
25 February 2015 25 March 2015
Item 1.3 - Matters Arising from NHS Waltham Forest CCG Governing Body Part 1 Meeting on 22 October including earlier Brought Forward Items
Minute No. Action Lead Due Date Commentary 315/14 Develop a CCG Health and Safety policy; ensure all staff HD March Board receive relevant mandatory health and safety training; agree to an independent audit and assessment of its health and safety arrangements. AW requested HD report back to governing body at the end of the year.
Action HD to update the Governing Body on progress in March
Outstanding Part 1 Matters Arising 1
Item 2.1
Title of report Board Assurance Framework
From Helen Davenport, Director of Nursing, Quality and Governance - WFCCG
Purpose of report The purpose of this report is to present NHS Waltham Forest Clinical Commissioning Group’s (WFCCG) Governing Body with its key strategic risks as at October 2014.
Recommendations The Governing Body is asked to note contents of this report. • There are 9 risks reported on the BAF of which 5 are red (extreme risk) rated and 4 are amber (high risk) rated.
• There has been 1 new risk added to the BAF since the last report to the Governing Body. The risk relates to patients whose Continuing Health Care needs have changed and may not be receiving the correct care (see risk reference QG5 at Table 2 of the main report).
• There have been 3 risks removed from the BAF since the last report to the Governing Body: o The CCG fails to achieve its planned surplus due to non - achievement of its £10.4M QIPP plan. This risk has been removed since the projected end year delivery of QIPP is at 91.4 percent of plan based on latest activity data and its overall and continuing favourable financial position. o Outstanding Serious Incidents (SIs): Barts Health Trust and North East London Foundation Trust have a significant number of SIs that have not been managed within the National Framework for Reporting and Learning from Serious Incidents timeframe. This risk has been removed as Barts Health and North East London Foundation Trust current reported status (September 2014) is that Barts Health have 0 outstanding reports and NELFT have 19 outstanding reports. NELFT have established processes that have significantly reduced back log to sustainable levels. o NHS Propco may charge rent and implement a lease agreement to community based services that use Propco estates from which to deliver services. This risk has been removed following a re-evaluation of the risk impact.
Table 3 of the main report details the ongoing management arrangements for these 3 risks.
Impact on patients & carers Impacts on patients and carers are identified in the individual reported risks.
2 Board Assurance Framework
Risk implications If not managed to acceptable levels, the risks reported on the BAF may lead to: • Some patients not receiving the quality care WFCCG commissions and therefore have a poor experience and risk of harm.
• Inhibit WFCCG from achieving its corporate objectives.
• Reputational risk.
Financial implications Financial implications are identified in the individual reported risks.
Equality analysis Equality impacts are identified in the individual reported risks.
Other committees/groups, including the CCG Reference Group and Rapid Feedback Group (please include detail of when the group were involved and in what capacity) • Executive Directors of WFCCG 10 November 2014
• WFCCG Audit Committee 5 November 2014
3 Board Assurance Framework
1 Introduction 1.1 This report identifies the key strategic risks to NHS Waltham Forest Clinical Commissioning Group (WFCCG). The risks are recorded on WFCCG’s Board Assurance Framework (BAF). This is subject to scrutiny and challenge by the Audit Committee on behalf of its Governing Body.
2 Summary of the BAF Risks 2.1 Table 1 presents a summary status of the 9 risks that are reported on the BAF as at the end of October 2014. It aligns the BAF risks with the WFCCG Corporate Objectives. 2.2 Table 2 presents the details associated with each risk. It identifies: • The description of the risk • The risks current risk rating • When the risk was first recorded on the BAF • The progress to date in managing the risk • Who has management oversight of the risk
2.3 Table 3 presents those risks that have been removed from the BAF since the last report to the Governing Body. It identifies the reason for the risk being removed from the BAF and how, if appropriate, the risk is being managed currently.
3 Challenge and scrutiny of the BAF 3.1 The BAF is constructed following review at individual director level prior to sign off through the WFCCG executive team. 3.2 The BAF is subject to review and challenge by the Audit Committee on behalf of the Governing Body. 3.3 The BAF alone does not provide the Audit Committee with all the assurances required to demonstrate the predicted year end risk position will be achieved. 3.4 To provide additional assurance the summarised BAF identifies those with responsibility of providing management oversight of the risk area and who are responsible for reviewing in detail the performance and risk mitigation plans. As will be seen, the detailed management of risk in the main is not managed by the Governing Body or the Audit Committee but by the relevant committee that reports to the Governing Body. This is where the BAF risk issues are addressed in detail.
4 Board Assurance Framework
Table 1: BAF Summary Status As at 28 October 2014
Corporate Objective Risk Description Summary
1.To improve the health 1a. (Risk Ref QC2) Continued failure of Whipps Cross Hospital (Barts Health outcomes of our local NHS Trust) to deliver sustained quality improvement in the delivery of safe population effective care.
This means that some patients are not receiving the quality care WFCCG commissions and some patients have a poor experience and are at risk of potential harm
1b. (Risk Ref QC3) NHS Waltham Forest Clinical Commissioning Group does not have assurance that all Care Homes are providing safe quality care to patients. This means that in some areas, recommendations and lessons learned have not been put in place to support improved practice and safe quality care
1c (Risk Ref QG 5) Patients whose Continuing Health Care needs have changed may not be receiving the correct care. This means these patients may be at risk of potential harm.
2. To deliver high 2a. (Risk Ref F3) The CCG does not achieve its targets for Referral to quality services through Treatment (RTT) waiting times due to poor performance by its providers, effective commissioning particularly Barts Health
2b. (Risk Ref F4) The CCG does not achieve its target for 95% of A&E attendees to be treated within 4 hours, as per the NHS Constitution, due to poor performance by Barts Health and other key providers
2c (Risk Ref SC1) The CCG does not secure effective governance arrangements to monitor the BCF via section 75. This means that the GB will not have appropriate oversight of a significant level of spend delivering core baseline services and delivering an element of the CCGs QIPP programme
2d (Risk Ref QC4) A lack of consistency and completeness in how the quality impact assessment documentation has been completed for each Cost Improvement Programme (CIP) scheme for Barts Health (BH) and North East London Foundation Trust (NELFT).
2e. (Risk Ref QG 5) Patients whose Continuing Health Care needs have changed may not be receiving the correct care. This means these patients may be at risk of harm.
5 Board Assurance Framework
3. To balance our books 3a. (Risk Ref FI) The CCG fails to manage its commissioning budget within financially by delivery of plan due to increased costs of acute Service Level Agreements leading to an our QIPP programmes overspend which identify areas 3b. (Risk Ref SC3) Practices may not reduce their referrals which lead to the where services can be CCG not meeting the full £1.2m QIPP target. Specifically this relates to (i) redesigned to improve Referrals Peer Review (ii) Referrals Pathway Redesign care and be more cost effective 3c. (Risk Ref QC4) A lack of consistency and completeness in how the quality impact assessment documentation has been completed for each Cost Improvement Programme (CIP) scheme for Barts Health (BH) and North East London Foundation Trust (NELFT).
4. To establish 4a. (Risk Ref F3) The CCG does not achieve its targets for Referral to collaborative Treatment (RTT) waiting times due to poor performance by its providers, commissioning particularly Barts Health arrangements with a focus on Barts Health 4b. (Risk Ref F4) The CCG does not achieve its target for 95% of A&E attendees to be treated within 4 hours, as per the NHS Constitution, due to poor performance by Barts Health and other key providers
5. To deliver effective There are no BAF reportable risks associated with Corporate Objective 5. patient and public engagement in line with A piece of work is being undertaken to establish the evidence sources the NHS Constitution available to provide the Governing Body with the necessary assurances that risks to this Corporate Objective are being identified and effectively managed.
6. To maximise clinical There are no BAF reportable risks associated with Corporate Objective 6. engagement with GPs in our three localities It has been identified that the internal audit plan does not entirely address this and other health Corporate Objective. A piece of work is being undertaken to establish the professionals from evidence sources available to provide the Governing Body with the necessary hospital and community assurances that risks to this Corporate Objective are being identified and services and Public effectively managed. Health through effective engagement and development
7. Through our strategic There are no BAF reportable risks associated with Corporate Objective 7. commissioning and commissioning It has been identified that the internal audit plan does not entirely address this processes we will Corporate Objective. A piece of work is being undertaken to establish the support an improvement evidence sources available to provide the Governing Body with the necessary in the patient assurances that risks to this Corporate Objective are being identified and experience of GP and effectively managed. GP out of hours services
6 Board Assurance Framework Table 2: Board Assurance Framework.
Current risk Directorate Risk Description rating reporting the risk Progress to date
This risk aligns to Corporate Objective 3: Finance First reported on the BAF : April 2014
To balance our books financially by delivery First reported BAF risk rating: of our QIPP programmes which identify Changes in the risk rating since first reporting: areas where services can be redesigned to improve care and be more cost effective.
12 Risk F1: The risk rating has remained unchanged since the last report to the Governing Body
The CCG fails to manage its commissioning Forecast rating of the risk to its acceptable level: budget within plan due to increased costs of acute Service Level Agreements leading to an overspend Target risk rating: Date expected to reach Target Risk Rating March 2015
Latest predicted risk rating (Note: The risk wording has been changed slightly since the last report to the Governing Pedicted rating last time reported to the Governing Body (September 2014) Body to reflect that the overall CCG position is projected to be better than expected) Management oversight of this risk is provided through the Finance &QIPP Committee Action plans: 1. Agreed and signed contracts for major acute Trusts - Barts Health, Homerton, UCLH, North Middlesex – within budget (Target Completion date: April 2014 – Completed with the exception of Homerton which is now scheduled to complete Jan 2015 (was July 2014) 2. Work with WELC CCGs through Barts Collaborative to manage risks of over performance in year through timely data reviews and challenge of Trust data where appropriate Reviews will take place on a monthly basis. Overall financial claims across the acute portfolio have improved during M6 and this helped inform an improvement in the overall CCG financial performance reported to NHSE. Some risks remain around additional activity associated with meeting RTT trajectories and the potential underreporting of Whipps X activity through the Cerner implementation. 3. Support GP practices to manage demand where clinically appropriate through timely and accurate reporting of contract performance. Contract reviews will take place on a monthly basis
7 Board Assurance Framework
Current risk Directorate Risk Description rating reporting the risk Progress to date
This risk aligns to Corporate Objective 2: Finance First reported on the BAF : April 2014
To deliver high quality services though effective commissioning First reported BAF risk rating: and to Corporate Objective 4: Changes in the risk rating since first reporting:
To establish collaborative commissioning arrangement with a focus on Barts Health 20
The risk rating has increased from risk score 16 to risk score 20 since the last report Risk F3: to the Governing Body. This is a result of poor data quality. The Trust has The CCG does not achieve its targets for acknowledged that it will be compliant in all specialities by March 2015 except for Referral to Treatment (RTT) waiting times due T&O, Urology and General Surgery. to poor performance by its providers, particularly
Barts Health Forecast rating of the risk to its acceptable level:
Target risk rating: Date expected to reach Target Risk Rating March 2015
Latest predicted risk rating
Pedicted rating last time reported to the Governing Body (September 2014)
Management oversight of this risk is provided through the Performance and Quality Committee in addition the CCG manage the patient safety through the Clinical Quality Review meeting and the Clinical Harm Review meeting. . Action plans:
1. The CCG has worked with Barts Collaborative and Barts Health to agree a recovery plan to achieve RTT targets at Trust level in Q1 and speciality level in Q2 (Target Completion date: March 2015 (was General, June 2014; speciality level, September 2014). Barts failed to meet the trajectory for Trust compliance at Q1 partly due to capacity shortages but most significantly due to data issues linked to the upgrade to Cerner at Whipps X. A resilience plan to achieve a 16 week maximum wait has been signed off by the CCGs and this is being monitored at performance group. A Contract Query Notice (CQN) has been issued to Barts covering both RTT and Cerner and a remedial action plan has been
8 Board Assurance Framework
rejected as requiring further work. Barts continue to do further work on their trajectories and are currently reporting that they will not meet the incomplete and non-admitted targets until March 2015, and will still not be achieving the admitted target then, due to capacity constraints in Trauma & Orthopaedics, urology and general surgery. A revised backlog clearance plan is due in late October. The CCG is working to reduce demand on Barts by identifying possible alternative providers to accept GP referrals.
2. Action plan is monitored on a fortnightly basis by the Barts Performance Group consisting of CCG and CSU leads and through the Barts contract monthly meetings, with remedial actions agreed as necessary Reviews will take place on a fortnightly and monthly basis.
3. The Trust has now suspended its RTT reporting nationally due to data integrity issues. This suspension is likely to remain in place until the end of the financial year whilst remedial action is taking place. The CCG has been given assurance that they will receive local activity information to show that the waiting list is being reduced. Given that this CCG and other commissioners were given assurances that data was robust prior to Cernar implementation the local CCGs, TDA and NHSE are to commission an independent investigation.
9 Board Assurance Framework
Current risk Directorate Risk Description rating reporting the risk Progress to date
Finance First reported on the BAF : April 2014 This risk aligns to Corporate Objective 2:
To deliver high quality services though First reported BAF risk rating: effective commissioning Changes in the risk rating since first reporting: and to Corporate Objective 4:
To establish collaborative commissioning 16 arrangement with a focus on Barts Health
The risk rating has remained unchanged since the last report to the Governing Body
Risk F4: Forecast rating of the risk to its acceptable level: The CCG does not achieve its target for 95% of
A&E attendees to be treated within 4 hours, as per the NHS Constitution, due to poor Target risk rating: Date expected to reach Target Risk Rating March 2015 performance by Barts Health and other key providers Latest predicted risk rating
Pedicted rating last time reported to the Governing Body (September 2014)
Management oversight of this risk is provided through the Performance and Quality Committee
Action plans:
1. The CCG, working with Barts Health, LBWF and NELFT through the Urgent Care Working Group will oversee the urgent care pathway and identify any necessary changes to reduce inappropriate demand on A&E and ensure patients are treated in a timely manner. Q2 (Target Completion date: Q2 2014 – not met:) - The Trust narrowly missed the target at 94.8% in Q2, but due to slippage needs to achieve c97% in Q3 and Q4 to achieve the annual target. Whipps X performance remains below that of the Trust at 92.6% in Q2 due to high bed occupancy impacting on an inability to deal with spikes in demand, low levels of weekend discharges, and an increase in delays to accessing continuing care assessments. Additional winter resilience funds have been made available and the Strategic Resilience Group is agreeing plans to increase capacity over the winter.
2. Performance monitored on a bi weekly basis by Barts Performance Group consisting of CCG and CSU leads and through Barts contract review monthly meetings, with remedial actions agreed as necessary Reviews are taking place on a fortnightly and monthly basis
10 Board Assurance Framework
Current risk Directorate Risk Description rating reporting the risk Progress to date
This risk aligns to Corporate Objective 2: Strategic First reported on the BAF : January 2014 Commissioning To deliver high quality services through effective commissioning First reported BAF risk rating:
Changes in the risk rating since first reporting:
Risk SC2: Integrated care 2: Better Care Funding (BCF): 12
The CCG does not secure effective governance The risk rating has remained unchanged since the last report to the Governing Body arrangements to monitor the BCF via section 75. This means that the Governing Body will Forecast rating of the risk to its acceptable level: not have appropriate oversight of a significant level of spend delivering core baseline services Target risk rating: Date expected to reach Target Risk Rating March 2015 and delivering an element of the CCGs QIPP Latest predicted risk rating programme Pedicted rating last time reported to the Governing Body (September 2014)
Management oversight of this risk is provided through the Finance and QIPP Committee and the Performance and Quality Committee
Action plans Establish a shared Project Management Office with LBWF for the implementation of
the BCF
(Target Completion date: June 2014 – action completed) Secure robust governance arrangements via a section 75 with clear measurable KPI’s and outcomes and clarity on the data required to monitor the section. Work programme in place and time scales are agreed. (Target Completion date: Draft Section 75 September 2014 - date met); Final Section 75 in place April 2015)
Regular review meetings with LBWF with involvement of finance colleagues in discussions
Agree a robust risk share as part of the governance arrangements (Target Completion Date: Draft Sept 2014 – date met; Final Dec 2014; Implementation March 2015)
11 Board Assurance Framework
Current risk Directorate Progress to date Risk Description rating reporting the risk
This risk aligns to Corporate Objective : 3 Strategic First reported on the BAF : April 2014 Commissioning To balance our books financially by delivery First reported BAF risk rating: of our QIPP programmes which identify areas where services can be redesigned to Changes in the risk rating since first reporting: improve care and be more cost effective.
Risk SC3: 12 Optimising outpatients: Practices may not reduce their referrals which The risk rating has remained unchanged since the last report to the Governing Body lead to the CCG not meeting the full £1.2m QIPP target. Forecast rating of the risk to its acceptable level:
Specifically this relates to: Target risk rating: Target Risk Rating met
1. Referrals Peer Review: Latest predicted risk rating
2. Referrals Pathway Redesign: Pedicted rating last time reported to the Governing Body (September 2014)
• There has been a delay to the Management oversight of this risk is provided through the Finance and QIPP commencement of the initiative. Committee and the Performance and Quality Committee • Delays around recruitment of clinical leads and identification of pathways. Action plans: Referrals Peer Review: Appointment of Clinical Lead to start visits when suitable for individual practices. (Target Completion Date: August 2014 - was May 2014 - Change in timescales (Note: that this risk relates to risk F2 : The CCG at request of Clinical Director) confirmation of progress to be provided prior to fails to achieve its planned surplus due to non - next Governing Body achievement of its £10.4M QIPP plan) Practices to produce action plans to allow for points of review and early intervention if required.
(Target Completion Date: Chingford and Leytonstone; 30 May 2014; Walthamstow 7 June 2014 – Completed: Process has been implemented with 3 action plans delivered to date )
Practices to receive developmental remuneration and extra support from Delivery team along with monthly Referral data and update reposts with clinical leads. Reviews will take place on a monthly basis
Optimising Outpatient Referrals Pathway Redesign :
12 Board Assurance Framework
CCG working with CSU Delivery Improvement Unit on model for revised pathway & programme management to assistance with project implementation
(Target Completion date: The targeted completion date of May 2014 has been revised to August 2014 with 3 business cases to be completed by end of July – All business cases completed)
13 Board Assurance Framework
Current risk Directorate Risk Description rating reporting the risk Progress to date
This risk aligns to Corporate Objective 1 Quality & First reported on the BAF : August 2013 Governance To improve the health outcomes of our local Directorate population First reported BAF risk rating:
Changes in the risk rating since first reporting:
Risk QG2: Continued failure of Whipps Cross Hospital (Barts Health NHS Trust) to deliver sustained 18 quality improvement in the delivery of safe effective care. The risk rating has remained unchanged since the last report to the Governing Body
This means that some patients are not receiving Forecast rating of the risk to its acceptable level: the quality care WFCCG commissions and some patients have a poor experience and are at risk of potential harm. Target risk rating: Date expected to reach Target Risk Rating March 2015
Latest predicted risk rating
Predicted rating last time reported to the Governing Body (September 2014)
Management oversight of this risk is provided through Performance and Quality Committee. Other routes are through:
• Barts Health NHS Trust CQRM • Peer Reviews • Whipps cross Clinical forum • Quality Assurance Visits • Patient/carer/family feedback and complaints • Serious Incidents reported • CCG Director of Nursing has signed up to the NHS Change Day - Pledge • Healthwatch (Patient feedback) • Maternity Services Liaison Committee • GP Alert System • Executive team meeting • Quality Surveillance Group • Delayed Transfer of Care weekly teleconferences (chaired by CCG)
14 Board Assurance Framework
Actions taken: • 29 July Director of Nursing, Quality and Governance convened meeting with Medical Director and senior management team for women’s and children’s services to raise concerns about repeated serious incidents and lack of clinical governance in relation to managing paediatric patients • 8 August 2014 the CCG Chair wrote to the Medical Director BH highlighting concerns regarding specific clinical safety issues. • In August 2014 the CSU carried out a review to measure Barts Health progress against the CQC action plan. The review indicated that the actions in relation to Whipps X are not fully implemented. At the WEL CCG Quality Leads meeting 12 August 2014, it was agreed that a formal letter would be sent to BH raising concerns regarding the progress with quality improvement. • WEL and BHR CCG have collectively issued a Contract Query Notice (CQN). BH has produced Remedial Action Plan in response to the CQN. Progress against the plan will be monitored at the Clinical Quality Review Meeting and the Service Performance Review meeting. • 2 September 2014 the CCG met with Barts Health Chair, Non-Executive Director and members of the Executive team to discuss and highlight the concerns relating to quality and safety of patient care.
• The Accountable Officer requested Barts Health Senior Management Team to attend the CCG Executive meeting 8 September 2014 to discuss the systemic failures at Whipps X hospital.
• WEL CCGS, NHS England and National Trust Development Authority convened to collectively plan management of quality improvement and agreed to establish a Quality Surveillance Group • The CCG has commissioned the Patients Association to lead a pilot project to improve the quality of care for patients at Whipps cross. The project for the development and implementation of a Gold Standard Service for Older People based at Whipps cross involves Barts Health staff, patients and carers.. The project commenced in August and will run until March 2015. • The CCG has a GP alert system in place. All GP Alerts are now formally notified to Barts Health with the expectation that patient safety issues are promptly resolved by Barts Health. A monthly report is presented to the Performance and Quality Committee to highlight the trends and themes of the GP Alert issues. The alerts are duly followed up with the relevant Clinical Academic Group at the CQRM and Whipps X Clinical Forum to ensure quality improvement has been implemented and maintained. The system is currently being reviewed and updated. • The CCG undertake Quality Assurance visits each month and a report is presented to the Performance and Quality Committee. Actions arising from the report are reviewed and updated at each visit to ensure quality
15 Board Assurance Framework
improvements are implemented and maintained. These reports are shared with BH. • The CCG has developed a patient experience Commissioning for Quality and Innovation (CQUIN) with Barts Health specific to patient experience to ensure that there are detailed reports relating to complaints and other patient experience indicators.
• A strategic Quality Workshop with Barts Health on 18 September 2014 Barts Health executive team provided an update on the progress of quality improvements to all commissioners, NHS England, the Trust Development Authority and related stakeholders.
• 27 October Executive team held meeting with Barts Health Clinical Director for Emergency Care and Acute Medicine (ECAM) agreed Barts Health should submit a business case outlining the requirement for level 2 unit at Whipps Cross site.
• 29 October Accountable officer wrote to Barts Health Primary Care Consultant to follow up actions agreed at meeting held 2 September.
• The CQC conducted an inspection at Whipps Cross Hospital week commencing 10 November 2014. The report is expected to be in the public Domain January 2015. As part of the process a community listening event to enable members of the public to share their experiences of care was held by the CQC in Walthamstow 11 November. The CCG participated in the peer review process at Whipps cross hospital in preparation for this inspection.
16 Board Assurance Framework
Current risk Directorate Risk Description rating reporting the risk Progress to date
Quality and First reported on the BAF : September 2013 Governance This risk aligns to Corporate Objective 1: Directorate First reported BAF risk rating To improve the health outcomes of our local population Changes in the risk rating since first reporting: 12
Risk QG3: NHS Waltham Forest Clinical Commissioning Group does not have assurance that all Care The risk rating has remained unchanged since the last report to the Governing Body Homes are providing safe quality care to patients. This means that some patients may be Forecast rating of the risk to its acceptable level: predisposed to risk through suboptimal care and poor patient experience. Target risk rating: Date expected to reach Target Risk Rating March 2015
Latest predicted risk rating
Predicted rating last time reported to the Governing Body (September 2014)
Management oversight of this risk is provided through the Performance and Quality Committee. Other routes are through:
• CQC inspections • WFCCG Director of Nursing, Quality and Governance holds monthly meetings with the CQC regional compliance inspector • Weekly review of the CQC website to scan for inspection reports • The 2014/15 Quality Assurance Visit schedule is in place • Monthly QA visits taking place • Progress reports are presented to the Performance and Quality committee. • CSU is leading a Self-Assessment Assurance audit programme of Care Homes 2014/15
17 Board Assurance Framework
Actions taken:
• The project plan agreed in April 2014 at the Performance and Quality committee has now been implemented and remains on target
• All Care Homes will be visited bi annually (March 2015). All outcomes of visits are presented to the Performance and Quality committee and actions monitored to ensure compliance.
• Following a Quality Assurance visit to Ross Wlyd Care Home 9 April 2014 the CCG have shared quality concerns with NHS England. Four Seasons are currently being reviewed at a national level as their other homes have similar issues.
• The CCG have further escalated concerns with the Safeguarding Adult Team within Waltham Forest Local Authority. A number of Serious Concern meetings were held in June and July 2014. Subsequently the Local Authority undertook an unannounced visit 16 August. Improvements were acknowledged, however the level of safeguarding referrals relating to pressure ulcers continues to cause concern.
• The Quality and Governance team are now receiving verbal updates from London Borough of Waltham Forest who are monitoring the action plan submitted by the Ross Wlyd Care Home. Further reviews are planned as part of the overall project.
• As from December 2014 the CCG will be conducting unannounced reviews of Care Homes that are in receipt of funding for patients that should be receiving one to one nursing care.
18 Board Assurance Framework
Current risk Directorate Risk Description rating reporting the risk Progress to date
Cost Improvement Plans Quality and First reported on the BAF : August 2014 Governance This risk links to Corporate Objective 1: Directorate First reported BAF risk rating: To improve the health outcomes of our local population Changes in the risk rating since first reporting: 16 and Corporate Objective 2: To deliver high quality services through effective commissioning The risk rating has remained unchanged since the last report to the Governing Body and Corporate Objective 3: Forecast rating of the risk to its acceptable level: To balance our books financially by delivery of our QIPP programmes which identify areas where services can be redesigned to Target risk rating: Date expected to reach Target Risk Rating March 2015 improve care and be more cost effective Latest predicted risk rating:
Predicted rating last time reported to the Governing Body (September 2014) Risk QG4: Management oversight of this risk is provided through the Performance and A lack of consistency and completeness in how Quality Committee the quality impact assessment documentation has been completed for each Cost Improvement Actions taken: Programme (CIP) scheme for Barts Health (BH) and North East London Foundation Trust Barts Health (NELFT). This means that the CCG cannot • CIP schemes for 2014/15 have been provided for review to CCG's within the provide the assurance required that the CIP Barts Health Clinical Commissioning Collaborative. schemes will not have an adverse impact on the quality and safety of services delivered. This is • A deep dive was carried out into 12 schemes to review how robust a process a requirement of the CCG operating plan. had been followed by Barts Health in the quality impact assessment of these schemes.
A letter has been sent to Barts Health from the Barts Health Clinical Commissioning Collaborative on 4 August 2014 highlighting concerns regarding the BH internal assurance and approval process. As of 8 September a response had not yet been
19 Board Assurance Framework received from BH, therefore a formal meeting was scheduled 19 September for commissioners to confirm BH approval process. The meeting took place as scheduled and it was confirmed that the process for monitoring CIP impact is clear and robust with mechanisms to build monitoring and quality assurance into the business as usual processes. However it was noted that any absolute guarantee that delivery of Barts Health CIP schemes will not impact on quality or safety cannot be given by the Trust or by CCGs. NELFT • A meeting was convened with NELFT on 1 July 2014 to review and respond to proposed CIPS. 3 July 2014 CCG raised additional queries as re submission lacked detail and clarity. • 16 July CCG requested NELFT for further detail and assurance. • 18 August 2014 further request from CCG to NELFT to provide more detail and assurance. • 30 August 2014 updated CIP Plan unsatisfactory further detail requested.
1 September 2014 CCG Multidisciplinary Team agreed concerns regarding viability of CIPs to be formally discussed at Service Performance Review meeting 11 September 2014. The Service Review Meeting took the decision that a review of CIPS was dealt with most appropriately as part of the CQRM agenda and WFCCG has set up a dedicated meeting with NELFT to progress.
20 Board Assurance Framework
Current risk Directorate Risk Description rating reporting the risk Progress to date
QG5 CHC back log Quality and Governance First reported BAF risk rating: This risk links to Corporate Objective 1: Directorate To improve the health outcomes of our local Changes in the risk rating since first reporting: population 16 and
Corporate Objective 2: To deliver high quality services through This is the first time that this risk has been reported to the Governing Body effective commissioning Forecast rating of the risk to its acceptable level: Patients whose Continuing Health Care needs have changed may not be receiving the correct care. This means these patients may be Target risk rating: Date expected to reach Target Risk Rating March 2015 potentially at risk of harm.
Latest predicted risk rating:
Management oversight of this risk is provided through the Performance and Quality Committee
Actions taken:
• NELFT have provided a business case for non-recurrent funding bid for additional resources
• A plan has been put in place for the agreed non recurrent funding to provide additional resources to in order to support the recruitment of additional staff (Time scale for additional resources to be in place: November 2014)
• A trajectory has been set to achieve removal of back log of cases by 31 March 2015 ( back log of cases at October 2014 = 143)
21 Board Assurance Framework
Table 3: Risks retired from 2014/15 BAF
Risk Last Reported to the Directorate Rationale for retiring the risk How the risk is now being Governing Body from the BAF managed
The CCG fails to achieve its planned surplus 23 July 2014 Finance Projected end year delivery of QIPP The risk continues to be due to non - achievement of its £10.4M QIPP is at 91.4 percent of plan based on managed through the Finance plan latest activity data and its overall directorate and continuing favourable financial position
Outstanding Serious Incidents (SIs). 23 July 2014 Quality and Barts Health and North East London The risk continues to be Barts Health Trust and North East London Governance Foundation Trust Current reported managed through the Quality Foundation Trust have a significant number of status (September 2014) is that and Governance directorate SIs that have not been managed within the Barts Health have 0 outstanding National Framework for Reporting and Learning from Serious Incidents timeframe. reports and NELFT have 19 This means that in some areas, outstanding reports. NELFT have recommendations and lessons learned have established processes that have not been put in place to support improved significantly reduced back log to practice and safe quality care. sustainable levels
NHS Propco may charge rent and implement 23 July 2014 Strategic Reduction in risk rating following The risk continues to be a lease agreement to community based Commissioning further evaluation managed through the Strategic services that use Propco estates from which Commissioning directorate to deliver services. This means that community based service providers decline to sign contracts unless they exclude rental charge.
Author: Dr David Pearce, Head of Governance
22 Board Assurance Framework
Risk scoring matrix
Most Likely Consequence (if in doubt grade up rather than down
Likelihood of 1 = Insignificant 2 = Minor 3 = Moderate 4 = Major 5 = Catastrophic Occurrence
1 = Rare 1 2 3 4 5
2 = Unlikely 2 4 6 8 10
3 = Likely 3 6 9 12 15
4 = Highly Likely 4 8 12 16 20
5 = Certain 5 10 15 20 25
23 Board Assurance Framework
Guide to the assessment of likelihood and consequence (impact)
Likelihood
Score 1 2 3 4 5
Description Rare Unlikely Likely Highly Likely Certain
Frequency The risk may occur but The risk is not The risk might occur at There is a strong The risk is expeced to only in exceptional expected to happen some time. There is possibility that the risk occur. circumstances but there is a some history of it, or will occur. There is a possibility that it could similar occurrences, history of it, or similar There is a history of it, occur at some time having occasionally occurrences, or similar occurrences, happened in the past frequently happening regularly happening in in the past the past
Consequence (Impact)
Score Description Impact Description
5 Catastrophic There is a very major and potentially disastrous impact on the achievement of the corporate objective(s)
4 Major There is a major impact on the achievement of the corporate objective(s)
3 Moderate There is a significant impact on the achievement of the corporate objective
2 Minor There is some impact, albeit not significant, on the achievement of the corporate objective (s)
1 Insignificant There is minimal impact on the achievement of the corporate objective(s)
24
Item 2.2
Title of report Communications Annual Report 2013/14
From Helen Davenport, Director of Nursing, Quality and Governance - WFCCG
Purpose of report To update the governing body on communications activity undertaken during 2013/14.
Recommendations To note the report.
Impact on patients & carers The report is intended to have a positive impact on patients and carers, by helping us reflect on how we have communicated with them over the past year, and consider how we can improve in future.
Risk implications The report mitigates against the risk of the CCG running its communication function unreflectively.
Financial implications There are no financial implications to this report.
Equality analysis The CCG is committed to fulfilling its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. The CCG will work with providers, service users and communities of interest to ensure that any issues relating to equality of service within this report are identified and addressed.
Other committees/groups, including the CCG Reference Group and Rapid Feedback Group (please include detail of when the group were involved and in what capacity) Not applicable at this point.
25
NHS Waltham Forest Clinical Commissioning Group Communications Annual Report 2013/14
26
Document revision history
Date Version Revision Comment Author/Editor
12.11.14 1 Anna Sullivan
12.11.14 2 Justin Roper
13.11.14 3 Formatting, punctuation, Case Studies revised Helen additional information, Davenport Further detail sections grammatical correction revised and recorded in appendix
13.11.14 4 Formatting, punctuation, Anna Sullivan grammatical correction
14.11.15 5 Formatting Anna Sullivan
Document approval
Date Version Revision Role of approver Approver
Page 1 27
Contents
1.0 Background 3 2.0 Quarter 1: April – June 2013 3 3.0 Quarter 2: July – September 2013 4 4.0 Quarter 3: October – December 2013 4 5.0 Quarter 4: January – March 2014 5 6.0 Plans for 2014/15 5 7.0 Conclusion 5 8.0 Appendix: Further detail of work undertaken 6
Page 2 28
1.0 Background This is the first annual report for the CCG communications function. In 2013/14 the CCG’s communication function was overseen by Alan Wells (Deputy Chair and Lay Member for Community Participation), Dr Tonia Myers (Clinical Director) and Helen Davenport (Director of Nursing, Quality and Governance). It was delivered by Anna Sullivan (Head of Communications and Community Participation), Rhian Burgess (Relationship Manager, NEL Commissioning Support Unit (CSU)) and other key NEL CSU staff. This report outlines the key activities the function has undertaken in the period from April 2013 to March 2014. For each quarter we have provided information relating to specific pieces of work, and highlighted the most significant pieces of work undertaken in that quarter. We have also provided further detail (please see appendix pages 6-9) of activities carried out in each quarter, to give a sense of the scale and range of work undertaken by the function in 2013/14. In addition to the work highlighted here, the communications function has undertaken joint work on ‘Transforming Services, Changing Lives’ with Barts Health NHS Trust, Newham CCG, Tower Hamlets CCG and other key partners. Finally all of this is set against the background of day-to- day operational activities, such as media monitoring and website updates.
2.0 Quarter 1: April – June 2013 The primary communications priorities in quarter 1 were to develop materials to explain to staff and stakeholders the purpose of the CCG and the key principles of the new commissioning landscape. We did this with the production of the Patient Prospectus and CCG Vision and Values. Patient Prospectus The CCG Patient Prospectus is a booklet produced by the communications team to introduce the CCG to local people and partners. It explains how the CCG works on behalf of the community to commission high quality, safer and effective health and care services. The prospectus also encourages residents to participate in the work of the CCG by providing input on their experience of the local NHS.
Vision and Values The CCG Vision and Values capture the spirit of the CCG and the standards that it applies when carrying out its commissioning responsibilities. As the CCG was a new organisation in the first quarter of 2013/14, it was crucial to decide the Vision and Values at an early stage to support strategic planning. The Vision and Values were drafted following feedback from staff and members. They were finessed and signed off by the CCG governing body in May 2013 (one month after conditional authorisation was granted by NHS England).
Page 3 29
3.0 Quarter 2: July – September 2013 In quarter 2 we developed and agreed a communications strategy. We also planned, delivered and monitored a public consultation on the draft joint mental health strategy for adults of a working age (‘Better Mental Health’). Communications Strategy We developed our communications strategy by considering the strategic objectives of the organisation and listening to the priorities of stakeholders. Key objectives emerged as redeveloping the website and GP Centre; communicating who we are and what we do; and social media. The strategy was signed off by the governing body at its meeting in September 2013.
‘Better Mental Health’ ‘Better Mental Health’ is a mental health strategy for adults of working age that was developed in partnership with the London Borough of Waltham Forest. In order to make sure that the strategy captured the priorities, needs and objectives of patients, carers and other stakeholders in mental health, it was decided to run a mini consultation process to test the content of the strategy with the public. The consultation launched in September 2013 and ran for ten weeks.
4.0 Quarter 3: October – December 2013 In quarter 3 we planned, delivered and monitored a public consultation on the proposed permanent closure of Naseberry Court. We also developed and delivered a marketing campaign to encourage the local community to participate in the work of the CCG. Naseberry Court In December 2012, North East London NHS Foundation Trust (NELFT) took the decision to temporarily close Naseberry Court (an acute mental health inpatient unit for people with serious mental illness) on the grounds of clinical safety. Following this, the CCG led a formal public consultation to ask patients and the public if the closure should be made permanent and to look at options for delivering care closer to home, where possible. The consultation began in October 2013 and ended in January 2014.
‘We Need You’ marketing campaign As part of the CCG’s commitment to involving patients and the public in its work, the decision was taken to set up two community participation groups: the CCG Reference Group and the Rapid Feedback Group. The communications team designed a leaflet to encourage people to join one or both groups. This was sent out to 20,000 local households, which were targeted to ensure good coverage of the geography of the borough and demography of residents. As a result of the campaign, the CCG received surplus applications and had to undertake an interview process to select the final membership of the Reference Group. Both groups are now fully subscribed to, and working well.
Page 4 30
5.0 Quarter 4: January – March 2014 In quarter 4, we completely revised the CCG’s website and GP intranet, and developed the CCG’s first annual report. Website and GP Centre development In early January, work began on reviewing the CCG website to provide a much more up to date and informative website. In February a map was produced to show how the new website would look and what new content would be needed, including changing the existing GP intranet into a predominantly public-facing part of the website. In March the redesign took place and new content was drafted. We intend to further develop and improve the website to include more health promotion information and more specific guidance on local health services.
Annual report As an organisation with statutory responsibilities, the CCG is required to produce an annual report, including financial accounts. As this was the first year that this report had to be produced, and as NHS England had supplied complex guidance to follow, plans for producing the report began at the end of the fourth quarter in March 2014.The final report is available on the CCG’s website: www.walthamforestccg.nhs.uk
6.0 Plans for 2014/15 Since April 2014 the communications function has been working on a variety of projects, including delivering the final version of the annual report; developing and delivering the CCG’s Annual General Meeting; and starting to deliver a CCG awareness campaign. We are also developing a work plan to cover the period from December 2014 to November 2015. This is being done in consultation with Directors and Deputy Directors, and will set out in detail our plans for the remainder of 2014/15 and beyond.
7.0 Conclusion This report has outlined the key activities the communications function has undertaken in the period from April 2013 to March 2014. For each quarter we have highlighted the most significant pieces of work undertaken in that quarter, from public consultations to marketing campaigns and website redesign. The scale and range of work undertaken by the function in 2013/14 has been comprehensive. We are further developing the work plan to ensure that these activities are aligned to the needs and resources of the organisation.
Page 5 31
8.0 Appendix: Further detail of work undertaken
Quarter 1 Digital and • Designed and implemented new layout for GP login area of CCG Marketing website
Media • Developed reactive media statement in response to article on privatisation in Waltham Forest Guardian
• Responded to Waltham Forest Guardian enquiry on effects of measles and encouraging MMR take up
Public Affairs • Drafted briefings on personal health budgets and GP access for Stella and Creasy MP Consultation • Produced letters for stakeholders and the council advising of CCG management changes and authorisation progress
• Supported mental health stakeholder pre-consultation event and developed frequently asked questions document
• Supplied presentation on changes to urology in inner north east London for joint health scrutiny committee meeting
• Drafted response to Iain Duncan Smith MP on referral routes for ENT
• Developed briefing pack to send to Health and Wellbeing Board and Health Scrutiny Committee on the new commissioning responsibilities of the CCG
General • Series of briefings on: service issues at Whipps Cross Hospital, stroke services, CCG’s business continuity plan and whistle blowing changes to constitution
• Produced first edition of CCG Patient Prospectus and first ten editions of GP newsletter ‘Members Update’
• Drafted suite of board development documents and a governing body paper on visions and values
• Finessed Better Mental Health strategy to make it patient friendly
• Developed CCG document templates, including letterheads, PowerPoint presentations and governing body papers
• Delivered corporate style training to administration team
Page 6 32
Quarter 2
Digital and • Designed and delivered vision and values boards and pop-up banners Marketing Media • Managed series of enquiries from Waltham Forest Guardian on CCG authorisation
• Developed a statement for the Health Service Journal (HSJ) on the CCG’s financial plans
• Drafted media release on mental health strategy consultation and arranged advertising in local papers
• Drafted media release encouraging local people to complete the GP survey
Public Affairs • Attended council health scrutiny all day planning event and Consultation • Produced health scrutiny paper on looked-after children (LAC) • Launched Better Mental Health strategy consultation, including producing supporting materials: work-plan, public leaflet, communications plan and web copy
• Produced letters for stakeholders and the council updating on CCG authorisation progress
• Drafted response to John Cryer MP about the role of NHS England
• Wrote a response to an open letter from ‘We are Waltham Forest: Keep our NHS Public’ on stroke services at Whipps Cross Hospital
• Wrote consultation document on proposals to close Naseberry Court
General • Series of briefings on: CCG journey to authorisation, new executive appointments, changes to angiopathy at Barts Health, Whipps Cross Hospital cost improvement plans and outpatient services, CSU claims management process, stroke services, HIV testing, cytology, adult rehabilitation service procurement, information governance and NELIE
• Produced five editions of GP newsletter ‘Members Update’
• Drafted suite of materials to communicate office move from SCORE building to Kirkdale House
• Wrote CCG protocol document for governing body
Page 7 33
Quarter 3 Digital and • Launched ‘We Need You’ marketing campaign to recruit to two patient Marketing reference groups, including online information, leaflet and mail drop to 20,000 households
• Developed proposals for ‘Not always A&E’ awareness campaign
• Carried out stock take of public-facing website and small refresh
Media • Developed media release on transfer of adult rehabilitation services from Barts Health to North East NHS Foundation Trust (NELFT)
• Drafted reactive media lines on the PELC out of hours service and CQC report on looked-after children (LAC) in Waltham Forest
• Developed media release announcing successful integrated care pioneer bid
• Developed media release on self-care week and organised photo opportunity for local papers
Public Affairs • Wrote paper for health scrutiny reviewing CCG’s progress towards and authorisation and addressing recommendations of the Francis Report Consultation • Launched Naseberry Court consultation, including producing supporting materials: consultation documents, web copy, media release, stakeholder letter and arranged advertising in local papers
• Produced letters for stakeholders and the council updating on CCG authorisation progress
• Produced best practice guide for consultation questionnaires
General • Series of briefings on: Whipps Cross Hospital employee tribunal and outcome of nurse abuse of elderly patients trial, CQC maternity survey results changes to adult rehabilitation services
• Drafted a response to a public enquiry on local GP involvement in NHS England’s care data programme
• Briefed Department of Health on local assisted fertility policy and independent funding request process
• Produced formatted versions of CCG communications strategy and community participation strategy
• Wrote communications strategy for integrated care
Page 8 34
Quarter 4
Digital and • Completed whole website review, then implemented amends and Marketing redrafted and reorganised content
• Wrote proposal for year-long campaign to raise awareness of the CCG
• Developed the ‘WF’ logo
Media • Developed reactive media statement in response to Health Service Journal (HSJ) interest in specialised commissioning budget allocations
• Wrote brief and delivered media training for CCG board members
• Developed media release on tackling obesity and ways to lose weight
• Developed media release on breast cancer in women over 70
• Wrote media release and column for Waltham Forest News on No Smoking Day
• Developed media release on prostate cancer awareness month
• Developed media release on importance of attending GP and hospital appointments
Public Affairs • Drafted NHS complaints process and independent funding review and process briefings for Stella Creasy MP Consultation • Produced presentation on health implications of SEN reforms for council
• Wrote governing body paper on Naseberry Court consultation
• Attended two health scrutiny committee meetings to discuss CCG’s commissioning priorities for 2014/15
General • Series of briefings on: CCG response to health scrutiny report on GP services and re-procurement plans for diagnostic services
• Developed factsheets on integrated care, Rapid Response, Care Coordination and GP networks
• Wrote best practice guide for good document management
• Drafted first CCG annual report
• Produced communications planner for integrated care programme
Page 9 35
Item 3.1
Title of report Performance & Quality Report
From Les Borrett, Director of Financial Strategy – WFCCG Helen Davenport, Director of Quality and Governance - WFCCG
Purpose of report The purpose of this report is to inform the CCG Governing Body of the CCG’s performance against the CCG Scorecard and other national performance and quality standards at the end of September. Where standards are not being met the report provides a narrative describing the issue and the actions being taken.
At the end of October the risk of not meeting the stated target is considered high for the following indicators: • Dementia diagnosis • Diabetes care plans • Urgent child development assessments • Bowel cancer screening
At the end of October the forecast is that the following targets will not be met in 2014/15 • Cancer Two Week Waits • RTT incomplete pathway • A&E all types performance at Whipps Cross • Medication error reporting
Recommendations The Governing Body is asked to note the report.
Impact on patients & carers The CCG is not meeting several targets, including the 18 week referral to treatment national standard. The report details the actions being taken by the CCG and by providers to address these concerns.
Risk implications Failure to ensure that there are improvements to the quality and performance of services commissioned may result in a failure to manage and mitigate risks with potential harm to patients and reputational damage.
Financial implications Failure to meet NHS Constitution standards or CCG Local Priorities may affect the size of the Quality Premium, an additional incentive payment made to CCGs in 2013/14.
36 Performance & Quality Report
Equality analysis The report has considered the CCG’s equality duty and where relevant has identified relevant actions which address any likely impact on equality and human rights.
Other committees/groups, including the CCG Reference Group and Rapid Feedback Group (please include detail of when the group were involved and in what capacity) An earlier version of this report was presented to the Performance and Quality Committee.
37
Performance and Quality Report
November 2014
38 Performance and Quality Report
Document revision history
Date Version Revision Comment Author/Editor
14.11.14 1 NA Enrico Panizzo
Document approval
Date Version Revision Role of approver Approver
14.11.14 1 NA Director of Financial Les Borrett Strategy
Page i 39 Performance and Quality Report
Performance and Quality Report (November 2014)
1.0 CCG Scorecard WFCCG has developed the scorecard below to report progress against key performance and quality targets in 2014/15. Indicators have been agreed for each of the CCG’s five clinical priorities. These provide a high level view of progress and have been assessed as the best overall measures of impact for the individual programmes. Indicators have been developed and agreed with the relevant clinical director. In some cases these indicators directly report elements of the CCG QIPP programme. The other indicators, not specifically aligned to clinical priorities, reflect the other organisational priorities chosen by the CCG for 2014/15 and in most cases these reflect commitments made in the CCG Operating Plan to meet national priorities and performance indicators. The scorecard therefore gives a quick view onto both CCG performance (how well the CCG is improving care for patients) and how well the CCG is progressing the implementation of its strategy for 2014/15. The priority areas described in the scorecard broadly align with the delivery initiatives and performance metrics in the WEL 5 year Strategic Plan. Priority # Target Indicator Baseline (2013/14) Improvement 2014/15 Jan Feb Mar Apr May Jun Jul Aug Sep YTD Trend Clinical Exec required in 14/15 Target Director Lead Care for Older People/ 1 Reduced emergency admissions for targeted high risk patients 4258 -16.7% 3549 -3% -14% -21% -18% -14% -13% -10% -23% - -15.6% SA JM Integrated Care 2 Number of integrated care patients flagged at A&E 280 920 1200 280 280 280 280 280 280 280 280 - 280 SA JM 3 Dementia Diagnosis Rate 55% 12% points 67% 54.3% 54.6% 55.1% 54.3% 54.5% 54.7% 54.0% 53.7% 54.1% 54.1% JS JM Mental health 4 Improvement in the IAPT access rate 9.4% 3.6% points 13% 9.4% 2.3% 2.7% 5.02% JS LB 5 Increase number of patients who complete structured education Implemented in Q4 N/A 150 15 0 23 3 7 13 7 15 17 62 SA JM Diabetes 6 Patients with HbA1C 9 to receive standardised care plans None N/A 1818 To be implemented fom October - SA JM
Clinical Priorities Clinical 7 Reduction in paediatric emergency admissions for asthma 233 -20% 186 136% 6% - -31% 6% -8% -32% -50% - -21% TM JM Child and Maternity Care 8 Child Development: urgent assessments within 4 weeks New KPI for 14/15 N/A 95% New KPI for 14/15 52.6% 52.3% 52.5% TM JM 9 Reduced cancer 2 week waits 96% N/A 93% 97.0% 93.1% 91.5% 84.1% 87.5% 81.4% 90.3% 89.4% - 86.7% NKL LB Cancer 10 Persons 60-69, screened for bowel cancer in the last 30 months 48.2% (13/14 Q4) 5% points 53.2% 48.20% - - 48.2% NKL JM
Integrated Commissioning 11 Personal health budgets offered to 65% of eligible patients 0% 65% 65% New project for 2014/15 18% 23% 100% 100% - HD
Community Health 12 Improved waiting times for routine District Nursing referrals New KPI for 14/15 N/A 65% 32% 28% 28% SA JM
Services 13 Inpatient rehabilitation service average length of stay N/A N/A 21 days 22.4 18.7 20.3 19.7 19.1 17.3 18.8 21.4 20.0 20.0 SA LB
14 RTT incomplete pathway performance 89.7% 2.3% points 92% 87.9% 88.1% 88.7% 90.3% 85.8% 86.3% 83.3% 82.9% * 83.5% DK LB Urgent Care & Planned Care 15 A&E 4hr all types performance at Whipps Cross 94.2% 0.8% points 95% 94.7% 95.1% 97.5% 95.2% 91.6% 92.6% 94.4% 92.6% 93.8% 93.3% NKL JM/LB
Prescribing 16 Medication error reports as a proportion of all incidents 8.7% (Oct 12-Mar 13) 2.1% points 10.8% 8.7% 8.0% 7.4% 7.6% 6% 6% 6.5% -- 6.5% MS HD 17 Improvement in Whipps Cross FFT Score 60 (Q4) 2.49% 61.49 49 69 61 77 71 29 60 82 53 63 DK HD Other CCG Priorities Quality 18 Number of C.Diff cases within planned trajectory 46 -9 37 7 7 3 3 3 1 4 4 3 18 DK HD 19 Improvement in seasonal Flu vaccination rates 147.2 17.8 165 Reporting from December AK JM Primary Care 20 Reduction in poor experience of GP & GP OOHs (GP Patient Survey) 10.8 (Jan 13-Sep 13) -2% 10.56 9.6 10.8 10.4 ------10.4 AK JM *Barts Health have withdrawn their data submission for September Page ii 40 Performance and Quality Report
The targets in the scorecard will be reported on a monthly basis, except where data is available on a quarterly basis, or as information becomes available. The latest performance data has been included up to the end of October 2014. Where the CCG has not met a set standard or is not on track to meet an end of year target the performance has been marked “red”. Where the CCG is not meeting these targets an exception report is included in the report below, which also provides update against other key national and local performance and quality targets.
2.0 Care for older people
• Reduced emergency admissions for targeted high risk patient cohort: The expansion of care-coordination to the high risk cohort is part of the CCG QIPP plan for 2014/15. In the first four months of 14/15 there has been a reduction of 405 admissions within the targeted cohort of patients. This is a 15.6% reduction on 2013/14 levels, but just outside the target (16.7%). The reductions in activity, compared to the previous year, have been greatest for patients with the following conditions: angina, chronic heart failure, fractures and bronchitis. The projected reductions in activity are due to rise in the second half of the year.
Forecast: The CCG expects to meet this target but there is some risk associated with this forecast. Current performance is very close to the required target with little margin to absorb unexpected challenges.
• Flagging of patients at A&E: An objective of the care-coordination project is for patients to have care plans that are shared across provider settings and importantly can be accessed by staff within A&E at Barts Health. Currently 280 plans have been uploaded at Barts Health and the project is on track to increase this to 1200 by the end of 2014/15. Whilst no improvement has been realised in 2014/15 we can expect to see a step change once agreement is reached with Barts Health on the process. Recent progress has been made in ensuring that administrative staff in the Whipps Cross Emergency Department are trained in the use of Health Analytics (the IT software onto which care plans are uploaded and stored). This training enables staff to link the records on Health Analytics to the Barts Health Cerner system. NELFT is making considerable progress in improving both quality and quantity of data input to the care/crisis plan and we expect to see a more consistent approach when Barts Health carry out their planned audit. Details for approximately 730 patients with care/crisis plans was sent to Barts early October for input on Cerner by end of month. This task is still to be completed by Barts Health. As of 31 October the total of patients with care/crisis plans on Health analytics has increased to 878, from 736 in the previous month.
Forecast: The CCG expects to meet this target, but there is some risk associated with this trajectory. Progress has been made increasing the overall number of care plans available on Health Analytics. Challenges ensuring the Barts put in place the required systems are being escalated.
Page 1 41 Performance and Quality Report
3.0 Mental Health
Dementia Diagnosis Rate: This is a national priority and the CCG has made a commitment in its operating plans to improve the dementia diagnosis rate to 67% in 2014/15 and a likely target of 75% in the following year. September performance is 54.09% (performance data is now being published nationally and the scorecard figures have been re-aligned to this national data). Whilst this is an improvement from 47.5% in June 2013 there has been no improvement in recent months. In October 2014, NHSE has unveiled a new ‘Dementia Identification Incentive Scheme ‘to improve dementia diagnosis. GPs will be paid £55 per patient for each additional dementia diagnosis they make over the next six months (October 14-March 14). The service is optional for GPs and pays for diagnoses only, with payment based on the net increase in the dementia register at the end of March 2015, compared with the end of September 2014. The Waltham Forest Mental Health Clinical lead is sending a mail to all practices to provide guidance and support for signing on this scheme. WFCCG has also approved a business case for additional investment to expand memory clinic services (NELFT) and commission additional support from Alzheimer’s Society. The agencies are currently recruiting these additional staff. CCG has set a Task and Finish group with key stakeholders and clinicians to start implementing the actions, which will include supporting GP practices to reconcile their data with NELFT and improve their registers. The increased investment in the memory service within NELFT will improve capacity and liaison with GPs. Dr Russell is designing a toolkit for GPs to improve coding and diagnosis. He is about to start a series of visits to GP practices to discuss the dementia diagnosis, pathway and he will be supported by link workers from NELFT and Alzheimer’s Society. Further education and training on dementia is planned at the locality meetings and in support of the implementation of the Directly Enhanced Service (DES) as part of the research and education events at Woodford Green Hotel. The memory clinic performance report on referrals commenced in Q2 as part of the data quality improvement plan. The provider has reported 133 new referrals to the memory service in Q2.
Forecast: The CCG expects to meet this target by March 2015, but there is a high degree of risk associated with this trajectory. A business case for additional investment has been approved by the CCG in October 2014. Achievement of the target requires significant improvement in the final three months of the year.
Improving Access to Psychological Therapies: This is a national priority and the CCG has made a commitment to improve access (the number of people receiving therapies against assessed level of need) to 13% in 2014/15 and deliver 15% access by 1 October 2015. Performance improved strongly at the end of 2013/14 with the CCG reaching 9.43% at year-end compared to 5.2% in the previous year. This was the result of work by the CCG. 2014/15 Q2 performance was 5.02% against a target of 5.75%. This is an improvement on Q1 and we can see an increased number of people entering treatment. In Q2 100 new people entered treatment. We also see an increased number of referrals to the service from GPs. In Q2 there was 145 more referrals compared to Q1. NELFT has produced an action plan and communications plan in the light of Q1 performance that is being monitored through the IAPT Task and Finish group. NELFT have attended the 3 locality
Page 2 42 Performance and Quality Report
meetings to discuss IAPTs with GP members. The increase in monthly referrals is encouraging and will be monitored through the Task and Finish group. The Clinical Lead Dr Lawrence has started a series of visits to GP practices to discuss the depression and anxiety pathway with members as a project to raise awareness and improve clinical engagement with the IAPTs provider. GPs are the main driver for signposting patients to the service including self-referrals. A business case is going to be submitted to raise public awareness and encourage self-referrals. The issue is the scale of step change: the CCG needs approximately 40% more referrals and there also needs to be further education about the role of IAPTs in relation to NICE guidelines and how the stepped care model functions within the depression and anxiety pathway.
Forecast: The CCG expects to meet this target. Performance is below target but is showing improvement towards the required trajectory.
4.0 Diabetes
• Structured Education: This is a NICE approved intervention to improve outcomes for patients with diabetes that was implemented by the CCG with NELFT in Q4 2013/14. The target is for 200 patients enrol (attend the first session) and for 150 to complete the course in 2014/15. Numbers completed to date have been below target with 62 completing up to the end of September. A recovery plan has been developed to extend access to structured education by working with the provider to encourage greater uptake of the programme by patients. Work is also taking place with GPs to improve the DNA rates and ensure patients complete the programme. Currently reported figures show the number who complete all six sessions, but NICE guidance states that completion should be measured on attendance at four sessions. NELFT have been asked to adjust their recording practices to reflect this. The Diabetes Project Group working in partnership with Diabetes UK ran an educational event, Living with Diabetes Day in Waltham Forest, on 2 October 2014 for approximately 100 people.
Forecast: The CCG expects to meet this target in 2014/15.
• Care Plans: The plan is to develop and implement a standardised care plan for patients with diabetes who are clinically deemed high risk (i.e. with an HbA1c value of nine or above). A new care plan model template has been designed and approved and is due to be rolled out in October, with performance monitoring to begin in November. A letter has also been formatted which will be going out to all GPs providing them with practice statistics and asking them to review the notes of all patients that are high risk and either see them in-house or arrange a referral. Supporting this, clear guidelines have been produced (to be given final approval) explaining when and where GPs should refer.
Forecast: The CCG expects to meet this target, but there is a high degree of risk associated with this trajectory as the systems for measuring performance are in development. The CCG is currently reviewing the plans and resources allocated to this project.
Page 3 43 Performance and Quality Report
5.0 Children and maternity
• Reduction in paediatric asthma emergency admissions: This is a CCG QIPP plan and continuation of a project from 2013/14. YTD there has been a 21% reduction in emergency admissions; however the numbers are small and subject to fluctuation. Paediatric emergency admissions rose in Waltham Forest in 2013/14 and this project aims to reduce hospital attendances through investment in additional capacity of community asthma nursing team within the specialist children's service provided by NELFT and by improving the knowledge and experience of GPs and other primary care professionals. An additional nurse has been appointed by NELFT and started to see patients in September.
Forecast: The CCG expects to meet this target but there is some risk associated with this forecast. Current performance is above target but subject to large swings due to the small patient cohort.
• Reduced waiting times for urgent referrals related to child development: This a new indicator with data reported for the first time in October. NELFT have submitted data showing performance at 52%, 21 out of 40 referrals met the target to be seen in four weeks. This performance is yet to be reviewed with the trust but a target of 95% has been agreed. NELFT have indicated that there are data quality issues with the reported position.
Forecast: The CCG expects to meet this target but there is a high degree of risk associated with this forecast. YTD performance figures have only just been received and are substantially below target.
6.0 Cancer
• Cancer Two Week Waits: August CCG performance was 89.4%, against a standard of 93%. This is a small deterioration from the previous month (90.3%). The CCG has not met the target since February 2014. In August there were 54 breaches out of 511 patients, with 50% (27) of breaches due to administration or capacity issues. Despite the fall in CCG performance data from Barts Health shows a trend of continuing improvement on 2WWs at Whipps Cross (approximately 80% of WFCCG cancer activity is through Whipps Cross) and for Barts Health overall. Provisional figures for September and October indicate performance of 91.9% and 95.9% at Whipps Cross and 92.4% and 93.7% for Barts Health overall. The specialities with high numbers of breaches are Breast, Skin and Upper GI. Barts Health have reported that they expect to be compliant in October 2014. Barts Health have reported increased numbers of referrals, especially for the breast symptomatic pathway and have scheduled additional clinics. This has in turn highlighted the need for additional consultant recruitment. The breast one-stop clinic at Whipps Cross is currently offering 34 slots per week and expansion will require additional imaging and pathology capacity. Cancer performance was highlighted in a Contract Query Notice and remedial action plan has been received. Weekly monitoring is in place for
Page 4 44 Performance and Quality Report
each specialty against the target and a local stretch target is being introduced to prevent patient choice breaches.
Forecast: The CCG does not expect to meet this target for 2014/15. Whilst the CCG does expect to see improvement in performance and to be compliant with the target from the end of Q3, the delay in improvements from Barts Health mean that the CCG does not expect to meet the target for the full year 2014/15. This will have a negative impact on the level of the CCG Quality Premium payment.
• Bowel Cancer Screening: This is a new indicator for reporting in 2014/15. The average uptake for Waltham Forest in Quarter 4 2013/14 was 48.2% compared to the national target of 60% and only four GP practices met the national target. The CCG is still awaiting information on Q1 2014/15 position. The CCG has set itself a target of achieving 53.2% performance in 2014/15 (a 5% point improvement from the 2013/14 Q4 position) with the goal of reaching the national target by 2016/17. Nationally individuals of South Asian ethnicity have the lowest uptake of Bowel Cancer Screening and Waltham Forest have a significant population within this ethnic group. Bowel screening is commissioned by NHSE and awareness campaigns regarding screening and uptake are part of the responsibility of LBWF Public Health. The CCG has developed a business case for a pilot project to incentivise GP practices to contact patients who are to be invited to take bowel screening test and emphasise the benefits of completing the test. This may also be supported by community outreach. Funding has been approved for a Macmillan GP that will help with GP education and development.
Forecast: The CCG plans to meet this target, but there is a high degree of risk associated with this forecast. A business case for a project to contact eligible patients through GP practices has been developed.
7.0 Integrated Commissioning
• Personal Health Budgets: As of the end of September all continuing healthcare patients that are eligible for Personal Health Budgets (PHB) have been offered the option of receiving a PHB and all newly eligible patients are being sent a letter. The CCG is currently considering additional targets to capture the total number of patients who receive their care via a PHB. Currently 12 patients have expressed a preference and have started the PHB process. PHBs may be held as a notional budget held by the CCG, a direct payment to the patient, or a payment made to a third party to manage on the patient’s behalf. All referrals for personal health budgets are followed up with a support planning process. In addition we have 13 people in receipt of a Direct Payment via the Section 75 for Learning Disabilities, overseen and managed by London Borough of Waltham Forest.
Forecast: The CCG has met this target.
Page 5 45 Performance and Quality Report
8.0 Community Health Services
• Improved response times for referrals to district nursing services: NELFT started reporting performance for response times for referrals to district nursing services in September 2014. Performance for non-urgent referrals is measured against 24hr, 48hr and 5 day thresholds. The Scorecard reports performance against the 24hr target as this is what is specified in the contract and is the operational target for the service. The latest figures from NELFT records a performance of 23% (down from 32% in Q1). However NELFT have flagged data quality issues related to the poor recording of the date and time of referrals received which then affect the reported response time. NELFT are working with the service to correct the issues identified and expect higher percentages in the future quarters. The proposed target for the reporting on the 2014/15 scorecard has been set at 65%, with the intention of setting a KPI for 95% in the 2015/16 community health services contract.
Forecast: The CCG expects to meet this target for 2014/15, but there is a high degree of risk associated with this forecast. Whilst current performance is below target this reflects data quality issues that are currently being addressed by service provider and which should improve the reported position.
• Rehabilitation Service Length of Stay: the inpatient rehabilitation service at Ainslie transferred to NELFT in November 2014. September performance was 20 days against a target (not to be exceeded) of 21 days.
Forecast: The CCG expects to meet this target for the year 2014/15.
9.0 Urgent Care and Planned Care
• Referral to Treatment (18 weeks) incomplete performance: In light of recent large scale data quality issues, Barts Health Trust board has taken the decision to suspend the monthly mandatory reporting of referral to treatment waiting times data from October (including the retraction of the September submission). The estimated timescale for the suspension is expected to be 6 months. Whilst the Trust will provide weekly returns to the TDA and commissioners in the interim, there are still serious concerns with the quality of the data and the Trust is unable to provide a forward trajectory. The Trust has provided a trajectory for clearing the over 52 week waiters. They expect to clear the majority of specialties by the end of December 2014 with the exception of T&O, General Surgery, Plastic Surgery and Urology which are expected to clear long waiters by end of March 2014. The Trust submitted 183 over 52 week waiters in September with 53 of these identified for Waltham Forest (up from 25 the previous month). The Trust believes that this number was inflated due to data quality issues. However the Trust’s commitment not to have patients waiting longer than 52 weeks from April 2014. These patients are being booked for procedures or discharged as quickly as possible. In the September reporting month, the Trust has removed circa 3,300 Therapies patients that were previously incorrectly included within the data.
Page 6 46 Performance and Quality Report
Data quality continues to be the main cause of underperformance. The Trust’s Patient Treatment Lists (PTLs) are an amalgamation of separate site based legacy processes and need reconstruction into one and unified list. Staff are unclear as to how to correctly apply the 18 week rules and this is further compounded by poor data entry, incorrect use of PAS and poor in-house legacy data validation processes. To date, the CCGs have approved the funding of £4.8 million as part of the Operational Resilience and Capacity Planning to improve the RTT position. Barts Health has been urgently putting in place actions including: Programme Management Office (PMO) Structure; a focus on data quality and working with NHS Intensive Support Team; Training programme and Standard Operating Policies; Development of a single, reliable PTL; and, clinical engagement; Capacity/Demand and Recovery Plans have been written at a granular level. Plans to treat the speciality backlog include increasing internal capacity and outsourcing. In addition to work within the trust the CCG has established a programme of peer-review of outpatient referrals as part of its 14/15 QIPP programme that is expected to improve referral process and reduce unnecessary referrals to Barts Health. The CCG is also considering recommending GPs refer to other providers. Waltham Forest CCG raised concerns with the RTT performance as part of the Contract Query Notice that was issued in August. The Trust has provided the detailed Remedial Action Plans that still require further analysis to determine the realistic timescale for meeting the RTT targets. The CCGs continue withholding a proportion of income from Barts Health until this is resolved.
Forecast: Barts Health have informed the CCG that they do not expect to be compliant in 2014/15 due pressures in Trauma and Orthopaedics, Urology and General Surgery. This will have a negative impact on the level of the CCG Quality Premium payment.
• A&E 4 hour target: Whipps Cross failed the 95% standard for September 2014 with performance of 93.8%, up from 92.6% in July. The YTD position is 93.3% which compares to 92.88% at the same time last year. WX has failed the standard in the four weeks up to 26 October with performance for the week ending 26 October of 92.87%. The underperformance is in part explained by and increased in length of stay and high bed occupancy (above 98% for some weeks against a target of 90%). Barts Health report an increase in the acuity of patients and an increase in the numbers of medically fit patients awaiting discharge. The Trust continues its recruitment process at Whipps Cross for two WTE ED consultants, five registrars, two junior doctors and to bring the nursing level establishment above 95%. Operational Resilience funding is being managed by the System Resilience Group. The first tranche of funding (£6m) has been agreed and projects are being mobilised. The second tranche of non-elective funding was agreed on 31 November, subject to final adjustments and sign-off. The key operational resilience projects for Whipps Cross include: implementation of a Patient Flow Centre; inpatient escalation beds; hospital at home; weekend ambulatory care; and 7 day consultant led rapid assessment. Operational resilience plans assume that the trust will deliver 95% in Q3 and Q4. The Urgent Care Working Groups continue to be the focus for all CCGs to support the whole system approach in health and social care for urgent and emergency care. The CCG is working on an updated urgent care strategy (due December 2014) and the re-procurement of the urgent care system to be completed in 2015/16.
Page 7 47 Performance and Quality Report
Forecast: The CCG expects Barts Health to meet the 4 hour target for 2014/15. Whilst YTD improvements have been made at Whipps Cross compared to the previous year we do not expect this hospital to meet the target. Whether Barts Health achieve the 4 hour target will affect the level of the CCG Quality Premium payment.
10.0 Prescribing
• Improved reporting of medication errors: This is a national target to improve the relative reporting of medication errors following research showing the under-reporting of these kinds of incident. Improved incident reporting is a marker of transparency and should feed into learning systems to improve prevention. The CCG has agreed with Barts Health a target to improve the reporting of medication related incidents to the average for other comparable trusts. Q1 data from the trust has shown a fall in performance. Barts Health have reported that this is due to improvement in the reporting rate for other kinds of incidents, reducing the overall proportion of medication errors reported. However it is not clear that the total number of reported medication incidents is increasing: in August 20 more incidents were reported that the previous year (14% improvement), but in September 17 fewer were reported (11% reduction). Barts Health have agreed to take steps to improve reporting by setting indicative targets for staff to report one incident a week and are seeking to raise reporting levels through staff bulletins highlighting the importance and benefits for patients from reporting errors.
Forecast: The CCG considers this target high risk and the current forecast is no improvement for 2014/15. This reflects the recent deterioration in performance at Barts Health. This has been challenged with the Trust, but we have not yet seen any change in performance. Non-achievement of this target may affect the size of the CCG Quality Premium payment.
11.0 Quality • Whipps Cross Friends and Family Test (FFT) Score: The Whipps Cross FFT score was 53 in September, below the target level. As with previous dips this was the result of an increase in negative feedback in the A&E aspect of the survey. However the YTD position still shows an improvement on the previous year. NHS England is now calculating and presenting the FFT results as a percentage of respondents who would/would not recommend the service to their friends and family. In August, the percentage of patients that would recommend A+E services was 97.55%. This dropped to 93.13% for September. Inpatient scores were 94.47% for August and 93.10% for September. This drop will be monitored by the CSU and will be reviewed against October data once this is available. Response rates for the Maternity FFT remain too low to perform any meaningful analysis. Results for the Q1 Staff FFT show that 49% of staff at Barts Health would recommend the Trust as a place to work
Page 8 48 Performance and Quality Report
(London: 65%) and 69% would recommend the trust as a place to receive care (London: 78%).
Forecast: The CCG expects to meet this target for 2014/15. Current performance is above target.
• C.Difficile: WFCCG currently has 18 recorded cases of C.Difficile in the period up to the end of August against a trajectory (not to be exceeded) of 19 cases. Three cases were recorded in September against a planned threshold of three. WFCCG has an annual trajectory (not to be exceeded) of 37 cases for 2014/15. Barts Health have 39 apportioned cases of C.Difficile up to the end of September against an annual plan of 71 cases. An infection control action plan was agreed at the September Clinical Quality Review Meeting. Actions include how to improve hand hygiene compliance and the possibility of a multi-professional audit of infection control practices focusing on indwelling devices, non-touch techniques and pressure ulcer care. The Specialist Expert in Infection Prevention and Control at the CSU is regularly meeting the Deputy Chief Nurse for Infection Control at Barts Health to monitor implementation of the infection control action plan.
Forecast: The CCG expects to meet this target for 2014/15. Current performance is above target.
12.0 Primary Care
• Flu Vaccination Rates: The CCG has agreed an improvement in flu vaccination rates with NHSE that would bring them above the London average. The performance measure is the combination of the vaccination rates across three patient cohorts. Official figures are not due to be published until December 2014. However data for 27 October showed the following levels of immunisation: 50.4% for the over 65yrs; 24.3% for the “at risk” group; and 16.7% for pregnant women. This gives a combined performance of 91.4 against the end of year target of 165. A flu steering group has been established with representation from CCG, Local Authority, NHSE, NELFT and Practice Nurse. The first meeting was held at the end of July 2014 and agreed an action plan. A GP flu pack has been distributed to all practices with helpful tips and advice, guidance on which vaccines to use, Patient Group Directives (covering the administration of vaccines by practice nurses), etc. Other actions have focused on raising public awareness. A press release on flu vaccinations for pregnant women was published on Waltham Forest Guardian website in October. A volunteer’s newsletter sent out to over 3000 volunteers in the area and a further article is due to appear in the Waltham Forest News. Homerton and Whipps Cross midwives have been signposting pregnant women to local pharmacy for vaccinations.
Forecast: The CCG expects to meet this target for 2014/15. Current performance is above target. Achieving this target should increase the size of the CCG Quality Premium payment for 2014/15.
Page 9 49 Performance and Quality Report
• GP and GP Out-of-Hours patient experience: This is a national indicator and one of the outcome ambition targets agreed with NHSE as part of the Operating Plan submission. The indicator combines patient satisfaction with GP services and GP Out of Hours services as measured by the GP Patient Survey. GP patient experience has been targeted for improvement by the CCG Primary Care Quality Improvement Panel which includes membership from stakeholders including NHSE, Public Health England, Healthwatch and the GP Network. A Primary Care Quality Improvement GP Education event is planned for 20 November. This is a joint event between Networks and CCG to showcase best practice. The CCG is continuing to work on the CCG Primary Care Strategy. Plans to extend opening hours are being discussed with the GP Network.
Forecast: The CCG expects to meet this target for 2014/15. Whilst we have no in-year data to support this forecast the historic trend shows an improving trend that is already within the end of year target.
13.0 Other Performance Targets (by exception) In its Operating Plan submission (4 April 2014), Waltham Forest CCG (WFCCG) self-certified that it had plans to ensure the standards in the NHS Constitution would be delivered in 2014/15. WFCCG noted a number of expected challenges for 2014/15: Referral to Treatment times (18 weeks) at Barts Health; A&E performance at Barts Health and Category A ambulance waits from the London Ambulance Service.
• Ambulance Category A Response Times: The London Ambulance Service (LAS) pan- London performance on Cat A (8 min) response times was 67.6% for August, compared to 66.6% for July, against a target of 75%. The Waltham Forest specific performance has also deteriorated from 60.0% in July to 59% in August. The initial performance improvement plan submitted by the LAS was rejected by NHS England, the NTDA and CCG Commissioners. As a result the additional measures which aim to increase capacity (primarily through recruitment) and/or reduce demand were agreed with NHS England and the NTDA on 11 September and have since been incorporated into the LAS performance action plan. The agreed performance trajectory now predicts that Cat A performance will return to 75% by the end of month 12.
• Diagnostic 6 Week Waits: September performance was 97.1%, an improvement from 95.5% in the previous month, but below the 99% standard. The underperformance was largely due to breaches in non-obstetric ultrasound and colonoscopy at Barts Health. Diagnostic waits are covered by the RTT action plan and the recent deterioration is expected to be related to the clearance of backlogs. The trust is expected to be compliant by October.
• Cancer (62 Day Urgent Referral): August CCG performance was 77.1%, compared to 84% in the previous month, against a national standard of 85%. This was the ninth consecutive month that the standard has not been met. Cancer performance was raised with Barts Health though a Contract Query Notice issued in August and the trust has submitted remedial action plans with trajectories that show compliance with the cancer standards in October.
Page 10 50 Performance and Quality Report
14.0 Other Quality Targets (by exception)
• Serious Incidents Reporting at NELFT: There remain five overdue Serious Incident reports from NELFT for Waltham Forest CCG patients at the end of October. There is a total of 25 overdue reports for the whole organisation. Over one hundred cases were overdue at the start of 2013/14. • MRSA: WFCCG has two attributed cases of MRSA up to the end of September (one case in May and one in September), both trusts assigned. Barts Health have had seven apportioned cases of MRSA year to date as recorded by Public Health England, against a zero tolerance target. One case has been identified at the Whipps Cross site. The CSU Infection Prevention lead is meeting with the trust to review action plans and learning.
• Eliminating Mixed Sex Accommodation (EMSA): There were four mixed sex accommodation breaches for WFCCG in September, three of which were at the Royal London and one at Whipps Cross. Breaches have improved substantially over the long term. The remaining breaches are largely due to bed availability and the transfer of patients from critical care.
Page 11 51
Item 3.2
Title of report Safeguarding Children Annual Report
From Helen Davenport, Director of Nursing Quality and Governance
Purpose of report The purpose of this report is to present NHS Waltham Forest Clinical Commissioning Group (Waltham Forest CCG) Safeguarding Children and LAC Annual Report 2013-2014.
Recommendations The Governing Body is requested to: • Approve the report • Acknowledge the progress made during the reporting period • Support the objectives for 2015/16
Impact on patients & carers The CCG is responsible for ensuring that the services commissioned are safe and of high quality. There is a potential risk of harm to children if safeguarding principles are not embedded in the services we commission.
Risk implications Risk of unsafe or sub optimal care not being identified, which may result in harm to the child. Reputational risk to the CCG if the statutory safeguarding principles are not embedded within the organisation or the services we commission.
Financial implications Failure of provider organisation compliance with the statutory requirements for safeguarding children procedures may lead to prosecution and fines.
Equality analysis The CCG is committed to fulfilling its obligations under the Equality Act (2010) and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. The CCG will work with providers, service users, and communities of interest to ensure that any issues relating to equality of service within this report are identified and addressed.
52 Safeguarding Children Annual Report
Other committees/groups, including the CCG Reference Group and Rapid Feedback Group (please include detail of when the group were involved and in what capacity) London Borough of Waltham Forest Safeguarding Children Board January 2015 London Borough of Waltham Forest Corporate Parenting Board. December 2014
53
Safeguarding Children Annual Report 2013-2014
54 Contents
Title Page Introduction 3 National Directives 3 Safeguarding Team 4 Safeguarding Children Policy and Procedure 5 Safeguarding Training 5 Safeguarding Children Board and NHS England Safeguarding and 5 Quality Meetings. Care Quality Commission Visit for Safeguarding Children 5 Voice of the Child 6 Violence Against Women and Girls 6 Multi agency Audit 6 Looked After Children Developments 6 Serious Case Review and Management Reviews 6 Child Sexual Exploitation and FGM 6 Child Death Overview Panel 7 Section 11 Audit 7 Multi-agency Safeguarding Hub 7 Objectives 2015-2016 7 Conclusion 8 References 8
2 55
1.0 Introduction 1.1 Ensuring the safety of children remains central to the planning and commissioning of all children services within Waltham Forest. Waltham Forest Clinical Commissioning Group (WFCCG) has continued to embed and develop Safeguarding process and principles in partnership with key stakeholders and providers within the borough. . 1.2 Whilst the responsibility for coordinating safeguarding children arrangements lies with Local Authorities, effective safeguarding is based on a multi-agency approach. WFCCG is accountable for ensuring its internal structures and processes are in place to meet the statutory requirements as set out in the Intercollegiate document 2014 and Working Together (2013). 1.3 The CCG in meeting their constitutional requirements are required to ensure an annual report is produced to highlight the progress made and the interrelations of Safeguarding Children and Looked after Children Services (LAC). 1.4 The following annual report identifies the initiatives put in place in the past year that give assurance to the Governing Body that the services commissioned are safe and effective. The report also identifies the work planned for the coming year that will continue to enhance the partnership and ensure safeguarding and LAC continues to be central to children services within the borough.
2.0 National Directives 2.1 The Accountability and Assurance Framework: Safeguarding Vulnerable People in the Reformed NHS.” The CCG is a statutory NHS body with a range of statutory duties, including safeguarding children. In March 2013, the NHS Commissioning Board (now known as NHS England) published the “Accountability and Assurance Framework: Safeguarding Vulnerable People in the Reformed NHS”. Although this framework focuses on the statutory requirements to safeguard children the same key principles apply in relation to safeguarding adults.
The national accountability and assurance framework aims to:
• Promote partnership working to safeguard children, young people and adults at risk of abuse • Clarify NHS roles and responsibilities for safeguarding, including in relation to education and training • Provide a shared understanding of how the new system will operate and, in particular, how it will be held to account both locally and nationally • Ensure professional leadership and expertise are retained in the NHS, including the continuing key role of designated and named professionals for safeguarding children • Outline a series of principles and ways of working that are equally applicable to the safeguarding of children and young people and of adults in vulnerable situations, recognising that safeguarding is everybody’s business.
2.2 The Savile Investigation - During 2013-2014, the Department of Health requested commissioner and provider organisations to review and provide information on three occasions as part of the Department of Health’s review relating to the findings of the J Savile investigation (Operation Yew tree). All providers of directly commissioned services requests were made to verify the current arrangements that are in place to safeguard vulnerable
3 56 people. Waltham Forest CCG has responded appropriately to the requests and has been able to give assurances to date. The Lampard Report - lessons to be learned by the NHS is due to be published in relation to the findings of the Savile case. 2.2 Three high profile serious case reviews were published which highlighted abuse at its worst in relation to Daniel Pelca, Hamza Khan and Kanuea Williams. The cases highlighted key failings in the system of identifying abuse and the role agencies have in escalating and sharing concerns of abuse. 2.3 Child Sexual Exploitation was highlighted in the serious case reviews relating to Rochdale, Peterborough, and Oxfordshire, which resulted prosecution of staff who were responsible for the looked after children in care homes in these areas.
3.0 The Safeguarding Team
3.1 Figure 1. The Structure of the Safeguarding Team - Quality and Governance Directorate.
Director of Nursing, Quality and Governance
Deputy Director Committee and Quality and CCG Systems
Safeguarding Administrator Adults
Designated Nurse Safeguarding Designated Children Nurse Looked after Children
3.2 The Director of Nursing, Quality and Governance has executive responsibility for safeguarding children and adults. The Director provides professional leadership to the Designated Nurse for Safeguarding Children and Designated Nurse Looked after Children. The Deputy Director of Quality and Safeguarding Adults provides daily operational management of the team. 3.3 The Named General Practitioner for Safeguarding Children role is currently vacant following the retirement of the previous post holder in May 2014. NHS England commissions this post. A Recruitment process is currently in place to appoint to the vacant post. The CCG commissions the Designated Doctor’s for Safeguarding Children, Looked after Children and Child Death Overview Panel from North East London Foundation Trust on a session basis.
4 57 4.0 Safeguarding Children - Policy and Procedures 4.1 Waltham Forest CCG Safeguarding Children Policy was reviewed and ratified in August 2014. This policy is compliant with the Working Together (2013) and Intercollegiate document (2013) recommendations.
5.0 Safeguarding Training 5.1 A training needs analysis was conducted for all CCG staff. A combination of e-learning training at level one and two is provided by the CCG. 5.2 Safeguarding Training is a mandatory requirement for all CCG staff. 5.3 Dates are planned for January 2015 and February 2015 to provide face-to-face training for General Practitioners and other staff wishing to attend. 5.4 A register of training compliance is kept by the Clinical Support Unit and within the Safeguarding Team. 5.5 Two face-to-face Looked After Children training events were provided to GPs and Primary Care staff during 2013-2014. The evaluation following the training was very positive. Future training will be provided later in the year to raise awareness of the needs and statutory responsibilities for Looked after Children.
6.0 Safeguarding Children Board and NHS England Safeguarding and Quality Meetings 6.1 The LSCB is independently chaired. The Chair meets regularly with the Director of Children and Family Social Services and the Cabinet Member with responsibility for Children and Family Services. The LSCB also reports into the Community Safety Network (Safety Net) and the Waltham Forest Health and Wellbeing Board. Greater alliance with the Waltham Forest Safeguarding Adult Board has been developed. This has increased a more cohesive child and family focus. 6.2 The Director of Nursing, Quality and Governance WFCCG is the CCG lead with membership of the Board. The Designated Nurse Looked after Children and the Designated Nurse Safeguarding Children also attend. The CCG attendance rate at this meeting is 100% for 2013-2014. 6.3 The CCG strives to work in partnership with NHS England. Attendance at these meetings ensures intelligence sharing and co commissioning is aligned to local services. The CCG currently attends the Safeguarding Assurance Committee and the Quality and Safety Committee. These meetings support the local work streams implemented to ensure safeguarding is considered nationally and at a local level.
7.0 Care Quality Commission inspection for Children Looked After Safeguarding 7.1 On 30 September 2013, The Care Quality Commission (CQC) conducted their first inspection of a CCG. This inspection used the new framework to review services for Safeguarding Children. This included reviewing Looked After Children Services. The CQC focused on evaluating the experiences and outcomes for children, young people, and their families who receive services. The CQC report commended the leadership role played by the CCG in supporting Children Services. The CCG Composite Health Action plan was devised to ensure the implementation of the 10 CQC recommendations (3 of which related to LAC) were addressed. All recommendations have now been fully achieved.
5 58 8.0 Voice of the Child 8.1 The CCG recognises that work is required to ensure the voice of the child is heard. The Designated Nurse for LAC has completed an audit on the perception of Voice of the Child within LAC services. The audit highlighted a greater emphasis on ensuring voice of the child is considered when developing services and commissioning for 2014-2015.
9.0 Violence Against Women and Girls (VAWG) 9.1 The Metropolitan Police and Members of LSCB launched the VAWG in December 2013. The CCG attended the event and pledged to support the cause. Independent domestic advocates are available to support and are based within Whipps Cross Hospital and Community Services. Further work to develop the local strategy is currently being finalised.
10.0 Multi Agency Audit 10.1 The CCG has supported and participated in multi-agency audit of Safeguarding Children investigations and Looked After Children cases in 2013-2014. The lessons learned have been shared with organisations involved and support has been given to provider services to share and implement recommendations identified from these audits.
11.0 Looked After Children Developments 11.1 The CCG in partnership with the Local Authority has produced in partnership Health Passports to highlight a profile relating to the looked after child. The passport includes information that will assist health and social care staff to support the child. The passport also provides useful information and contact details for the looked after child to use if required. The passports have now been issued to all LAC within and out of borough. 11.2 The Looked After Children strategy has been developed in partnership and currently out for consultation with external partners. The strategy will be published in January 2015.
12.0 Serious Case and Management Reviews The CCG has been involved in a multi- agency management review. Whilst the panel considered that, the case did not meet the threshold for a serious case review. There was recognition of the benefit of collective learning for all agencies concerned. There are currently two active out of borough Serious Case Reviews and 1 within borough.
13.0 Child Sexual Exploitation and Female Genital Mutilation 13.1 In 2013, the Local Authority in partnership with the Metropolitan Police launched the Child Sexual Exploitation Strategy. This includes and references the Pan London Protocol, which identifies the gold standard in addressing and supporting children who have experienced child sexual exploitation. This is a growing concern across London. The CCG is a member of the CSE sub Committee that is supporting the work the partnership is undertaking to eradicate CSE and ensure processes are in place to support the CSE agenda. 13.2 Female Genital Mutilation is a growing concern within the London region. The CCG is a member of the NHSE FGM working group who are developing a UK wide FGM pathway to ensure women and young girls receive the right treatment and support. This project is in its early stages but aims to provide improved care to this vulnerable group.
6 59 14.0 Child Death Overview Panel 14.1 The CCG continues to provide support and overview on any child deaths that occur within health commissioned services. The Director of Nursing, Quality and Governance and the Designated Nurse Safeguarding Children provide expert clinical advice to support decision- making and safeguarding advice when reviewing these cases. 14.2 In 2013-14, Waltham Forest received a total of 23 child death initial notifications. This is the lowest recording of child death notifications in five years. There were 39% unexpected deaths and 61% were expected. 14.3 The CCG has supported and attended a number of seminars and workshops to ensure the recommendations and action highlighted from these cases are shared. The CCG also hold the commissioned services to account to ensure the learning is embedded within their service.
15.0 Section 11 Audit 15.1 The Section 11 audit is completed by all LSCB partners to be assured that safeguarding processes are in place in relation to the services they provide. This includes the safer recruitment in place to ensure that any services that have contact with children provide safe and effective staffing to meet the needs of the child. The last audit took place in 2012. The CCG is compliant with this audit. The re-evaluation of this audit will take place in January 2015.
16.0 Multiagency Safeguarding Hub (MASH) 16.1 The CCG has continued to support and commission health visitors and an administrator to support the multiagency safeguarding hub. The service provides multiagency advice and coordination for Waltham Forest safeguarding children concerns referred to the service. The service has been closely monitored to ensure the contractual requirements are met for this service through the Clinical Quality Review Meetings chaired by the CCG.
17.0 Objectives for 2015-2016
• Develop a Safeguarding Children Strategy • Complete the 2014 Section 11 Audit • Development of a joint programme of targeted quality assurance visits for residential placements in and out of borough. • Engage and involve children, young people, and their carers by undertaking further ‘voice of the child surveys’, requesting their views on their experiences of commissioned services. • Work with CCG staff to ensure key performance indicators and quality indicators include national and local safeguarding children and Looked After Children statutory and legislative requirements and that these measures are monitored and achieved. • Further development of a hand-held LAC Health Passport and an electronic version to reflect the health journey. • Implement the Action Plan for the LAC Health Commissioning Strategy. • Monitor and provide face-to-face Safeguarding and LAC training programmes for staff in CCG and Primary Care.
7 60 • Complete scoping exercise on the health needs of care leavers and commission appropriate services. • Develop a pathway for the management of information for adopted children. • Contribute to the development of a Waltham Forest Teenage Pregnancy Strategy. • Improve further the timeliness for out-of-borough health assessments. • Participate in provider forums to raise awareness of health needs of LAC and Safeguarding Children. • Develop an integrated LAC Health, Education, and Social care dashboard. • Influence the design of a consent form to help reduce delays in undertaking assessments.
18.0 Conclusion 18.1 The annual report has highlighted the work that has taken place to strengthen partnership working and given assurance that commissioned services have safeguarding children at the centre of the care provided. The report also highlights the future work required quality improvement.
19.0 References London Borough of Waltham Forest Safeguarding Children Annual Report 2013-2014. Every Child Matters (HM Government, 2004) National Service Framework for Children, Young People, and the Maternity Services (DH, 2004) Promoting the Health and Wellbeing of Looked After Children (DH, 2009) Working Together to Safeguard Children (HM Government, 2013) Promoting the quality of life for Looked after Children (NICHE, 2010) Statutory Guidance on Joint Strategic Needs Assessments and Joint Health Wellbeing Strategies (DH, 2013a) NICE public health guidance 28: Looked-after children and young people (NICHE, 2010a) NICE quality standard for the health and wellbeing of Looked after Children and young people (NICHE, 2010b) Looked After Children: knowledge, skills, and competences of health care staff: Intercollegiate competences (RCPCH, 2013) Healthy Lives, Healthy People: improving outcomes and supporting transparency, Department of Health (DH, 2012) Safeguarding Vulnerable People in the Reformed NHS: Accountability and Assurance Framework (NHSCB, 2013) The NHS Outcomes Framework 2014–15 (DH, 2013) Public Health Outcomes Framework for England 2013–2016 (PHE, 2013) NHS England Strategic and Operational Planning 2014 to 2019
Authors: Lorraine Smailes Deputy Director Quality and Safeguarding Adults Anna Jones Designated Nurse Safeguarding Children Date: 14 November 2014
8 61
Item 4.1
Title of report Finance Report
From Les Borrett, Director of Financial Strategy - WFCCG
Purpose of report To provide an update to the Governing Body Board around the financial position of the CCG as at the end of October 2014.
Recommendations The Governing Body Board is asked to note this report.
Impact on patients & carers None
Risk implications There are some financial risks inherent within the CCG’s 2014/15 QIPP programme, pressures developing within continuing healthcare and on acute contracts outside of WEL.
Financial implications As a result of the information available to date the CCG is projected to achieve a total surplus of £7.4 million which is £4.3 million above the planned surplus for 2014/15 and to manage CCG management costs within the “capped” running cost allowance.
Equality analysis Not relevant for this report.
Other committees/groups, including the CCG Reference Group and Rapid Feedback Group (please include detail of when the group were involved and in what capacity) Finance and QIPP Committee
62
Finance Report
Update regarding the financial position of the CCG as at the end of October 2014.
63 Finance Report
Document revision history
Date Version Revision Comment Author/Editor
13/11/2014 1.1 Minor redrafting of narrative None Ian Clay
Document approval
Date Version Revision Role of approver Approver
14/11/2014 1.1 As above Director of Financial Les Borrett Strategy
Page i 64 Finance Report
Contents
1 Introduction 1
2 CCG summary income and expenditure position 1
2.1 Key headlines for M7 2
3 Commissiong expenditure 2
3.1 Barts Health contract 3
3.2 Associte acute contracts 4
3.3 Continuing healthcare 4
3.4 Prescribing 5
4 Other financial risks and mitigations 5
5 QIPP 6
6 Balance sheet, cash management and PSPP 7
7 Conclusion and recommendation 7
Appendix A Detailed income and expenditure position 8
Appendix B Detailed QIPP performance 9
Appendix C Statement of financial position (balance sheet) 10
Appendix D Bids against non recurrent funds 11
Page ii 65 Finance Report
1 Introduction The purpose of this report is to update the Finance and QIPP Committee on the financial position as at the end of October (month 7) and projections of income and expenditure to year end. The report goes on to describe any key variances to the commissioning budget and identifies financial risks and mitigating actions. The Finance and QIPP Committee is asked to note that the CCG is currently forecasting that it will achieve a total surplus of £7.4 million which is £4.3 million above the planned position for 2014/15 which was to deliver a 1 percent surplus; however there are risks as identified within the commentary.
2 CCG summary income and expenditure position A detailed budget position is attached at Appendix 1 and a summary position is shown in the following table:
Annual Year to Date Forecast Budget (surplus)deficit Outturn M7
£’000 £’000 £’000
Barts Health 129,566 (200) (343)
Other Acute 49,089 868 1,608
Mental Health 31,120 148 68
Other Non-Acute 47,738 937 1,646
Prescribing 33,388 (169) (290)
Corporate 8,153 (22) 30
Sub-Total 299,054 1,560 2,719
CCG Reserves 16,303 (4,066) (7,014)
TOTAL 315,357 (2,506) (4,295) EXPENDITURE
TOTAL INCOME 318,461 - -
NET POSITION 3,104 (2,506) (4,295)
Page 1 66 Finance Report
2.1 Key Headlines for M7 to note are: • The CCG is now reporting a surplus of £2.5 million against plan year to date (YTD) and is forecasting to deliver a total surplus of £7.4 million at year end after the partial application of reserves and brought forward balance sheet flexibility.
• A small number of acute contract negotiations regarding the final settlement for Q4 2013/14 remain outstanding. Negotiations with Barts have now concluded and settlement agreed at the value used across the entire contract to close 2013/14 accounts. The CCG continues to challenge the final settlement claim from the Homerton which in total represents a risk to WF of £0.4 million and we hope to conclude negotiations and provide a verbal update at the Committee.
• Barts have submitted SLAM data for M6 that if extrapolated results in a headline full year claim of £8.8 million above contract value after taking account of the Q1 settlement. This headline claim further reduces to £3.1 million after taking account of readmissions, threshold and productivity metrics adjustments which are largely undisputed and calculated using precedents agreed at Q1. There is still a risk that the underlying claim from Barts may be understated due to under recording of activity as a result of problems with the implementation of the new patient administration system at Whipps Cross which may be corrected in later months. The report includes detailed analysis showing our assessment of the risks associated with this contract which have reduced from the £0.2 million reported at M6 to a £0.3 million surplus at M7.
• We are projecting financial risks within a number of budgets linked to red rated QIPP schemes as detailed within Appendix 2.
• We are now projecting financial risk within the CHC budgets of £1.4M in addition to the £0.1M red rated QIPP.
• We have received actual prescribing data up to M5 and have extrapolated 2014/15 outturn on the basis of the average daily prescribing costs over the last 6 months. This indicates that the CCG is on plan to deliver a small surplus before taking account of increased QIPP delivery over the second half of the year. The medicines management team have calculated the impact of changes to drug tariffs announced by the Department of Health and we are projecting a net position of £0.3 million underspent against the prescribing budget. Actual performance against the phased QIPP plan up to M5 indicates positive progress on the delivery of savings which we are reflecting through Appendix 2
3 Commissioning expenditure At month 7 the CCG is reporting a £1.6 million deficit against commissioning budgets and a projected deficit of £2.7 million at year end. This deficit is covered by uncommitted contingency and reserves as detailed later in the report. Key commissioning variances and projected risk are as follows:
Page 2 67 Finance Report
3.1 Barts Health contract • Agreement has now been reached on closing down Q1 claims across the whole contract and the M6 SLAM claim submitted by the Trust indicates an extrapolated full year claim totalling £8.4 million above contract after taking account of this Q1 settlement. It is worth noting that £5.7 million of this difference between extrapolated headline claim and the risk adjusted claim relates to readmissions, marginal rate threshold and productivity metrics which are not materially in dispute with the Trust and have been calculated in line with principals agreed at Q1. A further £1.0 million of penalties are likely to be levied for Q2 based on poor RTT performance. A summary showing all of the adjustments made to the headline M6 claim extrapolated for the full year is contained within the following table:
M7 reporting Upside Base Downside M6 FOT £'000 £'000 £'000 £'000 Extrapolated FOT from M6 SLAM 137,535 138,035 138,035 140,763
Readmissions penalty (1,859) (1,859) (1,859) (1,666) Threshold (Q1) Agreed in Baseline 0 0 0 (1,243) Emergency Threshold Q2-Q4 (3,287) (2,787) (2,090) (2,409) Impact of Productivity Metrics (1,225) (858) (643) (858) Respiratory Physiology (238) (190) (143) (190) Claims (2,459) (1,721) (983) (1,900) RTT Risk 0 300 500 1,000 Penalties Q1 Agreed in Baseline 0 0 0 (2,300) Penalties Q2 (1,313) (1,012) (759) 0 Penalties Q3 - Q4 Est (1,126) (126) (126) 0 Remove Barts CQUIN Claim (3,015) (3,015) (3,015) (2,971) Other Adjustments (73) (73) (73) (200) Anticipated Future QIPP (528) (352) (176) (470) Hospital at Home 0 0 0 (600)
Sub-Total 122,412 126,342 128,668 126,957 CQUIN (base case assumes 95%) 2,801 2,881 2,913 2,851 Sub-Total 125,213 129,223 131,580 129,808 HOT Value 129,566 129,566 129,566 129,566 Total Forecast Risk (4,353) (343) 2,015 243
• The table details the value of adjustments we have made reflecting risk assessment from the contracting team relating to challenges which have been raised with the Trust. As can be seen, there are both upside and downside risks associated with the above projection and the scale of the range at M7 is £6.4 million. The gross claim before taking account of Q1 settlement increased by £1.5 million this month and this was largely due to a significant increase in claims relating to high cost drugs which may be a recording error and we have reflected this within our upside position.
Page 3 68 Finance Report
• The position assumes we will agree a recovery trajectory for RTT in Q3 and Q4 which the Trust meets and on which basis we will re-invest any RTT fines due for the second half of the year.
3.2 Associate acute contracts Based on M6 SLAM data received from other acute providers we are projecting a full year risk of £1.8 million with material risks developing at the following Trusts: • £1.3 million risk now projected against the £3.4 million North Middlesex University Hospital contract. Data suggests that both the volume of elective referrals and emergency flows to this provider are increasing as evidenced within the following graphs:
GP Referrals A&E Attenders North Middlesex University Hospital NHS Trust North Middlesex University Hospital NHS Trust 280 410 260 390 240 370 220 350 200 330 180 310 160 140 290 120 270 100 250
Series1 Linear (Series1) A&E Attenders Linear (A&E Attenders)
• £0.6 million risk projected against the £11.2 million Homerton contract. The provider has accepted challenges relating to maternity pathway claims within previous SLAM reports and negotiations continue around the final settlement of the Q4 2013/14 claim.
• £0.2 million risk projected against the £1.9 million Moorfields contract. Last month’s report suggested that this may be related to backlog reductions associated with the 18 weeks RTT target and the level of projected risk has not altered this month.
• £0.2 million risk now projected against the £1.1 million Royal Free contract. This risk is predominantly associated with a small number of high cost patients which are being investigated by the contracting team. The level of projected risk has reduced further since M6.
• £0.4 million risk projected against the £2.5 million extended choice network non NHS provider contracts. There is evidence that referrals to these providers is increasing and will be linked to the RTT issues at Barts Health.
3.3 Continuing healthcare At M7 we are projecting year end risk of £1.5 million which includes £0.1 million associated with risk assessed QIPP. Work is ongoing to review the high level of 1:1 care being provided currently to ensure that original panel decisions remain appropriate as clients settle into new placements. The following table shows that there has been a 13 percent reduction in the number of patients recorded within the CHC database during October 2014 and at present it is not possible to easily reconcile these numbers to
Page 4 69 Finance Report
invoices being submitted by suppliers. As such, analysis has been undertaken to estimate costs based on invoices received rather than rely on the projections from the data base. This process has identified a further risk related to an additional children’s continuing care case totalling £0.1 million. Further risks have emerged relating to a number of delayed assessments whereby the CCG has had to reimburse families for period of privately funded care amounting to £0.1 million. This continues to be an area of significant financial risk for the CCG and the Delivery Improvement Unit within the CSU have been commissioned to undertake a detailed review of the current reporting arrangements and the apparent underlying growth in demand.
Patient Numbers Recorded at Month End Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14
Adults 40 39 38 43 43 39 43 49 50 50 48 45 change in month -2.5% -2.6% 13.2% 0.0% -9.3% 10.3% 14.0% 2.0% 0.0% -4.0% -6.3%
Older People 107 109 110 115 117 102 130 143 150 125 121 118 change in month 1.9% 0.9% 4.5% 1.7% -12.8% 27.5% 10.0% 4.9% -16.7% -3.2% -2.5%
Fast Track Palliative 49 53 48 58 74 93 79 85 97 86 81 54 change in month 8.2% -9.4% 20.8% 27.6% 25.7% -15.1% 7.6% 14.1% -11.3% -5.8% -33.3%
Total 196 201 196 216 234 234 252 277 297 261 250 217 change in month 2.6% -2.5% 10.2% 8.3% 0.0% 7.7% 9.9% 7.2% -12.1% -4.2% -13.2%
3.4 Prescribing We are projecting a £0.3 million year end underspend based on extrapolating actual prescribing data covering the 6 month period from March 2014 through to August 2014 for a full year and then adjusting for delivery of phased QIPP savings against the full target of £1.0 million. As was reported previously there was a significant movement between projected year end expenditure used to set the baseline 2014/15 budget and final outturn (£0.75 million). The 2014/15 plan includes 6.3 percent growth (£2.0 million) so the movement in outturn has had a significant impact on the real level of uplift within the budget before applying QIPP. The medicines management team have reviewed the reasons for the increase in prescribing costs during the last few months of 2013/14 and a process of quarterly detailed reporting to the Finance and QIPP Committee has been established. The latest detailed QIPP monitoring data indicates that schemes are delivering against phased plans. Our latest projections include an assessment of the impact of recently published drug tariff increases which have been agreed by the Department of Health through its annual review of medicines margins as part of the pharmacy contract settlement.
4 Other financial risks and mitigations Other financial risks faced by the CCG and mitigations are: • NHSE had confirmed that a further transfer of allocation between CCGs and Specialised Commissioners will be actioned through month 10 to ensure that planned activity within the 2014/15 contract sits with the correct responsible commissioner. This transfer has been delayed however the analysis has been finalised and the risk identified to WFCCG is £0.1 million.
Page 5 70 Finance Report
• There are risks that 2014/15 budgets which were set reflecting projected outturn will not have adequately reflected misattributed specialised commissioning costs. The headline Barts claim and risk assessment reflects ongoing specialised commissioning activity charged in error to the CCG but until the claim is settled and clarity on any CCG activity charged in error to NHSE is resolved this remains a risk. Our M7 Barts assessment therefore excludes £0.4 million of potential benefit linked to costs which we believe have been charged to the CCG incorrectly but which may require matching funding transfers to NHSE in order to correct.
• Work continues with Barts around understanding the volumes of additional activity required and timelines involved with meeting RTT targets. It is likely that meeting the targets will involve increased elective costs above the levels contained within the current contract risk projected for Barts and our M7 projections include a £0.3 million provision to cover this risk.
• The 2014/15 budget assumes successful delivery of the £10.4 million QIPP programme. Non delivery of a number of red rated schemes has been reflected in our M7 reporting and the latest risk assessment of the overall programme will be provided later in the report.
• The CCG established a contingency reserve of £1.5 million within its 2014/15 plan and this has been fully applied within our projected outturn at M7.
• The CCG established non recurrent headroom of £7.6 million within the 2014/15 plan. We have made commitments totalling £4.9 million however after taking account of projected slippage and a further release of non-recurrent investment linked to CCG priorities which have now been prioritised and approved through the Finance and QIPP Committee in line with the process agreed by the Governing Body in October and detailed within Appendix D there is currently £2.3 million potentially available to mitigate further in year risk.
• As at M7 the acute risk reserve totals £6.0 million which includes a specific element for Barts Health of £1.5 million above signed contract value which allows for some level of in year risk. At M6 we released £4.3 million of this reserve thereby increasing the projected year end surplus to £7.4 million. These funds will be lodged with NHSE to be returned in future years to the CCG.
• Balance sheet flexibility had been identified at Q1 relating to liabilities provided for within the 2013/14 accounts which have not materialised. This benefit totals £1.9 million and has been applied in full within our current projections.
5 QIPP Appendix 2 shows the latest detailed risk assessment of the CCG’s £10.4 million QIPP programme which underpins our 2014/15 budget along with a projection of the level of QIPP which will be achieved at year end. The risk rating is summarised in the following table and shows the movements since our M6 reporting.
Page 6 71 Finance Report
Current Current Previous Value Percentage Assessment £m Red 2.2 21% 21% Amber 1.9 13% 18% Green 6.3 66% 61% 10.4 100% 100%
Appendix 2 shows that we are now projecting delivery of £9.5 million of QIPP savings within our reporting.
6 Balance sheet, cash management and performance against public sector payment policy (PSPP) Details of the CCG’s closing statement of financial performance or balance sheet along with comparable figures at M7 are shown within Appendix 4. The CCG had drawn down cash totalling £161.5 million at the end of M7 from the government banking service and had cash holdings of £0.1 million as at the end of October. CCGs need to minimise the level of cash held at bank in line with Treasury guidance. The level of cash holdings reduced by £1.3 million during the month and revised cash management rules require that we maintain monthly cash holdings at this level going forward. The CCG, in common with all public sector bodies, is mandated to pay suppliers within 30 days from submission of a valid invoice. As at the end of October the CCG’s cumulative performance was measured at 98.7 percent (based on the value of invoices paid) and 89.1 percent (based on volume of invoices paid against a target of 90 percent). Performance against these PSPP targets at the same time last year was 66.4 percent and 63.9 percent respectively.
7 Conclusion and recommendation The Finance & QIPP Committee is asked to note this report.
Page 7 72 Finance Report
Appendices A. Detailed income and expenditure position
Summary Position YTD Full Year Budget Actual Variance Budget Forecast Variance £'000 £'000 £'000 £'000 £'000 £'000 Confirmed (182,052) (182,052) 0 (318,461) (318,461) 0 Anticipated 0 0 0 0 0 0 Revenue Resource Limit Total (182,052) (182,052) 0 (318,461) (318,461) 0
Acute SLA's 98,756 99,590 834 169,317 170,725 1,409 SLA Exclusions and Other Acute 5,526 5,360 (166) 9,338 9,194 (144) Acute & Integrated Care Total 104,282 104,950 668 178,655 179,919 1,265
Mental Health 18,044 18,192 148 31,120 31,188 68 Learning Disabilities 2,510 2,452 (58) 4,303 4,204 (99) Continuing Care 7,059 7,917 858 12,102 13,614 1,512 Community Services 14,385 14,191 (195) 24,661 24,327 (334) Reablement 387 545 159 663 935 272 Programme Spend on Additional Activities 668 628 (40) 1,146 1,077 (69) CSS Services 1,613 1,845 231 2,766 3,162 396 Local Enhanced Services 19 0 (19) 33 0 (33) Out of Hours 1,190 1,190 0 2,040 2,041 0 Prescribing 19,476 19,307 (169) 33,388 33,098 (290) Projects 15 15 1 25 26 1 Non Acute Total 65,368 66,283 916 112,246 113,671 1,424
Total Commissioning Expenditure 169,650 171,233 1,584 290,901 293,590 2,689
CCG Running Cost (Excl CSU) 2,240 2,231 (10) 3,094 3,056 (38) CCG Running Cost (CSU) 2,099 2,085 (14) 2,917 2,895 (23) Operating Costs Total 4,339 4,315 (23) 6,011 5,951 (60)
GP IT 783 783 0 1,343 1,343 0 Programme Corporate Costs Total 783 783 0 1,343 1,343 0 Premises - Void Costs 466 466 0 799 889 90 Estates Costs Total 466 466 0 799 889 90
Risk Share 0 0 0 (155) (155) 0 Contingency (0.5%) 0 0 0 1,552 0 (1,552) Acute Reserves 3,491 0 (3,490) 6,035 2,478 (3,557) CCG Reserves 1,447 937 (511) 7,222 7,222 0 Winter Resilience 65 0 (65) 1,649 1,649 0 Balance Sheet Benefit 0 0 0 0 (1,905) (1,905) Reserves and Contingencies Total 5,003 937 (4,066) 16,303 9,289 (7,014)
Total Expenditure 180,241 177,735 (2,506) 315,357 311,062 (4,295)
Unadjusted Surplus / (Deficit) 1,811 4,316 2,506 3,104 7,400 4,295
Page 8 73 Finance Report
B. Detailed QIPP performance
Detailed 2014/15 Project Lead 2014/15 High Medium Low M7 QIPP QIPP Plan QIPP Risk Risk Risk Forecast Target £'000 £’000 £’000 £’000 £'000
Integrated Care C. Gilmartin 1,640 1,640 2,185 Health Coaches C Gilmartin 104 104 0 Planned Care F Hamilton 1,103 840 186 77 263 Independent Diagnostics B Pratt 100 100 100 Heart Failure F Hamilton 50 50 50
Barts Metrics B Pratt 1,416 216 1200 2,015 Other Metrics B Pratt 719 444 275 719 NELFT 446 I Clay 1,491 1,627 Other Non Acute 1,045
Prescribing A Onyeagwara 1,000 300 700 1,000
Corporate I Clay 373 373 373 CSS C. Edmunds 500 306 194 194 CHC M. Marc us 500 500 0 Unbundled CSS Diag. C. Gilmartin 150 150 0 Older Peoples C. Gilmartin 100 100 0 Pathway Ambulatory Care C Gilmartin 262 196 66 66 PELC C Gilmartin 375 375 375 NCA’s C Soltysiak 100 100 100 Pulmonary Rehabilitation J Driver 300 300 376 Pathology Duplication N. Keefe 50 50 0 Paediatric Asthma K. Hankins 44 44 44
Total QIPP Plan 10,377 2,246 1,262 6,869 9,487
Page 9 74 Finance Report
C. Statement of financial position (balance sheet)
Statement of Financial Position Position as at 31st October 2014
£000 £000 Mar Oct 2014 2014
NON-CURRENT ASSETS
Property, Plant and Equipment 8 5 TOTAL Non Current Assets 8 5
CURRENT ASSETS Trade and Other Receivables 4,453 966 Cash and Cash Equivalents 110 (62)
TOTAL Current Assets 4,563 904 TOTAL ASSETS 4,571 909
CURRENT LIABILITIES Trade and Other Payables (29,566) (20,382) Provisions - (1,930) TOTAL Current Liabilites (29,566) (22,312) NET CURRENT ASSETS/(LIABILITIES) (25,003) (21,408) Trade and Other Payables - - Provisions - - Borrowings - - TOTAL Non-Current Liabilites - - TOTAL ASSETS EMPLOYED (24,995) (21,403) FINANCED BY:
TAXPAYERS EQUITY General Fund (24,995) (21,403) TOTAL TAXPAYERS EQUITY (24,995) (21,403)
Page 10 75 Finance Report
D. Bids against non-recurrent funds
Non recurrent investments 2014/5 - final schemes
Directorate Bid
Cost Lead Descriptor (£000) Meeting scorecard targets Paed dietetics waiting list (childrens Clear the current backlog in referrals, assess impact of LBWF 1 CD CG/KH 50 assessments) cuts to service (corporate objective 2) To extend the pilot, based on evidence from east London CCGs 2 CD Bowel screening pilot CG/JD to support GP practices to drive up screening rates. Inclduing a 50 publisity capaign Based in localities, increasing the CL input by 3 sessions per 3 CD CL capacity for dementia visits to practices CG/NA 12 week.
Development of frail elder pathway to support new ways of working in ED - to prevent admission. Pilot to be run through 4 CD Frail elder pathway CG 0 winter 14/15. Project management support, further clinical support to ensure working across primary and community care
Additional CL time eg for IAPT, Anti coag, To develop pathways. Audits. Support and test buisness case 5 CD CG/CE 20 Carpal Tunnel assumptions To support development of IAPT programme, including 6 CD Admin support to CLs on IAPT programme CG/NA evaluation of visting programme, data analysis, setting up and 15 support practice visting programme 7 CD Read coding for practices CE
To meet the scorecard targets, training in improving quality of 8 CD Care plans on HA CG care plan, including practice based understanding of using and 0 developing these. (Supports corporate objective 2 and 3)
9 CD Diabetic education To pay additonal weekend or evening courses 6 10 NG CDC target HD to review if case for spend 0 To fund (PH) Flu campaign. Encourage take up. Leaflets to 11 NG Flu NK 30 pregant women with maternity letter. To produce leaflets, use radio adverts work with 3rd sector to 12 NG IAPT marketing campaign CG 25 promote IAPT 13 NG Blocks to accessing dementia services JR 0
QIPP delivery and planning Extension to March 2014 and evaluation with BC produced for 14 CD Extend health coaching pilot CG/PR 23 QIPP for 15/16, with contract rollout for 15/16 Devop the business case further with an implementation plan, 15 CD Consultancy support for LTC pilot CG/NA 45 to support the MH LTC project and set up project group pump priming investment in falls team, linked to frail elders 16 CD Falls strategy CG/PR 0 pathway, scoping development of falls clinic for WF
Project management support to ensure that ambulatory care 17 CD Ambulatory care pathway CG 20 QIPP is implemented and business case for 15/16 produced A full opthalmology review to explore areas for redesign, 18 CD Ophthalmology pathway AP reduce acute activity and other QIPP opportunities. There is an 10 ideal clinical lead to do this. Additional CSU time to support pathology QIPP as currently 19 CD Support to deliver pathology QIPP NK 12 CSU lead is strecth across other projects.
Supporting vulnerable women to access maternity services 20 CD Maternity Mates CG/KH 0 (links to corpoate objective 1)
work with third sector organisation to establish effective support for marginalised groups, to help them to navigate Supporting vulnerable groups to use EOL 21 CD CG/PR health services more efectively including EOL services and 0 and manstream health services making decisions on their future plans (DNR) Building on work already in development through LBWF Project management support to ensure that Diabetes QIPP is 23 CD Diiabetes integrated pilot CG/CE 70 implemented and futuer business case for 15/16 produced
Page 11 76 Finance Report
System Resilience
Create the capacity to develop the scope an effecitve assessment of bed capapcity across the WF health system, focussing on community bed capacity and pathwyas through acute and community settings. Product include benchmarking, 24 CD Health economy bed review CG/JF 0 identifucation of immendiate pathway fixes, evidence to support implmentation of BCF schemes, inclduing commissioning interntions. Also included in this the development of a surge managemtn protocol for the system
Supporting resiliance through community based step up step 25 CD Social workers and step down beds JM/CG facilities in WF health economy, redesigned in line with 75 findings of the audit. 26 NG Reduce CHC asssessment backlog HD Fund additional assessors via nelft to clear CHC backlog 65 End to end audit of ED to deliver clarity on current 27 CD Audit ED pathway JM/CG utilisastion/pathways/population behaviour and opportunities 30 for change To provide PELC with further space, to enable expansion of 28 CD PELC room upgrade CG/JF 0 streaming categories 29 CD Demand and Capacity audit CG 0 Additional non -recurrent capacity Short term input to bring team up to full compliment for 30 CD CG/NA 70 for Rapid, Assessment, Interface and winter 14/15 Discharge Create capacity for practices to be informed and supported to 31 CD supporting carers CE implement key areas of CCG strategy, working with carers 42 association to identify carers Additional internal capacity Polish up business cases (testing financial assumptions, getting information, benchmarking, comparing with best practice, Support to Delivery Team to cover 32 CD CE literature research, checking plans with providers), create and 15 vacancies etc. mobilise implementation plans, support Primary Care quality action plan (eg demand and capacity audit). 33 CD Support for practice visits CG 0 34(aNG website AS/CE redesign website 30 Centralised WF Communications create resource pack for managing CCG comms/presentations 34(bNG AS/CE 23 Resources etc. Business intelligence support required on many of the projects 35 CD Support to business intelligence JM/SYM listed. We have an internal expert, who can be backfilled to 41 release her capacity - one Band 7 for 4 months
OD CD Clinical Director PDPs JM support OD priorities 36 CD Clinical Lead PDPs 10 CD Facilitated OD time for admin team 37 CD Improvements to CCG accommodation DB new office equipment, etc. 14
38 NG H&S consultancy DP develop H and S strategy and training 5
Patient Feedback
Will provide instant feedback to GPs, OOH and commissioners 39 CD Machines in waiting rooms SR on patient experience. Will rollout FFT. Will cover all practices 22 and network for 2 years. Can negotiate lower price.
40 CD WX Lap tops JM To support CHC paperwork and F&F tests 0 41 NG GP alerts JR 0 42 NG Patient opinion reporting JR 0 43 NG Patient experience datasheets AS/JR 0 44 NG cancer patient experience JR/JD/TL 0 IT Consultancy support to Commg 45 CD CG 0 Directorate 46a Fin IT GP infrastructure LB/BS Upgrade GP IT equipment 95 46b Fin Digital IT strategy LB/BS Project manage digital strategy 65 Community engagement 47 NG MH service user forum CS/JR 0 48 NG Young peoples engagement strategy KC/JR 0 49 NG Vol sector health and social care network JR 0 50 NG Patient Training Programme JR 5 51 NG Plain English materials etc. AS 0 Consulting with LD service users and their 52 NG JR/KH 5 carers 53 NG patient individual bid JR 0 54 NG patient participation bid JR 20 55 NG comms re UC procurement JR/CGM 0 56 NG comms for UC strategy JR/CGM 20 57 NG TST engagement events AS 0 58 NG Mental Health Forum JR 0 59 NG Leaflets for new parents etc. HD 32 TOTAL 1,072
Page 12 77
Item 4.2
Title of report Update on the CCG’s 2015/16 Budget
From Les Borrett, Director of Financial Strategy - WFCCG
Purpose of report The report provides an initial assessment on the development of the CCG budget for 2015/16, highlighting key risks and mitigations.
Recommendations The Governing Body is asked to note this report.
Impact on patients & carers Without a balanced budget, services for patients and carers will be at risk.
Risk implications The risks are identified in the report.
Financial implications The report concerns the CCG’s financial position for 2015/16.
Equality analysis Not relevant for this report.
Other committees/groups, including the CCG Reference Group and Rapid Feedback Group (please include detail of when the group were involved and in what capacity) Finance & QIPP Committee.
78
2015/16 Budget Update
Update regarding the development of the 2015/16 CCG Budget.
79 2015/16 Budget Update
Document revision history
Date Version Revision Comment Author/Editor
13/11/2014 1.1 Minor redrafting of narrative None Ian Clay
Document approval
Date Version Revision Role of approver Approver
14/11/2014 1.1 As above Director of Financial Les Borrett Strategy
Page i 80 2015/16 Budget Update
Contents
1 Introduction 1
2 Background 1
3 The planning context 1
4 Draft 2015/16 budget 2
5 QIPP and risk assessment 3
6 Reserves and non-recurrent headroom 3
7 Conclusion 3
8 Recommendation 4
Appendix A Detailed income and expenditure position 5
Appendix B Detailed QIPP performance 6
Page ii 81 2015/16 Budget Update
1 Introduction This paper provides an initial indication around the 2015/16 budget based on rolling forward the CCG financial projections at M6 and reflecting currently available planning assumptions and confirmed growth. The paper identifies key assumptions and risks to the achievement of the CCG’s financial targets in 2015/16.
2 Background The CCG set a plan to deliver a 1 percent surplus or £3.1 million in 2014/15 and has subsequently increased it’s planned in year surplus to £7.4 million. The Department of Health announced CCG allocations for 2014/15 and 2015/16 in 2013 and provided indicative allocations for 2016-19. The intention of the DH is to allocate additional resources to under- capitation CCGs over the five year period to reduce, but not eliminate, inequalities in funding. Assuming the draft allocations for 2016-19 are honoured, WFCCG will move close to target by the end of the five year period. This is a position from which, albeit slowly, the CCG can begin to address the under- investment in local services identified in various benchmarking studies. Despite the increased allocations, however, the CCG continues to face significant pressures on its budgets: • Growth in population generally, and a younger population in particular, linked to rising maternity activity • Increasing life expectancy and prevalence of long term conditions • Growth in prescribing and continuing care costs • Financial pressures at Barts Health • Reductions in funding for local authorities, including social care services.
The above factors mean that even with baseline funding growth, the CCG still needs to make significant QIPP savings to meet financial targets.
3 The planning context CCGs are required to submit plans reflecting Department of Health financial rules that assure the delivery of the CCG’s commissioning objectives, including the key NHS constitution targets of: • Maximum referral to treatment waiting times • Access to cancer services • Maximum wait to be seen in A&E
For 2015/16, the CCG must set and deliver financial plans within NHS business rules. These are currently: • To achieve a minimum 1% surplus. • To maintain funds for non-recurrent investment of 1%. • To maintain at least 0.5% contingency.
Page 1 82 2015/16 Budget Update
The updated planning guidance will be published in December and reflected in our second cut plan.
The draft 2015/16 plan seeks to deliver these targets and additionally –
• Planning surplus of £7.4 million in line with return of 2014/15 surplus • Funds for non-recurrent investment have been earmarked at 1% • A further 1% has been earmarked for the London Health Commission • A contingency of 0.5% has been allotted to meet NHS business rules • No further WELC risk pool support will be required, but no repayment of previous support will be needed in 2015/16.
4 Draft 2015/16 Budget The CCG’s draft 2015/16 budget is based on an allocation of £333.2m which includes:
£000 Baseline Allocation 314,159 Return of 2014/15 Surplus 7,400 BCF Allocation 4,990 Adjustment for Overseas Visitors (267) Running Cost Allocation and GPIT 6,964 333,246
The confirmed allocation includes a 3.26% recurrent uplift on 2014/15. A) a programme uplift of 3.55% (1.7% above floor growth) B) a running cost deflator of -9.64%
The CCG is required to keep its running costs within a limit of approximately £22 per head of population which represents a 10 percent reduction since 2013/14. The draft corporate rollover budget for 2015/16 complies with this target. Appendix 1 provides a ‘bridge’ from the 2014/15 plan to that for 2015/16, identifying key movements, which are summarised within the table below:
£m 2014/15 M6 Projected Surplus 7.4
Non-recurrent income and expenditure 4.1 Net tariff efficiency and inflation 1.9 Demographic activity growth (9.7) QIPP 9.3 Cost pressures (6.6) Creation of non-recurrent reserve (6.4) Return of 2014/15 Surplus 7.4 2015/16 Surplus 7.4
Page 2 83 2015/16 Budget Update
5 QIPP and risk assessment Appendix 2 shows the CCGs £9.3m high level QIPP target which has been built into the plan. Further detailed business cases will be coming to the Committee over the next 3 months.
Other key risks to the plan are as follows • Acute demand growth leads to additional charges under payment by results beyond the 3.27 percent contained within the draft plan (covering population increase of 1.27% and general demand growth of 2%) • Plan is based on 2014/15 outturn which could be understated. • CHC demand may exceed the 3.5% assumed • Prescribing costs may rise by more than the 7% assumed
6 Reserves and non-recurrent headroom The plan includes three primary reserves, uncommitted at this stage:
• Contingency £1.6 million • Non-recurrent investment ‘headroom’ £3.2 million • London Health Commission priorities £3.2 million • Acute risk reserve £5.5 million (based on 3% of spend)
Headroom funds are intended to support non recurrent CCG investments designed to achieve transformational change.
The London Health Commission set up by the Mayor reported in October. A summary of its findings is attached. London CCGs are working with NHS England and the Mayor’s Office to agree an action plan to take forward the report, and a London Transformation Fund is proposed to support this plan, managed appropriately at CCG, SPG or London level. Key financial commitments are likely to relate to improving the primary care estate. Exact plans are not yet available but the draft budget assumes we will need to set aside 1% of our resource limit (£3.2m) to support this Fund.
7 Conclusion This initial CCG plan shows progress in meeting business rules for 2015/16 but significant risks remain, particularly in agreeing the Barts Health contract and delivery of QIPP. The plan identifies contingencies which are expected to be sufficient to manage these risks, but they will need to be closely managed.
Page 3 84 2015/16 Budget Update
8 Recommendation The Finance and QIPP Committee is asked to note the draft CCG rollover budget for 2015/16 and agree to receive updates at the January and March meetings.
Page 4 85 2015/16 Budget Update
Appendices A. Summary financial plan
Waltham Forest CCG Financial Plan 2015/16
Net CCG Efficiency Cost N/R DRAFT 2014/15 Adjust for Budget & Activity Pre ssure s/ Investment 2015/16 CCG £ 000's FOT NR Items Virement Inflation Growth QIPP Investments H/R Budget Income
Baseline Allocation (309,126) 5,734 0 0 0 0 0 0 (303,392) Return of 2014/15 Surplus 0 0 0 0 0 0 0 (7,400) (7,400) 2015/16 Growth 0 0 0 0 0 0 (10,767) 0 (10,767) BCF Allocation 0 0 0 0 0 0 (4,990) 0 (4,990) Anticapted Allocations 0 0 0 0 0 0 267 0 267 Running Cost Allocation and GPIT (7,686) 59 0 0 0 0 663 0 (6,964)
Sub Total RRL (316,812) 5,793 0 0 0 0 (14,827) (7,400) (333,246) Expenditure Acute - Barts Health 129,767 (551) 184 (1,423) 4,231 0 3,305 0 135,513 Acute - All other providers 51,299 (1,423) 0 (569) 1,631 0 3,484 0 54,423 Mental Health 31,080 (177) 0 (556) 1,011 0 1,022 0 32,379 Community 25,369 (8) 0 (456) 829 0 571 0 26,305 Continuing Care 13,517 (262) 0 (65) 459 0 0 0 13,648 Learning Disabilities 4,204 0 0 (76) 137 0 0 0 4,266 Other Commissioning 6,070 (56) (184) (103) 193 0 999 0 6,918 Prescribing 33,048 26 0 1,356 1,148 0 0 0 35,577 Corporate / Running Costs 5,994 0 0 0 0 0 0 0 5,994 GP IT costs 1,343 (596) 0 0 0 0 0 0 747 Premises Costs 889 0 0 0 0 0 0 0 889 Other CCG Reserves 0 0 0 0 0 0 10,490 0 10,490 1.0% N/R Reserve & QIPP 6,835 (6,835) 0 0 0 (9,314) 0 6,408 (2,906) 0.5% Contingency 0 0 0 0 0 0 1,602 0 1,602 Total Spend 309,413 (9,881) 0 (1,893) 9,639 (9,314) 21,473 6,408 325,844
(Surplus)/Deficit (7,400) (4,088) 0 (1,893) 9,639 (9,314) 6,646 (992) (7,403) % Surplus 2.44%
Page 5 86 2015/16 Budget Update
B. 2015/16 QIPP Programme
2015/16 QIPP Programme £m
Integrated Care Programme 2.1 Psychiatric Liaison 0.5 Ambulatory Care 0.2 Continuing Healthcare 0.2 Urgent Care Procurement Impact of 0.2 Primary Care Networks Mental 0.3 Health - Integrated Care Planned 0.1 Care 0.6 Women and Childrens 0.4 Medicine Management 1.0 Transactional/Contractual 2.5 Savings Corporate inc property 0.9 voids Other Schemes 0.3
9.3
Page 6 87
Item 4.3
Title of report Better Care Fund (BCF) Section 75 agreement
From Les Borrett, Director of Financial Strategy - WFCCG
Purpose of report This report asks the governing body to agree that the CCG enters into an agreement with the local authority for the hosting, governance and management of a pooled fund (the BCF) under S.75 of the National Health Service Act 2001 for the financial year 2015/16.
Recommendations The governing body is recommended to agree that the pooled fund is established as described in this report and that the Chief Officer be delegated responsibility to sign-off the agreement with the local authority in consultation with the CCG Finance Director and CCG Chair.
Impact on patients & carers This decision is an enabling requirement for the funding of the BCF plan and as such has no innate impact on patients or carers. The impact assessment of the BCF plan has been undertaken and reported elsewhere, the summary of which is that it is expected to have a beneficial effect on the health and wellbeing of protected groups, especially those with health problems and older people.
Risk implications The risks relating to the BCF programme are set out in the plan, attached. A risk sharing agreement forms a central part of the proposed S.75 agreement and is also attached.
Financial implications Waltham Forest’s share of resources for social care and health provision is under pressure and there is evidence that suggests it is historically under-funded in some areas. The CCG will require clear and careful financial impact analysis of its plans and strategies as they are developed, especially in light of the proposals to integrate health and social care systems. For example, Waltham Forest’s BCF allocation for 2015/16 is £17,512,000, plus a local top-up of £1,085,000, making the fund a total of £18,597,000. However this is not new money and it must all come from existing commitments, therefore the CCG will want to be satisfied that proposals brought forward under this heading represent the best and most effective use of public money.
88 Better Care Fund (BCF) Section 75 agreement
The immediate issue will be concern whether arrangements can be designed in such a way as to satisfy the requirements of the CCG auditors who will view this S.75 agreement as being material as it covers £12m of CCG expenditure with risk sharing of liabilities and assets.
Equality analysis Waltham Forest has a relatively deprived, diverse population which is ageing and increasingly suffering from multiple co-morbidities. Some outcomes, such as early mortality from cancer and cardiovascular disease, are amongst the worst in London. There are poor health outcomes and higher mortality rates for older people, particularly older Asian people with heart disease. There is a view that inequalities have worsened due to effects of welfare reforms with effects on health from overcrowding, anxiety and increased demand on GPs. The traditional divide between primary, community, acute and social care is not well suited to meeting these needs.
Other committees/groups, including the CCG Reference Group and Rapid Feedback Group (please include detail of when the group were involved and in what capacity) Not applicable.
89
Better Care Fund (BCF) Section 75 agreement
Establishment of a legal agreement between the CCG and the Council to govern a pooled fund of money for the delivery of services as set out in the Better Care Fund plan
90 Better Care Fund (BCF) Section 75 agreement
Document revision history
Date Version Revision Comment Author/Editor
3/11/14 1.1 Additional information about Following consultation with Michael financial management the chief finance officer Scorer requirements and deputy chief finance officer
13/11/14 1.2 Recommendation for Council to Following discussion at Michael host JCB on 12/11/14 Scorer
13/11/14 1.3 Additional information about Following consultation with Michael financial management the chief finance officer Scorer requirements and deputy chief finance officer
Document approval
Date Version Revision Role of approver Approver
13/11/14 1.3 As above Chief Finance Officer Les Borrett
Page i 91 Better Care Fund (BCF) Section 75 agreement
Contents
1 Summary 1
2 Background 1
3 Proposals 2
3.1 Commissioning 2
3.2 Governance 2
3.3 Contracting arrangements 3
3.4 Information sharing 3
3.5 Financial contributions 3
3.6 Pooled fund management 4
3.7 Risk share arrangements, overspends and underspends 5
3.8 VAT 6
3.9 Audit and right of access 6
3.10 Liabilities and insurance and indemnity 6
3.11 Performance management 7
4 Conclusion 7
Page ii 92 Better Care Fund (BCF) Section 75 agreement
1 Summary A Section 75 (S.75) agreement will need to be made between Waltham Forest NHS Clinical Commissioning Group (CCG) and Waltham Forest London Borough Council (LBWF) in relation to the Better Care Fund (BCF) and this paper explains that requirement and the need to make supporting arrangements. This paper explains the requirement to set up a pooled fund and to agree hosting, governance and management arrangements between the CCG and LBWF. A number of options for the pooled fund arrangements exist and this paper sets out the different implications. The requirement for a S.75 agreement considered in this paper is for the financial year 2015-2016. This report will also be considered by the Executive of the Council, at its cabinet meeting on 9 December 2014.
2 Background A S.75 agreement is an agreement made under section 75 of the National Health Services Act 2006 between a local authority and an NHS body in England (in this case Waltham Forest NHS CCG). Section 75 agreements can include arrangements for pooling resources and delegating certain NHS and local authority health-related functions to the other partner(s) if it would lead to an improvement in the way those functions are exercised. The BCF arrangements require a pooled fund, and the Care Act 2014, Section 121 provides for this. There are various ways in which pooled funds can be managed and there is a choice about which organisation manages the pooled budget. This paper sets out the potential advantages and disadvantages of the options that exist. The purpose of the pooled fund is “to ensure a transformation in integrated health and social care and is a critical part of the CCG 2 year operational plans and the 5 year strategic plans as well as the Council’s planning”, (NHS England guidance, http://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf- plan/). The minimum amount that must be in the pooled fund in Waltham Forest for 2015/16 is £17,512,000. However the Better Care Fund agreed by the Health and Wellbeing Board and submitted to government on 19 September is £18,597,000. The S.75 agreement governing the creation and management of the pooled fund must be in place before the beginning of the 2015/16 financial year (the year to which it applies). A template S.75 agreement prepared by Bevan Brittan on behalf of the national BCF programme office contains the following clause: “When introducing a Pooled Fund in respect of an Individual Scheme, the Partners shall agree:
Page 1 93 Better Care Fund (BCF) Section 75 agreement
. Which of the Partners shall act as Host Partner for the purposes of NHS Bodies and Local Authorities Partnership Regulations 2000 no 617 (NHSBLAP) 7(4)1 and 7(5)2 and shall provide the financial administrative systems for the Pooled Fund; . Which officer of the Host Partner shall act as the Pooled Fund Manager for the purposes of Regulation 7(4) of the NHSBLAP Regulations.” . The pooled funds need to be hosted by one ‘accountable’ organisation – this could be either London Borough of Waltham Forest (LBWF) or Waltham Forest NHS CCG. This does not necessarily affect the current commissioning and contracting arrangements. All services are to be run as a pooled fund. There will be no establishment of Non Pooled Funds for any services. There are potentially some advantages to hosting the pooled fund via the Council: . Budget surplus – any unused funds can be re-invested in the pool for the next financial year according to risk share agreed as NHS England will require the CCG to call back their share of the surplus (if any); and . Use of other contractual mechanisms – i.e. outside of standard NHS contract. NHS England announced on 29 October 2014 that Waltham Forest’s revised BCF plan had been ‘approved with support’, clearing the way to begin delivery of the proposals contained within the plan.
3 Proposals There is a choice to be made about whether the Council or the CCG hosts the pooled BCF. This report recommends that the Council hosts the pooled fund. Nonetheless, in 2015/16, the intention is that existing payments made by the CCG under existing contracts will normally be paid back to the CCG from the Council hosted fund, unless there is general agreement that it is appropriate to change this arrangement.
3.1 Commissioning There is not a formal requirement to make commissioning arrangements as part of the S.75 agreement, though in practice it may be advantageous. This could be through a “Lead commissioning” agreement where the Council or the CCG exercise the others functions; through “Joint commissioning” where the Council and the CCG continue to take their own decisions but the arrangements provide for co- ordination. This latter arrangement could be carried out through joint posts; by delegation of functions and authority to officer members of the JCB who take separate decisions together; or by coordinating
1 (4) The partners shall agree that one of them (“the host partner”) will be responsible for the accounts and audit of the pooled fund arrangements and the host partner shall appoint an officer of theirs (“the pool manager”) to be responsible for— (a)managing the pooled fund on their behalf; and (b)submitting to the partners quarterly reports, and an annual return, about the income of, and expenditure from, the pooled fund and other information by which the partners can monitor the effectiveness of the pooled fund arrangements.
2 (5) The partners may agree that an officer of either may exercise both the NHS functions and health-related functions which are the subject of the pooled fund arrangements.
Page 2 94 Better Care Fund (BCF) Section 75 agreement
decision making reports so that the Council and the CCG board are sighted on each other’s commissioning intentions and decisions. 3.2 Governance The Governance arrangements will be set out in Schedule 4. They are being developed with the need for reporting into the following groups being addressed: . Waltham Forest’s Health and Wellbeing Board . The Joint Commissioning Board . The Project Steering Group The explicit roles and responsibilities of each group and how they will work together to achieve the BCF outcomes needs to be defined. The detail of this may be dependent on the option that is chosen moving forward.
3.3 Contracting arrangements Existing contracts between the CCG and providers and the Council and providers should not be affected by the creation of a single host for the pooled fund. Future contracts are linked to the discussion about commissioning options, above.
3.4 Information sharing Organisations involved in providing services have a legal responsibility to ensure the way that they use personal data is lawful. Each partner needs to be aware of their obligations and feed this into their ways of working. In addition to developing joint working and governance structures, it is each partner’s individual responsibility to ensure that their organisation and security measures protect the lawful use of information.
3.5 Financial Contributions Schedule 1 to the Agreement, currently in development, will set out the detail for each scheme that is covered by the pooled fund. This could cover such issues as premises, IT support, staff, etc, which are necessary for the Council and the CCG to perform their obligations. This could either be considered on a scheme by scheme basis or on agreed overarching principles which will apply to such non-financial contributions. The Partners shall pay the Financial Contributions into the Pooled Fund in advance – the frequency of payment (monthly/quarterly etc) needs to be agreed. The proposal in this paper is for the Council and the CCG to agree overarching principles along the lines that each party will provide such non-financial contributions to ensure the success of each scheme as deemed necessary by the scheme’s commissioner and this shall not count as a call upon the initial pooled fund (wording to be devised by the Council’s legal adviser and agreed by the Council and CCG). We may want to leave the door open in so far as future business cases may require investment in additional support of this nature either recurrently or non-recurrently. Financial contributions for following financial years need to be agreed by Partners by 31 March.
Page 3 95 Better Care Fund (BCF) Section 75 agreement
Any arrangements for preparing capital expenditure need to be made separately and in accordance with section 256 (or section 76) of the NHS Act 2006 and Direction made thereunder. If a need for capital expenditure is identified this must be agreed by all Partners.
3.6 Pooled fund management It is recommended that each individual service where there is a pooled fund, shall have a designated pooled fund manager who is likely to be an existing officer within one of the statutory partners, with the following duties and responsibilities: . the day to day operation and management of the pooled fund; . ensuring that all expenditure from the pooled fund is in accordance with the provisions of the S.75 agreement and the relevant scheme specification; . maintaining an overview of all joint financial issues affecting the Council and the CCG in relation to the services and the pooled fund; . ensuring that full and proper records for accounting purposes are kept in respect of the pooled fund; . reporting to the Joint Commissioning Board (JCB) as required (this would be through the overall pooled fund manager); . ensuring action is taken to manage any projected under or overspends relating to the pooled fund in accordance with the S.75 agreement; . in conjunction with the overall pooled fund manager, preparing and submitting to the JCB quarterly reports (or more frequent reports if required) and an annual return about the income and expenditure from the pooled fund together with such other information as may be required by the JCB to monitor the effectiveness of the BCF and to enable the CCG and the Council to complete their own financial accounts and returns. . in conjunction with the overall pooled fund manager, preparing and submitting reports to the Health and Wellbeing Board as required by it. . The JCB may agree to the viring of funds between Pooled Funds (in line with Council and NHS Financial Regulations). Below is a diagrammatic representation of possible pooled fund management. The lines can represent reporting, accountability and line management (decisions yet to be made). Although it is not shown in the diagram, there will be a role for the BCF steering group and integrated health and care programme board.
Page 4 96 Better Care Fund (BCF) Section 75 agreement
3.7 Risk Share Arrangements, Overspends and Underspends The risk share arrangements will be set out in detail in Schedule 3 and will deal with overspends and underspends. Potential overspends should be identified by the scheme pooled fund manager and reported by them to the BCF finance manager who will decide what action to take to deal with the overspend. This could be a local decision, or alternatively a referral to the JCB with recommendations for decision. Unavoidable overspend and other financial risks will be shared by the Council and the CCG proportionally to each organisations financial contribution to the BCF. An example of how this would work is demonstrated in the following Table. Table 1: Example of Overspend and Underspend scenario Risk share Investments Benefits Waltham Forest Council will be Waltham Forest Council will responsible for the overspend that assume the loss of benefits takes place in programmes where associated with overspend for the they are currently lead programmes that they are lead commissioners commissioners of named services Overspend Waltham Forest CCG will be Waltham Forest CCG will assume responsible for the overspend that the loss of benefits associated with takes place in programmes where overspend for the programmes they are currently lead that they are lead commissioners commissioners of named services
Page 5 97 Better Care Fund (BCF) Section 75 agreement
Waltham Forest Council will be Waltham Forest Council will responsible for the underspend assume the benefits associated that takes place in programmes with underspend (dependent on where they are currently lead meeting minimum performance commissioners criteria) for the programmes that they are lead commissioners of Waltham Forest CCG will be named services Underspend responsible for the underspend that takes place in programmes Waltham Forest CCG will assume where they are currently lead the benefits associated with commissioners underspend (dependent on meeting minimum performance criteria) for the programmes that they are lead commissioners of named services
3.8 VAT Local Authorities and the NHS operate within slightly different VAT regimes and potential impacts have been considered. There is likely to be only one significant (though not large) contract affected by this consideration, which is the licence for the CCG’s risk stratification system where there is potential for the BCF to reduce its overall VAT liability by £30,000 if the contract were to novate to the Council.
3.9 Audit & Right of Access The parties will each have responsibilities for audit and so the arrangement needs to provide for the responsibilities of the host partner relating to audit and the right of internal and external auditors to be given access to anything they need to carry out their duties.
3.10 Liabilities & Insurance & Indemnity The parties will need to consider and agree what will happen in relation to the acts and omissions of each other which contribute to losses or give rise to a claim for liability. The parties will also have a requirement to consider their respective insurance position and take advice from their own insurance providers. There are particular issues about the availability of NHSLA cover for Health Bodies who perform Council health related functions and Councils will need to take their own insurance advice on this. The clause also provides for the parties to always take reasonable steps to mitigate any loss for which one party may be entitled to bring a claim against the other in relation to the Agreement.
3.11 Performance Management The performance management for the pooled fund is critical and underpins the governance and day-to- day operational arrangements to be implemented.
Page 6 98 Better Care Fund (BCF) Section 75 agreement
Metrics and reporting BCF Benefits & Outcomes . Non-elective admissions (NEL) . Nursing and Residential Home Admissions . Effective Reablement (% people still at home after 90 days from discharge) . Patient and Service User Experience . Local Metric – still to be defined Finance . Budget allocation . Actual spend . Other finance metrics Issues & Risks . BCF programme-wide . Individual schemes Other Key performance indicators (KPIs) . To be defined and should be related to individual schemes/programmes As the programme develops there will be a need to address major risks relating to the creation of integrated teams, eg employee terms and conditions, commissioning arrangements, effectiveness of services at meeting joint strategic requirements.
4 Conclusion A Section 75 agreement between the Council and the CCG in relation to the BCF is required to be in place before the beginning of the financial year 2015/16. Work is underway to ensure that the S.75 schedules, which form a critical part of the agreement, are completed and agreed. The Council’s legal department is leading on the provision of legal advice to both the CCG and Council through the development stage. Prior to signing, both sides will need to take independent legal advice. The S.75 agreement is an enabling agreement for the delivery of the BCF plan, which was approved on 29 October 2014. The joint Council and CCG vision as expressed in the BCF plan is to create a simplified and easy to access health and social care system for Waltham Forest residents and their families where services are personalised to fit their individual needs and provide value for money across both voluntary and statutory services.
Page 7 99
Item 5.1
Title of report Transforming Services, Changing Lives – the Case for Change
From Jane Mehta, Director of Strategic Commissioning - WFCCG
Purpose of report In February 2014, Waltham Forest, Tower Hamlets and Newham Clinical Commissioning Groups agreed to work in partnership with providers and neighbouring commissioners to establish Transforming Services, Changing Lives. The aim of this programme is to jointly assess the health economy (particularly, but not exclusively hospital-based care) in this part of east London and to positively plan for change to address the challenges we all face – thereby improving the health of the local community and preventing ill health. The programme has now concluded the assessment and initial engagement phase and has identified that there is a clear case for change. The final Case for Change and accompanying presentation summarise the findings and emerging programme of work recommended to deliver the required level of change.
Recommendations Board members are asked to approve the Transforming Services, Changing Lives (TSCL) Case for Change. Any changes requested by the board will be sent to the programme team for amendment. The CCG is requested to agree to the Chair of the board signing off the final version of the Case for Change (taking account any changes proposed by other CCG Boards).
Impact on patients & carers The focus of the programme to date has been to assess – with significant input from patients, their families and carers, and from healthcare staff – the effectiveness of healthcare provision in east London. The programme approach has very much put patients at the fore and there has been a high level of patient and public engagement: • A Patient and Public Reference Group was established as part of setting up the programme and has been actively involved throughout the process • 90 meetings were attended – including Healthwatch Events and Health and Well-being boards; • One-to-one interviews and patient focus groups were held for some key areas e.g. maternity • 64 online surveys were completed • Feedback was also obtained through information stands in hospitals and at CCG Annual General Meetings The programme has identified that the current healthcare system across east London is not consistently delivering the best possible outcomes for patients and that the patient experience also needs to improve.
100 Transforming Services, Changing Lives – the Case for Change
Once the Case for Change has been approved by the three CCG Governing Bodies, it will be published online and the programme team will communicate the findings to key stakeholders involved in its formation. The focus will then be on using the findings to develop a clinical strategy for east London and identifying and prioritising the work needed to deliver it. Patients and carers will then start to benefit from the changes. Board members are asked to note that discussions are taking place with the Chief Officers and Chairs of Tower Hamlets CCG, as well as those at Newham and Waltham Forest, to agree those next steps. A further Board update will be supplied once this becomes clear.
Risk implications Operational and strategic risk management has been undertaken diligently throughout the programme.
Financial implications The financial implications are that whole system change is needed for the east London health economy to become financially sustainable. The resource implications for progressing this programme are currently under discussion – including who will undertake this work. There will be a stringent financial assessment undertaken once there are proposals to consider. The source of funds for this programme will come from the 2% non-recurrent ‘top- slice’, which is intended to support transformational change It is recommended that Board members receive an update on this when the situation is clearer.
Equality analysis We will complete an Equalities Impact Assessment once there are proposals to consider.
Other committees/groups, including the CCG Reference Group and Rapid Feedback Group The TSCL programme has been discussed at over 90 meetings/committees/groups across east London including: • Waltham Forest, East London and City Maternity Quality Board • Meeting with Waltham Forest CCG member practices • Walthamstow, Chingford and Leyton/Leytonstone GP locality meetings • Meeting with North East London Foundation Trust • Meeting with Waltham Forest Young Advisors • Meeting with Whipps Cross Patient Panel • Meeting with Save Our NHS Waltham Forest • Meeting with London Borough of Waltham Forest • Waltham Forest Local Medical Committee meeting • Staff briefing at Whipps Cross Hospital • Information stands at Whipps Cross Hospital • Email bulletins via the Waltham Forest Health and Social Care Network and Healthwatch Waltham Forest • Inner North East London Joint Overview and Scrutiny Committee • Waltham Forest Health Scrutiny Committee meeting • Waltham Forest Health and Wellbeing Board • Waltham Forest Best Start in Life Board • Waltham Forest CCG Governing Body meeting • Waltham Forest CCG AGM
101 Final draft policy for approval
Transforming Services, Changing Lives
The Case for Change
31 October 2014
1
102 Final draft policy for approval About this document
This document is part of a library of materials that will be used to develop and improve health services in east London. Other materials include the interim Case for Change, videos, Clinical Working Group reports and data packs. These can be found at: www.transformingservices.org.uk or, for a paper copies, through contacting us at [email protected] or on 020 3688 1678.
Whilst this 'final' document echoes the interim version, it has been significantly amended following the comments we received. Clinical Working Groups have reviewed all of this feedback and, in the light of their own experiences, agreed reports that will form the building blocks of future local NHS planning. Of course the document is never 'final'. The future can be planned for, but political, environmental, economic, social and technological changes make it uncertain. The NHS will need to react quickly to new knowledge, policy and developments. However this blueprint for change has considerable support from patients, the public, stakeholders and staff. We will continue to discuss and shape our ideas and proposals, so if you are part of a community group or organisation we would be happy to send a representative along to a meeting to explain and discuss our progress.
In developing this Case for Change:
Information relating to the health of the population has been taken from a number of sources, in particular the Office of National Statistics and the HSCIC (Health and Social Care Information Centre.) This information is consistent with joint strategic needs assessments published by each borough public health directors.
Projections of population growth have been taken from the Greater London Authority (SHLAA- capped model 2013 release) and have been endorsed as the best available by borough public health directors
The groups considered the best available local data on current performance and activity from local providers and national sources. Whilst due to different coding and submission practices amongst providers there will always be limitations to this data, it was still felt helpful for participants to have access to this information
2
103 Final draft policy for approval
Contents About this document ...... 2 Foreword ...... 4 Executive Summary ...... 5 1 About Transforming Services, Changing Lives ...... 10 2 The east London health economy ...... 15 3 Our vision ...... 17 4 Summary of engagement: developing this document ...... 19 5 The Case for Change: key factors ...... 22 6 Our community ...... 23 6.1 The health profile of the three boroughs...... 24 6.2 Population growth and a changing age profile generates unique challenges ...... 27 6.3 Health and wellbeing: Factors contributing to the relatively poor health of the population 32 6.4 Improving health in the population requires a partnership and co-ordinated approach .... 35 7 Do all patients benefit from a consistently world class service? ...... 37 7.1 Recurring themes from all Clinical Working Groups ...... 39 7.2 Primary care in east London: facing unprecedented challenges ...... 43 7.3 Addressing mental health needs in our hospitals and health care services ...... 46 7.4 Maternity and newborn care ...... 51 7.5 Services for children and young people ...... 65 7.6 Services for people with long-term conditions ...... 72 7.7 Unplanned care services ...... 79 7.8 Planned care: Elective surgery services...... 90 7.9 Clinical support services ...... 95 8 Do we use our resources in a sustainable way? ...... 104 9 How sustainable is our workforce? ...... 116 10 The change required and next steps ...... 128 ...... 132
3
104 Final draft policy for approval Foreword
Foreword to be added and approved by CCG Chairs on approval of the document by CCG governing bodies
4
105 Final draft policy for approval Executive Summary
Context
In February 2014, Newham, Tower Hamlets and Waltham Forest Clinical Commissioning Groups agreed to work in partnership with providers and neighbouring commissioners to establish Transforming Services, Changing Lives. The aim of this programme has been to jointly assess east London’s health economy in relation to hospital care and how specialties work with primary and community care services.
We are positively planning for change to address the challenges we all face – thereby improving the health of the local community and preventing ill health. We are now taking forward this work as part of a programme called Transforming Services Together which is about how we transform the whole health care system in east London.
The case for change is clear
Our population is growing and the local NHS needs to respond to increased demand, for example in maternity and children’s services We need to better care for the increasing number of people with long term conditions We and our partners need to work together more closely to strengthen our prevention approaches, supporting people to live healthier lives and improving physical and mental wellbeing The local NHS needs to invest time and effort in tacking inefficiencies. Estates, IT systems and care pathways sometimes do not work for the greatest benefit of patients or staff We need to fix our urgent care system, ensuring patients are seen in the right care setting for their needs We need a transformed workforce for 21st century care – with different skills and roles, working in different settings Changes will need to be made to local services if they are to be safe and sustainable. More services need to be provided in the community, closer to home The local NHS and partners will need to work together to secure high quality and financially sustainable services in east London.
In July 2014 we issued an interim Case for Change. It described local NHS services, celebrated the excellent services that we are delivering, but also identified where we need to improve services and ensure we deliver better value for taxpayers' money. The process of establishing our Case for Change brought together healthcare professionals from a range of organisations and patient representatives, to share their expertise and knowledge and create a community for change – people committed to improving care and ensuring the sustainability of local NHS services.
Over the summer, we set ourselves the goal of testing our ideas with around 1,500 people rather than the 150 involved in developing the interim document. Since July, we have been able to engage with almost 3,000 people, ensuring that the initial sense of excitement and opportunity has spread further than we had hoped possible. 5
106 Final draft policy for approval The engagement
We tested our ideas and sought views in a number of ways. We analysed feedback from over 90 meetings and events; 64 questionnaires; focus groups (maternity and newborn; young people; and long term conditions) and by interviewing people in outpatient departments (children and young people).
We are indebted to the 350 clinicians across east London and over 3,000 members of the public, patients and stakeholders who took time to help us develop ideas for change. In particular we would like to thank Healthwatch, local councils, clinicians and members of the Patient and Public Reference Group for their time and effort.
The programme and its aims were generally welcomed wherever we went and whoever we were talking to. The process was well received and, as would be expected when discussing the future of the NHS, there was healthy debate and challenge. A number of contributors felt that it was helpful to get people together, sitting round a table and discussing the important issues. The documentation was described as clear and honest. We heard…
Almost everyone felt that the NHS needs to change in some way Patients should be the focus of the NHS and its partners above all else with equal dedication to best patient experience and improved outcomes. There needs to be a focus on improving the health and wellbeing of the population The NHS needs to modernise. This will drive better patient care.
6
107 Final draft policy for approval
The Case for Change
Our original proposal was that there were four key areas underpinning the need to change: Health and wellbeing: given the public health challenges of most Western societies and local factors in east London World class services: we need to develop them as there is variability Our workforce: which is currently under pressure – and needs to change to tackle modern health challenges Resources: which are being used inefficiently and unproductively
Our engagement provided considerable support for these factors, expanding our understanding of why services need to improve, as shown in the diagram below:
Our community
East London, one of the most exciting communities in the world, suffers from challenges similar to those in many other parts of the country – unhealthy lifestyles and an ageing population leads to increasing numbers of people with long term conditions, such as diabetes. There are also local challenges: high deprivation; rising birth rates and a growing population – we expect another 270,000 people to be living here in the next 20 years, equivalent to a whole new borough. These factors, as well as the rapid movement of population and our ethnic mix mean we need to go further than elsewhere in the country in our innovation and service improvement. We also need to
7
108 Final draft policy for approval be cognisant of the innovations and improvements that are also taking place in neighbouring boroughs that may impact on patient flows, for example the changes to King George’s Hospital in Ilford and agreed specialist cancer and cardiac changes across north central and north east London.
Whilst there are good examples of innovative prevention and disease management, the NHS, working with local councils and other partners needs to develop a better focus on preventing ill health, recognising that improved wellbeing can stop, reduce the effect of, or delay the onset of diseases. Health and Wellbeing Boards are strongly committed to the need for change.
Everyone has a responsibility for good health but at the moment people are not encouraged enough to keep healthy. When they do fall ill, the current system does not consistently support people to manage their own health and make informed choices.
World class services
We have examples of excellent clinical care, but most services are of variable quality. Services across primary care, the community and in our hospitals are of differing quality depending on where you live, what service you need and what time you need it.
More treatments, and more expensive treatments will mean that we need to make choices. The more efficient we can become, the better and more comprehensive our services a
Most importantly, poor efficiency can lead to poor patient experience. This can cause irritation (for instance delays in outpatients), but it can also cause poorer health outcomes for patients (e.g. cancellations of operations). Inefficiencies also mean we waste resources, through re-booking expensive theatre time or through repeating diagnostic tests because previous results cannot be accessed or have been mislaid. This can harm patients and damage the reputation of the NHS.
World class services are no use if the people who need them are unable to access them. However, travelling to services was not a significant issue in the feedback we received. Patients were much more concerned about the inability of the NHS to signpost them to the right person or service; the delays experienced in seeing the right person and the different services available (or unavailable) in different locations (the ‘postcode lottery’).
Sustainable support
There needs to be better joint working between all organisations involved in health and social care to prevent ill-health, to integrate care and to use scarce resources wisely (e.g. commissioning or supporting local community and health groups to provide support) if the current system of health and social care is to be sustainable.
Recruiting and retaining the skilled workforce we need is not easy and, in the future, a very different workforce will be required. An example of this is the role that clinical navigators are already beginning to play in helping patients experience joined-up care, across providers. Extended roles for specialist nurses and physicians assistants are also two new and emerging areas. Medical students just starting their training, depending on their profession, will take between five and ten years to become qualified – so we need to address current challenges and develop a workforce that has the skills to deliver a different type of service, working across the organisational boundaries that currently exist.
8
109 Final draft policy for approval Although we have some of the most modern facilities in the country we also have old facilities which do not contribute to a good patient experience or clinical care, and are costly to run.
We need to modernise our estate, our technology and our ways of working to enable better care and make savings. The public identified many areas in which the NHS seems to accept poor practice and staff told us their frustration in being unable to change ‘the system’.
Conclusion
The NHS in east London wants to be bold, and must be bold to make a difference and to be sustainable. There are tremendous opportunities to care for more people in their own home and support people to be healthier. We can use technology to make appointments through the internet possible and we can use pioneering robotics to undertake complex procedures more safely with ever improving outcomes. But we also need to get the basics right. We can talk about outpatient appointments via Skype at the evening or weekend (which would be convenient and cost effective for patients and clinicians) but not until we can organise our basic services to prevent patients receiving their appointment details the day before (or sometimes after) their appointment.
The local NHS recognises that current performance needs to improve. Cancer waits, referral to treatment times and waiting times in A&E are the subject of newspaper headlines because they are things that patients care about. Whilst there are a number of programmes of work that are addressing these immediate issues, this programme is seeking to solve the root causes of these problems.
We need to integrate care and design new, more efficient care pathways so that patients experience joined-up services. Simon Stevens, the Chief Executive of the NHS told the Royal College of General Practitioners (2 Oct 2014) “GPs themselves say that in many parts of the country the corner shop model of primary care is past its use-by date. We need to tear up the design flaw in the 1948 NHS model where family doctors were organised entirely separately from hospital specialists and where patients with chronic health conditions are increasingly passed from pillar to post between different bits of health and social services.”
The NHS in east London faces a huge challenge. Birth rates and A&E attendances are rising rapidly with the growing population, whilst a financial deficit overall remains; we cannot afford to carry on as we are. Fortunately there is a solution. Where there are clear advantages in co-locating some specialties we should do so. Where there is estate that is not being used effectively we should develop alternatives. There are also significant efficiencies to be made, for example by transforming integrated care pathways to provide more responsive care to patients, working across health and social care.
Preventing ill health and treating people holistically by looking at their physical and mental health needs together, is recognised to be a far more efficient and effective way of addressing the health needs of the community.
If we can achieve these efficiencies and create a virtuous circle, we can have our (low calorie) cake – and eat it.
There is a clear case for change, not just to improve existing services, but to ensure health and social care in east London addresses the continuous challenges we face and takes full advantage of the opportunities for improvement.
9
110 Final draft policy for approval 1 About Transforming Services, Changing Lives
Transforming Services, Changing Lives aims to jointly develop plans to meet health and healthcare challenges and opportunities in east London.
Programme aims
To improve services and health outcomes To enable clinicians, commissioners, patients and providers to sustainably and positively plan for change together To develop a clinically-led case for change and a clinical community for change across east London To ensure services meet the needs of our complex population Our initial focus is on hospital-based services, but we have looked across the whole health and social care system to identify where change is needed, including within local authorities and public health.
Organisations involved
In February 2014, Newham, Tower Hamlets and Waltham Forest Clinical Commissioning Groups agreed to work in partnership to establish Transforming Services, Changing Lives. Local providers, commissioners and patient representatives were invited to participate.
The organisations shown below joined the programme, providing expertise and representation on committees and clinical working groups. Local organisations such as City and Hackney Clinical Commissioning Group were also key consultees. Whilst the majority of discussions have focused on Barts Health services, both Barts Health and the Homerton took an active part in discussions.
Our engagement (see section 4) focused on Newham, Tower Hamlets and Waltham Forest but included organisations, patients and members of the public from neighbouring boroughs as people from these communities use our services and could be affected by service change.
10
111 Final draft policy for approval Where east London residents go for treatment1
Newham Whipps Barts and Total Barts Homerton BHR Other Total Cross Royal Health Foundation Hospitals Trusts London Trust Trust Trust
North East London - A&E Attendances Tower Hamlets 900 300 62,500 63,700 2,000 600 16,000 82,300 Newham 49,000 4,500 9,500 63,000 1,500 3,500 28,000 96,000 Waltham Forest 1,000 43,500 2,500 47,000 3,500 1,000 14,500 66,000 City & Hackney 300 600 7,500 8,400 62,000 400 23,000 93,800 Barking & Dagenham 2,500 600 1,500 4,600 400 42,000 19,000 66,000 Redbridge 1,000 14,000 2,500 17,500 700 38,000 14,000 70,200 Total 54,700 63,500 86,000 204,200 70,100 85,500 114,500 474,300
North East London - Unplanned Admissions Tower Hamlets 200 100 13,500 13,800 300 100 1,500 15,700 Newham 15,000 1,500 3,500 20,000 200 600 1,500 22,300 Waltham Forest 300 17,000 1,500 18,800 400 300 1,500 21,000 City & Hackney 100 200 3,000 3,300 10,000 100 2,000 15,400 Barking & Dagenham 800 200 900 1,900 100 10,000 700 12,700 Redbridge 300 5,000 1,500 6,800 100 10,000 1,000 17,900 Total 16,700 24,000 23,900 64,600 11,100 21,100 8,200 105,000
North East London Planned Surgical Admissions Tower Hamlets 100 0 7,000 7,100 400 0 2,500 10,000 Newham 6,500 2,000 2,500 11,000 500 300 2,500 14,300 Waltham Forest 100 10,000 1,000 11,100 500 100 3,000 14,700 City & Hackney 0 100 1,500 1,600 7,000 0 4,000 12,600 Barking & Dagenham 200 300 500 1,000 100 7,000 3,000 11,100 Redbridge 100 4,500 900 5,500 200 6,000 5,000 16,700 Total 7,000 16,900 13,400 37,300 8,700 13,400 20,000 79,400
1 Source: Secondary Uses SUS submissions, period 01/10/2012 – 30/09/2013. All figures individually rounded - numbers < 1000 to nearest 100, numbers > 1000 to nearest 500. The ‘total’ north east London figures include the London Borough of Havering. 11
112 Final draft policy for approval We are on a journey to improve services for the whole community
We are here
Around 150 Engaged Disseminate clinicians with over Case for came 3,000 staff Change, identify together to and public to ‘quick wins’. create an publish final interim Case Case for for Change Develop a Change clinical strategy and estates strategy.
Apr- June July - Sept Nov onwards
Informed by our programme principles
We will be courageous and we will trust, respect and challenge each Six Clinical Working other in developing the best options and solutions for the future Groups (CWGs) established to consider clinical services No change for change’s sake, we want to recognise areas of existing quality and best practice and build on these Clinical Reference Group (CRG) created We commit to listening to the patients’ and stakeholders’ voice and to consider acting on it overarching clinical and demographic issues We will work collaboratively across providers, commissioners and different sites to ensure that the overall healthcare system addresses Patient and Public our populations’ needs now and in the future Reference Group recruited to consider We will develop all our staff to maximise their potential and well patient experience and beingbeing priorities for change We will develop innovative and efficient healthcare services that work The programme sits for our population and for local people alongside other CCG initiatives including integrated care, mental We will communicate what we are doing and when key decisions will health and primary be made care transformation.
12
113 Final draft policy for approval Six Clinical Working Groups (CWGs)
Clinical Working Groups brought together clinicians from across primary, community and hospital services to:
describe the current state of services identify if change is needed to improve services for patients begin to develop a shared vision for how the local NHS can improve
Interim Case for Change reports were developed by each Clinical Working Group in July 2014 and further tested with clinicians, patients and the public throughout the summer. These reports form appendices to this document.
The Patient and Public Reference Group (PPRG)
Public and patient representatives were invited from the organisations below to help develop the Case for Change, guide the engagement process and provide ideas and challenge to clinicians leading the programme. Members were nominated from:
Healthwatch: Waltham Forest, Tower Hamlets, Newham, Redbridge, Barking and Dagenham, Hackney, City of London and Essex Clinical commissioning groups: Waltham Forest, Tower Hamlets, Newham, Redbridge, Barking and Dagenham and Hackney Hospitals: Whipps Cross, Newham, The Royal London, Mile End, London Chest and Homerton Mental health and community providers: North East London NHS Foundation Trust and East London NHS Foundation Trust.
I am impressed with the engagement process and development of the Case for Change PPRG member
13
114 Final draft policy for approval Clinical Working Groups have considered the following national policy context in their discussions:
Many of these policies are designed to create a higher quality and more efficient health and social care system, but there are also some challenges, for example through reduced social care funding.
For the NHS… Involving citizens in services Patients fully empowered in their Primary care, provided at scale design own care Modern, integrated care Access to the highest quality A step change in the urgent and emergency care, in line productivity of planned care with emerging recommendations from the Keogh review Specialised services, A focus on quality and the Seven day services concentrated in centres of governance of quality excellence Royal College and network recommendations for clinical services e.g. neonatal care
For mental health For community health For social care services... services… services… Ensuring mental health and Community services need to be The funding of social care is a physical health are recognised as more closely connected to all other significant issue. Over the past inter-related and equally important parts of the health and social care few years, there have been system fewer people receiving funding for care All public services to reflect the Close alignment with the rest of The new Care Bill will raise the importance of mental health in the healthcare system will enable upper threshold for means their planning community services to be a driving testing and introduce a cap for force in improving the health of private spending on social care individuals and communities – so people who would otherwise have had to pay for care may qualify for social care support. Enable better access to mental Community health services need However at the same time, in health services with short waiting to be much more closely involved order to qualify for services, times in key decisions about patients at people will need to show a an earlier stage in their journey more significant need through the system Improve access to psychological The impact on NHS services of therapies more people receiving social care in their own home or a care home will need to be monitored, particularly in light of changes to allocations resulting from the Better Care Fund. Designing a new measure for wellbeing
14
115 Final draft policy for approval 2 The east London health economy
Hospitals
Whipps Cross
Homerton General hospital (589 beds) with A&E/UCC (102,000 attendances), maternity (5,100 General hospital (500 beds) with births) plus some specialisms A&E/UCC (124,000) supporting the older population, attendances), maternity (6,000 including hyperbaric services births) plus specialist care in obstetrics, neonatology, fetal medicine, fertility, bariatric surgery and neuro-rehabilitation
Newham University Hospital London Chest General hospital (452 beds) with A&E/UCC (88,000 Specialised heart attack attendances), maternity centre and cardiovascular and (6,700 births) plus respiratory centre (103 beds). specialisms in fertility and diabetes
St Bartholomew’s
Specialist centre for cancer, cardiovascular disease, fertility and endocrinology (250 beds). Minor injuries unit for non- Mile End Hospital emergency cases. Community hospital health centre providing a range of inpatient (64 beds) and The Royal London outpatient services. These include family planning, Teaching hospital (747 beds) termination of pregnancy and with a full range of general rehabilitation. acute services, A&E/UCC (144,000 attendances), maternity (5,500 births) plus specialist services including paediatrics, obstetrics, neonatal critical care, major trauma, hyper-acute stroke care, cancer, neurosurgery, dental hospital.
15
116 Final draft policy for approval Primary, community and mental health services
The number of practices per borough ranges from 36 in Tower Hamlets to 61 in Newham, suggesting different primary care models are in operation with varying degrees of single-handed practices (6-29%).
There are also different models of mental health and community service provision, for example:
acute trusts provide some community services in Tower Hamlets and City and Hackney community trusts provide mental health and community services in the other four CCGs
. 46 GP practices . 46 GP practices . Community and . Community and mental mental health health services provided by services provided NELFT by NELFT
. 44 GP practices . Community services provided by Homerton . Mental health services . 40 GP practices provided by ELFT . Community and mental health services provided by NELFT
. 61 GP practices . 36 GP practices . Community and . Community services mental health provided by Barts Health services provided . Mental health services by ELFT provided by ELFT More than 150 opticians, 190 dental practices and almost 350 pharmacies
16
117 Final draft policy for approval 3 Our vision
We want to build an NHS that delivers high quality care in a financially sustainable way. We want an NHS which improves health and well-being, works with partners to prevent ill health and ensures that the right care is provided, at the right time, in the right place:
When need arises, ensures
right care right time right place , ,
Enhanced primary and Specialised services 2 community care services
Rare / dangerous / Actively managing complex needs best treated by a Local hospital services long term specialist conditions with patients to reduce hospital admissions
Acute episodes of care treated efficiently according to severity / urgency
There is a real opportunity here… if these things can be worked through early and are done well, to really improve things. Barking and Dagenham Health and Wellbeing Board
17
118 Final draft policy for approval We want our population to have good health and experience good care
Our Case for Change tells us that patients expect:
Consistently high quality and efficient services Good patient experience and information: o Individual services for patients, taking account of their own circumstances o Continuity of care – so patients do not have to constantly repeat their case history or repeat tests o Short waiting times for appointments o Text reminders about appointments and the ability to book online o Access to the right advice, test results and service, in the right place, first time o Being seen on time, given advice and kept updated o Friendly, welcoming and trustworthy staff
Support with managing their own health: o Non-judgemental advice on living more healthily and making good choices o Promotion of good mental health and wellbeing, including access to appropriate services when needed o Enough information and time to ask questions at a consultation
Staff have told us this can be achieved by…
Consistently high quality and efficient services o Good transitions between and within organisations with clear clinical responsibility in handing over care o Maximising the use of new technology to improve outcomes within services
Good patient experience and information o Effective IT systems that can communicate care records across organisations o Investing in a happy, engaged, flexible and well-trained workforce
Support with managing their own health o All parts of the system working together and supporting good health: social care, schools, primary care, community care, mental health services, hospitals and public health departments o Clear information regarding available local services and the development of consistent pathways o Training and development in promoting behavioural change
I can plan my care with people who work together to understand me and my carer(s), allow me control and bring together services to achieve the outcomes important to me. National Voices 18
119 Final draft policy for approval 4 Summary of engagement: developing this document
Our engagement work aimed to inform people, test ideas, invite comment and, ultimately, start building a community for change.
We aimed to increase the number of people engaged with the programme from around 150 involved in developing the interim Case for Change to 1,500. We published the interim Case for Change on 9 July 2014 and asked to hear from anyone with an interest in the health of local residents and the healthcare economy over the summer months. Our engagement period ended on 21 Sept 2014.
We are very grateful to over 350 east London clinicians and almost 3,000 patients, members of the public or members of stakeholder organisations who have given up their time to develop and contribute to this document.
The programme and its aims were generally welcomed wherever we went and whoever we were talking to. The process was well received and, as would be expected when discussing the future of the NHS, there was healthy debate and challenge. Everyone who responded to the questionnaire wanted the NHS to change in some way. Those who took part in our engagement said that the programme is a good way of getting people together, sitting round a table and discussing the important issues. Our interim Case for Change and accompanying documentation was described as being clear and honest.
Engagement resources
The resources we used were tested with our Patient and Public Reference Group, Programme Executive and Communications Steering Group.
The resources consisted of:
publicity (e.g. flyers and media releases informing people of the engagement) documentation (e.g. summary and full version of the Case for Change and PowerPoint presentations) a questionnaire on healthcare in east London (available in hard-copy and online) a website – that provided a repository for the significant number of documents produced.
Engagement activity
We attended 90 stakeholder meetings and ran a number of events specific to the Case for Change e.g. information stands at hospitals and an event in partnership with Waltham Forest Healthwatch, at Whipps Cross Hospital 64 people expressed their views via the questionnaire (both online and on paper). Additionally, we organised a number of focus groups and interviews with patients and the public, particularly in areas that the Clinical Working Groups felt the public and patient voice was not strong enough:
19
120 Final draft policy for approval We held two focus groups (one for young mothers and one for those with long term conditions) We interviewed young people and met young advisers in Waltham Forest (as the Patient and Public Reference Group had no young representatives).
Further clinical engagement was also conducted over the summer to developed the ideas of the Clinical Working Groups with a greater number of clinicians, particularly across Barts Health.
The responses
The need for change was almost universally agreed and the direction of travel was broadly welcomed, with support for the overall vision. Responses also supported the way in which local challenges and areas that need to change had been described.
A major theme was poor administrative practices and patient experience. Whilst when patients get to see a clinician they are generally satisfied, administrative issues, poor patient experiences and inefficient and confusing patient pathways were highlighted as being particularly problematic.
Patients and the public did praise plenty of clinical practices and procedures but late appointments, appointments where necessary tests or scans were not available, being passed from one specialist to another and a feeling of being not being in charge of their own care gave them a strong sense of frustration.
The staff who responded recognised all the points made by patients and the public. Staff felt frustrated at the poor internal communications which left them unaware of the different support options available for patients or the involvement of other NHS staff. They said poor IT systems and fragmented pathways make the job more difficult than it needs to be, and variations in commissioning mean that there are unnecessary differences in the care that people receive. In summary, staff feel that there are significant inefficiencies in the NHS that make it hard for them to do their jobs.
There was no clear different of opinion on these matters between patients and the public, different age groups, ethnicities, genders or amongst people with disabilities. The themes were recognised by people regardless of where they live, but some geographical differences were noted. For instance:
People in Waltham Forest were particularly concerned about the future of Whipps Cross hospital, the quality of the estate and the cost of running the Royal London People in Newham were concerned about the future of Newham hospital People in Tower Hamlets were particularly concerned about the administrative systems in operation at the Royal London.
20
121 Final draft policy for approval 1. Patient experience and ‘customer’ satisfaction Patients explained that their own experience of care is central to the clinical care that they receive. Patients saw clinical quality and patient experience as being inextricably linked and encouraged the NHS to always see everything from a patient’s perspective (see overleaf diagram).
The NHS view The patient view
Friends and family
Clinical Clinical Patient quality quality experience
Patient experience
2. Health and wellbeing Patients and the public accepted that there was a need for people to take more responsibility for their own health if the population is to become healthier. However there was a general view that people needed support in order to make changes to their own lives and that the NHS is not currently set up to provide this support. Significantly enhanced information and better support mechanisms are required if patients and the public are going to be able to manage their own health better.
3. Efficiency and productivity Whilst there was some call for greater funding of the NHS, there appeared to be considerable acceptance that the NHS can improve efficiency and productivity to reduce waste. Staff and patients identified numerous instances where inefficient processes were adding to the financial burden; and a great many opportunities for introducing smarter working.
Conclusion
Part of the purpose of consultation is to: “allow those consulted to give intelligent consideration and an intelligent response... One of the functions of a consultation process is to winnow out errors in the decision-maker’s provisional thinking. True consultation is…not a matter of how many people object to proposals but how soundly based their objections are”2
Whilst this was an engagement process – our aims were almost identical. The engagement has allowed intelligent consideration and response. It has allowed us to understand errors in our provisional thinking, and to a great degree, we can take comfort from the considerable consensus that there is a strong case for change and agreement about what change is required.
The outputs of our engagement were shared with each of the Clinical Working Groups programme executive and have been incorporated into this Case for Change.
2 R (Brompton and Harefield NHS Foundation Trust) v Joint Committee Of Primary Care Trusts & Anr - Court of Appeal (19 April 2012) 21
122 Final draft policy for approval
5 The Case for Change: key factors
22
123 Final draft policy for approval 6 Our community
The health of our population can be improved. There are too many early deaths due to preventable diseases and life expectancy is short when compared to the rest of England. There are wide health inequalities across the area covered.
Key local factors contributing to the poor health of the local community include high deprivation, rapid movement of population and a rich ethnic mix. This means that we need to go further than elsewhere in the country in our innovation and service improvement to address these diverse needs.
The population is growing and changing rapidly The population is growing at a faster rate than anywhere else in the country. The highest proportionate change is amongst the over 65s. This means that demand for health services is going to increase over the next few years and services will need to change to respond to this.
Services need to be designed to meet the particular needs of the population We have some innovative prevention and disease management services in east London, but more needs to be done if we are to keep people healthy and manage their conditions. When we are changing services this needs to be done in a way that responds to the particular needs of the population and reduces health inequalities.
Improving health requires us to work together
Everyone has a responsibility for good health: the NHS, local councils, health and wellbeing boards, businesses, schools, patients and the public.
23
124 Final draft policy for approval 6.1 The health profile of the three boroughs
This section gives an overview of the health issues in the three boroughs that make up the Waltham Forest and east London (WEL) area. For a fuller description readers should go to the Joint Strategic Needs Assessment (JSNA) reports published annually by the Public Health Director of each borough3.
The three boroughs have a diverse population and extremes are recorded in every social and health indicator.
The Greater London Authority estimates that the population of the three boroughs is 861,000 people, of which 174,000 are children and 64,000 are elderly.
2013 GLA population Tower Waltham Newham Total WEL estimates Hamlets Forest Age 0 to 14 50,59755,03569,199174,831 Age 15 to 64 204,617184,138233,829622,584 Age 65 and Over 15,91126,96621,66664,543 Total 271,125266,139324,694861,958
This is a young population compared with the rest of London and England. As a proportion of the total there are more children and fewer older people than elsewhere.
The health of our population could be improved The table below shows that, for the majority of the population, life expectancy is worse than in most of England. Life expectancy is particularly short for the residents of Newham and Tower Hamlets. Healthy life expectancy is the number of years from birth that a person can expect to remain in “good” or “very good” health. As for life expectancy, the healthy life expectancy for the residents of the three boroughs is shorter than for the population of England.
Life Expectancy and Healthy Life England Tower Waltham Note Newham Worst Average Best Expectancy at birth Hamlets Forest
Life expectancy (male) 1 77.5 76.7 79.0 73.8 78.9 83 Life expectancy (female) 1 82.0 81.9 83.1 79.3 82.9 86.4 Healthy life expectancy (male) 2 58.8 52.5 62.7 52.5 63.2 70 Healthy life expectancy (female) 2 56.4 57.2 57.9 55.5 63.6 71
Significantly worse than the England average
Not significantly different from the England average
Significantly better than the England average 1. Years of life at birth 2012; 2. Estimated years spent from birth in "good" or "very good" health 2010-2012
3 Tower Hamlets JSNA: http://www.towerhamlets.gov.uk/lgsl/701-750/732_jsna.aspx, Newham JSNA: http://www.newham.info/jsna, Waltham Forest JSNA: http://www.walthamforest.gov.uk/Documents/JSNA-Report-2014.pdf 24
125 Final draft policy for approval The age of the local population is relatively young so there is a low prevalence of diseases associated with old age such as cancer; respiratory, cardiovascular and heart disease. However the table below shows that in Tower Hamlets and Newham more people than should be expected are dying early from these and other diseases. So although there are fewer people with life threatening illnesses, those people who are sick tend to have more severe health problems and a poorer prognosis.
England Mortality Rates for common Tower Waltham Note Newham Worst Average Best causes of death Hamlets Forest
Early deaths - heart disease & stroke 1 87.3 87.0 65.7 113.3 60.9 29.2 Early deaths - cancer 1 102.6 128.5 109.4 153.2 108.1 77.7 COPD - Standardised Mortality Rate 2 138.6 172.1 108.7 197.5 100 39.2
Significantly worse than the England average
Not significantly different from the England average
Significantly better than the England average
1. Directly age standardised rate of deaths per 100,000 population aged under 75, 2009-2011; 2. Directly standardised mortality rate per 100,000 population 2010-2012
There are a number of other factors where health indicators show poorer results than elsewhere in England. England Selected Public Health Tower Waltham Note Newham Worst Average Best Indicators Hamlets Forest
Hospital stays for alcohol related harm 1 2,760 2,290 2,637 3276 1895 910 Drug misuse 2 11.6 16.3 8.3 26.3 8.6 0.8 People diagnosed with diabetes 3 6.9 6.0 5.9 8.4 5.8 3.4 New cases of tuberculosis 4 137.0 61.0 48.4 137 15.4 0 Acute sexually transmitted diseases 5 1,347 1,926 1,342 3210 804 162 Perinatal mortality rate 6 8.5 9.7 7.8 11.5 7.2 2.0 Obese Children (year 6) 7 25.6 25.1 23.5 28.5 19.2 10.3
Significantly worse than the England average
Not significantly different from the England average
Significantly better than the England average
1. Directly age sex standardised rate per 100,000 population, 2010/11; 2. Estimated users of opiate and/or crack cocaine aged 15-64, crude rate per 1,000 population, 2010/11; 3. % people on GP registers with a recorded diagnosis of diabetes 2011/12; 4. Crude rate per 100,000 population, 2009- 2011; 5. Crude rate per 100,000 population, 2012 (chlamydia screening coverage may influence rate); 6. Still births and deaths <7 days per 1,000 births - 2010 to 2012 (pooled); 7. % school children in Year 6 (age 10-11), 2011/12
These indicators show the average rate or percentage for each borough. Within each borough, further analysis has also highlighted that there is a great deal of variation in results amongst the population. The two maps overleaf show life expectancy at birth for smaller area (Super Output Areas) of WEL; the darkest areas indicating the shortest life expectancy. This shows that even neighbouring areas in the same borough people can have quite different life expectancy. For example life expectancy for people living in the docklands area of Newham and Tower Hamlets is up to 13 years longer than for people living just two miles to the north.
25
126 Final draft policy for approval
Male and female life expectancy at birth by local super output area
The wide variation across the area in life expectancy is reflected in mortality rates for various disease type. The two maps below show the pattern of early deaths for coronary heart disease and circulatory diseases. Avoidable Deaths from Coronary Heart Disease and Circulatory Diseases
26
127 Final draft policy for approval 6.2 Population growth and a changing age profile generates unique challenges
The population is changing and the local NHS will need to respond to this. The Greater London Authority predict that over the next 20 years:
The population of the three boroughs is set to grow by almost 270,000 (32%) – the equivalent of a new London borough Growth will be across all age bands and the greatest increases will be amongst people of working age The greatest proportional growth will be amongst the older age group; over 65s will increase by 37,000 (60%) and form 9% of the population. There will be 40,000 extra children in the three boroughs. As children and the over 65’s are heavy users of health services, this shift will have a significant effect on demand for health services over and above the increase in population.
Neighbouring boroughs will also see high population growth: Redbridge (20%), Barking and Dagenham (34%), City and Hackney (24%).
Projected population growth for the WELC area (source GLA SLHAA capped model)
27
128 Population Growth 2011 -2031: Tower Hamlets 450,000
400,000
350,000 14.9% 16.6%
300,000 13.7%
4.4% 250,000
2.9% 200,000 8.9% 14.6% 14.1%
150,000
100,000 Final draft policy for approval 50,000 7.9% -1.0% Population growth will be predominately in Tower Hamlets12.3% 14.0% and Newham
0 Baseline 2011 Projected 2016 Projected 2021 Projected 2026 Projected 2031 Aged 0-14 Aged 15-65 Aged 65 Plus Population Growth 2011 -2031: Tower Hamlets Projected Projected Projected Projected Total 450,000 Population Growth 2011 -2031: Newham 450,000 2016 2021 2026 2031 Growth Baseline 2011 256,694 400,000 Population 290,402 332,233 362,523 373,079 373,079 400,000 16.4% Growth 33,708 41,831 30,290 10,556 116,385 350,000 14.9% 18.7% % Growth 13.1% 14.4% 9.1% 2.9% 45.3% 16.6% 350,000 Annual % Growth 2.5% 2.7% 1.8% 0.6% 1.9% 12.9% 300,000 13.7% 10.4% 300,000 4.4% 250,000
250,000 2.9% 200,000 8.9% 14.6% 14.1% 4.2% 200,000150,000 7.8% 7.4% 11.1% Population Growth 2011 -2031: Newham 450,000 150,000100,000 400,000 50,000 16.4% 100,000 7.9% -1.0% 12.3% 14.0% 18.7% 350,000 0 12.9% 50,000 Baseline 2011 Projected 2016 Projected 2021 Projected 2026 Projected 2031 8.0% 6.7% 0.6% 7.4%Aged 0-14 Aged 15-65 Aged 65 Plus 10.4% 300,000
0 Projected Projected Projected Projected Total Baseline 2011 Projected 2016 Projected 2021 Projected 2026 Projected 2031 2016 2021 2026 2031 Growth 250,000 Baseline 2011256,694 Aged 0-14 Aged 15-65 Aged 65 Plus Population290,402332,233362,523373,079373,079 Population Growth 2011 -2031: Waltham Forest 200,000 4.2% Growth Projected33,70841,83130,29010,556116,385 Projected Projected Projected Total450,000 7.8% 7.4% % Growth 13.1%14.4%9.1%2.9%45.3%2016 2021 2026 2031 Growth 11.1%
BaselineAnnual % 2011311,917 Growth2.5%2.7%1.8%0.6%1.9% 150,000 Population343,961371,224402,176419,834419,834 400,000
Growth 32,04427,26330,95217,658107,917 100,000 % Growth 10.3%7.9%8.3%4.4%34.6% 350,000 Annual % Growth2.0%1.5%1.6%0.9%1.5% 50,000 6.7% 0.6% 7.4% 8.0% 300,000 13.8% 0 12.4% Baseline 2011 8.6%Projected 2016 Projected 2021 Projected 2026 Projected 2031 250,000 8.3% Population Growth 2011 -2031: Waltham Forest Aged 0-14 Aged 15-65 Aged 65 Plus 450,000 Projected Projected Projected2.8% Projected Total 200,000 2016 20213.8% 2026 2031 Growth 3.3% 400,000 Baseline 3.5%2011311,917 150,000 Population343,961371,224402,176419,834419,834 Growth 32,04427,26330,95217,658107,917 350,000 % Growth 10.3%7.9%8.3%4.4%34.6% 100,000 Annual % Growth2.0%1.5%1.6%0.9%1.5% 300,000 13.8% 12.4% 8.6% 50,000 250,000 8.3% -0.4% -1.5% 8.5% 3.4%
2.8% 0 200,000 3.8% 3.3% Baseline 2011 Projected 2016 Projected 2021 Projected 2026 Projected 2031 3.5% Aged 0-14 Aged 15-65 Aged 65 Plus 150,000 Projected Projected Projected Projected Total
100,000 2016 2021 2026 2031 Growth Baseline 2011260,373
50,000 Population273,453 284,065 295,022 304,514 304,514 -0.4% -1.5% 8.5% 3.4% Growth 13,080 10,612 10,9579,492 44,141 % Growth 5.0%3.9%3.9%3.2% 17.0% 0 Baseline 2011 Projected 2016 Projected 2021 Projected 2026 Projected 2031 Annual % Growth1.0%0.8%0.8%0.6%0.8% Aged 0-14 Aged 15-65 Aged 65 Plus
Projected Projected Projected Projected Total Projected population2016 growth2021 for the2026 WELC2031 boroughsGrowth (source GLA SLHAA capped model) Baseline 2011260,373 Population273,453 284,065 295,022 304,514 304,514 Growth 13,080 10,612 10,9579,492 44,141 % Growth 5.0%3.9%3.9%3.2% 17.0% Annual % Growth1.0%0.8%0.8%0.6%0.8% 28
129 Final draft policy for approval Population growth will be highest in regeneration areas The map below shows the areas of greatest population growth over the next 20 years. Darker brown areas indicate the electoral wards where growth will be highest. This is in regeneration areas such as the docklands and Queen Elizabeth II Park Just eight electoral wards will contribute 100,000 of the 160,000 increase in population forecast for the next ten years The main hospital sites surround the areas of high growth and all will be affected.
Map showing areas of highest population growth (source GLA SLHAA capped model)
The implications of population growth on service planning The population growth we will experience is challenging because it will create increased demand for which increased capacity in health services will be required. This means that more of the following resources will be needed in the future:
Workforce: doctors, nurses, midwives etc. Hospital infrastructure: beds, operating theatres, diagnostics etc. Community and primary care infrastructure: clinics, GP surgeries
29
130 Final draft policy for approval When considering our future capacity requirements, we take into account factors that will increase demand on local services. Some of these relate to the growing size of the population and the growing number of elderly people, however we also need to take into account the implications of commissioning decisions in neighbouring parts of London, such as the planned closure of King George Hospital A&E department. This closure will increase patient numbers at Whipps Cross and Newham Hospitals. These factors are described on the left hand side of the diagram below.
Whilst these factors are expected to increase demand, we also need to understand how the changes we want to make to operate more efficiency and provide new out-of-hospital models of care will affect capacity requirements. These factors have been described on the right hand side of the diagram below.
Each of these factors affect services in different ways; so for example the projected increase in births will need to be met with a corresponding increase in the number of midwives, and the increasing population will need a corresponding increase in the number of General Practitioners.
As part of our work, we have considered the number of acute beds that are likely to be needed in the future. Whilst the growth in the population increases the demand for beds, the shift towards providing more care out of hospital and the efficiency improvements we want to make reduce the length of time that patients will spend in hospital beds. This will free-up capacity. We estimate that in net terms, local hospitals will not need to increase bed numbers over the next five years, but at the same time we don’t expect bed numbers will reduce significantly.
30
131 Final draft policy for approval
Issues of population and health needs discussed by the Clinical Working Groups
Each of the Clinical Working Groups received reports setting out the specific health needs and challenges in their own area. These are summarised in section 7 of this report, with further detail being contained within accompanying Clinical Working Group appendices.
Some of the main issues were as follows:
The Maternity and Newborn Clinical Working Group identified the rising numbers of births as a major challenge. The fertility rate (number of children to each woman in the population) in the area is already high. The increase in the population will be largest in working age families so the number of births will continue to increase. It is predicted that over the north east London area, the number of births will increase from 31,500 to 36,400 over the next ten years, with most of these births likely to be delivered in maternity units in Waltham Forest and east London. At the same time the complexity of births is also increasing; there are high numbers of babies with low-birth weight and an increasing number of pre-term babies.
The Children and Young People Clinical Working Group heard that there are 217,000 children aged 0-19 in the three boroughs, representing 27% of the population. Over the next five years this number will grow by 8%, a further 16,000 children. Deprivation is a significant factor within east London with high child poverty and poor nutrition rates expected to contribute to the demand for health services. The levels of childhood obesity are also above the England average, contributing to a predicted earlier onset of health complications related to long term conditions. A significant proportion of children in the area have a mental health disorder.
The Long-Term Conditions Clinical Working Group heard that prevalence of many long- term conditions such as cardiovascular disease, renal disease and stroke is low compared to other areas of England. This relates to the younger age profile of the population. One significant exception is diabetes where prevalence is high and growing. This is likely to reflect the high proportion of the population with a south Asian background. Whilst the prevalence of most long term conditions is low, the mortality rates are high, indicating that those people who are sick will tend to have more serious health problems such as multiple illnesses.
The Unplanned Care Clinical Working Group reported on the high use of acute services created by unplanned admissions and attendances at A&E. They heard that the diversity and turnover of the population presented special challenges for delivering health and social care.
31
132 Final draft policy for approval 6.3 Health and wellbeing: Factors contributing to the relatively poor health of the population
Whilst a person’s health depends somewhat on ‘fixed factors’ such as age, gender and ethnicity, it is now widely accepted that the strongest determinants of health are social, economic and environmental. This is evident from what is known about health inequalities and the reasons for them. The body of knowledge on this issue was comprehensively summarised by Sir Michael Marmot’s strategic review of health inequalities4.
The central finding of the Marmot Review was that differences in people’s health are explained to a large extent by differences in the social, economic and environmental circumstances of their lives that impact from before birth and throughout life. The main factors supporting a healthy life are:
Access to high quality care and support for new mothers Good parenting High quality early education High quality educational and skills development provision A sense of control over one’s life Secure employment Being in a workplace that supports health and wellbeing Having an income that is sufficient for healthy living Living in a physical environment that supports health (housing, public space) Having social and community support networks Evidence based programmes addressing behaviour risk factors for health Access to high quality health and social care services throughout life.
It follows that areas of high deprivation, where there is high unemployment, poor housing, low incomes and low educational attainment, will also have poor health. Three factors in particular are contributing to poor health in the WEL area.
Deprivation: the map (below left) shows where households are amongst the most deprived in England. People living in poverty tend to have poorer health. Ethnicity and language: the map (below right) shows the areas where a high proportion of the population are from a black or minority ethnic (BME) group. Many people in east London do not speak English as a first language. This adds to the complexity of delivering healthcare services. Population mobility: the East End is often the area where new immigrants move to first and then move on, so people and the ethnic mix of the population is constantly changing. This creates an administrative burden and challenges in providing continuity of care (particularly in General Practice). Continuity of care can be a problem with people moving in and out of the area; people often remain undiagnosed for long periods if they do not understand the NHS and how to access care.
4 Fair Society, Healthy Lives: The Marmot Review. 2010 32
133 Final draft policy for approval
Maps showing areas of high deprivation and proportion of population from BME group
It is these factors that go a long way to explaining the variation in the health of the population. So for example the low deprivation and low ethnic diversity in the north of Waltham Forest is reflected in longer life expectancy.
Reducing inequality in health service provision Variation in the provision of services may also be a factor affecting variation in health. This Case for Change highlights both good and bad examples; for example, most medical outpatient services in the area follow a “20th century” model of care where patients attend for rolling check-ups on a routine reappointment system. However some services, such as diabetes, are gradually introducing appointments through internet services such as Skype that available when patients most require them. We believe that the local NHS and partners can do better to ensure that: There is equal access to health services Services are designed around the needs of local population Services are flexible enough to change as the population changes Health inequalities are reduced Variations in the quality of services are removed. One example where services have been redesigned to match local health need is described below:
33
134 Final draft policy for approval
Case study: High quality and innovative prevention and disease management
Patients in the area who have had a stroke, have diabetes or heart disease and who need their blood pressure and cholesterol managed, benefit from:
One of the country’s best (top 10) services in Tower Hamlets London’s second best service in Newham The fifth best service in London in City and Hackney (and the best service in London for atrial fibrillation anticoagulant use)
This success has been supported by the Clinical Effectiveness Group based at Queen Mary University of London, which provides guidelines, education, data entry templates and other ‘on- screen’ support tools alongside dashboard feedback on practice-level progress.
Footnote: Waltham Forest were not part of this original case study which was commissioned by East London and the City Primary Care Trusts
34
135 Final draft policy for approval 6.4 Improving health in the population requires a partnership and co- ordinated approach
We have discussed how the main determinants of a healthy life are social, economic and environmental. So changing the way health services are delivered can only go some of the way to tackling the poor health in the population and the health inequalities that exist. As the diagram below shows, for there to be significant improvement there needs to be a co-ordinated approach involving the NHS, local government, providers of education, the private and voluntary sector as well as the general public themselves.
Health and Well-Being Boards (HWBBs) are the bodies within each borough tasked with improving health. The local NHS recognises that it can work harder with other stakeholders to make these boards more effective and help co-ordinate the approach to improving the health of the population.
The NHS and patients both have obligations under the NHS Constitution
The NHS Constitution sets out patients’ rights and obligations. The NHS can fall short of some of these. For example:
Sometimes the NHS relies on an over-medicalised and paternalistic model that seeks to “fix” patients rather than empowering them to make choices about health and healthcare Sometimes people wait too long for treatment.
35
136 Final draft policy for approval At the same time, sometimes patients don’t keep their side of the bargain. For example: Half of medication prescribed for long term conditions is not taken or not taken as prescribed Between 5% and 10% of people do not attend their GP appointments; for hospital outpatients it is c19% (above the national average) Measles, Mumps and Rubella (MMR) vaccination rates range from 72% in Newham to 93% in Tower Hamlets In 2013, 12% of Barts Health and Homerton staff, 13% of NELFT staff and 22% of ELFT staff reported experiencing physical violence from patients, relatives or the public in the last year.
The NHS, local government and providers of education must do more to help the public help themselves. For example:
Better, clearer information about medication could reduce wasted prescriptions Better, more targeted communications could reduce the number of people who do not register with a GP Better use of information technology could reduce the number of wasted appointments Involving patients more in the design of services would ensure they are more patient- centred Children need to be empowered to take control of their own health through closer working between the NHS and schools.
If we really want to involve patients we need to get them to design the outcomes and be involved in designing the solutions. Newham Adult Safeguarding Board
36
137 Final draft policy for approval 7 Do all patients benefit from a consistently world class service?
The way people live has changed dramatically over the past 20 years. This has been accompanied by advances in both technology and healthcare.
As a result, we can help people get better faster when they are ill, and treat people safely closer to their own home. Some advances have helped us live longer, but as a result we often have more complex healthcare needs.
Recent developments in healthcare mean that we are moving towards a way of working that takes into account more than simply a person’s healthcare needs, and sees them as a whole person. This includes empowering people to live fuller lives and make more informed choices about their health. The NHS needs to work harder to help support people to use the health system responsibly.
We know there are some great examples of world class services in east London. We also have some of the country’s best clinical staff. But often the way that services are set up means that we aren’t able to provide excellence everywhere.
As we have described in the previous chapter, the population of east London is growing rapidly and will continue to do so. We know that our population brings with it unique challenges meaning that we need to go further than elsewhere in the country in our innovation and service improvement. To do this, it is vital that we understand what is needed in order to provide high quality, sustainable care for everyone.
Six Clinical Working Groups developed the clinical Case for Change
In order to develop a detailed understanding of where there are opportunities to improve and work in new ways, we brought together six groups of clinicians. Each of these Clinical Working Groups (CWGs) focused on a different clinical area.
37
138 Final draft policy for approval These Clinical Working Groups were established to ensure that the programme and emerging Case for Change were shaped and underpinned by strong clinical leadership and a strong local understanding to develop the emerging evidence base. In developing this Case for Change, the group considered: Patient experience information Best practice information, policy and guidance (including NICE guidance) Their own shared clinical experience The best available local data on current performance and activity from local providers and national sources. Whist due to different coding and submission practices amongst providers there will always be limitations to this data, it was still felt helpful for participants to have access to this information. These groups also engaged with over 350 local clinicians across all health care settings in order to test and validate their work.
Based on the above sources of information the groups were asked to consider: An overview of services that are currently available The impact of local population changes and demographics on the services The implications of local strategies and plans What high quality, sustainable care looks like, for the future How current services compare to this vision What obstacles exist to achieving this The emerging model of care and priority areas for improvement Improving mental health and primary care were given consideration within each of the groups, as we recognise that improving these integral parts of the health service will lead to better outcomes in all clinical areas.
Whilst the Clinical Working Groups focused their discussions on high quality, sustainable services for the future, they also recognised that there are current operational challenges faced by hospitals on important issues such as cancer waiting times, referral to treatment times and waiting times in A&E. Each Clinical Working Group recognised that there are existing improvement programmes in place to improve performance in these critical areas.
The next section provides an overview of recurring themes from all Clinical Working Groups, as well as an overview of how primary care and mental health care need to change in order that high quality, sustainable services can be provided in the future.
Summarised findings from each of the Clinical Working Group are outlined from page 51 whilst the full reports of each Clinical Working Group can be found within appendices 1-6.
38
139 Final draft policy for approval 7.1 Recurring themes from all Clinical Working Groups
There are pockets of excellent clinical care, but there is too much variability
Whilst we have pockets of excellent clinical care, there is too much variability in the quality of health services across east London. This variability is often based on:
where patients live (e.g. what services are available to patients living in different areas). For example there are differing arrangements in place for patients to be transferred when they need more specialist care in each borough what time of the day or week patients need care.
This variation in quality is not a direct reflection of the skills of clinicians themselves but often an unintended result of the constraints of the systems within which they work.
The Clinical Working Groups agreed that this variation highlighted the opportunity to improve care on different sites and across north east London by working together across hospital sites and organisational boundaries.
We must focus much more on preventative services to reduce future pressure on hospital services
Throughout the process both patients and clinicians have expressed the need Many of the messages [in the Case for a greater focus on preventative for Change] echo the work services. There is an opportunity every [underway] locally in Tower Hamlets time a clinician talks to a patient to refer Tower Hamlets Health and them to a preventative service. This Wellbeing Board may be to help them stop smoking, to promote good mental health or to support people to lead a healthier lifestyle. Over time this will reduce the pressure on hospital services.
Technology should be used widely to deliver more efficient and effective care
There are significant opportunities to increase the efficiency and productivity of healthcare services. Whilst we have heard that there are administrative, IT and operational arrangements that need to be improved in order to reduce waste, we also know that there are opportunities where modern technology is already being harnessed to improve services. Radical new models of care are already in place that are both clinically effective and efficient. For example Skype is being used in Newham to deliver diabetes care for patients remotely.
This Case for Change provides a chance for commissioners and providers to explore new ways of working in order to modernise the way healthcare system works in east London and provide a system that is clinically and financially sustainable.
39
140 Final draft policy for approval Working together with partners to develop more integrated care will improve both quality and efficiency
We have an opportunity to deliver improved care through integrating services across east London.
For health, care and support to be ‘integrated’, it must be person-centred, Concerned about the NHS coordinated, and tailored to the needs and working in silos - will this break preferences of the individual, their carer and these down? family. It means moving to a more holistic Redbridge Health Scrutiny approach to health, care and support that Committee puts the needs and experience of people at the centre of how services are organised and delivered.
Patients can sometimes experience poor coordination of services. Clinicians report that they are frustrated with how information is transferred and shared across organisations. We also know that to truly integrate care we must fully involve people in their care. For example the provision of personal health budgets has allowed patients to bring together and take control of services to achieve the improvements in health that are important to them5.
We know that there is work being done to improve integration which has already achieved success. We now need to rapidly expand this work as it represents a great opportunity for us as providers and commissioners to work together to improve healthcare in east London for the future.
Patient experience is not consistently good enough
Understanding patient experience of clinical services has been central to developing our Case for Change. Each of the Clinical Working Groups carefully considered the feedback we have received from our patients and their families. For a summary of our wider engagement please see section 4.
Patients tell us that patient experience of healthcare services in east London varies, and that it is not consistently good enough. Whilst many people commended the excellent services and staff in the NHS, we have also heard of many instances when care and services have fallen short of expectations.
Patients explained that the NHS sometimes seems to regard patient experience and clinical care as separate things (with patient experience seen as less important). Patients overwhelmingly viewed their care in a much more holistic way.
Poor communication leads to both poor patient experience, worse outcomes and waste. Communication and poor patient experience of care were the most common issue raised by patients and the public. Sometimes this just causes irritation (for instance delays in outpatients), but sometimes this is linked to poorer outcomes (e.g. cancellations of operations) and results in wasted resources (e.g. in re-booking theatre times or multiple diagnostics because previous tests cannot be accessed or have been mislaid).
There was some evidence where things hadn’t worked and patients’ wellbeing could have been compromised, for example through not being fed for long periods whilst in hospital or by having
5 National Voices 2013, A Narrative for Person-Centred Coordinated care, http://www.england.nhs.uk/wp-content/uploads/2013/05/nv- narrative-cc.pdf 40
141 Final draft policy for approval treatments delayed because scans weren’t available at the right time. This is something the local NHS must act upon.
Patients higlighted the need for more coordination, and for clearer information about available services. Many found the health service hard to navigate and were not always sure what treatments were available to them. This was especially true when they needed urgent care.
Some people found that they were having to travel to a hospital for multiple appointments about the same Clinicians and / issue. Some of these tests could have been done departments need to talk closer to home. to each other more Attendee at long-term Sometimes patient and clinician time is being wasted conditions focus group by inefficient administrative processes resulting in long waiting times and cancelled appointments at very short notice.
Often respondents felt confused as their care was not integrated and they were left in a bureaucratic system which was passing them from pillar to post.
Nationally available data reflects the local stories that we heard and there is a realisation that we must do better across all care settings.
Accessing GP care is also an area that could be improved. Current data shows that in London, GP patient satisfaction scores are low for access and for seeing a GP of choice. This includes getting through on the phone and booking appointments. No CCG in east London meets the England average for patient satisfaction.
Surveys of patient experience of acute care services also shows low scores in east England average 86.70% London. Barts Health has lower than national City and Hackney CCG 84.90% average scores on inpatient, A&E and Barking and Dagenham CCG 80.30% combined friends and family scores. The Tower Hamlets CCG 79.90% biggest variation is in A&E where Barts Waltham Forest CCG 78.30% Health scores 48 compared with a national average of 57. Newham CCG 78.30% Redbridge CCG 74.10% Out of 22 London hospital maternity services, England worst 74.10% Barts Health is ranked 19th and the Homerton 21st6, although a recent CQC inspection of Satisfaction with General Practice using NHS Outcome framework indicator: maternity services at the Homerton rated the “Patient experience of GP services, percentage whose experience is very good or services as good. fairly good.”
6 2013: Care Quality Commission 41
142 Final draft policy for approval Case studies: examples of world class services
Across east London we have examples of world class health services. We know that there is an opportunity to replicate these examples across east London:
: Social prescribing, a scheme that links patients with non-medical sources of support in the Doctors at the London Chest recently community, is being used effectively in Tower injected a patient’s own stem cells into Hamlets to provide preventative care in his heart at the start of the world’s partnership with the voluntary sector. largest-ever trial of adult stem cell therapy – aimed at reducing deaths from heart attacks. The Barts Health clinical biochemistry team recently won the national Patient Safety in Diagnosis Award.
In Barking and Dagenham, Havering and GPs in Waltham Forest can now test for heart Redbridge, GPs use individualised failure using B-type Natriuretic Peptide (BNP) patient scorecards to support patients testing, saving patients a trip to the hospital. suffering from chronic obstructive pulmonary disorder (COPD) and help them manage their condition.
In April 2014 the Emergency Department at the Homerton University Hospital was the first in the country to be certified as ‘Outstanding’ after a CQC inspection. Whipps Cross has an emergency gynaecology unit, to provide one-stop diagnosis. This has halved emergency attendances and reduced waiting time breaches by 80%. Patients now wait The children’s hospital at Barts Health offers a less than 48 hours for ultrasound wide range of regionally specialised medical and diagnosis, and there has been an 84% surgical services including paediatric intensive reduction in complaints. care within close reach of children of East London.
Patients in Newham are being supported to manage their diabetes via Skype appointments. The Royal London Hospital’s hyper acute stroke unit and Whipps Cross and Newham’s stroke units provide patients with some of the best care not only in London but across the Whipps Cross use evidence based country. techniques such as fetal fibronectin and transvaginal cervical scans to identify The Care Quality Commission assessed women who are in the early stages of Homerton’s A&E services as outstanding. labour, which reduces unnecessary transfers and stays in hospital.
42
143 Final draft policy for approval 7.2 Primary care in east London: facing unprecedented challenges
We know that there is a direct relationship between the way primary care services are delivered and the role that acute services play in providing healthcare locally. This close relationship meant that each Clinical Working Group considered primary care throughout their discussions.
Effective support within primary care means that less people will need to go to hospital for treatment. For example, clinicians told us that with the right support, more children can be treated closer to home by GPs, rather than needing to travel further to hospitals and taking more time out of school. This would allow paediatricians to spend more time with children with complex specialist needs.
New models of care need to be adopted, that meet the needs of patients and prevent ill health more effectively.
Local primary care clinicians report facing unprecedented challenges, including finances and the growth in demand
Funding in General Practice has been relatively flat with, nationally, a real term decline in investment over the last two years. Locally this position is even more challenging due to rapid population growth and a ‘lag’ in funding following this. As with the rest of London, spend on primary care in east London is low (in the lowest 25% nationally)7.
GPs in east London are also reporting unprecedented It’s brutal out there levels of demand. Coupled with the increasing demand is in terms of the an increase in complexity of patients being seen in primary pressure care. Local doctors have reported that the 10 minute East London GP consultation model no longer meets the needs of the complex patients that are being seen. We must look at new ways of working that support an expanded primary care role which delivers a high quality service for patients.
General practice needs to be supported to play a stronger role at the heart of integrated out-of-hospital services
NHS England has a vision for General Practice to play an even stronger role at the heart of more integrated out-of-hospital services that deliver better outcomes, more personalised care and excellent patient experience. This should build on the strengths of GPs such as their generalist skills, their opportunity to successfully manage long term conditions and highly systematic use of IT. This may involve working at greater scale to support better access to convenient and reliable unscheduled care in a way that is highly coordinated, efficient and financially viable8.
Working together in networks can help primary care respond to the challenges
Improving primary care is a major challenge within current resources and requires transformational change. Newham, Tower Hamlets and Waltham Forest practices have formed or are creating networks to help them work together, with greater coordination. Tower Hamlets established its network model in 2009, with the 36 practices in the borough forming into eight networks of four to five practices to focus on population health. The network structure is being developed to enable
7 Monitor, NTDA and NHS England (2013) WELC SPG planning document 8 NHS England (2013): Transforming Primary Care in London 43
144 Final draft policy for approval practices to deliver economies of scale, share back office functions and management infrastructure. It has also helped Tower Hamlets achieve improved immunisation rates and improved diabetes care.
There is significant variation in the provision, access, experience and outcomes of General Practice services in east London
For example:
Many patients rate their experience of accessing GP services poorly Patient experience of access to GP services has been rated as poor (the bottom 25% nationally) for every CCG as measured by the GP patient survey9. This has been reflected in our engagement work with members of the public reporting challenges in accessing General Practice, and expressing a need for more evening and weekend access. It is noted that there is significant national policy emerging in this area, including the Prime Minister’s Challenge Fund.
Significant numbers of practices do not meet GP outcome standards There are a significant number of GP practices in east London which do not meet the GP outcome standards. These standards cover a range of services provided by general practice, such as screening, diagnosis and patient experience, and represent a level of care everyone should expect to receive from their GP surgery.10
There are also variations in achievement against the Quality and Outcomes Framework (QOF) indicators, for example in how well practices are identifying people who are at risk of a long term disease.
There is variation in the number of GPs working in each borough The number of GPs per 100,000 population is a good indication of the provision of General Practice services in an area.
Tower Hamlets has 85.8 GPs per 100,000 population – the second highest rate in London Redbridge has 59.3 GPs per 100,000 population – the fifth lowest rate in London East London has more than the national average of ‘small’ General Practices (one or two GPs).
9 GP Patient Survey (2014) 10 www.myhealth.London.nhs.uk 44
145 Final draft policy for approval
GPs (excluding Retainers & Registrars) headcount per 100,000 population London PCTs
100.0 90.0 80.0 70.0 60.0 50.0 88.7 40.0 85.2 83.5 83.1 78.2 77.6 76.7 74.1 73.3 70.7 70.6 70.1 69.0 67.3 67.0 66.9 66.6 66.4 66.3 66.1 30.0 64.8 64.4 62.8 61.9 60.9 60.7 59.3 57.7 55.2 20.0 52.2 49.8 10.0 0.0 City and… City Haringey… Ealing PCT Greenwich… Sutton and…Sutton Barnet PCT Enfield PCT Enfield Harrow PCT Harrow Barking and…Barking Camden PCT Bromley PCTBromley Croydon PCTCroydon Islington PCT Islington Kingston PCT Kingston Lambeth PCT Havering PCTHavering Newham PCT Lewisham PCT Lewisham Hammersmith… Hounslow PCT Richmond and… Richmond Hillingdon PCT Redbridge PCT Redbridge Brent Teaching… Southwark PCT Southwark Tower Hamlets… Tower Kensington and…Kensington Waltham Forest… Waltham Westminster PCT Westminster Wandsworth PCT Bexley Care Trust CareBexley
GPs (excluding Retainers & Registrars) headcount per 100,000 population National Average
Health and Social Care Information Centre . 2013. Local Basket of Inequality Indicators, The number of full-time equivalent (FTE) primary care professionals per 100,000 population (weighted for age and need). [ONLINE] Available at: http://nww.indicators.ic.nhs.uk/webview/. [Accessed 5th August 2014].
The workforce challenges faced in General Practice are significant and are discussed further in the workforce section (section 8) of this report.
The primary care challenges have been central to the discussions of the Clinical Working Groups and the opportunities for improvement and potential for Primary care to support new models of care are discussed throughout the Case for Change.
Primary care service transformation across east London will be taken forward within a separate work stream of the Transforming Services Together programme (see chapter 10 for more information).
45
146 Final draft policy for approval 7.3 Addressing mental health needs in our hospitals and health care services
Context
Mental health has been an important focus area for each of the Clinical Working Groups. In addition to the groups’ findings, further discussions have taken place with clinical and commissioning leads for mental health, as well as providers of mental health services. This section brings these findings together and looks at how hospital services can effectively meet the mental health needs of people in east London, and how we can provide effective support for people in all healthcare services.
There are high levels of mental illness in east London
There are high levels of mental illness in east London (for child and adolescent mental health services, for adults of working age, and for older people – including dementia). This may be influenced by the fact that east London has a high prevalence of risk factors that can contribute to the development of mental health problems in individuals.
Ensuring parity of esteem between physical and mental health care is vital
The key principles that have emerged from the Clinical Working Groups are aligned with national policy and focus on ensuring there is parity of esteem between physical and mental health. The
diagram below shows how all parts of an effective health care system works must together.
46
147 Final draft policy for approval Mental health: the case for change
This section details our case for change to address mental health needs in our hospitals and health care services.
1. Our approach to integrated care should be strengthened in relation to mental health so that we deliver a more patient-centred model of care.
Mental health leaders in east London have told us that the areas that need to be strengthened within integrated care approaches are:
Vision, leadership and workforce: the vision of integrated care for mental health needs to be strengthened, with a strategy for a workforce that is able to ensure early identification and response to mental health needs. Every person delivering health and social care has a role in identifying people with mental health needs and supporting their emotional wellbeing or referring them on to services that can.
Addressing medically unexplained symptoms: this is a key area that highlights that parity is required. Community psychiatric nurses (CPNs) are not trained in identifying medically unexplained symptoms. This creates a real gap for patients with long term conditions who experience these, which are often a symptom of a mental health problem.
Communication and IT systems: our systems need to support the sharing of care plans between all providers, including mental health.
Evidence-based practice driving the strategic response: we need to ensure that care integration and support for mental health needs are delivered in line with NICE guidelines and that these form the basis of goals and outcomes that we are seeking to achieve.
2. By creating a parity of esteem between physical and mental health, we can better meet the needs of our population. This will help prevent people experiencing a mental health crisis and enable us to respond more effectively if they do occur.
Many people with long-term physical health conditions also have mental health problems and having mental health problems can exacerbate a physical illness. This can lead to significantly poorer health outcomes and reduced quality of life. People with a primary mental health need can also have their physical health needs overlooked. Total health care costs are increased by at least 45% for each person with a long-term condition and a mental health problem11.
Local clinicians have set out the following aspirations for care to strengthen parity of esteem:
All clinicians should be able to identify and respond to mental health needs Mental health should feature as a core aspect of every care plan Mental health support for patients with long term conditions should not complicate the care patients receive (for instance extra appointments and travel). Care should be coordinated with the wider care plan and a team approach to delivery
11 The Kings Fund (2012): Long Term Conditions and Mental Health – the costs of co-morbidity 47
148 Final draft policy for approval Clinicians providing care for people with a physical health condition need to be supported by psychological services and have clear pathways that support onward referral for mental health support People should not be in a hospital because there is nowhere else for them to go. This is currently the case for many patients with dementia The end-of-life care principle for long term condition care should have a strong mental health focus in relation to emotional support and managing wellbeing in the last years of life. A model that was considered to be effective by local clinicians for providing mental health support for people with long term conditions was described as having the following structures and levels of support:
• Consultant level oversight and expert opinion Governance
• Mental health specialists supporting clinicians to identify mental health
Expert support needs and raise awareness of pathways they can refer to for support
• All clinicians have a role in considering the mental health needs of their Responsive patients and referring on to appropriate services that can support them clinical services
Currently in east London, we are not achieving this vision for care. There is some good practice, such as the respiratory nurse team in Tower Hamlets, which undertakes anxiety assessments as part of the care that they provide to patients, but good practice needs to become routine across east London.
Patients with a diagnosis of dementia are Average length of stay spending significantly longer in hospital 2.34 than patients with other conditions. For Grand Total 10.48 most trusts the average length of stay was Whipps Cross 2.22 up to 10 days longer for people with 10.15 dementia than the average length of stay 2.23 Newham 6.51 for all other conditions (unplanned and 2.15 planned care admissions). This can be Homerton 13.05 seen in the graph. In addition, dementia Barts and The London 2.56 patients account for 2.84% of hospital 12.90 spells at Whipps Cross Hospital, yet 0.00 2.00 4.00 6.00 8.00 10.0012.0014.00 account for 11.8% of their bed days12. All other spells dementia
Average length of stay for patients with a diagnosis of dementia (diagnosis code 1-20) April 2013 – March 2014, planned and unplanned care admissions (SUS)
12 SUS April 2013 - March 2014 48
149 Final draft policy for approval Mental health is a third most common reason for emergency (non-elective) admission into our hospitals amongst 19-69 year olds. Between and a fifth and a quarter of admitted patients receive a diagnosis for a mental health condition, with alcohol related problems and dementia featuring particularly prevalently.
Reasons for non-elective hospital admission for patients admitted with Non elective admissions with a mental health diagnosis as a proportion a mental health diagnosis – 1st April 2013 to 31 March 2014 of total non elective admissions 1st April 2013 to 31st March 2014
The Rapid Assessment, Interface and Discharge service offers support to specialists in acute settings. Alongside raising awareness of mental health across the entire workforce, awareness of this service needs to be promoted.
In-patient care for patients with alcohol and substance misuse problems has been highlighted as a key issue, as well as people having unplanned episodes of care due to domestic violence. Our partnerships with local authorities need to ensure effective local, community-based services are in place to support people with these needs. Community-based services can provide an alternative to hospital-based care, in a better recovery setting.
49
150 Final draft policy for approval 3. We need to ensure support is available 24/7 for children and young people with urgent mental health needs.
There are varying models operating across acute sites to deliver an urgent response for children and young people presenting at A&E with a mental health need, particularly out-of-hours. It is common practice that out-of-hours, children and young people will be seen by a psychiatrist for adults. There are opportunities to strengthen this approach.
4. We need to ensure high quality CAMHS services are in place and that young people are well supported to transition into adult mental health services.
The fragmented way in which Children and Adolescent Mental Health Services (CAMHS) are commissioned has been highlighted by clinicians as something that needs to be improved. The services that are provided in schools was raised as a specific area of concern alongside the increasing variance in provision that is being observed, particularly in free schools13.
Transitions for young people into adult services, which happens when young people become 18 years old, are often poor and can lead to people who need mental health services falling out of the system. Local CCGs are working to address this through reviewing and reorganising CAMHS and are considering extending provision to 0-25 years, in order to develop a smoother transition across services.
5. We need to do more to minimise the risk and impact of post-natal depression for new mothers throughout the entire maternity care pathway.
In east London we have good service provision for new mothers with high level mental health needs, but we do not currently have an effective service response for those with low to medium level mental health needs. Care provision is currently provided by the Improving Access to Psychological Therapies (IAPT) service. As there are variable models of care across the boroughs, the service is not always able to provide a fast and integrated response. In addition, mental health and emotional support is not currently embedded in the antenatal care pathway.
Emerging priorities and models of care for better mental health
Based on the analysis undertaken by the Clinical Working Group and clinical leads for mental health, the key emerging priorities and models of care are detailed below. These will need to be discussed and taken forward in through the Transforming Services Together mental health work stream (see Chapter 10 for further information):
Ensure that the vision and strategy for integrated care delivers parity of esteem for mental and physical health needs e.g. all care plans consider mental health needs The health and social care workforce need to be trained to recognise and identify appropriate support for mental health needs, supported by experts in mental health care We need to support new mothers with mild and moderate mental health needs better We need to ensure appropriate support is available 24/7 for children and young people with urgent mental health needs.
13 A Free School in England is a type of academy, a non-profit-making, independent, state-funded school which is free to attend but which is not controlled by a local authority 50
151 Final draft policy for approval 7.4 Maternity and newborn care
Context
The birth rate in England is rising, with a 23% increase in babies born between 2001 and 2012 to reach the highest annual number of births since 197114.
Since 2008 average annual growth in births locally has been high, up to 2.7% in some boroughs. We now have some of the highest birth rates in the country with more than 31,000 births across the seven north east London CCGs in 201315.
There is likely to be almost 5,000 more births per year in north east London by 2023- 24
We have every reason to believe that the number of births in the area will continue to increase over the next decade. The largest population growth is forecast to be in people of working age and it follows that if the fertility rate remains high then the number of births will continue to rise as new families move to the area.
Projections of births by borough have been undertaken by applying the average fertility rate for each borough for 2011-2013 to the forecast population of women of child-bearing age and are displayed in the table below. The projections show:
Births in north east London are likely increase by 4,88216 per year in the ten years up to 2023-24. The total number of births is likely to be close to 36,400. The area of greatest increase is likely to be Tower Hamlets and Newham, where the forecast population increase is the largest. This is likely to carry on for a further ten years given population growth forecasts. Potentially there could be 40,000 deliveries per year across north east London in 20 years’ time.
Total Births Forecast Increase % Increase 2013-14 2023-24 Tower Hamlets 4,608 6,080 1,472 31.9% City & Hackney 4,500 5,142 642 14.3% Newham 6,267 7,615 1,348 21.5% Waltham Forest 4,721 4,862 141 3.0% Redbridge 4,591 4,941 350 7.6% Barking & Dagenham 3,796 4,252 456 12.0% Havering 3,004 3,477 473 15.7% Total 31,487 36,369 4,882 15.5%
14 Royal College of Midwives (2013): State of Maternity Services report 2013 15 Office for National Statistics (ONS) 16 Projections are local calculations based on GLA methodology using the most recently published projections of fertility rates from the ONS. It should be noted that there is significant variation in the various birth forecasts available and the figures used represent one of the higher projections. Further work will need to be done on birth projections. 51
152 Final draft policy for approval Births are becoming increasingly complex, with more pre-term births and high rates of full-term babies with low birth weight
Complex pregnancies in the region are putting more demand on health services. There is a rising trend of pre-term births and this is placing more pressure on neonatal services, particularly where advancing medical practice is resulting in more demand for care for babies born very early.
East London also has high rates of low birth weight babies at full term with rates as high as 10.1% in Newham compared to the England average of 7.3%17.
Pre-existing health conditions also contribute to more complexities during pregnancy. For example east London has a higher prevalence of obesity than the London average (9.9% compared to the London average of 9.2%18). Diabetes prevalence amongst the adult population is high and rising in some parts of east London with prevalence rates forecast to rise to 10.4% in Newham by 2015 against a forecast England average of 7.6%19. Mental health prevalence in east London is higher than the England average indicating that more care is required for women during the antenatal and postnatal period. Rates of poverty and family homelessness20 are worse than the England average, indicative of poor nutrition and poorer health outcomes as a result of health inequalities.
Maternity services in east London are delivered by a large number of providers across multiple sites
The current configuration of obstetric and midwife-led units across Homerton University Hospital and Barts Health can be seen in the map below. Homerton, Newham and Whipps Cross hospitals all have obstetric units with midwife-led units operating alongside them. The Royal London currently has an obstetric unit with a midwife-led unit planned to open later this year. Barts Health Configuration of maternity units in east London
17 Public Health England (March 2014), Child Health Profiles 18 McKinsey (2012) Developing the case for change in establishing an Integrated Care System across Waltham Forest, East London and the City 19 LTC CWG data pack 20 Public Health England (March 2014), Child Health Profiles 52
153 Final draft policy for approval also has two free standing midwife-led units, the Barking and Barkantine birthing centres. There are then numerous community providers, GPs, local authority services and independent organisations providing antenatal and postnatal care and family support services.
As the map below illustrates, there are four neonatal units across Barts Health and Homerton. Two of these units are designated “level 2”, which provide high dependency care for neonates, and the Royal London and Homerton are “level 3” units, providing intensive care for neonates. The level 3 units provide a service to all seven boroughs in north east London.
53
154 Final draft policy for approval Maternity and newborn care: the case for change
The case for change has been developed by comparing current services with principles that the Maternity and Newborn Clinical Working Group set out for good care:
Standardised pathways with smooth transitions delivered by a supportive, empathetic workforce
PRINCIPLE 4: PRINCIPLE 1: PRINCIPLE 2: PRINCIPLE 3: Newborn care close Antenatal care to home where High quality High quality provided close to appropriate nad in intrapartum care postnatal care home specialist centres where needed
Underpinned by preventative approaches, robust approaches to safeguarding and continuity of care
Parity of Joined up Consistent Early A patient esteem for across care across Care close Supported identification, centred mental and different the to home staff early approach physical intervention services and geography health teams
This section describes our case for change:
1. We can reduce the number of women experiencing complications during birth by increasing the number of women starting their antenatal care early.
Women should start their antenatal care as early as possible to maximise the benefits of healthy living during pregnancy and to aid identification and monitoring of risk factors as soon as possible.
National Institute of Clinical Excellence (NICE) guidance recommends that pregnant women are supported to access antenatal care, ideally by 10 weeks21.
The 13 week booking indicator shows us that too few women in east London are starting their antenatal care early enough and that there is too much variance across our CCGs. The rate of women starting their antenatal care by 12 weeks after conception ranges from 63.9% to 96.1%, against an England average of 86.2%. This can result in risks or complications to a woman’s pregnancy, if problems are not being identified early enough.
21 National Institute of Clinical Excellence (2008), Clinical guideline 62 54
155 Final draft policy for approval 2. Through effective mapping of antenatal care across east London we can work to ensure all women are seen by the right healthcare professional in the most appropriate setting.
There is no central mapping of antenatal activity in east London but the Clinical Working Group’s experience is that community provision is highly variable and that too much activity is taking place in hospitals that could be appropriately delivered in primary or community settings. NICE recommends that midwives and GPs should care for women with uncomplicated pregnancies and that antenatal appointments should take place in a location that is readily accessible and appropriate to the needs of women and their community22.
Health for North East London (HfNEL)23 recommended that 95% of antenatal and postnatal care should be available outside of hospitals. To achieve this recommendation, it would mean 16,200 bookings a year would be managed in the community or GP setting and 850 managed by hospitals24. Work conducted since HfNEL, has demonstrated that achieving this shift of care is complicated by the existing commissioning arrangements and financial incentives.
Further complications exist with a shortage of midwives and variability in GP skills and knowledge. There is a national shortage of qualified midwives25 and this is a particular problem locally. Shifting care out of hospitals would require more midwives working in the community as opposed to hospitals.
The shortage of midwives means there are challenges in providing continuity of care by a named midwife model, as recommended by NICE26. The Clinical Working Group believes that all providers should operate a named and known midwife model to ensure continuity and care and more effective integration between antenatal care providers. However only Homerton currently operates a named and known midwife model of care.
Given the rising fertility and birth rates, the increasing demand for deliveries in Not enough breastfeeding support – obstetric units and challenges in you don’t always want to leave the recruiting to vacant midwifery posts, house to go to the children’s centre acute services are also finding it Attendee at maternity and newborn challenging to provide all pregnant care focus group women with the same levels of access to antenatal group support.
22 National Institute for Clinical Excellence (2008), NICE clinical guideline 62 23 23 Health for North East London was a transformational change programme, clinically led and with extensive public engagement, to reconfigure hospital services within North East London. The recommendations emanating from this programme (and endorsed by the Secretary of State for Health in 2010) provide a key point of reference for planning and service development of hospital services in north east London. 24 SUS data 25 Royal College of Midwives (2014), State of Maternity Services report 2013 26 National Institute of Clinical Excellence (2008), NICE clinical guideline 62 recommendation 1.2.2.1
55
156 Final draft policy for approval 3. Integration of health care with local authority services and support groups would improve the support available to women.
The Clinical Working Group believes that services are poorly integrated. The wide variety of providers across health, social care and voluntary organisations, the lack of a directory of services, and the lack of a shared electronic care record are barriers to effective communication and integration.
The group recognises that a healthy pregnancy is supported by organisations beyond the NHS, particularly with regard to prevention services. However, this support should be coordinated so that it is easy for women to know about and receive the services they need.
Women living in east London report variable experiences regarding the amount of information they receive about the available options. Women have reported through our engagement process and focus group that they sometimes ‘found out by accident’ what assessments should happen and when, and what support is available to them – for instance by friends asking why they hadn’t yet seen a midwife. This is a particular issue amongst women from deprived backgrounds, as evidence suggests they are more likely to experience difficulties accessing services available.
4. We need to work together to ensure we are prepared for the additional births across north east London.
Given the opening of a new midwifery-led unit (due later this year) alongside the Royal London obstetric unit, there is currently sufficient physical capacity across the Barts and Homerton campuses to meet demand (see table below). The new facilities at the Royal London will increase capacity on the site to 6,000+ deliveries per year.
However, we need to work together to ensure we are prepared for the additional births forecast across north east London. A system of managed flow has been introduced to smooth demand across the five maternity campuses. Clinical Working Group considered the recent implementation of this managed flow system successful, but have also highlighted that women will often present for delivery at a site different to the one they have been booked to deliver in, which can make managing capacity and demand challenging.
Physical capacity in east London delivery units
56
157 Final draft policy for approval If births continue to increase as predicted then:
If no action is taken the physical capacity of east London’s maternity departments could start to be breached from 2016-17; and by 2023-24 east London will need space for an additional 3 – 4,000 deliveries. Based on current utilisation east London will require 12-15 additional Special Care Baby Unit (SCBU) cots by 2023-24. The factors that are driving the increase in births (population increases, immigration and ethnic mix) are all likely to continue to apply after 2023-24.
Managing capacity and demand is an on-going challenge across the maternity network. This is particularly true for managing sufficient and consistent staffing levels across sites, as well as ensuring patient choice in delivery setting.
5. Midwifery-led deliveries should be the ‘norm’ for births. This provides an opportunity for us to continue to provide women with a choice of where they have their baby appropriate to their level of risk.
The Clinical Working Group has reviewed data from Homerton and Barts Health to identify differences in the rates of deliveries in obstetric, alongside midwifery-led unit (AMU) and free standing midwifery-led units (FMU), demonstrating that the system is not yet delivering the proportion of births across the current configuration as described in HfNEL recommendations shown below.
• 60% births in team Campus model setting (midwife, anaesthetist, obstetrician) • 30% births in alongside midwifery-led unit Home • 10% Out of hospital births 5% split 50:50 home / free Obstetric- standing midwifery-led Led Unit unit 60%
Alongside Free Midwifery- Standing Led Unit Midwifery- 30% Key Led unit Obstetric-Led Unit 5% Alongside Midwifery-Led Unit Out of hospital birth
Activity flow
Woman/baby
Health for North East London proposal for a campus model
57
158 Final draft policy for approval For instance, 6.2% of deliveries at Barts Health were performed at home or at a standalone midwifery-led unit against a recommendation of 10%.
The Clinical Working Group report that too many deliveries are taking place in obstetric units and far too few are taking place at FMUs or at home. The Clinical Working Group believes there are four key factors influencing this:
1. Women and the antenatal care providers are not always aware of all of the birth options available to them. 2. There may be referrals to obstetric teams from antenatal care teams when these women could have been appropriately managed in a different setting e.g. the Clinical Working Group identified that in one month on one site within Barts Health, 35% of referrals from midwife to obstetrician were potentially inappropriate and could have been managed safely and effectively in midwifery-led antenatal care27. 3. The induction of labour pathway currently leads to mothers delivering in an obstetric led unit. We need to encourage women to have normal births and these women could potentially deliver in a midwifery-led environment. 4. There are local challenges that need to be addressed to increase midwifery-led births at the FMUs. The Barking and Barkantine Birth Centres, are known to be underutilised and attempts to promote these as safe units providing a positive birthing experience have had limited success, despite positive feedback from women who have delivered there. This may be due to the lack of awareness by professionals working in antenatal care as to what these centres offer. With low utilisation rates, the two centres are expensive to run and not currently achieving the efficiencies that could enable the acute system to cope better with the additional forecast births.
6. New ways of working mean we have the opportunity to provide more women with a natural birth and reduce the number of women who have interventions such as emergency Caesarean-sections (C-sections).
The percentage of assisted delivery rates (those with interventions) range from 4.7% to 13.7% of deliveries which is likely to be influenced by protocols and variation in clinical decision making.
27 Barts Health NHS (2014): Antenatal booking audit 58
159 Final draft policy for approval
As the table below indicates, C-section rates vary from 27.0% to 29.5%. Both Barts Health and Homerton are above the national and London average. The Clinical Working Group concluded that this is driven by differences in risk tolerances and variation in protocols, and potential pressure on obstetric units. An audit of emergency C-sections at Whipps Cross Hospital found that in 29% of cases, it was thought that a different management plan either antenatally or during labour may have resulted in a different type of birth28.
Variation in C- section rates across east London
2012/13 2013/14 Trust No of Births No of % Caesarean Births No of % Caesarean Caesarean Sections Caesarean Sections Sections Sections Royal London 4,762 1,307 27.4% 4,744 1,291 27.2% Newham 5,613 1,731 30.8% 6,491 1,769 27.3% Whipps Cross 5,381 1,438 26.7% 4,431 1,254 28.3% Homerton 4,344 1,238 28.5% 5,594 1,609 28.8% Total all sites 20,100 5,714 28.4% 21,260 5,923 27.9%
The Clinical Working Group reported that there is a general lack of agreed protocols between providers and organisations. The group identified that this can result in varied behaviours amongst clinicians with some making more risk averse intervention decisions. Recent reductions in C- sections at Newham Hospital have been the result of efforts between local partners to promote and work towards natural, midwifery-led deliveries.
The levels of intervention and C-section rates must however be taken in the context of the higher risk profile of women in east London in relation to lower weight babies and an increased prevalence of hypertension and diabetes in pregnancy among particular populations. The Clinical Working Group agreed that a level of variation may not necessarily be a cause for concern. Mortality and morbidity rates have been proposed as an alternative quality measure.
7. There remains a challenge in meeting best practice staffing levels across east London for obstetrics and midwifery.
Consultant presence on labour wards varies from 70 to 80 hours per week across the four Barts and Homerton sites. Homerton is planning to extend cover to 98 hours in October 2014. This compares to Royal College minimum standards of 9629 and London Quality Standards of 168 hours per week for units with more than 5,000 deliveries per year30. It is important however to recognise that no trust in London is currently meeting the London Quality Standards.
None of the Barts Health units are currently able to meet the London Quality Standards in relation to the midwife to birth ratio of 1:30. Barts Health sites range from 1:32 at both the Royal London and Newham to 1:33 at Whipps Cross. Neither the Royal London nor Newham sites are meeting 1:1 midwife care during labour across all birth settings and the supervisor of midwives to midwife ratios are short of the 1:15 recommended at all of the four east London sites.
28 Barts Health NHS (2014) Clinical audit of emergency and planned C-Sections Grades 1,2,3 29 Royal College of Obstetricians and Gynaecologists (2008), Standards for Maternity Care, report of a working party 30 London Health Programmes (2013): London Quality Standards - Quality and safety programme, Maternity Services 59
160 Final draft policy for approval The reasons for the shortfalls in recommended staff ratios across midwifery nationally are varied, with existing vacancy rates, an ageing workforce and the ambiguities in calculating capacity and capability of the midwifery workforce required, all adding to the complexity of this issue. The Royal London site has however achieved success in their recruitment of midwives and has been able to move away from using agency staff in maternity services. This has not yet been achieved at all other sites.
8. Postnatal care is an area we know we need to improve. There is a need to standardise it across east London and improve the communication between hospitals, GPs and community services.
There is considerable variation in the provision of postnatal care across east London. This is because there I was discharged by a student nurse… are a large number of service and she also gave me all my files that providers operating under different the hospital should have kept. I even locally defined pathways and had to call a community nurse as no protocols. midwife or nurse checked me before or after my birth. Without consistent and visible New mother in east London pathways, hospital clinicians and patients find it very difficult to access and navigate postnatal care outside of the hospital, particularly for out of area deliveries. As a result, in some cases women are not consistently being given appropriate referrals or receiving full and accurate information about care after discharge.
Poor communication between hospitals, GPs and community services is constraining high quality, seamless care. East London lacks sufficient IT facilities for clinicians to access and share medical records, whilst discharge information is often not detailed enough and sent by unreliable means. The discharge letter typically provides only limited information and does not allow for the transfer of more detailed knowledge and advice that could be used by out-of-hospital clinicians to provide better quality care. Discharge letters are typically hard copy letters sent by post or via the parents themselves. A lack of a system for sharing electronic care records between organisations increases the risk of important or urgent discharge information not being communicated effectively.
9. We need to do more to minimise the risk and impact of postnatal depression for new mothers throughout the entire maternity care pathway.
Currently in east London we have good service provision for new mothers with high level mental health needs, but we don’t have an effective service response for those with low to medium level mental health needs. Care provision is currently provided by the Improving Access to Psychological Therapies (IAPT) service. As there are variable models of care across the boroughs, the service is not always able to provide a fast and integrated response. In addition, mental health and emotional support is not embedded within the antenatal care pathway.
10. We need to develop ways of measuring and benchmarking neonatal care in east London to ensure it is of high quality.
It is difficult to compare or benchmark the quality of neonatal care across east London. This is reflective of the national picture where data quality remains an issue. In order to develop a detailed 60
161 Final draft policy for approval plan for the future we will need to develop an agreed set of indicators for all sites. This important information should be then be used to inform any clinical strategy developed in the area of neonatology.
11. By standardising neonatal care pathways and protocols and transitional care we will be able to make sure that babies can return home as soon as it is safe and that unwell babies continue to be cared for safely.
Transitional care is defined as the care which cannot be provided by the mother at home such as intravenous antibiotics that occurs either outside a neonatal unit or in a ward setting and is not included in the specialised commissioning portfolio31. The Clinical Working Group has highlighted two important challenges in meeting the needs of what are sometimes referred to as ‘unwell, well babies’ and need transitional care:
1. There is a lack of an agreed pathway for transitional neonatal care. 2. There is a lack of an agreed mechanism for organisations to accurately capture current levels of demand for transitional care. These factors have resulted in variations in practice, appropriate staffing (skills and numbers), joint working with other specialties and protocols of care (e.g. use of antibiotics). This is seen by the Clinical Working Group to create delays to some discharges in obstetric and paediatric units, which in turn puts increased pressure on neonatal unit capacity.
The Clinical Working Group reflected on the constant challenge in neonatal care of making sure that babies are treated in the right care setting. This challenge includes understanding labour needs and neonatal capacity through earlier identification of complications and risks.
12. The capacity and capability in neonatal care and its workforce will need to increase to meet demand more effectively.
Neonatal care activity is increasing and so capacity management and ensuring appropriate staffing levels is becoming increasingly difficult.
Intensive care cot activity across Barts Health and the Homerton has risen by 11% during the last two years. High dependency activity has increased by 1.5% and special care activity has fallen by 8%32. The Clinical Working Group acknowledged that neonatal demand is likely to increase with the increase in births forecast. Approximately 9% of all births will require some level of care within a neonatal unit. This indicates that both physical and workforce capacity and capability will need to cope with higher levels of demand in the future.
Calculating the number of cots that may be required in the future is complex, given that services care for a wider population than just east London. In relation to the special care cot numbers, it is estimated that a further 12 special care cots will be required in east London units. It is acknowledged by the Clinical Working Group that this is a preliminary figure and more detailed work needs to be undertaken to further define the increase in number of neonatal cots required.
The Clinical Working Group also recognises the current and future challenges in relation to the neonatal workforce. The optimal levels of perinatal medical staffing recommended by the British
31 NHS England (2012-13), NICU and SC Service Specification 32 London Perinatal Network (2012), Annual Report 2011/12 61
162 Final draft policy for approval Association for Perinatal Medicine33 are being met in east London. However, nursing staff ratios specific to each level of care are variable as are the ratios of neonatology qualified to general trained nursing staff as recommended in the Commissioning High Quality Neonatal Care Toolkit34. It is important to recognise that this is a national issue across all neonatal care providers, and not unique to London.
13. Through developing stronger consistent pathways and transfer protocols we can deliver more efficient and effective neonatal and paediatric services.
The transition from neonatal to paediatric services is not adequately supported by efficient and effective handovers. Discharge information does not share the full depth of neonatal clinical knowledge with GP and community services and without joined up IT systems it is difficult for services outside of hospital to access hospital records. Clinical Working Group members have reported some babies being admitted to paediatric care, even just a few days after neonatal discharge due to lack of robust information on discharge.
14. Given the interdependency between how neonatal demand is managed in east London neonatal units and the neonatal transfer service, any recommendations made in relation to future models of neonatal care must take the impact on neonatal transport into account.
Neonatal transfers were discussed by the Clinical Working Group and considered to be inconsistent. There have been too many instances of long waits (up to six hours) in east London. New specialist ambulances have provided higher quality facilities but it was felt by the group that some babies are having to wait too long to be transferred to the most appropriate care facilities and that having to provide a nurse for the transfer is negatively impacting the staffing and care at the sending trust.
Emerging priorities and models of care
Based on the analysis undertaken by the Clinical Working Group, the key emerging priorities and models of care are detailed below:
We need to address the barriers that are preventing us from delivering more care closer to home
Working closely with the primary care Transforming Services Together work stream, there is a need to map the current model of antenatal care in more detail to identify where it is being provided and by whom. Through better integrating and strengthening antenatal care we believe we will:
empower more women to make the right choices in relation to their care by ensuring they are better informed of what care is available and how they can access it identify risks earlier therefore improving access to appropriate treatment and further assessment when needed.
In recognition of the essential role effective antenatal care plays in managing demand across the maternity pathway, we also believe that women who access antenatal care early are more likely to choose a place they wish to give birth that is most appropriate to their level of risk. We believe this will result in:
33 British Association for Perinatal Medicine (BAPM)(2014)Optimal Arrangements for Neonatal Intensive Care Units in the UK including guidance on their Medical Staffing. 34 Department of Health (2009) Toolkit for High Quality Neonatal Services 62
163 Final draft policy for approval reduced demand on acute midwife workforce the development of a named midwife model of care with the associated outcome and patient experience improvements better management of intrapartum35 demand.
We need to increase opportunities for women to have a normal delivery with the best possible outcomes for mothers, babies and their families
Increasing the opportunities for women to have a ‘normal delivery’ will reduce risks of complications for both the mother and baby. It will also improve their experience of birth and help manage demand through ensuring we make the best use of our workforce and physical capacity.
To improve the likelihood of women having a normal delivery, maternity service providers should prioritise the following actions:
Streamline the induction of labour (IOL) pathways and protocols according to best practice to decrease the time women wait from time of admission to induction of labour and reduce the risk of them needing an emergency C-section Implement new training programme for obstetric registrars to increase confidence and competence to trial instrumental deliveries when safe to do so prior to making a decision to perform C-sections Identify and reduce the existing barriers for increasing the use of midwifery-led units and development of home-birth midwifery teams as recommended in HfNEL Ensure the service improvements listed above are closely linked to the proposals for improving the antenatal care provision, increasing the likelihood of providing all women with a named midwife to promote appropriate choice and better outcomes.
We need to support women more effectively through postnatal services
To achieve this, we need to undertake a more detailed review of how postnatal care is currently provided and the outcomes being achieved. We also need to set out proposals for providing more detailed information for GPs and acute maternity services about the services and care that are available for women and their families in east London and how they access it. We need to work with local authorities and voluntary organisations to achieve this.
We need to plan for the future recruitment, education, training and professional development needs of our workforce
More midwives and consultants are needed, however it is difficult to quantify how many, where they will be working and what skills and competencies they will require. Therefore, we need to undertake a detailed review of workforce capacity and capability requirements to understand where existing gaps are in order to formulate sustainable plans to address these challenges.
We need to ensure the system is prepared for the forecast additional births
35 Intrapartum care: the care of healthy women and their babies during childbirth.
63
164 Final draft policy for approval We need to take forward work to plan for the forecast additional births in north east London. In particular, shifting towards more normalised births should help to take the pressure off of obstetric units by:
increasing the numbers of home births increasing births in midwifery-led units where some units have capacity reducing the number of inductions overall and increasing the numbers of inductions done on an outpatient basis.
It is important to note that these proposed solutions will only help with capacity in the short to medium term. They do not solve the longer term workforce constraints. Providers and commissioners will therefore need to:
conduct detailed capacity and demand modelling which is regularly revisited, to understand which sites will come under most pressure plan capital investment to increase capacity where it is constrained consider further changes to referral pathways to match forecast deliveries to the safe capacity at each hospital undertake a workforce needs assessment to plan for future recruitment ensure that providers have robust plans for recruiting and retaining staff that take account of future expected growth.
We need to ensure adequate support for women who have mild to moderate levels of mental health need
Work needs to be taken forward to develop an effective way of identifying women with low to moderate levels of mental health need, and may include the following actions:
developing a fast track Improving Access to Psychological Therapies (IAPT) service implementing a named midwife model to improve integration between midwifery services. working with local authorities to understand and address concerns regarding future changes to health visiting services – there is concern that there will be less focus on emotional well-being, given the challenges of their safeguarding responsibilities providing information to all service providers (including the voluntary sector) on support available, including for out-of-area women.
We need to ensure robust mechanisms are put in place to measure the quality of neonatal care, patient outcomes or demand for transitional care
We need to take forward work to confirm a baseline in relation to the quality of neonatal care currently being provided.
Plans to increase the numbers of middle-grade neonatology and paediatric registrars on call are a potential solution to increasing access to the required medical staff cover, however this needs to be reviewed as a potentially viable, and affordable option across all sites.
We also need local agreement on a standardised approach to measuring demand for transitional care. The impact of the birth forecast on neonatology requirements needs to be considered as part of wider capacity and demand analysis.
64
165 Final draft policy for approval 7.5 Services for children and young people
Context
East London has a higher than average proportion of children and young adults. Approximately 217,000 children, aged 0-19, account for 27% of the population in Newham, Tower Hamlets, Redbridge and Waltham Forest. The number of children and young people within the four boroughs will continue to rise rapidly with approximately 8% growth expected over the next five years (representing an additional 16,000 children and young people)36. Forecast growth is particularly high in the 10-14 years age group.
The population of children and young people is culturally diverse, with between 80.2% (Waltham Forest) and 92.8% (Newham) of school children from a minority ethnic group and higher than average rates of non-English speakers37.There is a high level of population movement – as high as 30% annually in Newham38.
Importance of prevention and screening in the local population
Deprivation is a significant factor within east London with high child poverty and poor nutrition rates contributing to the high demand for health services. The rate of child poverty and family homelessness in the area is higher than the England average with between 23% (Redbridge) and 43.6% (Tower Hamlets) of children under 16 years living in poverty (England average is 20.6%39).
Locally there is a real need for developed prevention, public health and screening provision. The levels of childhood obesity are above the England average in all boroughs, contributing to a predicted earlier onset of health complications related to long term conditions, potentially increasing the demand for health services in the future.
By using the 2012 public health population estimates we can predict that just over 24,000 local children and adolescents (5 – 16 years) will have a mental health disorder. Reviewing emergency admissions data reveals the number of emergency admissions for children and young people for self-harm range from 0.66 per 1,000 (Redbridge) to 1.21 per 1,000 (City & Hackney).
Paediatric services are provided at all four of the main acute hospital sites. The Royal London provides both complex and less-complex paediatric services whilst Homerton, Newham and Whipps Cross hospitals provide less complex paediatric services. All sites provide paediatric emergency services.
36 Office for National Statistics (ONS) (2012) and Greater London Authority 37 Public Health England (March 2014), Child Health Profiles 38 Newham CCG (2013), Primary healthcare strategy 2013-18 39 Public Health England (March 2014), Child Health Profiles 65
166 Final draft policy for approval Children and young people: the case for change
We have made our case for change by comparing current services with principles that the Children and Young People’s Clinical Working Group, have set out for good care:
1. We can better support young people transitioning into adult services to ensure they don’t fall through the gaps.
Preparation for adult services: The Clinical Working Group reflected that children and young people are not being adequately prepared for adult services. Too many young people are struggling to effectively function in adult systems where there is a general expectation that they take more control of their own health (self-care). There are insufficient safety mechanisms to ensure that young people transitioning to adult services do not fall between the gaps in services. This is a particular risk for people transitioning with long term conditions.
Consistent and simple transitions: Varying cut-off and acceptance ages for different services and providers can result in staggered and overly complex transitions across a number of different care pathways for children and young people with complex needs. Young people with mental health and special educational needs are often not meeting adult service acceptance thresholds when they transition, and can therefore immediately drop out of a care system at a vulnerable age.
Neonatal transitions to paediatric services: Discharge and handover arrangements are often too simplified in a single letter to a GP, with an associated loss of valuable knowledge and expertise. Existing information technology systems do not support easy access to medical records across providers. There is a risk that babies with complex needs, once discharged from neonatal units, who subsequently attend or are admitted to paediatric services, will see staff who have no prior knowledge of their needs.
2. More children should be cared for closer to home through the provision of stronger primary care support.
Access to specialist advice and guidance: The Clinical Working Group acknowledge that there is significant variation in the skills, confidence and formal training of primary care clinicians in
66
167 Final draft policy for approval paediatric care. The group discussed the variable levels of confidence of GPs in their paediatric skills, and the lack of a current curriculum for primary care education. With increased access to specialist advice and guidance, a greater proportion of children could be cared for in primary care.
Improving the appropriateness of referrals: There were 117,000 outpatient appointments across the three Barts Health sites and Homerton from Oct 2012 to September 2013. There is an indication of significant variance (62.5% level of variance) in the rate of first outpatient attendances (numbers of referrals) for 0 – 18 year olds, even if figures for City and Hackney are discounted. (This can be seen in the graph below).
High levels of referrals for City and Hackney are due to a rapid access clinic for paediatric care operating at the Homerton, which is cited as a model of good practice by clinicians
3. Clearer pathways for children would reduce the burden on general paediatrics and mean that patients see the right clinician the first time.
The graph below shows that over a third of attendances take place within a paediatrics clinic setting with the greatest volume concentrating at the Homerton and Newham showing the high level of demand on these departments.
Key issues that the CWG has reflected on in relation to referrals are: There appears to be significant variation in the referral pathways and processes for each of the hospital sites across east London. There are variations in referral criteria, thresholds for acceptance and triage at the different sites, which may contribute to the variation, and create challenges for the referring clinician and patient in navigating the pathway. Best available data suggests a significant proportion of consultant to consultant referrals, particularly at Newham Hospital (57% of referrals), potentially indicating a redirection of the patient after first assessment that might not have been necessary. This indicates the potential
67
168 Final draft policy for approval for greater efficiency in how paediatric referrals are operating so that children can see the right clinician the first time.
4. There is the opportunity to provide more joined up care for children and young people with complex needs.
Children and young people with complex needs are often given multiple appointments with a broad range of teams to support them with their care. There is often little coordination of the numerous contacts with specialist teams, resulting in a poor patient experience.
Variation and inconsistencies in care pathways, influenced by local procedures and clinical decision-making, is seen across the area. Clinicians often struggle to provide a coordinated service, in large part because they simply do not know about the different services available and the acceptance criteria required.
5. The development of consistent standardised pathways across east London in all clinical settings would provide more equitable, consistent and higher quality services for children and young people.
Equitable access. The Clinical Working Group has observed that children and young people do not have equal access to hospital care in east London. HfNEL recommended establishing clinical Barts and The Homerton Whipps Cross Newham OtherSites Grand Total CCG networks across hospitalLondon sites. The Clinical Working Group support this recommendation and NHS REDBRIDGE CCGrecognise the important role206 that clinical 22networks can1,074 play. However,81 it is important2,225 to reflect on 3,608 NHS CITY AND HACKNEYthe fact CCG that we have so far719 failed to establish2,687 robust, operationally40 viable19 networks 394with a formal 3,859 NHS TOWER HAMLETSgovernance CCG structure covering3,606 the complex43 array of children21 and young40 people’s care175 including, 3,885 NHS NEWHAM CCGpaediatric specialist care,658 medical care, elective45 surgery287 and emergency2,954 surgery. 365 4,309 NHS WALTHAM FOREST CCG 162 123 3,964 33 344 4,626 OtherNELCCG Right care, right place:1,359 There is significant324 variation in122 the admission199 rates of children and young2,004 Grand Total people. There also appears6,710 to be variance3,244 in onward5,508 admission to specialist3,326 services,3,503 with 19%22,291 of CityNon and-Elective Hackney Spells by children,CCG and Site 15% of Non-Elective Spells by CCG and Site 5,000 Newham children and only 3.5% of 8,000 4,500 Waltham Forest children admitted to the 7,000 40 4,000 Royal London (see graph). 6,000 3,500 5,000 3,000 This highlights the variance in urgent care 4,000 2,500 and inpatient models and pathways at 3,000 2,000 each site and suggests variance in the 2,000 1,500 1,000 1,000 experience and quality of care across east 0 500 London. Barts and The London HomertonWhipps CrossNewham 0 NHS REDBRIDGEConsistentNHS CITY AND careNHS TOWER and dedicatedNHS NEWHAM NHS WALTHAM NHS REDBRIDGE CCG NHS CITY AND HACKNEY CCG CCG HACKNEY CCG HAMLETS CCG CCG FOREST CCG facilities: The Royal College of NHS TOWER HAMLETS CCG NHS NEWHAM CCG Barts and The London Homerton Whipps Cross Newham OtherSites Paediatrics and Child Health (RCPCH) NHS WALTHAM FOREST CCG OtherNELCCG states that, wherever possible, children should be treated by paediatric specialists in separate, dedicated or child-focused facilities41. To understand our current position and local compliance against other standards, including those set out in HfNEL and the London Quality Standards, Barts Health and the Homerton completed self-assessment audits. These showed that paediatric surgical and anaesthetic expertise is not provided consistently across all sites and in some cases fails to meet the required standards42, potentially resulting in variations in quality of care. Whipps
40 Secondary Uses Service (SUS) data 41 Royal College of Paediatric and Child Health (RCPCH) (2011), Facing the future: A review of paediatric services 42 Barts Health and Homerton (2014), self-assessment audit 68
169 Final draft policy for approval Cross is the only site that meets the standard for all emergency admissions being seen and assessed by the responsible consultant within 12 hours of admission.
6. We need to develop clear, easy to navigate, consistent pathways that enable children and young people to access the right urgent care support
Right place first time: Too many children and young people are attending A&E when they could be safely cared for at, or closer to, home. Attendances for children and young people at Barts Health and the Homerton’s A&E sites account for 28% of total attendances against a national average of 23%43. Between October 2012 and September 2013, 73,555 attendances across all sites resulted in no diagnosis or treatment, indicating that many children could potentially have been provided with care closer to home44.
A high level mapping exercise of paediatric urgent care services available Too many referrals and too much in east London revealed inconsistent being passed around. My provision in the range of services daughter’s stoma bag had come provided and their hours of operation. loose. I went to the GP, who sent There are no services offered across me to my local hospital, who sent east London that provide clear and me to the Royal London – where consistent urgent care pathways with a the care was brilliant. single point of access, available 24/7, Mother of 7-year old daughter enabling access to the right care, with bowel condition. Romford quickly and easily. This is very likely to resident be influencing the high levels of A&E activity.
Consistent standards of care: The A&E and Urgent Care Centre services at Barts Health sites and Homerton are working with different models. There are notably inconsistent observation facilities across sites. Non-elective admission rates across CCGs and sites vary from 47 per 1,000 population to 64 per 1,000 in different CCG populations. All sites were considered to have strengths and weaknesses that could provide opportunities to share good practice. In addition, too many children and young people are being admitted to hospital, particularly for a day or less, when many could be treated in a different setting and avoid being admitted.
Staffing: A large proportion of A&E attendances are from 0-19 year olds across all sites, for example they account for 28% of total A&E attendances at the Royal London. Yet currently A&E paediatric consultant staffing is not sufficient to provide consistent high quality care at all sites, 24 hours a day, seven days a week. As evidenced by the London Quality Standards self-assessment, there are insufficient paediatric consultants to cover A&E and there is a consequent reliance on the paediatric acute team to support A&E, diverting clinical care away from inpatients.
43 SUS data 44 SUS data 69
170 Final draft policy for approval Emerging priorities and models of care
Based on the analysis undertaken by the Clinical Working Group, the key emerging priorities and models of care are detailed below.
Young people should be well supported into adult services and should receive individualised care in environments that are appropriate to their age.
We need to develop simple, consistent yet flexible, transitions for young people that respond to their individual needs rather NHS staff have a positive attitude to than the limits of service provision. We children. The attitude to young people / need to improve communication between teenagers is often less positive professionals and organisations to ensure Young Adviser, London Borough of patients’ needs are not missed. Waltham Forest (attendees were aged 15 – 21) Coordination of care needs to be improved through the use of lead professionals to help young people navigate their way into adulthood.
A potential solution could be the development of a directory of services to support young people, parents, carers and professionals to navigate care pathways and available services.
Children and young people should receive coordinated care across teams in (and between) acute, community and primary care. Care should be provided with as few contacts as possible and close to home or education settings where appropriate.
We need to explore alternative models of service delivery that will allow the integration of services across agencies and sectors. This may be considered in relation to enhancing existing integrated care programmes to include children and young people. A lead professional, to coordinate and navigate care for children and young people with complex needs and mental health problems should again be considered. We need to ensure that we maximise the potential for universal services so that we are able to identify problems early and take action to achieve better outcomes in the future.
We need to build on good practice to develop initiatives to help the primary care workforce improve the appropriateness of referrals and ensure that they have appropriate access to specialist advice and guidance, and so help them manage patients within primary care, when possible.
Children and young people should have equal access to surgery, medical and specialist care based on clinical need. Children and young people should receive consistent, evidence-based standards of hospital care regardless of where they live, supported by effective clinical networks.
We need to take forward work to develop effective and operationally viable clinical networks to share best practice, develop shared protocols and actively manage capacity, resources and demand across east London. This should include the development of standardised, evidence- based protocols to support the consistent delivery of high quality care. Standardised pathways 70
171 Final draft policy for approval need to be put in place, with clear policies and services that are staffed by a sufficient workforce, suitably trained in paediatric skills.
Children and young people should be supported to get to the right urgent care advice, in the right place, first time. Specialist paediatric expertise and observation facilities should be available at all urgent care sites.
To address this, we will need to further map the full range of facilities that provide paediatric focused urgent care, including their location, hours of operation and the level of complexity of the conditions they treat. This will help us take forward work to develop alternative models of urgent care with consistent entry points to reduce confusion of the service offer. In particular we should focus on investigating enhanced walk-in care for children as part of the unplanned care provision.
Our work needs to be supported by work to further develop consistent primary care extended hours schemes. We need to develop an urgent care directory of services that clearly sets out what is available to patients in the local area, how to access services; and conduct an assessment of workforce needs. This work should be taken forward by the urgent care workstream in the Transforming Services Together programme.
My daughter had an X-ray in adult radiography department in one hospital and got very upset. She had second X-ray in paediatric radiography at the Royal London. There was a TV screen above her and she was so much calmer. Mother of 7-year old daughter with bowel condition. Romford
71
172 Final draft policy for approval 7.6 Services for people with long-term conditions
Context
Locally, there is a low prevalence of long term conditions like cardiovascular disease, renal disease and stroke45. This is likely to reflect the younger age profile of the population in east London. However, some conditions, such as diabetes are far more prevalent within the local Diabetes Prevalence: Estimated total diagnosed and population46. This is likely to reflect the high undiagnosed prevalence in adults 2012 to 2030 proportion of the population with a south Asian background.
The growth in the prevalence of many long term conditions is lower than London and England’s average growth rates47, but the prevalence of some conditions is expected to rise. For example, the prevalence of diabetes in east London is growing at a rate that is faster than the national average (see graph). In Newham the prevalence of diabetes will be 56.8% higher than the national average by 203048.
People with long term conditions tend to be heavy users of health care resources49. For example, nationally people with long term conditions account for half of all GP appointments and half of all inpatient bed days. In east London, 20% of the population accounts for 80% of acute care costs50. Nationally, this estimate is 30% of the population accounts for 70% of the acute care costs51.
Outpatient appointments Long term condition outpatient attendances by site (October 2012 to September 2013) In 2012/13 there were 385,111 long term condition 52 outpatient attendances across all sites . Over 40% of these appointments were at the
St.Bartholomew’s or Royal London sites, with a fairly even split between Whipps Cross ( 22%); Homerton (19%); and Newham (18%).
A breakdown by specialty indicates that the top five high-volume specialities are respiratory medicine, gastroenterology, cardiology, rheumatology and dermatology.
45 Public Health Observatories (2010), prevalence modelled from factors in the population 46 Public Health Observatories (2010), prevalence modelled from factors in the population 47 Network of Public Health Observatories (2012) 48 National Diabetes Information Service, http://www.yhpho.org.uk/default.aspx?RID=154049 49 General Lifestyle Survey (2009) 50 McKinsey (2012), Developing the case for change in establishing an Integrated Care System across WELC 51 Department of Health (2012), Long term conditions compendium of information 52 SUS data has been extracted according to a set of specialities for patients aged over 20 from October 2012 to September 2013 72
173 Final draft policy for approval The biggest reason for outpatient appointments not taking place are: at the Royal London and Whipps Cross, cancellations by the hospitals; at Newham and Homerton, patient “did not attends”
Hospitalisations of people with long term conditions
Benchmarking shows that there is large variation in hospitalisations for chronic ambulatory care sensitive conditions. City and Hackney has the lowest number of these per head of population in London with 325 per 100,000 compared to a national average of 1,182. Unplanned hospitalisations per 100,000 population Barking and Dagenham has the highest for chronic ambulatory care sensitive conditions number of admissions per head of (2012/13) population for chronic ambulatory care sensitive conditions in London (1,406 per NHS Barking and Dagenham CCG
100,000 population) also higher than the NHS Waltham Forest CCG England average NHS Redbridge CCG It is also worth noting the effect of long NHS Tower Hamlets CCG term conditions have on planned care. 53 There were 56,572 planned spells for NHS Newham CCG patients with long term conditions in NHS City and Hackney CCG 2012/13. 57% of spells took place at the St.Bartholomews or Royal London site, National
19% took place at Whipps Cross, 15% at 0 200 400 600 800 1,000 1,200 1,400 1,600 the Homerton and 9% at Newham.
Public health interventions, social care support and joint working
Taking into account the levels of deprivation faced in east London, the wider determinants of health are a factor in the prevalence of long term conditions. Benchmarking of local authority spend in the east London boroughs indicates that there is significant variation in spend on public health from £36 per head of population in Redbridge to £117 per head of population in Tower Hamlets, compared to a London average of £74 per head of population. Direct spend on adult social care services also varies significantly from £203 per head of population in Newham to £317 per head of population in Tower Hamlets, compared to a London average of £299 per head of population54.
Over the last year the WELC Integrated Care Collaborative55 has been working to develop a joint integrated care programme across Newham, Tower Hamlets and Waltham Forest. The purpose of this programme is to work together to provide more patient-centred services for physical health, mental health and social care. The long term conditions Clinical Working Group and WELC Integrated Care Collaborative collaborated on their vision for care for people with long-term conditions.
The important role of carers
The Clinical Working Group recognised and valued the vital role that carers play in the delivery of care and support of people living with a long term conditions. In the definition of what good care
53 Elective spells for North and East London CCGs i.e. Barking & Dagenham, Barnet, Camden, City & Hackney, Enfield, Haringey, Havering, Islington, Newham, Redbridge, Tower Hamlets and Waltham Forest CCGs. 54 YHPHO - Spend and outcome tool (SPOT): local authorities. 2014. http://www.yhpho.org.uk/resource/view.aspx?RID=203757. [Accessed 2nd September 2014]. 55 Newham, Tower Hamlets and Waltham Forest CCGs plus the respective local councils, Barts Health, ELFT, NELFT and UCLP 73
174 Final draft policy for approval looks like, is the principle that care needs to be tailored to individual needs. This includes valuing and recognising the needs of carers.
Services for people with long term conditions: the case for change
The Clinical Working Group developed the case for change by comparing current services with principles that the group, have set out for good care:
PRINCIPLE 1: PRINCIPLE 2: PRINCIPLE 3: PRINCIPLE 6: A high People PRINCIPLE 4: PRINCIPLE 5: People in the quality, inter- supported by Primary care- Specialists Care last years of disciplinary professional based teams support addresses the life are coordinated to live proactively delivery of a mental and supported to care healthy coordinating model of care physical transition approach is lifestyles and care, pulling at or as close health care into palliative the norm empowered in specialist to home as goals of care to take an expertise possible individuals active role in when their care necessary
A greater emphasis on the prevention of LTCs and promoting healthy lifestyles underpins the care of those with long term conditions
The case for change is as follows:
1. High quality care planning is not systematically delivered. Clinicians have told us that in many cases the extent to which the system supports patient to better manage their health is piecemeal and tokenistic. A whole system approach is needed in order to support people to manage their own health and lead fuller lives.
Nationally, only a third of people with a long term condition report having a care plan in place, and a Percentage of people who feel supported to recent Diabetes UK study found that for many, NHS manage their condition (GP survey, 2014) support in creating a care plan felt like a ‘tick box’ 56 exercise . Locally, the picture is even worse, with CCG CCG England 91% of patients reporting that they did not have a Average written care plan in place57. City & Hackney 58.9% 68.5% Care planning is also often completed in organisational silos, a situation that is exacerbated Tower Hamlets 58.5% 68.5% by the increasingly fragmented health and social care system. There is no agreed, standardised Redbridge 58.2% 68.5% approach across services for developing or Barking & Dagenham 57.8% 68.5% managing care plans jointly and systems and processes are not set up to support collaborative Waltham Forest 57.2% 68.5% care planning or the electronic sharing of care records. Mental health needs of patients with long Newham 53.7% 68.5%
56 Diabetes UK (2014), Lack of care planning failing people with diabetes. http://www.diabetes.org.uk/About_us/News/Lack-of-care- planning-is-failing-people-with-diabetes/ 57 GP Survey (2013), http://practicetool.gp-patient.co.uk/Practice 74
175 Final draft policy for approval term conditions are also not fully assessed and managed as part of the care planning approach.
We are currently operating an over-medicalised and paternalistic model that seeks to “fix” patients rather than empowering them to make choices about their health and healthcare. There is a perception that primary care reimbursement programmes, such as the Quality and Outcomes Framework (QOF) are not aligned to encourage interventions that support a strategic behavioural change approach, as this is more difficult to measure and therefore reward.
The QOF, in particular, follows a condition-specific model, does not cover all conditions and focuses on task-oriented activities rather than promoting engagement and empowerment. Additionally, it is widely agreed that clinicians across the system lack the space and time to support self-management.
Equally we know there is often low uptake of patient education courses nationally58 and that there is the need to provide support that is culturally appropriate.
2. With support and resource there is the potential for primary care teams to lead on the coordination of care for patients with long term conditions and re-establish the role of the GP as the “expert generalist”.
Primary care teams are not currently set up, or do not have the support systems in place from the wider health and social care system, to be the coordinators of care for patients with long term conditions. There needs to be a refocusing of the GP as the “expert generalist” who is supported by the wider healthcare system to integrate services for the patient.
Capacity, training and education need to be improved to allow this to happen. Primary care access and quality scores indicate that there is an opportunity to improve access to general practice as all of the boroughs in east London are below the national average.59
Social care arrangements to support GPs in a care coordination role vary by borough. The escalation of a patient’s condition to the point that they need admission can be as much a failure of social support systems as the healthcare system. Health and social care professionals need to work together to stop unnecessary admissions to hospital. Feedback from local mental health clinicians indicates that the approach to integrate mental and physical health is falling short of providing parity.
3. New models of outpatient care have the potential to deliver more effective, sustainable care to patients when they need it.
The Long Term Conditions Clinical Working Group believe that the current model of outpatient care is th A 10-minute consultation is not outdated. The system is wedded to a 20 century enough time to make life- model of service delivery, which is compounded by changing decisions contractual arrangements, custom and practice. In Attendee at long-term particular, the Clinical Working Group believes that conditions focus group three-monthly routine follow up interactions which last for little more than 10 minutes add limited value
58 Ref National Diabetes audit 59 https://www.primarycare.nhs.uk. The aggregated January to March and July to September 2013. 75
176 Final draft policy for approval and that with the right support primary care staff could appropriately manage some of these patients.
4. The NHS needs to work more closely with partners to facilitate discharge and prevent avoidable readmissions.
Where admission to hospital takes place, systems should be in place to facilitate discharge and prevent avoidable readmissions. In terms of delayed transfers of care, the Homerton has more delayed transfers of care relating to social care reasons (the highest proportion relate to awaiting a care package), while Barts Health sites have more relating to health reasons (completion of assessment or waiting further NHS non-acute care)60. The accessibility of community and social care services has a significant impact on length of stay and the ability to discharge patients appropriately. The current high levels of unplanned care activity for people with long term conditions are a key indicator of a failure in the current planned care system.
5. To truly improve the care people receive we must address both their mental and physical needs.
There is a strong link between physical long term conditions and psychological distress/disorder. Mental health problems are much more common in those with physical illness. Compared with the general population, people with diabetes, hypertension and coronary artery disease have double the rate of mental health problems61. People with two or more long term conditions are seven times more likely to have depression62. The case for change in relation to achieving parity of esteem between physical and mental health care is important and has been discussed further in the mental health section of this document.
6. Too few people are supported to die at home at the end of their life. We must develop better ways of meeting the individual needs of people.
The Department of Health reports that 75% of people say they would prefer to die at home but nationally, only 21% do. Locally, only City and Hackney exceeds national levels (22.5%)63. Waltham Forest has the lowest proportion of people dying at home (17%) and the highest proportion of people dying in hospital (67%). None of the CCGs in east London achieve a rate better than the national average for patients dying in hospital (50%). Care needs to be appropriate to the needs of the individual including supporting people to die with dignity.
60 NEL CSU 2013/14 Performance Data 61 Department of Health (2012) Long term conditions compendium of information 62NICE (2009) Depression in adults with a chronic physical health problem: treatment and management http://www.nice.org.uk/nicemedia/pdf/ CG91FullGuideline.pdf 63 http://www.endoflifecare-intelligence.org.uk/profiles/CCGs/Place_of_Death/atlas.html
76
177 Final draft policy for approval Emerging priorities and models of care
Based on the work of the Clinical Working Group, the emerging priorities and models of care are:
Every patient with a long term condition should have a live and shared care plan in place.
There needs to be a fundamental change in the way that care planning is undertaken to ensure that it is the cornerstone of care for people with long term conditions. Care planning needs to effectively take into account both the physical and mental care needs of patients. Ways of working, as well as IT systems, need to support the sharing and updating of care plans across organisations to enable care plans to be ‘live’ tools. The WELC Integrated Care Collaborative is working to develop care plans and the care planning process further and will take forward this aspiration.
Workforce education, training and development
Work needs to be taken forward with the Local Education and Training Boards (LETB) to support a refocus on the education and skill development of clinicians, to ensure that clinicians are able to encourage behaviour change in their patients. Additionally it will be important to work with NHS England to ensure incentives are aligned to enable this approach.
Defining the future model of long term conditions care in primary care
Working collaboratively with the integrated and primary care strategic programmes we need to describe a model for providing people with long term conditions with care in primary care settings. Work needs to be done to consider how funding is aligned to support this.
Redesigning acute outpatient care
We need to change the current model of outpatient care to design a more accessible and responsive model that is available when needed, rather than it being wedded to routine practice. This model should maximise opportunities to use technology or work differently to reduce the need to travel to the hospital to access specialist input, and treat patients holistically avoiding the need for multiple appointments. We believe that this will result in an improved patient experience and a reduction in unplanned care episodes.
Significant work is already taking place to redesign outpatient services at Barts Health through an outpatient transformation programme, which started in October 2012. This work aims to develop high quality pathways, improve standards and explore how technology can support outpatient care. As part of this work, waits for colorectal continence pathways have been improved from two months to two days and the number of services operating one-stop clinics of multi-disciplinary teams has increased from four to eight. Telephone clinics have also been launched for cancer services, colorectal, paediatric and neurology services.
The work that Barts Health has undertaken has been published and presented locally and nationally64. Areas of good practice should be rapidly expanded allowing patients to be treated
64 Health Service Journal, 6 October 2014, ‘Keep up with change: The trusts transforming the outpatient pathway’
77
178 Final draft policy for approval close to home where possible and stopping activity which adds limited value and requires a trip to hospital.
Enhancing mental health within the integrated care programme
The profile of mental health in the integrated care programme needs to be raised to ensure the full integration of mental health support for people with long term conditions. Additionally there needs to be training across the health and social care workforce to recognise symptoms of mental illness and ensure that onward support is provided for them.
System working to reduce the need for acute care
Work needs to be taken forward across the health and social care system to ensure that patients are only in hospital when they need clinical care – not because there is nowhere else for them to go or because of systematic inefficiencies that delay their discharge.
Feedback from patients has indicated that patients with long term conditions receive most support to manage their condition from support and self-help groups operating outside of the NHS. We need to learn from, and work alongside, these organisations to provide people with the best support to manage their health.
Engaging patients and the public in redesigning long term condition care
Further work is required to actively engage and involve the population in co-designing services. Patients need to be supported by the system to be equal and active partners in service redesign.
Helping people to die in accordance with their wishes
We need to take action to improve care in the last years of life, including more people being able to die in their place of preference, through tailored and shared care planning. We should:
work with patients and their families to understand better the care and support they would like in the last years of life skill up professionals and have clear pathways for end-of-life care explore increasing capacity to meet the demand for nursing homes or care homes provide 24 hour care to ensure high quality services in the community reduce unnecessary hospital admissions consider the provision of befriending services to improve quality of life in the last years.
78
179 Final draft policy for approval 7.7 Unplanned care services
Context
Four sites in east London provide 24/7 Emergency Departments: the Homerton University Hospital, Newham University Hospital, The Royal London Hospital and Whipps Cross University Hospital. Each of these sites also has an urgent care centre (UCC) on site. St. Bartholomew’s has a minor injuries unit on site. Mile End Hospital has no emergency services on site.
The Royal London Hospital is a major trauma centre and has a hyper acute stroke unit. Specialist cardiac services at The London Chest Hospital are due to transfer to St. Bartholomew’s in spring 2015, making the site a heart attack centre. Network arrangements operate to facilitate access to these specialist services.
The table below outlines the services provided at each site. The urgent care centres operate slightly different hours of operation which have been described within the table below.
N.B. Specialist cardiac services at The London Chest Hospital are due to transfer to St. Bartholomew’s in spring 2015
Each of the sites also operates a slightly different “front door” model for their unplanned care services. This is in relation to how they stream patients, their strategies for avoiding unnecessary admissions and their community in-reach approaches. The effectiveness of the hospital front door has implications for the flow of patients into each trust.
Urgent care is also provided outside of a hospital setting, in primary care, community care and by the ambulance service. The effectiveness of this provision can influence emergency pathways in acute trusts, by providing alternatives to acute admission and facilitating discharge.
There are varying levels of emergency care delivered across sites in east London
In 2012/13, there were 458,030 A&E attendances across the Barts Health and Homerton sites. Just over a third of attendances (31%; 144,561 attendances) were at the Royal London; 27% were at the Homerton (123,909 attendances); 19% were at Newham (87,776 attendances) and 22% were at Whipps Cross (101,784 attendances). Differences in the designation of the emergency departments and the urgent and emergency care models, particularly UCCs, operating at each site account for some of this variation.
79
180 Final draft policy for approval
A&E Attendances by CCG including UCC (Oct 2012 - Sep 2013) 160,000 140,000 120,000 100,000
80,000 60,000 40,000 20,000 0 Barts and The London Newham Whipps Cross Homerton
City & Hackney CCG Newham CCG Tower Hamlets CCG
Waltham Forest CCG Redbridge CCG Other NEL CCGs
N.B. Data for 12 NEL CCGs, all age bands included. Source: SUS data Oct 2012-Oct 2013
On average, emergency admissions account for 45% of all admissions to Barts Health and the Homerton but are responsible for 83% of bed days across all sites, and have a comparatively longer length of stay than elective cases. Average length of stay for emergency cases varies from 5.4 days at Newham to 8 days at the Royal London.
Emergency admissions as a percentage of all Percentage of all bed days accounted for by emergency admissions by site admissions by site
100% 100%
80% 80%
60% 60%
40% 40%
20% 20%
0% 0% Barts and The Homerton Newham Whipps Cross Barts and The Homerton Newham Whipps Cross London London
Elective Emergency Elective Emergency
Emergency and elective surgical services are delivered across four sites in east London. This includes varying levels of secondary care and specialist services.
The Royal London currently provides the largest proportion of specialist services which reflects its status as a major trauma centre. The Clinical Working Group reflected that this is likely to be because the case mix of patients treated at the Royal London site for emergency surgical procedures is more complex. While some specialist surgical services are available across all sites, formal and informal transfer arrangements are in place to facilitate access to acute complex and specialist surgical services. Each site performs emergency surgery at different volumes and there is considerable variation within specialties. 80
181 Final draft policy for approval The diverse nature of our population presents challenges for delivering unplanned care. As discussed in other chapters, high levels of deprivation are linked to poor underlying health, lower life expectancy, high prevalence of mental health conditions, as well as a greater need for social care support. Locally, we have some of the highest levels of deprivation in England.
There are also specific challenges for unplanned care services in all east London boroughs because of the complex nature of the population served. For example:
30% of patients in Tower Hamlets have English as a second language. Consultations for these patients are 1.9 times longer than those who speak English there is high level of movement into and out of the boroughs (e.g. Tower Hamlets has the eighth highest rate of population turnover in London with 281 per 1,000 population), which presents challenges in delivering continuity of care, as well as an administrative burden for General Practice there is also a large part of the population unregistered with GPs. For example, a third of patients attending St Andrew’s walk-in centre in Tower Hamlets are unregistered and 30% of people who attend A&E are not registered with a GP a significant number of people working in the east London boroughs also require access to unplanned care services while in the area. For example, there are estimated to be 350,000 people per day entering the City and 100,000 people in Canary Wharf who may require access to healthcare there is a large homeless population in some parts of east London. The most recent data shows there are currently 326 rough sleepers in Tower Hamlets, which is an increase of 96 from 2008/965.
Unplanned care: the case for change
The case for change has been developed by comparing current services with principles that the Unplanned Care Clinical Working Group, have set out for good care:
Supported by education, training and development and integrated IT systems
PRINCIPLE 1: PRINCIPLE 2: PRINCIPLE 3: PRINCIPLE 4: PRINCIPLE 5: Promote Support people Serious or life Care should be Ensure services threating needs planned care to with urgent for urgent, delivered as a help prevent care needs to should be connected non-life treated in unplanned get to the right threating needs model of contacts where advice, in the services with urgent and are delivered the best they are right place, first at or as close to emergency avoidable time expertise and care home as facilities to possible reduce risk and maximise survival and good recovery
Financial incentives to drive best practice
65 Combined Homeless and Information Network 81
182 Final draft policy for approval The case for change is as follows:
1. The existing urgent care system will not be able to continue working in the same way. We need to fix our urgent care system, ensuring patients are seen in the right care setting for their needs.
Nationally, millions of patients each year seek or receive help for their urgent care needs in hospital when they could have been helped much closer to home. Locally the picture is not dissimilar. A quarter of patients attending the Royal London Emergency Department (A&E and UCC combined) were discharged with ‘no investigation and no significant treatment’ and over 40% of attendances at the Homerton were for low level investigation and treatment (category 1 investigations with category 1-2 treatment). We recognise that this data is imperfect and must be treated with caution, but it does suggest that there are significant numbers of patients who could receive better treatment elsewhere.
Similarly, benchmarking shows that there is large variation in hospitalisations of people with long term conditions who could be better managed in the community. These are known as ‘chronic ambulatory care sensitive conditions’66. Examples include conditions such as asthma and diabetes. City and Hackney has the lowest number of these admissions per 100,000 population in London with 325 admissions compared to a national average of 1182. Barking and Dagenham has the highest number of admissions (1406 per 100,000 population)[2].
If these conditions are better managed outside of hospital (perhaps through changes in lifestyle), then this reduces the need for hospital admission.
Access to services that prevent the need for A&E attendance and related admissions vary by borough. This variation is shown particularly around care planning approaches for people with long term conditions and the support available to help patients manage their own conditions. The role of local authorities in preventing unplanned care episodes through prevention work within communities is critical. Benchmarking of local authority spend in the east London boroughs indicates that there is significant variation of spend on public health from £36 per head of population in Redbridge to £117 per head of population in Tower Hamlets, compared to a London average of £74 per head of population.67
2. The current system of unscheduled care is complex and confusing.
There are multiple points of entry into the urgent care system. People can access urgent care advice through the telephone (GP, out-of-hours services, NHS 111) or in person (walk-in clinics, urgent care centres, minor injury units). Each service offers a slightly different model, at slightly different times, in different places.
The complexity of the urgent care system means that people often ‘default’ to A&E. Not only is it a trusted brand, but the service provided is highly responsive with an average national wait of 50 minutes for treatment with the vast majority of cases seen within the four-hour target. The problem of A&E acting as a default is exacerbated by primary care access, which is variable across the patch. There are also inconsistent social and community care arrangements in each borough; some operating 24 hour services seven days a week, whilst others do not. A study completed in
66 Kings Fund (2013): Transforming our Health Care System: Ten priorities for commissioners. Chronic conditions for which it is possible to prevent acute exacerbations and reduce the need for hospital admission through active management. [2] Health and Social Care Information Centre 2014, CCG level breakdown from Hospital Episode Statistics (HES), Period 2012/13, ONS mid-year population estimates and GP registered patient counts from NHAIS (Exeter) 67 YHPHO - Spend and outcome tool (SPOT): local authorities. 2014. http://www.yhpho.org.uk/resource/view.aspx?RID=203757. [Accessed 2 September 2014]. 82
183 Final draft policy for approval Newham68 A&E on the reasons for attendance found that A&E was not the most appropriate setting of care for 48% of attendees interviewed.
There are, however, challenges to achieving a better model for unplanned care provision through primary and community care. Local clinicians reported that in Newham there are approximately 90 fewer GPs than is required to serve the local population; while in the whole of London there remains a significant shortage of District Nurses qualifying in recent years. Over the past decade there has been a 40% decline in those choosing to enter the district nursing profession nationally.
3. There is significant opportunity to provide more care over the telephone or closer to home.
The opportunity to provide more unplanned care services closer to home is significant. The future model of unplanned care should ensure that those needing urgent, but non-life threatening, treatment receive their care at, or as close to home as possible. Nationally, it is estimated that 50% of 999 ambulance call attendances could have administered treatment at the scene69. The London Ambulance Service has committed to develop and grow its “see and treat” and “hear and treat” services so that their clinicians can provide more care and treatment for patients on the scene.
There is a significant opportunity to maximise the role that community pharmacists have in preventative activities. Locally, the majority of community pharmacies are open between 9am and 6pm, with around half opening until 1pm on Saturdays and a few open on Sundays. The vast majority of community pharmacies offer minor ailments services as well as private consultations for patients to discuss their medicines. However, very few offer advanced services such as reviewing health appliance use. It is also not clear from currently available information how well utilised any of these services are.
Evidence suggests that a large proportion of urgent care activity seen by GPs or other health professionals could be handled over the phone or through Skype/video conference. Modern technology would be more convenient for some patients, has the potential to increase the number of people that can be helped and would also free up face-to-face appointments for those who most need or prefer them. A study conducted in Newham of 111 calls transferred to the GP out-of-hours service found that over 50% of advice and treatment was given over the phone70. In addition, the future model of unplanned care should include improved communication between community and hospital, whether that be face-to-face, via telephone or Skype or through a medical link. Currently, systems, processes and behaviour do not promote active communication and information sharing across organisational and professional boundaries, or promote the fact that all our clinicians have a role in delivering unplanned care.
4. Improved ambulatory care would mean more patients would be able to go home after receiving the treatment they need.
The current arrangements and delivery of services in east London means that the reason for admission at each hospital site is not always determined by clinical need. Benchmarking data shows that emergency admission rates per 1,000 population varies between boroughs; from 115
68 “A study into the reasons for attendance of patients to Newham General A&E” (2005), P. Mayer, S. Roberts and C. Smith – 1st year medical students at St. Bartholomew’s and the Royal London – sample size 133 69 NHS England (2013) 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 Superseded. http://www.nhs.uk/NHSEngland/keogh- review/Documents/UECR.Ph1Report.FV.pdf 70 GP Co-Op Board Meeting papers, May 2014 83
184 Final draft policy for approval emergency admissions per 1,000 population in City & Hackney to 95 per 1,000 population in Tower Hamlets. This is in comparison to the national average of 109 admissions per 1,000 population71.
Ambulatory care services offer trusts an alternative to routine admissions and can therefore help avoid unnecessary hospital stays, improve patient experience and ensure limited acute resources are available and accessible by those who most need them. Currently, admission avoidance teams operate in all four emergency departments in east London. However, to be effective, ambulatory care requires “early decision-making and rapid access to diagnostics, as well as immediate access to support services in the community for optimised integrated care”72. Evidence from local hospitals’ self-assessment against the London Quality Standards for emergency departments suggests that these conditions are not in place across all sites.
In addition, some sites are unable to meet recommended standards for consultant cover, with variation seen between the weekdays and weekends.
Trusts’ self-assessment against the London Quality Standards (Emergency Department review)
Source: London Quality Standards Self-assessment 2013 (selected standards chosen to demonstrate variation across sites), http://www.england.nhs.uk/london/wp-content/uploads/sites/8/2014/04/sa-lqs-ncel-area-t-1.pdf
(Please note HUH is Homerton University Hospital, NUH is Newham Hospital, RLH is the Royal London and WXH is Whipps Cross)
The Health Foundation’s Flow Cost Quality programme73, found that a more important operational issue than overall demand is the availability of staff at the right times to meet demand. The programme also found that poor patient flow (how and when patients are admitted and discharged within hospitals) was associated with an increased likelihood of harm to patients and higher healthcare costs because of longer lengths of stay, higher bed occupancy and readmissions. Improved flow was associated with the opposite effects, as well as with improved patient and carer experience. Analysis found that when patients had to wait for senior assessment overnight or at
71 NHS England (2014), Commissioning for Value Tool 72 NHS Institute for Innovation and Improvement (2012), Directory of Ambulatory Care for Adults, Ambulatory Emergency Care Delivery Network, 3rd edition 73 The Health Foundation (2013), Improving patient flow: Learning report 84
185 Final draft policy for approval the weekend, they were much more likely to be put on the wrong pathway leading to a longer than necessary length of stay.
5. New ways of working may mean more people can return home safely, earlier.
There are many factors that impact on the length of time a patient stays in hospital, many of which are beyond the control of the hospital, such as the nature and severity of the illness of injury or the structure of services in the community and social care. However some factors can be influenced by the way the hospital operates: for example timely and proactive discharge planning; access to senior decision-makers; and clinicians and patients receiving prompt test results. A review of the trusts’ self-assessment against the London Quality Standards indicates that there is variation between sites and different processes in place during the week, to weekends, for example in the frequency of daily ward rounds within acute medical units, access to key diagnostics and discharge planning.
Trusts’ self-assessment against the London Quality Standards (acute medicine)
Source: London Quality Standards Self-assessment 2013 (selected standards chosen to demonstrate variation across sites), http://www.england.nhs.uk/london/wp-content/uploads/sites/8/2014/04/sa-lqs-ncel-area-t-1.pdf
(Please note HUH is Homerton University Hospital, NUH is Newham Hospital, RLH is the Royal London and WXH is Whipps Cross)
Effective working and reducing length of stay ensures that there are free beds for those who need them most. To do this, discharge systems need to have timely access to support services and teams. Delayed transfer of care data indicates that the health and social care services could work together to do this more efficiently. For example, in 2012/13 discharges were delayed for 457 patients at Barts Health. 26% of delays were for patients awaiting further NHS non-acute care and 19% were awaiting completion of an assessment. At the Homerton, 35% of delayed transfers of care were for patients awaiting a care package in their own home.
The accessibility of community and social care services has a significant impact on length of stay and the ability to discharge patients appropriately. Currently, the community and social care service arrangements differ by borough. Newham runs a seven days a week social care service but this is not the case in Tower Hamlets or Waltham Forest (although work has started to develop the service).
85
186 Final draft policy for approval Access to neuro-rehabilitation services is cited as a particular cause of delays, with Barts Health estimating patients waiting up to 50 extra days in hospital for transfer to a neuro-rehabilitation unit and placement on average in 2012/13). These delays expose vulnerable patients to increased risk of secondary complications like hospital acquired infections and impact on their potential for longer term recovery and longer term quality of life74.
6. We need to design a new model of urgent care to ensure patients see the right clinician the first time, based around strong local pathways. This model will need to consider if the consolidation of some services would be a more effective, responsible and sustainable use of our limited specialist resources (both people and physical).
The Royal College of Surgeons75 states that the provision of safe and efficient emergency general surgery requires the following services and facilities to be in place:
sufficient dedicated emergency theatre access sufficient access to on-call surgical teams (numbers/expertise) anaesthetists and critical-care doctors along with intensive therapy/high dependency resources interventional and diagnostic radiologists dedicated emergency beds where children are admitted, inpatient paediatrics and specialist children’s facilities. The current set-up of services means that not all sites have all of these services/facilities in place consistently across the week. There is now an opportunity to look together at the way services are delivered across all sites in order to deliver the best possible care for patients in a sustainable way.
While there is evidence for some specialities that providing complex care in higher volumes delivers better outcomes, the Royal College of Surgeons states that a safe and efficient emergency surgical service could be provided on both a specialist and local basis as long as the requirements stated above are in place. A local example of this is the way that Homerton hospital transfers a significant proportion of complex emergency surgical cases to the Royal London hospital as its closest provider of specialist surgical services. With the bariatric service provided by the Homerton offering the site larger numbers of patients and the ability to maintain a general surgery rota with more upper gastro-intestinal surgeons.
Consultant surgical training and requirements for service delivery are changing. Specialities that have previously been part of one team and one rota will separate into three rotas of subspecialists. This means that in the future it will be increasingly challenging to staff rotas to meet recommended national guidelines
We know that currently surgeons in some hospitals see lower numbers of patients. Evidence shows that undertaking a greater number of surgical procedures is associated with better
74 Barts Health (2014), Developing Neurosciences - neuro-rehabilitation services 75 Royal College of Surgeons (2013), Emergency General Surgery. London: Royal College of Surgeons; https://www.rcseng.ac.uk/healthcare-bodies/docs/emergency_general_surgery.pdf 86
187 Final draft policy for approval outcomes and that minimum numbers of operations need to be undertaken by surgeons within their speciality to maintain their expertise.
There are a number of workforce challenges in relation to supporting services locally: Theatre nursing staff: there is a shortfall in recruiting trained theatre staff nationally. Across Barts Health there are 60 vacancies in this staff group. This means there is an overreliance on bank and agency staff. This is a less cost-effective model and can have implications for the consistency of standards and high quality care. Anaesthetists: there has been a reduction in anaesthetic training posts nationally. This has knock on implications locally as trainees are part of the teams covering the on-call rota. Consultants will be relied on to cover the shortfall. This has knock on implications for elective surgery – if consultants are covering on-call they will not be able to cover elective lists the next day.
7. There is a chance to better utilise the capacity across the system by looking across hospital sites and separating emergency and elective surgery where appropriate.
Patients operations are sometimes cancelled or delayed due to patients with life threatening conditions taking priority. Theatre capacity is limited by both physical space and limited numbers of highly skilled staff and as a result, emergency surgical activity at the site has a direct knock on effect on how quickly people waiting for less urgent operations can be treated and discharged.
Currently, wards are set up to cater to both emergency and elective patients to allow capacity to be flexed between emergency and elective cases. However at sites with high levels of emergency activity this can mean that patients who do not have life threatening conditions, but cannot be discharged until after an operation are staying in hospital longer than necessary.
Demand and capacity modelling76 completed by the trust has established that to cope with future demand, approximately 230 hours per week of extra operating time would be required. This large number shows that there is clearly a need to utilise capacity across all sites in order to meet demand. This work has also identified that an extra 25 beds would be required across the trust to cope with the total projected increase in demand (based on previous years’ growth).
Emerging priorities and models of care
Based on the analysis undertaken by the Clinical Working Group, the key emerging priorities and models of care are detailed below.
We need to fix our urgent care system, ensuring patients are seen in the right care setting for their needs.
Local services need to develop models of urgent care which have consistency of standards, are easy to navigate and are co-ordinated effectively between acute, 111, primary care and pharmacy services, taking into account the recommendations contained within the Sir Bruce Keogh Urgent and Emergency Care Review. A next step will be to work with local urgent care boards to conduct detailed capacity and demand analysis and review the benefits and constraints of local provision in each borough so that options for improvement can be considered.
76 Demand & Capacity Programme led by Diana Lacey and Simon Harrod 87
188 Final draft policy for approval Addressing a confusing and complex urgent care system: Discussions have clearly concluded that a “one size fits all” approach to urgent care would not be appropriate in east London for addressing the specific health needs of the populations that are served, but the Clinical Working Group agreed that there are opportunities for greater collaboration and coordination that would improve outcomes and help patients navigate the system more easily.
Promoting and better utilising planned care programmes such as integrated care and care planning to reduce the burden on unplanned care services: We need to ensure that the existing unplanned care programmes across east London are closely aligned to the WELC Integrated Care Collaborative, particularly in terms of monitoring impact. This would help increase the amount of planned care, with a dramatic reduction in unplanned care episodes for people with long term conditions. Health and Wellbeing Boards will have a central role in ensuring that the potential for local authorities to address the wider determinants of health are fully exploited.
In addition, we need to work closely with patients and their representative groups to explore how the NHS can better support them in managing their own health, and the implications of the language used to describe this, which patients have reported implies the discharge of NHS responsibilities. We need to use language that is clearer about a partnership approach to healthcare delivery.
Provide more care over the telephone, or closer to home: Work now needs to be taken forward across the sector and with NHS England to increase the role of community pharmacy in the delivery of urgent care and ensure that this is integrated into pathways for urgent care provision, such as 111. In addition, we need to increase the role of acute specialists in the delivery of unplanned care, providing support to GPs through systematic use of telephone and skype advice formalised through the urgent care pathway.
Ensuring that clinical need is the reason why people are receiving hospital based care: Commissioners and providers will need to work together to explore the opportunities for an improved and extended care offer, to support early decision making, rapid access to diagnostics and immediate access to community support services. This work will need to align with community services programmes (to facilitate admission avoidance). It will also need to include work by commissioners of health and social care to review the out of hours offer in community and social care services that will support effective discharge, with a specific focus on dementia and neuro- rehabilitation discharge pathways.
Commissioners and providers will need to work together to develop a robust plan for meeting the London Quality Standards in relation to consultant cover in A&E and for acute medicine to ensure that the evidence-based approach for admission is followed, as well as supporting effective discharge planning.
Delivering safe and efficient emergency surgical services as recommended by the Royal College of Surgeons: A clear case for change in relation to the improvements in emergency surgical services has been made. We now need to take forward a strategy for the future delivery of emergency surgery across the Barts Health sites so that we can ensure that the best outcomes are delivered for patients in east London, and to address the workforce issues that are arising due to the increasing specialisation of the surgical workforce. This must also take into account the importance of collaboration with community healthcare providers for rehabilitation and reablement mentioned above.
88
189 Final draft policy for approval Strengthening the networked model of delivering urgent and emergency care: Further collaboration is needed between local urgent care boards to take forward discussions about the strengths of their urgent care networks, both within and across their geographical areas, to ensure that local clinical interactions bridge the gaps between primary and secondary care. These discussions should again have a strong focus on the recommendations contained within the Sir Bruce Keogh Urgent and Emergency Care Review.
Too many people using A&E as first access point Male Redbridge resident, aged 26-40 (also a service user, NHS staff member)
89
190 Final draft policy for approval
7.8 Planned care: Elective surgery services
Context
Currently emergency and elective surgical services are delivered across four sites in east London. This includes varying levels of secondary care and specialist services. The diagram below indicates the split of surgical provision across the four sites with the darker shaded boxes reflecting specialist surgical provision. The Royal London provides the largest proportion of specialist provision, in part due to it being a major trauma centre. This means that the case mix of patients treated at the Royal London site for emergency surgical procedures is likely to be more complex.
While some specialist surgical services are available across all sites, formal and informal transfer arrangements are in place to facilitate access to acute complex and specialist surgical services.
Elective surgical service provision across east London hospitals
*Specialised colorectal has moved to Royal London
Although there may be pockets of good practice, the Clinical Working Group agreed that there were areas where surgical services could be improved both in terms of patient outcomes and the effectiveness of current services. This in itself is not a reflection on the skills of individuals or teams but on the systems within which they deliver services.
Locally, we face challenges from the legacy Barts Health trusts around finance, workforce, IT and estates. We also face the challenges that the wider health system is facing; of making further financial savings, and working in a community where there is significant social deprivation and a growing population. Based on this, it is important to consider if delivering similar planned services across sites is the most efficient and sustainable use of our finite specialist resources, in terms of people and equipment.
90
191 Final draft policy for approval Planned care, elective surgical services: the case for change
The case for change has been developed by comparing current services with principles that the Elective Surgery Services Clinical Working Group, has set out for good care.
PRINCIPLE 1: PRINCIPLE 2: PRINCIPLE 3: PRINCIPLE 5: PRINCIPLE 6: Appropriate Appropriate Separation of PRINCIPLE 4: Safe care, in Coordinated access to preoperative elective and Day cases as the right reablement high quality care closer to emergency the norm: place at the and recovery surgery home surgery right time
The case for change is as follows:
1. There is an opportunity to better use surgical capacity across sites as the current demands of emergency and elective surgery means that sometimes elective operations are cancelled due to a lack of capacity and issues of patient flow.
In 2012/13, 52,67477 patients were admitted for surgery across all the sites. Of those admissions, 74% were admitted for elective surgery, although there is considerable variation within specialties and across sites.
The proportion of emergency and elective procedures by site is detailed below:
Emergency Elective Elective admissions as admissions admissions % of total
St. Bartholomew’s and Royal 6,826 16,291 70% London
Homerton 1,972 10,427 84%
Newham 4,315 8,736 67%
Whipps Cross 5,169 17,220 77%
SUS data October 2012 to September 2013 – non-elective and elective admissions under a surgical specialty by site
This data shows a large variation in the relative proportions of elective and emergency surgery taking place within sites. Nationally, 84% of procedures are elective78.
Some of this variation reflects the role of the Royal London as a major trauma centre and provider of specialist services with transfer arrangements in place between sites. For example the Royal London provides acute complex and specialist provision for surrounding hospitals (such as trauma and neurosurgery) and accommodates out-of-hours cases for services normally delivered in hours at surrounding sites (e.g. vascular surgery).
This complex tertiary work in particular can have a significant impact on the overall pattern of non- elective work taking place within hospitals79. Discussion at the Clinical Working Group suggested that the higher complexity of patients seen at the Royal London impacts the non-elective flow of
77 SUS data October 2012 to September 2013 – non-elective and elective admissions under a surgical specialty by site 78 National Confidential Enquiry into Patient Outcomes and Death (NCEPOD), 2003 79 Ibid 91
192 Final draft policy for approval patients within the trust. This is discussed in detail within the appendix pack for Elective Surgery Services.
This programme provides an opportunity to look across sites and utilise capacity better through: Enhanced core surgical offering, through the local delivery of lower risk procedures where there are not efficiencies in consolidating these. This local surgical offer should underpin current maternity and emergency services. Utilising local facilities such as the Newham Gateway Centre for higher volume elective surgery. These new facilities already exist and could deliver benefits through the provision of dedicated elective resources. Formal protocols and surgical assessment to ensure that elective patients receive the most appropriate care at the right time, with the consolidation of resources and dependent clinical services in a way that improves outcomes and redistributes demand in line with capacity across sites.
2. There is an opportunity to look at how services could be consolidated in order to ensure surgeons meet national guidance and utilise theatres and staff effectively.
The training of surgical staff has changed substantially over time and surgical training has become more specialised. Currently, because similar elective services are offered across four sites, surgeons in some hospitals see low numbers of patients and evidence shows that higher numbers of patients is associated with better outcomes80.
National guidance indicates that minimum numbers of operations will need to be undertaken by surgeons within their speciality. With the current configuration of services and activity, it will be more difficult to meet national guidance at all sites and ensure the best possible outcomes. Therefore, there is a need to review how surgical services are delivered locally and ensure that new rotas meet the required criteria across sites for the elective part of the surgical pathway.
With some types of procedures being delivered across multiple sites, lower numbers of these procedures taking place mean that full theatre rotas are harder to plan and maintain. This results in theatre utilisation varying across site. Initial analysis has shown that although theatre utilisation varies between site and specialty, currently no Barts Health site achieves above 50% utilisation consistently (using the knife to skin metric). This demonstrates a clear opportunity to improve and maximise the productivity of the resources available81. It also represents an opportunity to reduce waiting times. At an organisation and CCG level, referral to treatment performance (the 18 week target) varies across east London and across specialties. Performance data from March-April 2014 shows that Barts Health underperformed with an overall rate of 82.55%, failing to achieve the 90% standard in nine specialties, whereas the Homerton achieved the standard with 91.47%.82
Best practice also demonstrates clear benefits to separating surgeons’ elective and emergency commitments for outcomes and efficiencies. However, recent sub-specialisation means that emergency and elective surgical commitments are harder to separate whilst ensuring that skilled staff are utilised effectively. Although emergency and elective surgical commitments are now separated for some specialties on some sites, this is not the case across all hospitals.
80 A systematic review of the impact of volume of surgery and specialization on patient outcome, M. M. Chowdhury, H. Dagash and A. Pierro http://onlinelibrary.wiley.com/doi/10.1002/bjs.5714/pdf 81 Utilisation data, Barts Health 82 NHS England, consultant-led Referral to Treatment Waiting Times Data 2014-15 92
193 Final draft policy for approval This result of this is that dedicated elective resources (beds and equipment) are difficult to ring- fence as utilisation cannot be guaranteed. Pressures from emergency commitments on bed capacity sometimes means that operations are cancelled for non-clinical reasons. Initial analysis has shown that at the Royal London, a significant proportion of cancelled operations are due to capacity issues. The availability of both high dependency unit beds and ward beds, as well as theatre capacity constraints, contribute to the majority of cancellations. We know that as a result, too many patients are waiting too long for their operation.
3. Consolidation of some surgical services would mean that dedicated resources could be used to implement enhanced recovery.
Much enhanced recovery work takes place before patients have their operations and helps ensure they are prepared for surgery and that appropriate steps are taken in advance to aid their recovery. There are four major pathways for enhanced recovery – urology, orthopaedics, gynaecology and colorectal. Barts Health now runs enhanced recovery in three of the four areas but this is not consistent across sites and there is potential for substantial improvement. Enhanced recovery is in place at the Homerton across all major pathways.
Implementing best practice enhanced recovery pathways across all sites and specialties is easier at higher volumes where specific resource can be allocated to individual specialisms at each site. Similarly, small numbers of patients at each site, due to the current configuration of services, make it difficult to maintain viable and compliant critical care teams.
On reviewing data from east London hospitals, we can see variability in the average length of stay for different elective procedures. Some of this may be to do with the complexity of cases seen, but the variation indicates that there is an underlying opportunity to improve and safely get people home more quickly. An example of this is that there is a variation of two days in average length of stay for intermediate knee procedures (non-trauma without complication) depending on which site patients received treatment. Meanwhile, variation is one day for major hip procedures (non-trauma, category one)83.
We know that some patients are staying in hospital longer than necessary and that enhanced recovery, starting prior to admission, would help people at all sites return home safely, earlier.
4. Barts Health and the Homerton have the potential to deliver best-in-class services for day case procedures.
Although Barts Health and the Homerton generally perform better than peers on day case rates, there is an opportunity to increase this further by defining a set of low complexity procedures and developing a specific high quality local surgical offer. This would allow for dedicated preoperative and postoperative care and education of patients to increase the local provision of day case surgery.
There is a further opportunity to improve the quality of local surgical services by consolidating some high volume, low complexity procedures in order to ring fence dedicated capacity and equipment and further improve outcomes. This would enable more patients to go home earlier safely, free up capacity by using less beds and enable the trusts to achieve best practice tariffs in performing some day case procedures as outpatients.
83 SUS Data 2013/14 using the top 5 HRGs (Health Resource Group) excluding day case and out-patient appointments 93
194 Final draft policy for approval Emerging priorities and models of care
Based on the analysis undertaken by the Clinical Working Group, the key emerging priorities and models of care are detailed below.
Undertake further analysis and develop options for delivering services across sites to provide higher quality care in a more sustainable way
The longer term underlying issues discussed above cannot be addressed at individual site level in the current configuration of services. We need to look at the way services are delivered across all Barts Health sites in order to deliver the best possible care for patients. This should involve consolidation of elective surgical services where this delivers more effective and efficient care and offers an opportunity to strengthen local surgical offering by ensuring high quality local surgical provision that underpins the delivery of maternity and emergency services.
The appropriate consolidation of services could provide:
higher numbers of patients for more effective care with dedicated specialist consultant cover more experienced staff with dedicated resources for enhanced recovery and higher day case and outpatient rates Steadier flow of patients to enable better planning and utilisation and fewer cancellations the potential to provide dedicated pre- and postoperative care that improves shared decision making, preoperative quality of care and safely reduces length of stay.
94
195 Final draft policy for approval 7.9 Clinical support services
Context
Clinical Support Services (CSS) are provided across all Barts Health sites and the Homerton. All sites provide pathology services (both phlebotomy and drawing samples). However, the processing of specimens is managed differently across sites to enable economies of scale. For example, high volume disciplines, such as haematology and clinical biochemistry, are provided across all sites, whereas lower volume disciplines, such as virology and cytology, are processed at the Royal London for all sites. This arrangement applies to the Homerton too – cellular pathology, cytology and some virology are processed by the Royal London pathology laboratory. Therefore the activity presented for Barts Health will include some Homerton activity for those particular disciplines. The Homerton pathology laboratory processes a range of tests including microbiology, haematology, clinical biochemistry, virology, histopathology and phlebotomy. 60% of activity is associated with clinical biochemistry.
In 2013/14, Barts Health undertook 15.9 million pathology tests84. Demand varies significantly by referral source. 60% of pathology activity is generated internally (from A&E, inpatient, outpatient and sexual health clinics) and 36% of activity is generated by GP referrals. In 2013/14 the Homerton completed 1.2 million GP requested pathology tests in addition to their own hospital testing.
In 2013/14, Barts Health completed 673,688 radiology examinations. Radiology services are provided across all sites with more specialist imaging, such as 24 hour interventional radiology, provided at the Royal London. Network arrangements are in place to enable patients from elsewhere to access these more specialist services. The Homerton provides plain film and ultrasound services. In 2013/14, 23,816 radiology GP referred examinations were completed, 58% were for plain film x-rays and 42% were for ultrasound.
Each site has an on-site hospital pharmacy and the Newham and the Royal London both have community pharmacies on site too.
Clinical support services: case for change
The case for change has been developed by comparing current services with principles that the Clinical Support Services Clinical Working Group, have set out for good care:
84 Includes some activity generated by the Homerton (68,408 or 0.4%) across virology, cellular pathology, clinical biochemistry, haematology and cytogenetics (in order of biggest volume). Source: Barts Health Pathology Data Warehouse extracted April 2014 95
196 Final draft policy for approval The case for change is as follows:
1. We need to plan effectively for the rising demand in diagnostics, in terms of the types of test, the population and prevalence of long term conditions.
Our population is growing at a rate that is 50% faster than the London average. The growing population is expected to lead to an increase in demand for healthcare services, including clinical support services. Using Greater London Authority population projections85, pathology activity from major commissioners is predicted to grow by 10.6% from 2013/14 to 2020/21. This represents an additional 1.7m tests. 2014/15 is predicted to have the highest growth of 1.96% or 284,799 additional tests. The rate of growth is predicted to slow following that, but it still significant, dropping to 1.26% by 2010/21 or an additional 202,566 tests.
Increasing prevalence of some long term conditions, and an emphasis on early identification and diagnosis of people is also driving demand. In Newham the prevalence of diabetes will be 56.8% higher than the national average in 203086. Based on these demographic changes the demand for pathology services is predicted to rise. The current set-up of services (capacity, workforce, and infrastructure) is unlikely to be able to sustain such growth in a way that maintains quality and performance.
There is no long term joint plan within the local NHS for future diagnostic provision. The only solution currently is to increase resources which is not a financially long term viable option. This is particularly pertinent given the variation in current performance.
2. We have an ambition of ensuring equity of access to the latest diagnostic techniques across east London. This includes ensuring that patients receive the tests they need while minimising wasted resources.
The NHS Atlas of Variation in Diagnostic Services is designed to help the local NHS understand if the variation in the rates of diagnostic services in their area is warranted (i.e. true clinical variation) or caused by other factors such as poor access to services or the need for education.
There are a number of examples where there is variation in the use of diagnostic testing in east London. For example, the estimated annual rate of use for blood glucose (fasting) tests ordered by GPs per 1,000 practice population ranges from 4 per 1,000 in Waltham Forest to 154 in Redbridge87. Further work is required to understand whether the variation identified is warranted or not, particularly as diagnostics can serve to reduce much more expensive care later on in the patient pathway.
The Clinical Working Group has grouped potential reasons for over investigation as follows: Unnecessary rework: this can be due to tests being reordered because results are not appearing in the patient record, tests being reordered as the result is believed to be ‘lost’, or the clinician not being able to see results already requested due to the test being performed too recently. In some cases a lack of knowledge results in tests being performed more frequently than appropriate.
85 No age band growths have been applied - pathology data by age band not available at time of writing. The same growth assumptions have been applied to all sources and disciplines of activity – only one year’s worth of activity data currently available. GLA population growth trends for Barking & Dagenham, City & Hackney, Newham, Redbridge, Tower Hamlets and Waltham Forest. Source: Barts Health Pathology Data Warehouse extracted April 2014 and Greater London Authority population growth. 86 National Diabetes Information Service http://www.yhpho.org.uk/default.aspx?RID=154049 87 NHS Atlas of Variation: Diagnostic Services, 2012/13 data (http://www.sepho.org.uk/extras/maps/NHSatlasDiagnostic/atlas.html) 96
197 Final draft policy for approval A lack of confidence resulting in 'defensive clinical practice' and tests being requested ‘to be safe’ A lack of knowledge about the most appropriate test to use, alternatives to this test and the tests on offer locally A pressure from patients to receive tests that they think that they need The group highlighted that the underlying root cause for this is clinical behaviour, and that secondary care clinical support service experts could, with appropriate resources, take a much more active role in demand management and improve clinical knowledge and confidence.
3. Developments in new technology and future models of care require us to look at how clinical support services will need to operate differently and plan for this.
The Clinical Working Group highlighted that previous service reconfigurations/developments have not always included clinical support services as part of the planning process i.e. Newham Gateway Centre. This has resulted in slower uptake of these new facilities and difficulty in ensuring high levels of utilisation.
4. Moving to 24/7 services offers the chance to improve access and the speed of clinical decision-making.
NHS England’s vision for seven days a week services includes specific ambitions with regards to clinical support services88.
The challenge is to meet the standards Diagnostic services are often miles in a clinically and financially away from hospital. Diagnostics sustainable way and will require should be used to underpin radical transformational change and change … We could have a walk- collaboration between through diagnostics service, with the results available before the providers of services and different appointment sectors of the health and social care Barts Health staff member system.
A mapping exercise has been completed to understand which clinical support services are required to support a 24/7 model locally, along with national standards for seven day services. Key findings of this work are:
Network arrangements are helping the trusts meet many of these standards for urgent patients – but in other cases there are still issues that need to be resolved to ensure that standards are being met across all sites There is real difficulty in dealing with patients classed as critical (requiring advice or diagnostics within an hour) where reporting out-of-hours means being able to deal with a complex, but also broad case mix. A single consultant may not be able to provide this depth of knowledge across the trusts It was highlighted that the current network arrangements for interventional radiology rely on rapid transfers and beds being available at the Royal London site. Capacity restrictions are impacting on bed availability and therefore access to this service A key pressure point is demand from the urgent care system, and there is a need to look at this more closely with regard to over-investigation.
88 NHS England 2013, Seven day services, http://www.england.nhs.uk/wp-content/uploads/2013/12/brd-dec-13.pdf 97
198 Final draft policy for approval Diagnostic and scientific workforce issues have been identified as a key limiting factor for provision of seven day services across England and the group agreed that this was also an issue locally. The main challenges include recruitment and retention of skilled staff, skill mix issues, compliant staff rotas, as well as the need for changes to current terms and conditions and contracts should the services move to a 24 hour, seven days a week model.
5. There is an opportunity to streamline pathways by providing high quality direct access testing to everyone.
The majority of direct access provision is acute based and predominantly operates within working hours (9-5pm). Existing direct access to ‘Any Qualified Providers’ of diagnostic services have been of varying quality. The group reported that the quality of images often means exams need to be repeated. They attribute this to differences in the quality of equipment used and incompatibility between systems.
Local CCGs have recently decided to re-procure this service. Not all types of tests will be retained in the future. The types that are retained will vary across each borough, meaning there will be differences in future diagnostic provision across east London.
6. Adopting new technologies at scale across east London has the potential to maximise benefits and pave the way for new treatments and ways of working.
The group discussed the variation in access to some of the newer technologies across the patch. Some of these are be summarised in the diagram below:
Barking, Havering and Redbridge Waltham Forest Phlebotomy through NELFT at Chadwell City and Hackney Near site testing/phlebotomy in Heath, Church Elm, Lane Marks Gate, Near site some practices Porters Avenue, Thames View Health testing/phlebotomy in Phlebotomy through ELFT and Centre, Vicarage Fields some practices Whipps Cross Upney Walk-in Centre, domiciliary Phlebotomy at HUH Tendering for direct access US, service for housebound patients and at Imaging at HUH MRI, audiology and physical Queens or King Georges measurement Imaging at Queens and King Georges Imaging at Whipps Cross
Tower Hamlets Near site testing/phlebotomy in all practices Newham Tendering Near site testing/phlebotomy in some Phlebotomy at RL or Mile practices End ELFT Phlebotomy at Appleby Health Imaging at RL or Mile Centre, Vicarage Lane Health Centre, End Shrewsbury Road Health Centre, Centre Manor Park Phlebotomy at NUH Tendering for direct access MRI and US Imaging at NUH Non-obstetric ultrasound in practices and community
High level map of CSS services across East London
98
199 Final draft policy for approval There is not currently a joint process across local CCGs for reviewing benefits realised by new technologies. Without this, the adoption of new technologies is likely to continue to be piecemeal, reducing the benefits delivered and creating difficulties in providing 24/7 access and creating further inequities of access for local residents.
7. There is the opportunity to develop testing that is closer to patients’ home, minimising both patients’ and clinicians’ wasted time.
Patients have reported that they often have to travel long distances, many times for preoperative tests that could be delivered more closely to home. These take up outpatient appointments and often involve repeat visits. The Clinical Working Group acknowledged this and recognised the potential to deliver improvements for patients, with the following considerations being critical:
Ensuring quality of preoperative tests performed out of hospital Ensuring the right tests are being taken – in time for results to be reported Ensuring effective sharing of results across sites and organisations Ensuring continuity of care for the patient.
The Clinical Working Group agreed the following principles for the provision of local access to diagnostics:
Where local access has a clear benefit to patients (e.g. local when involves fasting tests for older people; patient mobility, transport issues) Ease of local implementation of services Frequency of examinations (e.g. anticoagulation) Economic impact of localisation The most effective use of a workforce with specialist skills Impact on waiting times Impact on multidisciplinary involvement.
If my Consultant appointment is at 4pm and is delayed, and I get sent for a blood test, but phlebotomy closes at 5pm, I have to come back the next morning. That means more time off school and work. Mother of 14-year old daughter with ulcerative colitis. Newham resident
99
200 Final draft policy for approval
8. We can improve clinical decision making in primary care through clearer local diagnostic pathways.
Clinicians noted that, although some informal knowledge existed, there is no defined list of local diagnostic pathways or clear clinical guidelines, on the management and use of diagnostics and alternative tests across primary care. Similarly, although there are NICE guidelines on preoperative testing it is not clear if these are local acute protocols or are always actively applied and this may mean that in some cases additional tests are requested without a clear need.
9. Performance could be improved further by ensuring that we measure the things that matter to clinicians and patients.
Performance data provided by Barts Health suggests that there is variation in turnaround times, particularly for high volume disciplines such as haematology and clinical biochemistry. For example turnaround times for electrolytes serum tests ranges from 73% of tests turned around within one hour at Whipps Cross to 29% of tests turned around within one hour at Newham. Some performance is driven by operational issues, such as staffing in the specimen reception as well as request practice in A&E. Work is underway to improve this situation in Barts Health. However, there is room for improvement to ensure that with increasing demand the trust is able to not only maintain but improve performance for all disciplines not only in the lab or reporting but across the whole pathway.
Current systems are not set up to monitor the end-to-end pathway in either imaging or pathology. In imaging, the request to report parts of the pathway are well monitored as they align with national targets. There is, however, no real monitoring of whether reports have been sent to the referrer. These issues are compounded by variable IT systems and the use of manual processes.
10. There is potential to improve care through developing effective methods of communicating with primary and community care on discharge.
Feedback from clinicians has been that the discharge summaries are too complex and do not draw out what the key changes in medication are, which is the information that general practice needs to know. This results in challenges around continuity of care and creates additional pressure on General Practice in terms of follow up and medication reconciliation. Community pharmacists feel that improved communication between them and the hospital pharmacies could improve the quality of care for patients after discharge.
11. Pharmacists working in new ways can play a vital role in getting people home quicker
Pharmacists, told us they believe that the procedures for discharging patients and prescribing practices on discharge can be improved. In relation to the discharge of patients, medication prescribing is often initiated only at the point of the decision to discharge. This creates an instant delay and wait for patients going home. There are some examples of good practice at Barts Health in relation to this issue and these include for patients who stay longer than 48 hours, medication requests are given on the day before discharge so that it is ready for the patient and there are no delays. This improves both bed utilisation and patient satisfaction. Opportunities to replicate advanced planning approaches for shorter-stay patients should be actively considered.
In addition to this, we need to recognise the medication management support that a patient needs on discharge from hospital. We need to recognise that for patients who are newly diagnosed with a 100
201 Final draft policy for approval long term condition, medication adherence and compliance will be a challenge in the first 6-8 weeks. Nationally, medication errors contribute to 5 – 8 per cent of hospital admissions and readmissions, of which almost half are preventable89. There needs to be good clinical support following discharge in order to improve outcomes and prevent patient’s being readmitted due to medication errors.
12. There is the potential for community pharmacists to deliver some care closer to home.
The Clinical Working Group agreed that there was an opportunity to expand the role of pharmacy to include enhanced services and deliver care closer to home. The group saw the potential for improved pharmacy services across a range of patient need. There is the potential for pharmacists to become more visible, providing proactive patient care in the location that is most convenient for the patient. The Planned Care: Elective Surgery Clinical Working Group also recognise the opportunities to increase the role of the community pharmacist in planning preoperative care assessment, for less complex patients.
The group also mentioned the following as models that had potential benefits for the system as a whole:
Pharmacy first Named pharmacist for people with long term conditions Health champions The provision of 24/7 community pharmacy services, particularly to support end of life care care services.
However, a key barrier to adopting any potential new models of pharmacy, especially those relating to enhanced services, is the fragmentation of the commissioning of these services. Without a consistent, joined up approach, these initiatives will remain time-bound projects and not become part of the seamless delivery of care.
13. We need to work hard to address local issues to ensure that IT is an enabler rather than a barrier to integrated care and enables new ways of working.
IT systems and technology were identified by the Clinical Working Group as a key enabler for ensuring high quality clinical support services. The way that existing IT systems currently operate was considered to compound performance issues. One of the major issues that needs to be addressed, is the interconnectivity between sites and some manual systems of operating that are still in place.
Not all Barts Health sites operate using the same systems and there are compatibility issues between the different operating systems, although initiatives in place to address these are acknowledged. However, enhancements to this current programme of work are needed to ensure it is possible to measure the end-to-end pathway for pathology and radiology not simply one section. There also need to be work to eliminate manual systems, and improve IT infrastructure to support CSS in the community and connectivity with other providers.
89 (HSJ 2012) 101
202 Final draft policy for approval 14. The move to 24/7 services will bring with it further challenges for attracting and retaining the highest calibre workforce for clinical support services.
Analysis of workforce data provided by Barts Health indicates that the Clinical Support Services Clinical Academic Group has the highest annualised voluntary turnover of all groups (16.7% compared to 12.8% trust average). However, of those staff appointed in the last 12 months it has the second lowest turnover of staff in the trust, suggesting this is an improving situation (7.3% compared to a trust average of 16.1%). One of the largest challenges facing the workforce is the move to seven day services, with a particular issue for Barts Health being lack of weekend consultant cover for radiologists at the Newham and Whipps Cross sites.
Emerging priorities and models of care
Based on the analysis undertaken by the Clinical Working Group, the key emerging priorities and models of care are detailed below.
Understand and plan for any additional capacity and more effective ways of working required due to population growth and the changing demand profile.
It is unclear if there is sufficient local clinical support services capacity to deal with the population increase and disease profile of the local population. There is no long term, shared plan across the east London NHS to deal with this. So that we can ensure local services can meet future demand there is a need to undertake detailed capacity analysis and modelling to understand if this is deliverable within current services. This must also take into account:
potential efficiency gains from improved ways of working changes in technology and the effect on capacity and the tests required. a move to 24/7 services and the effect on capacity this may have potential reductions in over investigation through local initiatives to reduce the inappropriate use of technology. If there is insufficient capacity locally, there is a need to develop a local plan between providers and commissioners. This should also consider how such a service should work across sites.
Aligning hospital capacity with future models of care and developments in technology.
Clinical support service representation needs to be secured on future planning groups for any new service development or potential reconfiguration of services, so that the impact of service change on clinical support services is always fully understood.
Tackling the over-use of tests and reducing the burden of inappropriate testing.
There is evidence of over-investigation originating from both hospital, community and primary care. In order to reduce this, we propose that there is a role developed for Could pharmacists talk to GPs more, clinical support services experts to coordinate care? locally in demand management, Suggestion from member of TSCL development of evidence-based Patient and Public Reference protocols and systems to reduce Group inappropriate testing. 102
203 Final draft policy for approval Providing equity of access: we are seeing variation in equity of access to high quality services outside of the acute trusts
In order to provide equity of access across north east London and benefit from economies of scale we propose that:
providers and commissioners collaborate to align commissioning of clinical support service provision across boroughs where these services are inequitable there is detailed workforce planning to scope the impact of moving to 24/7 services across sites in relation to workforce and potential efficiency gains that there is future collaboration with other Clinical Working Groups to confirm which tests could be delivered more efficiently in the community via technology or remote models of working a local ‘route to market’ process is developed to ensure rapid implementation of the latest technology in a way that is equitable across north east London. In order to ensure value for money and that benefits are realised through adoption at scale, there should be a joint process across the CCGs for reviewing potential benefits realised by new technologies and to agree on when these should be rolled out at scale across the boroughs.
We need clear and robust local pathways of care.
In order to move towards meeting the London Quality Standards there is a need to take forward strategy work to ensure robust network arrangements are embedded across sites – especially in a way that tackles bottlenecks for capacity, for example in interventional radiology. Options for achieving this need to be considered alongside the current configuration of maternity and emergency surgical provision.
We need to address operational issues that are impacting our ability to deliver high quality and efficient services.
There is a need to resolve IT issues where these are causing clinical risks and preventing new ways of working being adopted. Work should be undertaken to reduce clinical risks across the current IT system and prioritise the solving of blockages.
There is a need to develop oversight of the whole clinical pathway to enable effective management of bottlenecks and rapid clinical decision-making. In order to tackle this issue, there should be work with commissioners to put in place appropriate performance measures and standards for the whole pathway – whilst ensuring that the payment system incentivises the right behaviours. There should also be further work, linked to actions already identified to support skill development, embedding local protocols and addressing the impact of IT systems on clinical and quality of care issues.
We need to realise the potential in community pharmacy to improve the links between settings of care and deliver care closer to home.
There is a need for work to develop a north east London strategy for pharmacy enhanced services. This should bring together the NHS England area team, CCGs and North East London Pharmaceutical Council. This work should try to tackle the fragmentation of the commissioning of extended pharmacy services in order that it becomes a key provider and interface between other commissioned services.
103
204 Final draft policy for approval 8 Do we use our resources in a sustainable way?
Our resources: Summary
The NHS and local government are facing significant funding constraints, with growth in demand expected to rise more quickly than growth in funding over the next 5 years. We need to work together to make better use of our resources so that we can improve patient experiences, and invest in better care. In particular we need to:
make £434 million of quality and productivity savings over the next five years and get better at preventing ill health if we are to become financially sustainable. improve communication and information sharing across different parts of the NHS and with our partners so patients can better care for themselves and do not have unnecessary appointments and tests make more effective use of technology to improve care and improve efficiency make better use of infrastructure make choices about the best way to spend resources, for instance reducing the amount of money we spend on our more out-dated, less efficient buildings and support services so that we can invest more in modernising facilities and caring for people at home.
Case studies: We have recently invested in some excellent facilities
A new acute assessment unit has recently opened at Whipps Cross as part of a £27m investment in emergency care at the hospital
Patients are benefiting from a £7m redevelopment of the A&E at Newham and £17.5m investment in the maternity unit
A new Royal London hospital
A world class specialist cardiovascular centre at St Bartholomew’s has the potential to save up to a 1,000 lives a year
The Sir Ludwig Guttmann Health Centre in the Olympic Park will provide state of the art primary and community health facilities for the growing local population
A £4m scheme at Homerton to refurbish the Clifden centre for sexual health and open the Jonathan Mann clinic for the treatment and support of people with HIV.
•
104
205 Final draft policy for approval Finance and efficiency
NHS funding to commission health services is reducing in real terms
There are now three different groups of NHS commissioners and each is facing real-term reductions in funding over the next few years.
NHS England National efficiency requirement of 2.5%. The current commission primary allocation method is under review. Co-commissioning with care services (GPs, CCGs is being considered. Current expenditure on GP pharmacists, dentists, contracts for Tower Hamlets, Newham and Waltham Forest optometrists) is £118m (including associated costs). Primary care spend in East London is in lowest 25% nationally
CCG funding varies from £1,151 per head in Tower Hamlets CCGs commission to £995 per head in Waltham Forest (2014/15). This will community, mental reduce in real terms over the next five years by an average health and acute of 11% across the three CCGs, meaning that the CCGs hospital care services need to make £128m of savings
NHS England commission specialised NHS England is looking for at least 3% efficiency savings services (e.g. trauma, each year. There is a long term challenge as demand neurosurgery). About a historically grows by 5% each year, and a balanced budget third of services for 2014/15 was only achieved nationally through non- provided by Barts recurrent support Health are specialised
Local hospital, community and mental health providers are all facing significant financial challenges as the prices they can charge for services are held steady and have not been keeping pace with inflation, pay increases or other cost pressures. Acute providers are also facing reductions in income as a result of new models of primary and community care and commissioner savings plans, as these aim to reduce the number of patients using hospitals. Projecting future income and costs forward shows that local providers will need to find £434 million of savings over the next five years Barts Health: £324 million of savings. (5.1% of turnover) Homerton: £54 million of savings. (3.8% of turnover) East London Foundation Trust: £56 million of savings (3.9% of turnover) Barts Health in particular has a big challenge with an underlying deficit of £47 million in 2014-15. These challenges predate the Barts Health merger and provided some of the rationale for the merger, however only a small proportion of the expected savings have been delivered to date.
105
206 Final draft policy for approval Local CCG allocations
The annual increase in funding coming into the economy will not keep up with the cost of increases in the underlying demand for health services caused by a growing population.
There is no funding for inflation, pay increases or other cost pressures. All increases in costs have to be paid for through efficiencies and cost improvements. Effectively the economy faces real- terms reductions in funding for the next five years. The graph below shows the allocation per person to the three CCGs when adjusted for forecast inflation90.
Commissioners need to identify Quality Improvement Prevention & Productivity savings each year to contain the cost of increasing demand.
Tower Hamlets: £27m of savings (net of new investments). Between 1.8% and 1.4% of turnover each year. Newham: £42m of savings (net of new investments). 2.5% of turnover each year. Waltham Forest: £47m of savings (net of new investments). Between 3.5% and 2.5% of turnover each year.
Staff and the public gave us about many examples of where our services are inefficient and wasteful
Typical of these were: Duplication of tests, prescriptions, taking histories etc Failure to maintain continuity of care when patients move from one step on a pathway to the next (e.g. discharges from hospital to community services) Appointments or operations cancelled at the last moment, often without explanation Poor procurement leading to higher prices than necessary
90 Allocations as notified by NHS England. Health cost inflation assumptions: 2013/14= 2.5%, 2014/15 = 2.5%, 2015/16 = 2.9%, 2016/17 = 4.4%, 2017/18 = 3.4%, 2018/19 = 3.3% 106
207 Final draft policy for approval Staff that were inappropriately skilled or trained to do the job Many respondents felt that low staffing levels were contributing to inefficiency.
We need to work together to find ways to deliver better value
The efficiency of Barts Health when compared to similar organisations shows there are opportunities to making savings and improve value for money. Of the £324m of savings required, it is estimated that approximately £200m could be achieved through productivity improvements and a further £38m through better recovery of income (although this will then present a cost pressure for commissioners). Examples of productivity improvements include: reducing length of stay reducing costs of clinical supplies standardising best practice pathways We need to rebalance funding between acute and community making better use of the staff we care, to discharge elderly frail have people from hospital and free up better methods of measuring acute beds and reduce waiting performance, leading to local times. improvements Dame Angela Watkinson DBE, improving asset utilisation MP for Hornchurch and Improving our systems Upminster These gains will require new ways of working and will require joint working between all partners within east London Better efficiency will not achieve all the savings required, so there will be a need to make savings from other initiatives such as reconfiguration of services and rationalisation of estates.
• Barts Health has saved over £2 million in the last few years by cutting water consumption, recycling more and saving energy (a scheme which is set to save £400,000 a year and won the HSJ Energy Efficiencies Award) • Homerton Hospital has saved money by retendering services, reducing reliance on agency staff and increasing productivity in theatres.
107
208 Final draft policy for approval Better Information Technology is essential if we are to make efficiencies and improve patient care and experience.
To achieve that, we need to improve basic information sharing and communications
The NHS often communicates via paper (referral letters, requests for tests and tests results), even for urgent cases Patients are still expected to book consultations on the phone or in person (creating extra work and delays), and attend consultations in person (generating a reliance on the physical estate). We do not make best use of mobile technology; texting and emailing Our IT systems and infrastructure are not designed to support mobile management or remote care which is particularly important in supporting the shift of care closer to home Our systems need to be connected so we can enable our clinicians to communicate effectively across different organisations and different settings of care Our information sharing with social services is fragmented resulting in unnecessary delays, particularly in our care for elderly and vulnerable patients We need patients to have one portal view to enable their self-care and self-management.
We do not share information consistently or effectively
Patients are often seen by many staff, who are working across many systems. Tests are duplicated and patients are asked for information many times. Patients have a right to expect that a single summary record should be able to be shared between the NHS to ensure a joined-up service.
This is a challenge as: 1. The NHS has many different information systems and platforms leading to a fragmented view of a patient 2. These systems do not easily interact with one another 3. Inconsistent levels of information are recorded and shared 4. Information governance can be perceived as a barrier to sharing information between different services and organisations 5. Our clinicians have varied understanding and skills to use data available to them for clinical decision making. We need to increase the use of NHS numbers to enable records to be linked and shared.
Our patients and the public have said….
We asked our patients and the public to give us feedback on the current challenges and There needs to be a opportunities that technology or the lack of it streamlined booking system brings: across medical services Feedback from Newham, Patients want to see improvement to the Waltham Forest and appointments system both within hospital Redbridge Healthwatch event and primary care treated as a priority. They want to be able to book appointments online
108
209 Final draft policy for approval Technology should be introduced with the benefits to patients in mind; make it simple, intuitive and seamless for those who use it Patients want to have access to their records so they have tools to manage their own conditions and have better Patients and staff should choice have electronic access to their records and test results. Services should always engage with Female Waltham Forest patients and the public to re-design resident, aged 41 – 65 technology that will be used by them. (also a service user and NHS staff member) Our clinicians and staff have said…
Our clinicians have highlighted to us specific IT and technology issues that prevent them from delivering best possible care for their patients: We lack reliable access to patient records with up-to-date information from different services We need to sort out the basics through updating infrastructure and the effectiveness of systems we have already implemented The variation of IT system used across and within healthcare organisations and the lack of effective interface between them means we do not have access to patient data when we need it most, particularly in urgent or crisis situations We need to eliminate manual records to create fully digitalised patient records that can be accessed in real time Technology needs to be enabling and supporting the shift of services from hospitals into the community Technology needs to support multidisciplinary team working by effective sharing of real time information on patients We are currently not fully utilising technology to improve patient safety Technology needs to be used to improve access to services and enable patients to take better care of their own conditions.
We received consistent feedback from patients and clinicians that relates to future work:
Engaging patients in technology and IT redesign so the solutions are developed with their benefits in mind Giving patients access to their care records will empower them to manage their own conditions.
Available technology has not yet been widely introduced to enable patients to be monitored remotely for a range of long term conditions (i.e. COPD, diabetes etc), preferably by a named clinician(s) to enable continuity and confidence. Female Waltham Forest resident, aged 41 – 65 (also a service user and NHS staff member)
109
210 Final draft policy for approval Better use of technology can transform the way we access healthcare services, support clinicians in decision-making and patients in managing their conditions.
There are great opportunities for technology to change the way we work. Technology can help save money, provide better care and an improved patient access and experience.
The first person in the UK was fitted with a wireless pacemaker at Barts last year Wireless foetal monitoring equipment is being used at Newham allowing women with higher risk deliveries to still have the choice of a water birth A team at Johns Hopkins University uses videoconferencing to provide speech therapy to patients suffering with a cleft palate in other countries.
Self-monitoring devices can empower patients in their self-care:
For instance Myhealthlocker is an electronic personal health record for people using mental health services. Service users can collect, store, edit and manage their own heath information, including their GP and hospital records, in one place. Rate my day is an online tool to track sleep, anxiety and energy levels WebGP in Tower Hamlets – Practices in Tower Hamlets have been trialling a WebGP tool to help reduce numbers of appointments for minor ailments by offering self-help on over 100 common conditions that patients come with to their GPs. It includes symptom checking facility to ensure that only patients with ailments appropriate to general practice attend an appointment signposting others to alternate services available to them such as pharmacies. It also contains a call back facility from a 111 nurse 24/7 within an hour via a web form available through the system.
We need to be ambitious in introducing and utilising technology for better patient outcomes.
By aiming to create patient-centred, timely, accurate and secure data which is linked across different components of our patient pathways, we can achieve efficiencies whilst improving patient experience and treatment.
The digitisation of healthcare data which is linked around a patient presents a unique opportunity to transform the way we can drive individual and public health improvement in real time. It will support clinicians in decision-making, liberating them to focus on patients’ needs. It can transform patients’ attitudes by prompting, directing and supporting them in managing their own health leading to large scale efficiencies and improved patient experience.
In improving our technology for better patients outcomes we need to take into account:
Patient and clinicians needs – we need to wrap technology around services rather than the other way round 110
211 Final draft policy for approval We need to aim to have real time information for clinical decisions to be effective Aim to change attitudes to using technology among clinicians, staff, patients and carers to maximise the benefits that technology brings We need to continuously train our staff, particularly clinicians, in new technology and we could include the technology training in the medical students’ curriculum When introducing or designing new technologies we need to take our system’s maturity into account We need to introduce incentives to encourage individual organisations to adopt new technology or a joined up approach in commissioning it We should work with patients and carers to fully utilise and embed new systems enabling self care and self management We need to work together to have a joined up approach to technology and IT design, implementation and continuous innovation.
Effective design and deployment of IT and technology has been recognised as one of the key sources and enablers of the care services transformation.
A strategic WELC IT and Technology group which has primarily focused on supporting the integrated care agenda was established in 2013. This group will be incorporated into an overarching programme to strengthen the IT and technology collaboration among health and social care organisations serving our east London population.
The group will focus on: Identifying existing programmes of IT and technology work to maximise opportunities of collaboration and shared learning among partnering organisations Developing and implementing governance, consent and information sharing arrangements among all partnering organisations Encouraging progress being made by partnering organisations in fixing basic IT-related issues experienced by patients and staff – such as fast network connectivity, hardware and software infrastructure Building on what has been achieved through the WELC Integrated Care Programme, develop an overarching IT and Technology Strategy for east London that identifies: o principles for IT and technology collaborative work in east London o areas of IT and technology where joint working, approach and resource sharing will be appropriate and beneficial to patient care (such as developing an integrated patient portal) o principles for identifying joint commissioning opportunities for IT and technology o governance mechanisms for the delivery of the strategy.
Developing, implementing and monitoring the delivery plan underpinning the IT and Technology Strategy Developing stronger links with local authorities and health alliance organisations to align the initiatives across the system Continuous horizon scanning for new opportunities of joint working to maximise the IT and technology resources and eliminate inefficiencies.
111
212 Final draft policy for approval
Summary of IT & technology issues discussed by the Clinical Working Groups
The Maternity and Newborn CWG discussed the challenges of delivering care when IT and technology systems are not joined up across acute and community settings or across different areas of East London. There are examples of technology being utilised to increase patient benefits such as wireless foetal monitoring equipment being used in Newham allowing women with higher risk deliveries to have a choice of a water birth. Some of the opportunities have been identified but not yet implemented such as improving discharges at Whipps Cross utilising technology-driven solutions.
The Children and Young People CWG focussed their discussions on technology-enabled information sharing, which is a key enabler for effective safeguarding for children and young people. Robust information sharing would also support effective discharge and handover arrangements across different settings of care.
The Long Term Conditions CWG saw technology and IT systems being key enablers to transforming and improving care with a central fully digitised patient record which can be accessed by clinicians working in a range of care settings and organisations. The introduction of an electronic process of discharge and handover, particularly where there has been a change in medication would increase patient safety and quality of care. Finally, the use of self-monitoring devices needs to be more widespread to empower patients to become experts in their own condition and its management.
The Unplanned Care CWG recognised the fact that technology currently used does not provide a reliable oversight of demand across the health system making the urgent care pathways less responsive. Fully digitised patient record would support effective triage of patients by 111 or at other ‘entry points’ for unplanned care benefitting the overall patient care and reducing the demand on A&E. The group has also discussed huge opportunities for using mobile diagnostic to support the delivery of unplanned care closer to home, particularly for nursing and care homes’ residents.
Planned Care – Surgery CWG focussed on the opportunities that new technology brings where holding telephone consultations reduced face to face contacts by 50% and waiting times were reduced from 5.5 days to one day.
Clinical Support Services CWG discussed extensively current systems available to clinicians to do their job more effectively and the opportunities for providing better patient care that new technologies can unlock. The lack of connectedness between different systems and the ability to share information on diagnostic results have been singled out as a key barrier for clinicians at this point in time. Eliminating paper referrals and using voice recognition recording across all sites and settings of care would improve the quality of care and improve effectiveness of clinical services. The group also discussed the need to use technology to enable the visibility of the entire patient care pathway along with the provision of services in the community.
112
213 Final draft policy for approval
The local NHS estate
We are too reliant on estates and facilities that we do not use effectively
Because the way we work is based on physical and paper interactions, we spend a lot of our shrinking financial envelope on estate that we don’t use effectively. Every £ spent on inefficient estate is a £ that could be spent on improving care.
The ownership and occupancy of buildings used by the NHS to deliver services has become increasingly complex. This has made it difficult to keep track of all the assets used by the NHS and information such as cost, condition and utilisation. To plan strategically the local health economy will need to build and maintain better records of the assets being used.
Quality of the community & primary care estate: There are nearly 150 GP practices and approximately 70 community premises in inner north east London (Waltham Forest, Newham and Tower Hamlets) costing an estimated £90m per year. Some of these facilities are poor and not fit for providing modern healthcare delivery. Extended working hours and new technologies could support a reduction in the number of premises that we need; and bringing services together into fewer, larger premises could help us deliver better care and reduce costs.
Full utilisation of the best quality estate: A large part of the estate is new (or newly reconditioned). The challenge for much of this new estate is to make sure that it is fully utilised. For example much of the Sir Ludwig Guttmann Health Centre in the Olympic Park is currently empty, although it will become a valuable resource as the population in the area grows. There is also space that could be better utilised at the Royal London, Newham Hospital and a number of health centres.
Whipps Cross: The most significant estates issue in secondary care is the Whipps Cross site. Much of the site is more than a century old, in a poor state of repair and not suitable as a place for providing healthcare in the 21st century. Barts Health and the CCGs all agree that this is not acceptable and that the redevelopment and modernisation of the site is essential to provide local residents with the facilities they deserve. Future plans for Whipps Cross need to be founded on a strong clinical strategy for east London.
What we heard from staff and public
There was criticism of the condition of some estate, particularly some primary care estate. Staff and public gave examples of buildings and infrastructure that were not suitable for modern healthcare.
There was disappointment at the loss of staff accommodation over the last few decades. This was felt to be making recruitment and retention more difficult. The view was presented that providers should be actively promoting the development of key-worker housing.
Many respondents pointed to NHS buildings that had remained empty for long periods and felt that more should be done to make use of these assets.
113
214 Final draft policy for approval How the findings in the Case for Change and likely to impact on the NHS estate
A strategic estates planning group has been created involving all of the commissioners and providers across the WELC area. The group has considered how the estate needs to change in order to respond to the changing demands of health services.
The population growth will create new demand for health services. In some instances this will require new facilities, in others additional space will need to be released from existing buildings. One specific example is maternity services where the Maternity and Newborn CWG has identified that there needs to be more delivery rooms in maternity departments to meet the growing number of births. There is concern about some of the poor quality estate, the variation in the condition of some estate and a recognition that some estate needs to be improved. We anticipate that many of the proposals to develop clinical services that will be proposed in future will require estate work before they can be implemented. This might include making facilities at one unit larger so that services on many sites can be consolidated, or it might involve investment in community buildings so that hospital services can be moved out to a community setting. As relationships with local authorities build and services become more integrated there may be opportunities for shared use of council and NHS facilities, this was highlighted as particularly important by the Children and Young People CWG. There are some productivity gains that will require capital investment to realise. For example old hospital wards are often expensive and inefficient to operate because the staffing levels need to be higher and the hospital has limited flexibility in how beds can be used. The development of key-worker housing could contribute positively to the workforce agenda. New technologies, such as new methods of diagnosis may also require changes to the estate. There will need to be savings made from better use of the estate. In some instances this can be achieved through better utilisation of the current assets: o Identifying space that is vacant and resolving this o Making better use of space that is only used for parts of a week or a day o Extending the use of space into evenings and weekends
In other circumstances savings will need to be made by moving services and disposing of sites when they become redundant.
Priorities for developing the NHS estate
The strategic estates planning group will be incorporated into an overarching programme to strengthen estates planning in east London. Thereafter it will oversee an estates strategy for the area. The priorities for this group will be:
Build and maintain a comprehensive asset database of all of the different estate owned and used by the NHS. The database will include information about the condition, use and cost of all assets.
114
215 Final draft policy for approval Using this analysis to develop a strategic plan for delivering new and improved estate provision. This should identify: o where investment is required to respond to increasing demand, changing health provision and poor quality estate o how efficiency can be improved through disposal of some assets and better utilisation of others o how to respond to the service changes that will be identified in the next phases Investigate partnering with housing associations with a view to improving opportunities for staff housing Develop stronger links with local authorities to identify where there can be shared arrangements.
The strategic estates planning group will be incorporated into an overarching programme to strengthen the IT and technology collaboration among health and social care organisations serving our east London population.
We will use this analysis to develop a strategic plan for delivering new and improved estate provision, where required. We will engage with all key stakeholders, including local planning authorities, to plan new health provision that meets NHS requirements within the new planning and development framework.
115
216 Final draft policy for approval
9 How sustainable is our workforce?
Summary
Whilst there are examples of leading edge schemes to build a sustainable, flexible, professional and engaged workforce, there are a number of considerable workforce challenges that need to be addressed to reduce health inequalities and improve health of people in east London. The vast majority of our current healthcare workforce was trained to support a model that was anchored in hospital care. This is not a suitable and efficient approach for a rapidly growing number of elderly people with both mental and physical co-morbidities. There is an urgent need to address difficulties in attracting and recruiting skilled staff for specific posts in both primary and secondary care, which reflects the national experience. The nature of health care work is changing with a major shift to predominantly community- based, multidisciplinary way of working that is tailored to services operating seven days a week. We need to change our approach so that we develop staff who have flexible mindsets and transferrable competencies including strong teamworking, technology-enabled continuous improvement skills and ability to effectively support self-management of their patients. These competencies need to be developed against a backdrop of continuous investment in maintaining a balance between generalist and specialist professional skills of individual staff members. Our workforce will be increasingly working across health and social care domains and we need to consider the integration of roles whilst supporting our workforce in making this transition. Resolving these challenges relies on strong and well supported leaders at all levels of organisations who play a critical role in engaging local teams and nurturing a culture of compassion.
There are additional issues in east London, in particular due to the high cost of living and housing shortages. We need to work closely with local authorities as recruiting a local workforce is essential to delivering appropriate and sustainable care. We need to:
i) Address the current challenges and workforce gaps ii) Ensure our workforce have the skills needed to deliver the model of care in the future iii) Ensure our workforce is engaged, flexible and motivated to be able to deliver high quality patient care and innovate to support continuous service improvements iv) Recognise the importance of distributed and collective leadership in driving improvement across professional boundaries.
116
217 Final draft policy for approval
Patients and the public have said…
We have asked our patients and the public to give us feedback on the current workforce challenges and opportunities. They can be summarised in three key areas:
Current resourcing levels
Staff appear to be stretched and overloaded so there is a need for a more careful consideration of the number of staff with the right skills needed to deliver quality services Maintaining high levels of staff retention should become one of the areas of focus as it contributes to the continuity of care and prevents loss of valuable knowledge about patients and services.
Supporting and developing our workforce
Staff need to be appropriately trained and supported in their on-going development to deliver best possible care. In particular, the need to improve overall customer care and communication skills emerged as a significant training need at all levels and across different professions Staff morale needs to be improved as we recognise the link between high staff engagement and their ability to deliver high quality care There is a need for workforce to be more flexible with working patterns that are aligned with when the services need to be provided, including weekends, to meet patients’ needs It is essential that staff performance is actively managed.
Leadership
There is a need for empowering staff at all levels to lead the services and introduce changes needed for better patient care There was a perception that managerial roles do not improve patient care and that there needs to be more investment in clinical roles.
Workforce is key Redbridge Health
We see NHS staff leaving the UK to go Overview and Scrutiny and work abroad. We think that there is Committee more opportunity for the careers in the NHS to be promoted to young people in schools. There should be more open days,and apprenticeships. Young Adviser, London Borough of Waltham Forest (attendees were aged 15 – 21)
117
218 Final draft policy for approval Clinicians and staff have said…
Our clinicians have highlighted to us specific workforce issues. They have been grouped into three key areas of consideration which are presented below:
Recognising and resolving current workforce issues that are a barrier to delivering best patient care now: o In some areas there are posts that remained unfilled due to either local or national shortages of skills o Staff retention levels needs to be improved which will help us reduce the usage of bank and agency staff o In some areas current staffing levels are not appropriately matched to the requirements of the service o In some areas current skill mix of staff for each service is not aligned to the service and patient needs and requirements
Our current workforce configuration does not support future models of care o Workforce is one of the key enablers for the shift to seven day services o Our workforce models need to be underpinning the improvement drive aimed at reducing the variation of care and current care quality gaps o Our workforce models need to enable the drive for multidisciplinary team working across different acute services and care settings o It is essential to build a flexible workforce model that is aligned with the changing demand for the service supported by staff members embracing the work on varied rotas across different sites
Training and development for current and future service needs o Focus on maintaining a broad spectrum of clinical skills in increasingly specialised clinical areas to ensure flexibility o Re-focus and improve primary care training and development to ensure it matches current and future service needs o Improve secondary care training and development to support the move away from the paternalistic model of care with the emphasis on patient self-management
There are significant similarities in feedback we have received from both patients and clinicians and some of these issues are already being addressed by primary and secondary care providers in east London.
Barts Health has set a target Homerton is developing a Primary Care organisations of 95% permanent staff by clinical leadership are looking to adopt the role December 2015. Initiatives programme which aims to of Physician Associates to to meet this include Saturday strengthen staff’s ability and support the work of assessment days and effectiveness of working in clinicians in multidisciplinary overseas recruitment for multidisciplinary teams teams difficult to fill nursing posts
118
219 Final draft policy for approval Case studies: we have some excellent workforce models
Barts Health is a major employer. Nearly 40% of staff live in east London and the trust is increasing the recruitment of local people by:
direct and reserved access to entry level jobs for people who are unemployed in east London job readiness assessment and support apprenticeships which lead to permanent jobs. Between April and Dec 2013, 75 candidates were placed. As well as apprentices in theatre support, pharmacy, administrative and laboratories, new roles will be created in maintenance and a pilot for healthcare assistant roles in outpatient department settings. Barts Health has moved from the traditional concept of vacancy rates to focussing on ‘fill rates’. This involves forecasting recruitment needs over the year, based on turnover (both leavers and internal moves/promotions), predicted service changes and staffing pressures such as maternity leave. Approval to recruit is undertaken in bulk, contributing to a more efficient process. This has enabled the trust to reduce their time to fill (e.g. date of instruction of the vacancy to unconditional offer of employment) from 18 to eight weeks. Patients benefit from improved quality and continuity of care as reliance on agency/bank staff reduces. At Homerton, 83% of staff agree that “Care of patients / service users is my organisation's top priority“. This is against a national average of 68%. The Barts Health ‘Community Works for Health’ programme seeks to recruit a culturally and linguistically sensitive workforce. This improves patient care and helps the Trust’s understanding of, and response to, the needs of patients Tower Hamlets operate an innovative network system. These bring together GP practices to work collectively to manage long-term conditions and other services with shared incentives and outcome measures. The networks have developed a more cohesive primary care community and reduced variation in quality, for example in diabetes care and childhood immunisation performance.
The focus of the NHS must be to provide quality, efficient services delivered by highly skilled and motivated staff. Female Waltham Forest resident, aged 41 – 65 (also a service user and NHS staff member)
119
220 Final draft policy for approval We have existing gaps in the hospital workforce
The existing staff structure doesn’t enable a high quality service.
Adult emergency surgery: we do not meet requirements for all emergency admissions to be seen and assessed by a relevant consultant within 12 hours Emergency admissions: for fractured neck of femur, no Barts Health site ensures all patients are seen and assessed by a consultant orthopaedic surgeon within 12 hours Antenatal and postnatal care: the need for a closer attention to women’s mental health issues during antenatal and postnatal care is currently not reflected in workforce models and professional skills training Children and Young People: there are insufficient numbers of acute staff with appropriate skills and expertise to meet the activity needs whilst complying with European Working Time Directive - particularly in consultant and staff speciality and associate specialist grade Even where the staff structure may be appropriate, we sometimes cannot fill the posts. Despite a range of initiatives to recruit and to retain staff, there are some posts that are difficult to fill and some areas that have national and local shortages. There are particular challenges in recruiting: o A&E consultants o Paediatric nurses o Nurses o Midwives Key worker accommodation is o Health visitors very important o Theatre staff Waltham Forest Health and o Geriatricians Wellbeing Board o Biomedical services o Consultant obstetricians o Generalist medical consultants
For consultant roles, these challenges are compounded by increasing specialisation of medical training resulting in decreased flexibility of the workforce we employ. Whilst focussing our efforts on recruiting high calibre staff we also need to improve our retention levels so we are able to achieve healthy workforce levels without relying excessively on bank or agency staff filling our workforce gaps. In addition, our nursing workforce is ageing and we need to be able to attract new recruits into the profession. In 2011 12.4% of the UK’s nursing workforce was aged 55 and over with 48.6% of midwives eligible to retire in the next 10 years. Overall, The King’s Fund predicts that by 2021 there will be a potential shortfall of between 40,000 to 100,000 nurses in the UK. We need to continuously support staff in fulfilling their potential, ensuring that optimum workforce productivity levels are achieved. Our current performance management practices need to be clearer and more consistent to enable effective support for those members of staff whose performance do not meet our requirements.
120
221 Final draft policy for approval We have existing gaps in the primary care workforce
There are significant challenges in recruiting practice nurses and district nurses. This pressure will get worse as this workforce has an older age profile – meaning that significant numbers are approaching retirement. The situation is compounded by the fact that the profession is not perceived as an attractive option for newly qualifying nurses and there has been a 40% decline in those choosing to enter the profession nationally last year. There is a shortage of GPs. By 2021 the country will need 16,000 more GPs than there are now. Tower Hamlets and Newham already have some of the worst GP to patient ratios in the country91. It is an ageing workforce. In London 17% of GPs are over 60 compared to 10% nationally, and many areas are dependent on single-handed GP practices. There are key clinical skills / training gaps. Only 31% of the capital’s GPs believe they have received sufficient training to diagnose and manage dementia and only half of all GP associates in training have the opportunity to work in secondary care paediatric services to gain experience of identifying and managing sick children. This is compounded by variable access to specialist clinical advice and second opinion across London resulting in higher referral rates to secondary care. The wider primary care workforce is not utilised effectively. A north central and east London primary care workforce project, working with the Local Education and Training Board found that some key ways to address this would mean a greater focus on: o team working across professional boundaries o fostering innovation through education o developing new roles in navigation skills and support o the development of practice nurses o improving healthcare support workers training o community pharmacy development.
In particular, a need for more specialist skills to support primary care and community pharmacy in prescribing and medicines management has been identified. Shifting the resources from the acute pharmacy to community setting is considered to have the potential for increasing delivery of care closer to home.
91 2012, Centre for Workforce Intelligence (CfWI) 121
222 Final draft policy for approval Our workforce does not support new models of care
London Quality Standards
Clinical experts and patient panels have developed evidence-based quality standards for each service area. Compliance with the London Quality Standards is not mandatory, but assessment against them does illustrate some key workforce issues The London Quality Standards have been an important mechanism in establishing a move towards seven day services and significant changes to working patterns around how emergency and planned care clinical responsibilities are managed Self-assessments at Barts Health and Homerton show there are a number of London Quality Standards that are unmet both on weekdays and at weekends.
122
223 Final draft policy for approval Our workforce needs to be better engaged and motivated
An engaged and motivated workforce is essential. Trusts with higher levels of staff engagement are generally rated by the Care Quality Commission as outperforming other trusts. They have: o better quality services o more robust finances o higher patient satisfaction scores o lower staff absenteeism o consistently lower patient mortality rate
The Care Quality Commission92 stated that staff feel disconnected from Barts Health’s executive leadership team, undervalued and unsupported. They reported that morale was low across all staffing levels and some staff felt bullied. In their 2013 NHS Staff Survey, Barts Health received scores in the lowest 20% nationally for overall staff engagement and staff recommending the trust as a place to work or to receive treatment. However staff do believe their role makes a difference to patients Barts Health measures staff engagement within the organisation. The results in March 2014 showed significant variance across Clinical Academic Groups (CAG), with engagement ranging from 56% of staff in women’s health to 33% in clinical support services.
Women’s and children’s CAG has identified issues relating to culture and behaviour. There is a programme underway, Great Expectations, which addresses the levels of bullying and harassment that staff in this CAG are reporting (47%).
In primary care, Newham CCG has reported challenges in attracting and retaining GPs, nurses and practice managers.
West and Dawson: NHS Staff Management and Health Service Quality
92 Care Quality Commission (CQC), January 2014, CQC Inspection Report 123
224 Final draft policy for approval Meeting the challenges of the future will require new ways of working, new roles and new skills underpinned by innovative training and development initiatives.
The health and social care demand has undergone a radical change and the east London needs a workforce ready to meet patient and public needs in the 21st century.
The named clinician ambition in primary care will be a challenge.
The Department of Health is consulting on its proposal for a named clinician, which is where a single point of contact is provided to coordinate the care of vulnerable older people. This policy is likely to have a significant resource impact for general practice and will mean thinking differently about how we develop the rest of the workforce (practice nurses, healthcare assistants and community teams).
Current skill mix and training is not necessarily appropriate and we should start attaching more importance to those models of training that equip healthcare staff with transferable competencies.
The alignment of workforce skills to service needs should be undertaken on a regular basis. In Barts Health this is achieved through a corporate and clinical advisory group annual strategic planning process and for adult and specialist services resulted in extending the role of community nurses and introducing a newly commissioned role of care co-ordinator.
We need a greater focus on education and training of staff – both formal (e.g. courses) and informal (e.g. staff rotations)
Future models of care suggest a need to change the skill mix of the workforce. This is driven by: Increased delivery of care in a community setting Integrated care The introduction of seven day services. For example, the Academy of Royal Colleges has suggested that there is a need for a more generalist consultant physician role that can undertake ward rounds and agree patient discharges at weekends and out of hours. This may impact on how we train healthcare staff and the commissioning of education. This will be particularly important to the delivery of integrated care, creating roles that can cut across professional and organisational boundaries. Increased flexibility will also be a key skill of the future Educating and developing staff is clinical workforce. We are likely crucial in delivering change to see clinicians travelling to Barts Health staff member deliver care in a community setting or providing alternatives to face to face care for patients, enabled by technological development. We need to model our workforce based on the needs of services which will be increasingly providing care all days of the week.
We need more care provided by multidisciplinary teams that can provide the right type of care in a setting that meets patients’ needs. The success of this new way of working will depend on staff flexibility in the roles that they can perform and will require a shift in organisations’ approach to workforce recruitment, training and continuous professional development.
124
225 Final draft policy for approval Without this organisational shift, we will continue seeing the challenge of recruiting into posts that are based out of multiple locations or in the community which are currently perceived as less attractive employment options for potential candidates.
Given national shortages and ageing workforce profiles of some professions, particularly in primary care, we need to be more creative about the way we utilise our workforce and adopt widely roles such as Physician Associates or Care Navigators to support the delivery of services with the support of staff with most appropriate skills.
All the future changes will require our workforce to adopt both technical and behavioural changes. Only then patients will see a step change in the care provided to them. It has been recognised that no organisation alone is able to effectively address the workforce challenges outlined in the Case for Change and therefore, a strategic workforce group has been established to work collaboratively on resolving them across east London. The group incorporates all key workforce stakeholders and will be incorporated into an overarching programme to strengthen workforce arrangements amongst health and social care organisations serving our east London population.
Following the discussions held at the first group meeting, the main priorities have been outlined as:
Forming and implementing a pro-active plan to increase supply into caring professions across different settings of care. This will be achieved through: o Connecting with schools and universities to promote the professions and NHS jobs to people currently in education o Creating a brand and communications aimed at informing the public about the whole variety of roles available at different entry points o Linking with organisations supporting ‘back to practice’ schemes to align any promotional activities Enhancing career development opportunities for caring professionals through linking both social and health care career paths Explore opportunities brought by creating joint arrangements on bank and agency staff to drive the efficiencies across the system Focus on creating innovative new roles that will help us address workforce shortages and enable us to work across professional and organisational boundaries o Develop a shared and evidence-based understanding on what skills and competencies we need our workforce to have in order to deliver our services and best possible care; use this analysis to design new roles needed in the workforce with an implementation plan to deliver the transformation o Developing and investing in care navigators and healthcare assistants roles to support more joined up care for our patients
Exploiting opportunities of joint working and sharing resources in education and training, particularly with regards to: o Statutory and mandatory training o Leadership training o Cross – organisational training o Maximising the impact of work currently initiated by Community Education Providers Network
The group identified key enablers for the above streams of work:
125
226 Final draft policy for approval Patients’ perceptions and mindsets need to transform so patients recognise that best care can be provided by a range of professionals, not just doctors Embedding NHS values to release and empower our staff to deliver compassionate and joined up care Investment in training of current and future staff to increase levels of competence, flexibility and generalist professional skills Creating new ranks in existing and future workforce structures to allow new recruits to join the workforce at different entry points, including through volunteering The group agreed that the achievement of their common goals will be supported by the following approach to their joint initiatives:
Including patient and staff voice and representation in any future workforce initiatives to ensure that they are shaped with their feedback and experiences in mind Continuous sharing of information on opportunities of joint working and collaboration to drive system efficiencies through workforce with long term planning view These priorities will be discussed with a wider group of stakeholders to form and agree a joint working plan along with timescales and resources will be agreed.
Workforce issues discussed by the Clinical Working Groups
Each of the CWGs considered workforce issues as integral to their ability to deliver excellent patient care. The summary below captures some specific workforce themes that were highlighted by each of the CWGs.
The Maternity and Newborn CWG discussed specific workforce issues relating to the population growth in our area. There could be 5,800 additional births by 2020 so there is a particular focus on ensuring appropriate staffing levels against the backdrop of recruitment difficulties and an ageing workforce, particularly with relation to the midwifery profession. Our workforce models need to be reconsidered so the emerging trends of rising intensive care cot and high dependency activity and falling special care activity are taken into account. There is a higher mental health prevalence in north east London so our workforce needs to be appropriately skilled to pay close attention to women during ante and postnatal care.
The Children and Young People CWG considered training-related issues in both primary and secondary care. The current trend of specialisation of training does not enable a holistic approach to patients, particularly with regards to mental health needs. Moreover, the primary care and community workforce has historically had limited paediatric training which combined with limited time for observation during 10 minute appointment slots in GP practices results in higher levels of referrals to secondary care. Any shift of activity into community will be difficult to achieve if the appropriate training and access to specialist clinical advice and second opinion across east London are not provided.
The Long Term Conditions CWG reflected on the effects of the lack of seven day services in community and social care services which results in the acute trusts’ ability to discharge patients over the weekend. This is compounded by a lack of acute physicians such as generalist medical consultants which results from the increasing specialisation of medical training. On the other hand, the group recognised the fact that the primary care workforce is stretched and needs support and training to help patients manage their long term conditions without referring them to secondary care. There are some excellent workforce models underpinning integrated care models such as multidisciplinary team working in the areas such as diabetes care packages but they need to be expanded beyond specific care pathways and have consistent mental health and social care inputs. The move towards integrated care provision has126 already created a need for a different type of skills in currently existing roles and will continue driving the need for new posts such as care navigators. We need to ensure that we support our current and future workforce to respond to these changes.227
Final draft policy for approval
The Unplanned Care CWG echoed the concerns of the Long Term Conditions CWG over the lack of seven day services in community and social care services resulting in their limited ability to discharge patients over the weekends. The difficulty to recruit to certain posts such as A&E consultants, qualified critical care, theatre nurses and general surgeons was a particular theme discussed by the group who reflected on the impact that this has on the increased use of bank and temporary staff to fill these gaps. The group has also emphasised the correlation between the shortage of GPs and district nurses and increased demand for A&E and other urgent care services. In addition, the group highlighted the long duration of medical training being a significant challenge that affects the speed of changes that need to be implemented with relation to training or changing medical skills set.
Planned Care – Surgery CWG reflected on the increasing specialisation of the profession and a growing number of sub specialists. This is being affected by a decreasing number of cases due to new alternative treatment options meaning that patients do not require a surgery. In addition to some sub specialities not getting sufficient exposure to maintain their specialist skill set, some that attract higher numbers of patients such as day case surgery are not currently perceived as an attractive career option. These trends observed in the surgery area result in the workforce model that is not well matched with the service and population needs. Similarly to challenges in unplanned care, the pace of change needed is affected by the length of the medical training. We also need to be utilising the existing workforce better and break down barriers in using primary care, particularly community pharmacy workforce in postoperative care, which would be possible if the right training is provided.
Clinical Support Services CWG discussed the impact of the rising population on the demand for their services and the need for increased workforce capacity in dealing with them. This was considered against a backdrop of observed shortages and difficulty to recruit to biomedical services posts, particularly pathology. There is a need to expand multidisciplinary team working and reflect this in staff rotas so that a team consisting of a radiologist, a radiographer and nurses were enabled to work across the network. The group recognised the key role that technology will continue to play in the skills set needs and development for their staff.
127
228 Final draft policy for approval 10 The change required and next steps
The Transforming Services, Changing Lives programme identifies a number of areas in which there is a Case for Change to secure high quality care in a sustainable way. Patients, residents and clinicians from across east London have made it clear that achieving these changes in hospital care will require the whole health and social care system (primary and community care, mental health, hospitals and social care) to come together, to work across organisational boundaries, in order to deliver lasting improvements for patients.
Many of these changes can take place quickly, whilst others will need to be given further thought. Our programme outlines where we plan to transform services over the next 2-3 years to meet our future challenges.
Eight areas of consensus are:
Our population is growing and the local NHS needs to respond to increased demand, for example in maternity and children’s services
We expect 270,000 more people to be living within our three boroughs over the next 20 years; equivalent to one new borough. Rather than build a new hospital for this huge population growth, we are planning to transform the use and effectiveness of our current health system and estate.
There are however areas of care that will need to be expanded if the local health system is going to provide high quality care in a sustainable way. Demand for maternity and children’s services is expected to increase because of our rising birth rate, with up to 5000 more births expected over the next ten years and 16,000 more children living within the three boroughs over the next five.
Detailed analysis needs to take place over the coming months to identify which maternity services will need to grow and where children’s services will need to change. Different models of care need to be developed to ensure hospital based service can cope with additional demand. For example, clinical leaders within hospital and community children’s services are working together to design enhanced urgent and integrated care.
We are currently determining how best to take forward work in these areas, through for example, a strengthened maternity network for the whole of North East London involving both commissioners, providers and service users and a Children’s network.
We need to care better for the increasing number of people with long term conditions
The highest proportional increase in population is expected to be amongst over 65’s, who can expect to live longer but suffer from more long term conditions, requiring more complex care. We therefore need to enhance and strengthen our integrated care approach.
In order that services respond to this increase, detailed capacity and demand modelling will need to be undertaken over the coming months to understand where and how services need to change, and the impact this will have on support services such as diagnostic testing. By redesigning the way in which services operate and by providing enhanced primary and community care through better care planning, we can ensure that a greater proportion of our ageing population are supported to stay healthy and out of hospital, through to the end of their lives.
128
229 Final draft policy for approval An example of our transformational work is the way that outpatient services at Barts Health are being reviewed to develop more responsive services. Remote monitoring and Skype clinics can sometimes be more effective ways of providing long term condition patients with ongoing care.
This work will continue to be taken forward by the WELC Integrated Care Collaborative which is already ensuring those with multiple long term conditions receive better care planning.
We and our partners need to work together more closely to strengthen our prevention approaches, supporting people to live healthier lives and improving physical and mental wellbeing
We know that the health of our population can be improved; too many people are dying early due to preventable diseases and too many people are not receiving the mental health support they need, early enough. Everyone has a responsibility for this and the NHS, local councils, health and well-being boards, businesses, schools, patients and the public need to work together better. We have heard that the NHS is not currently set up to provide enough support to people to help them lead healthier lives and we do not provide as much support for mental wellbeing as we do for physical health. Through workforce development, service redesign and working closely with colleagues in Public Health, we need to embed a prevention approach, working in partnership with patients to support them with their health and ensuring all of our clinical staff feel better able to support patients with their mental health.
We are already working together to try to increase the prevention work that takes place our schools to stop children and young people developing long term conditions such as diabetes in the future. However, more needs to be done to ensure our approaches are co-ordinated, widespread and as effective as they can be.
The local NHS needs to invest time and effort in tackling inefficiencies. Estates, IT systems and care pathways sometimes do not work for the greatest benefit of patients or staff
Commissioners, local authorities and primary care services need to support local providers to save £434 million over the next five years. Given this, hospitals need to ensure resources are not wasted by operating inefficiently. From administrative processes which result in patients receiving notification of appointments too late, to cancelled operations and clinicians needing to conduct multiple and duplicative tests because information sharing is not enabled, the local NHS needs to do better to ensure services work for patients, staff and taxpayers.
Local services need to accelerate their work to fix the basics in poor administration and different parts of health and social care need to work together to develop effective ways of sharing care records, to improve outcomes. This needs to be done in a secure way, so that patients feel assured that their health records are held securely by services that they trust. Work to improve IT and enable data sharing will be taken forward by the WELC IT and Technology Group.
Resources are also wasted through underutilised estates. We will work to make full use of our underutilised high quality estate so that we can dispose or redevelop poorer quality buildings. An example of this is that Barts Health are relocating services from the old London Chest hospital site into a new purpose-built development at St Bartholomew’s in order to deliver world class specialist care.
We endorse the London Health Commission’s call to reform the rules on Trust asset disposal, as this will enable receipts from local disposals to contribute both to solving our underlying financial 129
230 Final draft policy for approval challenge and would provide investment. This would, facilitate the provision of higher quality, more effective and efficient care, both in and out of hospital settings. An example of how this would help is in modernising the Whipps Cross site.
Finally, discussions have highlighted several areas where transforming care pathways may provide both quality of care and efficiency improvements. For example, on average, patients with dementia stay up to six times longer in hospital. Improvements in hospital and in out-of-hospital care settings, could enable those with dementia to receive more appropriate care in the best possible setting. Significant work has also been undertaken by local providers and commissioners to redesign pathways for patients needing neuro-rehabilitation. This means patients with these conditions experience fewer delays in receiving the care they need. Further work needs to take place over the coming months to identify all the specific pathways in which it would be valuable to work together.
We need to fix our urgent care system, ensuring patients are seen in the right care setting for their needs
Every year, thousands of patients in east London are cared for by A&E departments when they could have received more appropriate care much closer to home. We also know that local A&E services are having to cope with ever rising demand and will need to be able to respond to changes to provision elsewhere, such as the closure of King George’s A&E department in Ilford. There is therefore an urgent need to progress work which ensures more patients access care in the right setting for their needs.
Local services need to develop models of urgent care which have consistency of standards, are easy to navigate and are co-ordinated effectively between acute, 111, primary care and pharmacy services, taking into account the recommendations contained within the Sir Bruce Keogh Urgent and Emergency Care Review. We also need to build upon the work we are already undertaking to explore effective ambulatory care models that offer rapid access to patients who require diagnostics and treatment, but do not need a hospital stay.
A next step will be to conduct detailed capacity and demand analysis and review the benefits and constraints of local provision in each borough so that options for improvement can be considered.
We need a transformed workforce for 21st century care – with different skills and roles, working in different settings
Meeting the challenges of the future will require new ways of working. The London Health Commission calls for new hybrid health and social care worker roles to be explored, defined, commissioned and ultimately for staff to be trained. Ensuring patients are treated in a care setting appropriate to their need will require more clinical staff to work across organisational boundaries and staff such as care navigators to play an important part in supporting patients to experience joined-up care. In addition, if staff are to achieve the programme’s aspirations they will need to be trained to better recognise disease prevention opportunities as well as where mental health support is required by patients. This will enable the population to be healthier and ensure mental health is given parity of esteem with physical health. The programme has brought together providers and partners to form an East London Strategic Workforce Group and it is recommended that this and other emerging findings are taken forward together, through this forum.
Changes will need to be made to local services if they are to be safe and sustainable. More services need to be provided in the community, closer to home
130
231 Final draft policy for approval The programme has highlighted that change is likely to be required to emergency care co- ordination, elective surgery and outpatient provision. In outpatients, this means rapidly expanding areas of good practice, such as providing Skype and telephone consultations to patients whilst stopping some practices which add little value to patient care and inconvenience them by making them travel unnecessarily to hospital sites. In other areas, care needs to be provided close to home, where possible, and in specialist centres where appropriate. We need to learn from examples such as the arthroplasty centre at Newham General Hospital which has ensured patients needing joint replacements’ recovery phase is planned prior to their operations, allowing them to recover at home, with better support.
Further work needs to be conducted to develop options. As part of this, detailed workforce audits and capacity and demand modelling needs to be completed. However each site will need to maintain core surgical services in order to meet growing maternity and emergency demand, but there may be an opportunity to develop more world-class services through the development of centres of excellence for some specialties and improving the management of both emergency and planned care flows.
The local NHS and partners will need to work together to secure high quality and financially sustainable services in east London
One of the key findings of the Case for Change is that hospitals cannot secure high quality and financially sustainable service on their own. Clinical leaders from across primary, community and hospital services need to continue to work together with commissioners and local authority partners on our programme of reform if it is to be a success. An example of the success we can achieve when working together is Barts Health achievement of its waiting time target for A&E last year. This was the result of a huge programme of collaboration across primary care, community services, ambulance services and Barts Health sites that made a real difference to the quality of care our patients experienced.
Transforming Services Together, our Five-year Strategy and next steps
Because organisations need to work together to create change across the whole health care system, the work to redesign hospital based care will be taken forward through a Five-year Strategy programme called Transforming Services Together.
Newham, Tower Hamlets and Waltham Forest CCGs have produced a Five-year Strategy which sets out how organisations will work in partnership to:
help patients to be in control of their own health so they lead longer and healthier lives provide more co-ordinated health, social and mental health care in our communities improve hospital services and primary care services, including GPs ensure that our budget is spent in the best way to provide a more sustainable health service for the future
As described in the diagram overleaf, the findings of Transforming Services, Changing Lives will form the basis of work to improve hospital based service through the Care Delivery aspect of this programme. Transforming Services, Changing Lives findings on Workforce, IT and Technology, Estates and Finance will be taken forward through the enabling workstreams of Transforming Services Together.
131
232 Final draft policy for approval
Care Delivery workstreams
Primary Care
Integrated Care
Mental Health
+ Acute: Productivity, Service Development & Reconfiguration (TSCL)
Urgent Care
Technology for Technology
Project Management Project Organisational Development Organisational Leadership / Clinical Finance Estates Workforce Workforce IT & IT Healthcare Enabling workstreams
The next stage of our work is to understand more precisely where and how services and care models need to change for each patient group. This will then develop into more detailed proposals that can be fully evaluated to understand how these and existing plans help address the financial challenge.
Over the next few months we will continue to engage with key stakeholders, the public and patients to develop our strategies for hospital services, estates, workforce and IT and technology within the Transforming Services Together programme.
We feel strongly that this Case for Change provides the basis for higher quality, more efficient and joined up care in east London. Continuing this work will mean that the whole health and social care system will work together better to improve the health of the population and secure high quality sustainable services for staff, patients and taxpayers.
Appendices
Appendix 1: Maternity and newborn care CWG report
Appendix 2: Children and young people CWG report
Appendix 3: Long term conditions CWG report
Appendix 4: Unplanned care CWG report
Appendix 5: Planned care: elective surgery CWG report
Appendix 6: Clinical support services CWG report
132
233 Transforming Services, Changing Lives
The Case for Change: Delivering a world class healthcare service in Waltham Forest
Waltham Forest CCG governing body meeting Wednesday 26 November, 2014
234 Purpose of today To approve The Case for Change. The aim of this presentation is to support this approval process. Key milestones
21 September Public engagement closed
29 September Final CWG meeting of Phase Two 8 October (joint Clinical/Delivery Consider draft Case for Change and emerging workplan Team) 15 October (Clinical Reference Clinician feedback on and agreement of the Group) Case for Change
31 October (TSCL Programme Approve Case for Change prior to submission to Exec) CCGs for sign off During November - approval • Tower Hamlets (4/11) • Barts (5/11) • Newham (12/11) • Waltham Forest (26/11) • Redbridge (28/11) During November – presentation to • Barts (5/11) • B&D (25/11) (will note C4C) key stakeholders • ELFT (6/11) • Homerton (26/11) • NELFT (18/11)
December Publish Case for Change
235 The journey to improve services
Publish final Case for Change
Around 150 Engaged with Explore and clinicians further 3,000 agree joint developed an staff and public priorities to interim Case improve local for Change services
April - June July - Oct Dec onwards 2014
The programme aims to: • improve services and health outcomes • enable clinicians, commissioners, patients and providers to sustainably and positively plan for change together • develop a clinically-led case for change and a community for change Our initial focus is on acute trust services, but we have looked across the whole health and social care system to identify where change is needed. 236 Organisations involved
• Waltham Forest Lead • Newham • Barts Health Commissioners: • Tower Hamlets • Homerton East London clinical commissioning Acute trusts groups (CCGs)
Patient and public reference group (PPRG) Representatives from Healthwatch, acute trusts, community and mental health services and CCGs
Community and Other • NHS England mental health commissioners • Barking and services • East London Dagenham CCG Foundation Trust • Redbridge CCG • North East • Local authorities London including public Foundation Trust health 237 How we worked (governance)
• Six clinical working groups (CWGs) • A patient and public reference group • Clinical reference group (CRG) to consider overarching clinical and demographic issues • A programme executive to provide strategic direction • The programme sits alongside other CCG initiatives including integrated care, mental health and primary care transformation
Each with a strong focus on primary care, mental health and public health 238 Hospitals: Barts Health and Homerton
Homerton Whipps Cross General hospital, plus some specialist General hospital, plus some services (500 beds). Includes A&E / specialist services (589 beds). Unplanned Care Centre (124,000 Includes A&E / urgent care centre attendances per year) and maternity (102,000 attendances per year) (6,000 births per year) and maternity (5,100 births per year) London Chest Specialist teaching hospital for Mile End Hospital treatment of heart and lung Community hospital health centre conditions, plus some local providing a range of inpatient (64 services (103 beds) beds) and outpatient services.
St Bartholomew’s Newham University Hospital Specialist teaching hospital centre General hospital, plus some for cancer, cardiovascular disease, specialist services (452 beds). fertility and endocrinology, plus some Includes A&E / urgent care centre local services (250 beds) (110,000 attendances per year) and maternity (6,700 births per The Royal London year) General teaching hospital, plus some specialist services (747 beds). Includes A&E / urgent care centre (144,000 Note: attendances per year) and maternity Specialist services are for people with more (5,500 births per year) complex medical needs who need particular equipment and specially trained staff. These are not available in
every hospital (i.e. fertility or cancer treatment).239 Barts Health NHS Trust Homerton University Hospital NHS Foundation Trust Primary, community, mental health services
. 45 GP practices . 46 GP practices . The number of practices per . Community and mental . Community and borough ranges from 36 in health services provided mental health by NELFT services provided Tower Hamlets to 61 in by NELFT More than Newham, suggesting 150 opticians, 190 dental different primary care practices and models in operation with almost 350 varying degrees of single- pharmacies handed practices (6-29%)
. Different models of mental . 44 GP practices health and community . Community service provision: services provided by Homerton . acute trusts provide . . Mental health 40 GP practices some community services provided . Community and mental by ELFT health services provided services in Tower by NELFT Hamlets and City and Hackney . community trusts provide mental health . 36 GP practices . 61 GP practices and community . Community services provided . Community and mental by Barts Health health services provided services in the other . Mental health services by ELFT four CCG areas provided by ELFT NELFT: North East London Foundation Trust 240 ELFT: East London Foundation Trust How we engaged 330,000+ opportunities to • We tested our ideas and analysed engage feedback from 90 meetings and events, including focus groups for women who 2,800* people engaged have used maternity services, young 90 meetings and people and those with long term events attended conditions, and interviews with children and young people. 64 questionnaires completed • Thank you to the clinicians, members of the public, patients and stakeholders 1,300+ visitors to the website who helped us develop ideas for
change. In particular local Healthwatch, * Estimated number reached through face- to-face discussions at meetings and events, councils, clinicians and members of the questionnaires filled in, email and phone conversations patient and public reference group. 241 Engagement in Waltham Forest
• Waltham Forest CCG representatives on clinical groups:
• Dr Anwar Khan, Clinical Reference Group • Dr Tonia Myers, Children and Young People, and Maternity and Newborn Care • Dr Dinesh Kapoor, Elective Surgery, and Clinical Support Services • Dr Carolin Kumana, Maternity and Newborn Care • Dr Abdul Sheikh, Unplanned Care • Waltham Forest represented on patient and public reference group: • Healthwatch Waltham Forest • Whipps Cross Hospital patient panel • North East London Foundation Trust • Healthwatch Waltham Forest (along with Healthwatch Newham and Healthwatch Redbridge) helped to organise an event at Whipps Cross hospital. Around 100 members of the public and patients attended
242 Engagement in Waltham Forest
Other engagement activities Non-clinical engagement included, but were not limited to: • Meeting with Waltham Forest Young Advisors
Clinical engagement • Meeting with Whipps Cross Patient Panel • Meeting with Save Our NHS Waltham Forest • Experience-led commissioning mental • Meeting with London Borough of Waltham Forest health commissioning forum • Waltham Forest Local Medical Committee meeting • Waltham Forest, East London and City Maternity Quality Board • Staff briefing at Whipps Cross Hospital • Meeting with Waltham Forest CCG • Information stands at Whipps Cross Hospital member practices • Email bulletins via the Waltham Forest Health and • Meeting with maternity consultants Social Care Network and Healthwatch Waltham Forest • Barts Health clinical support services • Inner North East London Joint Overview and Scrutiny imaging board Committee • Mental Health Focus Group • Waltham Forest Health Scrutiny Committee meeting • Pharmacy Focus Group • Waltham Forest Health and Wellbeing Board • Walthamstow, Chingford and Leyton/Leytonstone GP locality • Waltham Forest Best Start in Life Board meetings • Waltham Forest CCG Governing Body meeting • Meeting with North East London • Waltham Forest CCG AGM Foundation Trust
243 What we heard The Case for Change is a good document and very clear. The diagnosis of problems The direction of the interim Case for Change is fully aligned. was welcomed, as was the process. All the Waltham Forest ideas were supported but with more emphasis Health and Wellbeing Board proposed around: • Patient experience. Respondents felt there were good/ excellent clinical services in places, but the NHS is poor at putting patients at the centre of care. If the NHS focuses on this, then everything else will fall into place • Better health and wellbeing. But
I have turned up for surgery but it people need support has been cancelled. This has • Inefficiency. Staff and patients happened before – I received a identified numerous instances where cancellation letter the day after my appointment. savings could be made Patient, Whipps Cross Hospital
244 The Case for Change
Our population
Health and A partnership wellbeing approach 1. Our community
Clinical Estates excellence PatientsPatients Integrated health Technology Our workforce and social care
Patient IT experience
Finance and Accessible efficiency services
245 1. Our community • The health of our population could be improved – Our area has a diverse population and we need to ensure we provide services that meet the needs of all residents. – Waltham Forest, Tower Hamlets and Newham cover some of the most deprived areas in England: all boroughs rank in the bottom 10% in the country • There is a growing demand for services – By 2031 the population in our three boroughs is expected to have grown by 270,000 people; the equivalent of a new London borough and the highest projected growth rate in the country. – The number of people who require more support, such as older people and those with long term conditions, will continue to rise. • Everyone has a responsibility for good health, the NHS, local councils, businesses, schools, and patients and the public.
246 Population challenges
Deprivation Diversity Areas in brown show where households are Areas in pink show where more than 42% of amongst the most deprived in England. people are from a black or minority ethnic group.
247 Population growth • The population of the three boroughs is • Current population figures, with darker set to grow by c270,000: a new London brown showing the areas with most borough by 2031 population growth.
Waltham Forest population 293,000
Newham population Tower 350,000 Hamlets population 262,000
Projections of population growth have been taken from the Greater London Authority (SHLAA- capped model 2013 release) and have been endorsed as the best available by borough public 248 health directors. Good health, excellent disease management and a speedy recovery if you become ill is everyone’s responsibility
Nurses, doctors, healthcare assistants, Advice, early diagnosis and therapists and support to self-care other staff
Local councils and public Housing, transport, health, health environment, safety, education, quality of life Schools, businesses, community, Health education, health voluntary groups promotion, support and early identification, mental health
Public Behaviour change & self- care (includes patients, parents, carers)
249 2. World class services
We have some excellent services Over 500 lives could • be saved in London but there is variation across the each year if patients admitted at region weekends had the same quality of care • Patient experience is often poor. A as patients admitted on weekdays better experience will lead to better outcomes • Services are not sufficiently NHS staff have a integrated positive attitude to children. The attitude • Some services are not accessible to young people or teenagers is often less positive. Young Adviser, Waltham Forest
250 3. Sustainable support
• There are existing and future challenges with our healthcare workforce • Financial savings could be made through better quality services, increasing productivity, improving efficiency and preventing ill health. • Our buildings and estates could be used more effectively • Embracing new technology and improving IT systems will improve patient outcomes and experience
251 How do we deliver this?
• The Transforming Services, Changing Lives programme focussed on hospital services and the impact of the wider system on it
• The CCGs have agreed a wider programme is required, looking at the whole health system, and a five year strategy has been developed
• The CCGs have agreed to take forward an overarching programme to deliver this five year strategy called Transforming Services Together
• The recommendations from Transforming Services, Changing Lives will be incorporated into the Transforming Services Together (TST) programme.
252 Care Delivery workstreams Our workstreams Primary Care Integrated Care care delivery workstreams We have created five Mental Health to ensure Transforming Services Together improves the health of our residents. + Acute Productivity & Reconfiguration (TSCL) 1. Primary care: Work with NHS England to Urgent Care ensure our GPs, pharmacists, optometrists and dentists provide co-ordinated and accessible care that better supports patients to manage their health
2. Integrated care: ‘Join-up’ health and social care Developm’nt services for the elderly, people with long-term conditions and those with mental health problems so they receive care that is co-ordinated, efficient and responsive to their needs. Project Management Project Organisational Organisational Leadership Clinical / Workforce for Technology & IT Healthcare Estates Finance 3. Mental health: Promote mental health and Enabling workstreams wellbeing , prevent residents from developing more significant problems and ensure services are of the 5. Urgent care: We will look at all settings of best quality and help people to recover. care required to provide high-quality acute care 4. Transforming services, changing lives aims to improve urgent and emergency care; maternity and newborn; surgical services; clinical support services; services for children, young people; and 253 those with long term conditions. Our five year strategy
Our five year strategy sets out how we will work in partnership to: • help patients to be in control of their own health so they lead longer and healthier lives • provide more co-ordinated health, social and mental health care in our communities • improve hospital services and primary care services, including GPs • ensure that our budget is spent in the best way to provide a more sustainable health service for the future
254 How do we resource this?
• To deliver this significant change, we will need a robust programme to manage the workload, which links closely to current CCG resources to maximise the contribution to the programme.
• The programme team for Transforming Services Together will be a mix of direct CCG employees, complemented by support from others, including the North East London Commissioning Support Unit.
• The source of funds for this programme will come from the 2% non- recurrent ‘top-slice’, which is intended to support transformational change.
255 Aspirations and proposed timeline
256 Key Messages: Outline of emerging workplan (1)
• Productivity / efficiency across system • Reducing LOS • Theatre utilisation • Effective discharge planning • Managing flows • Reduce duplication/unnecessary tests/appointments • Tackle inefficiencies and getting the basics right
5 257 Key Messages: Outline of emerging workplan (2)
• Enhance and develop • Prevention, HWBB role in tackling wider determinants of health • Use of mainstream services, e.g. school nurses • Maternity networks, improve protocols for more normal deliveries, and improve delivery of antenatal and post natal care • Integrated care, including children (new) • LTC pathway redesign – pilots – Renal, Diabetes, Hypertension etc • Outpatient model – rapid expansion and roll out • Ambulatory Care pathways development, link with social care and community services (adult and children) • Discharge planning, enhanced recovery • Emergency/Urgent Care Coordination (common protocols/pathways) • IT/sharing information • Effective and appropriate diagnostics, agreed pathway and clinical priority 5 258 Key Messages: Outline of emerging workplan (3)
• Implement agreed changes (Health4NEL) • e.g. Paediatric pathways for equal access to surgery/medical/specialist care
• Possible areas for reconfiguration • Emergency surgery and effective pathways, role out of hours • Elective surgery some consolidation • Non-acute beds
• Enablers • Workforce – recruit & retain, develop, new roles, address gaps (GPs) • Estate – whole system work • IT – get basics right, whole system work
All to be underpinned by effective modelling capacity and demand – links to both service developments and reconfiguration – impact on finance, estate 5 and workforce 259 Timeline : two-year programme
Involve/engage/co-design Involve/engage/co-design
Do now and fix basics: implement enhancements and productivity improvements
Interim Final Develop and Implement agreed changes where formal option C4C C4C sign off clinical appraisal / consultation is not required strategy
If applicable: pre-consultation Post consultation reporting option appraisal Consultation and decision-making and business case business case
260 To know more Tel: 020 3688 1540 Email: [email protected] www.transformingservices.org.uk
261
Item 5.2
Title of report The Five Year Forward View
From Jane Mehta, Director of Strategic Commissioning - WFCCG
Purpose of report This report outlines the content of the Five Year Forward View published by NHS England in October 2014. The report looks into the future of the NHS and sets out how the NHS needs to change to accommodate the challenges faced by today’s NHS including a growing population that is ageing and becoming less healthy; that long term conditions account for 70% of the health service budget and technology is transforming the ability to predict, diagnose and treat disease. The report describes a new relationship with patients and communities, new models of care, a description of how this will be achieved and some short case studies of some of the models described.
Recommendations The Governing Body is requested to note for information the summary of the key messages of the Five Year Forward View.
Impact on patients & carers The Five Year Forward View presents an argument of a more engaged relationship with patients, carers and citizens in order to promote wellbeing and prevent ill health.
Risk implications Relying on short term solutions that do not address the challenges set out in the report could lead to a widening health and wellbeing gap, a widening care and quality gap and a widening funding and efficiency gap
Financial implications Financial risks and opportunities are an inherent part of any ambitious commissioning plan. However diligent planning and the availability of adequate resources will help ensure these organisational risks/opportunities are actively managed.
262 The Five Year Forward View
Equality analysis Equality Impact Assessments will be undertaken as business cases are developed.
Other committees/groups, including the CCG Reference Group and Rapid Feedback Group The Five Year Forward View will inform the planning discussions at CCG Committees and Groups.
263
The Five Year Forward View: October 2014
264 The Five Year Forward View: October 2014
Document revision history
Date Version Revision Comment Author/Editor
17/11/14 1.0 Sharon Yepes-Mora
Document approval
Date Version Revision Role of approver Approver
Page i 265 The Five Year Forward View: October 2014
Contents
1 Introduction 1 2 The Five Year Forward View 1
2.1 Why does the NHS need to change? 1
2.2 A new relationship with patients and communities 1
2.3 New Models of Care 3
2.4 How will we get there? 4
3 Recommendation 6 Appendices 7
Appendix A The Five Year Forward View 7
Page ii 266 The Five Year Forward View: October 2014
1 Introduction
The Five Year Forward View is a report that looks into the future of the NHS that recognises that as a nation we are living longer and health issues are becoming more complex and are sometimes of our own making. The Forward View sets out how the health service needs to change to accommodate this; arguing for a more engaged relationship with patients, carers and citizens in order to promote wellbeing and prevent ill-health. It sets out a vision of a better NHS, the steps than should be taken to achieve the ambition and the actions needed from other stakeholders.
The plan was published in October 2014 and has been developed by the partner organisations that deliver and oversee health and care services, including NHS England, Public Health England, Monitor, Health Education England, the Care Quality Commission and the NHS Trust Development Authority.
The full document is attached in Appendix A.
2 The Five Year Forward View The plan sets out why the NHS needs to change and describes a new relationship with patients and communities and proposed new models of care with a description of how this will be achieved with some short case studies of some of the models described.
2.1 Why does the NHS need to change? The plan sets out the challenges faced by the NHS and argues that no change is not an option.
• There is a growing population that is ageing and becoming less healthy. • Patients’ health needs and personal preferences are changing; people wish to be more informed and involved with their own care. • Long term health conditions now take 70% of the health service budget. • Technology is transforming the ability to predict, diagnose and treat disease. • There are still unacceptable variations of care provided to patients. • The NHS could try to muddle through the next few years, relying on short term solutions, but this would lead to: o A widening health and wellbeing gap: health inequalities will widen and result in needing to spend billions of pounds on avoidable illness. o A widening care and quality gap: patients’ changing needs will go unmet, people will be harmed who should have been cured, and variations in outcomes will persist. o A widening funding and efficiency gap: resulting in worse services, fewer staff, deficits, and restrictions on new treatments.
2.2 A new relationship with patients and communities A need to get serious about prevention - the health service can and should now become a more activist agent of health-related social change; leading a range of new approaches:
• Incentivising and supporting healthier behaviour for all of major health risks (including tobacco, alcohol, junk food and excess sugar) - to actively support and reinforce comprehensive, hard-hitting and broad-based national action.
Page 1 267 The Five Year Forward View: October 2014
• Improving and supporting local democratic leadership on public health - local authorities now have a statutory responsibility for improving the health of their people. The Local Government Association also believes that local authorities should be granted enhanced powers to allow local decisions on public health policy that move faster than national law.
• Targeted prevention - the NHS has a distinct role in secondary prevention. Proactive primary care is central to this, as is the more systematic use of evidence-based intervention strategies. All organisations also need to make different investment decisions - for example, in prevention schemes rather than treatment.
• NHS support to help people get and stay in employment – using targeted health support to help keep people in work thus improving their wellbeing and preserving their livelihoods.
• Workplace health – allowing employers to provide financial support for vocational rehabilitation services without employees facing a tax bill. There would also be merit in incentivising employers in England to provide NICE recommended workplace health programmes for employees.
Empowering patients – patients, even those with long term conditions, are likely to spend less than 1% of their time in contact with health professionals. The rest of the time they, their carers and their families manage on their own. The plan states an intention to:
• Offer services that support patients and carers, and promote wellbeing and independence as key outcomes of care.
• Do more to support people to manage their own health - staying healthy, making informed choices of treatment, managing conditions and avoiding complications.
• Increase the direct control patients have over the care provided to them; giving patients choice over where and how they receive care.
• Introduce integrated personal commissioning (IPC), a new voluntary approach to blending health and social care funding for individuals with complex needs.
Engaging communities – a need to engage with communities and citizens in new ways, involving them directly in decisions about the future of health and care services. The plan commits to four actions to build on the energy and compassion that exists in communities across England:
1. Supporting carers - to find new ways to support carers, building on the new rights created by the Care Act, and especially helping the most vulnerable amongst them i.e. the approximately 225,000 young carers and the 110,000 carers over 85 years old. 2. Encouraging community volunteering - the Local Government Association has made proposals that volunteers should receive a 10% reduction in their council tax bill, worth up to £200 a year. The plan support testing approaches like that, and the NHS can go further; accrediting volunteers helping them partner with NHS staff. 3. Stronger partnerships with charitable and voluntary sector organisations - to reduce the time and complexity associated with securing local NHS funding by developing a short national alternative where grant funding processes have proved burdensome. 4. The NHS as a local employer – the plan wants to ensure that the boards and leadership of NHS organisations better reflect the diversity of the local communities they serve, and that the NHS provides supportive and non-discriminatory ladders of opportunity for all staff.
Page 2 268 The Five Year Forward View: October 2014
2.3 New Models of Care Over the next five years and beyond the NHS needs to break down the traditional divides between primary care, community services, and hospitals, as it’s becoming a barrier to the personalised and coordinated health services patients need. Health services also need to work closely with social care and mental health services as people increasingly need all three. Long term conditions are now a central task of the NHS; caring for these needs requires a partnership with patients over the long term rather than providing single, unconnected ‘episodes’ of care. As a result there is now quite wide consensus on the future direction:
• Increasingly there is a need to manage systems – networks of care – not just organisations. • Out-of-hospital care needs to become a much larger part of what the NHS does. • Services need to be integrated around the patient. • To learn much faster from the best examples, not just from within the UK but internationally. • As they are introduced there is a need to evaluate new care models to establish which produce the best experience for patients and the best value for money.
One size fits all? The plan sets out intent to support and stimulate the creation of a number of major new care models that can be deployed in different combinations locally across England. Recognising how diverse England is, the approach will be to identify the characteristics of similar health communities across England, and then work with them to consider which of the new options are viable ways forward. In all cases however one of the most important changes will be to expand and strengthen primary and ‘out of hospital’ care. The principal additional care models which will be promoted in England over the next five years are:
Multispecialty Community Providers (MCPs) – Primary Care as ‘expert generalists’ proactively targeting services at registered patients with complex ongoing needs. This could expand to include nurses, therapists and other community based professionals, and could also offer some care in fundamentally different ways. To offer this wider scope of services it will be made possible for extended group practices to form, either as federations, networks or single organisations.
Primary and Acute Care Systems (PACS) - a new variant of integrated care will allow single organisations to provide NHS list-based GP and hospital services, together with mental health and community care services.
Urgent and emergency care networks - the mounting pressures on these hospital departments means the NHS needs to move to a more sustainable model of care. Over the next five years, the NHS will do far better at organising and simplifying the system, which means:
• Helping patients get the right care, at the right time, in the right place • Developing networks of linked hospitals that ensure patients with the most serious needs get to specialist emergency centres • Ensuring that hospital patients have access to seven day services where this makes a clinical difference to outcomes. • Proper funding and integration of mental health crisis services, including liaison psychiatry. • A strengthened clinical triage and advice service that links the system together and helps patients navigate it successfully.
Page 3 269 The Five Year Forward View: October 2014
• New ways of measuring the quality of the urgent and emergency services; new funding arrangements; and new responses to the workforce requirements that will make these new networks possible.
• Viable smaller hospitals - it is right that smaller district general hospitals should not be providing complex acute services, but these local sites may, with the right commissioner and community support, help sustain local hospital services. The NHS will take three actions to support this:
1. NHS England and Monitor will consider amending the NHS payment system to support smaller providers in providing safe and efficient services 2. Examine new models of medical staffing and ways to achieving sustainable cost structures 3. Create new organisational models for smaller acute hospitals that enable them to gain the benefits of scale without necessarily having to centralise services.
• Specialised care - in some services where there is a strong relationship between the number of patients and the quality of care, derived from the greater experience these more practiced clinicians have, access to costly specialised facilities and equipment, there is a case for greater concentration of care.
• Modern maternity services - research shows that for low risk pregnancies, babies born at midwife- led units or at home did as well as babies born in obstetric units, with fewer interventions. To ensure maternity services develop in a safe, responsive and efficient manner the NHS will: • Commission a review of future models for maternity units, which will make recommendations on how best to sustain and develop maternity units. • Ensure that tariff-based NHS funding supports the choices women make, rather than constraining them. • As a result, make it easier for groups of midwives to set up their own NHS funded midwifery services.
• Enhanced health in care homes - data suggests that had more active health and rehabilitation support been available, some people aged 85+ discharged from hospital to care homes could have avoided permanent admission to those homes. Many people with dementia living in care homes are not getting their health needs regularly assessed and met; one consequence of this is avoidable admissions to hospital. Using the opportunity created by the establishment of the Better Care Fund, work with the NHS locally and the care home sector to develop new shared models of in-reach support, including medical reviews, medication reviews, and rehab services.
2.4 How will we get there? In addition to the strategies above, the following complementary approaches are needed: Diverse solutions and local leadership - NHS England intends to offer CCGs more influence over the total NHS budget for their local populations and will also work with ambitious local areas to define and champion a limited number of models of joint commissioning between the NHS and local government.
Aligned national NHS leadership - NHS England, Monitor, the NHS Trust Development Authority, the Care Quality Commission, Health Education England, NICE and Public Health England have distinctive national duties laid on them by statute. The following are examples of shared work as it affects the local NHS: • Through the programme to support the development of new local care models, as set out above. In addition to national statutory bodies, NHS England will collaborate with patient and voluntary sector organisations in developing this programme.
Page 4 270 The Five Year Forward View: October 2014
• Monitor, TDA and NHS England will work together to create greater alignment between their respective local assessment, reporting and intervention regimes for Foundation Trusts, NHS trusts, and CCGs. • Using existing flexibilities and discretion deploy national regulatory, pricing and funding regimes to support change in the interest of patients. • An intention to re-energise the National Quality Board as a forum where the key NHS oversight organisations can come together regionally and nationally to share intelligence, agree action and monitor overall assurance on quality.
Support for a modern workforce - the NHS becoming a better employer, is important to retain the right people with the right skills. There will be support for the health and wellbeing of frontline staff e.g. for employees to raise concerns; ensuring managers act on them. To address immediate skills gaps in key areas by putting in place new measures to support employers to retain and develop their existing staff, increase productivity and reduce the waste of skills and money. NHS employers will need to consider how working patterns, pay and terms and conditions can best evolve to reward high performance, support job redesign, and encourage recruitment and retention.
Exploit the information revolution - nationally there will be a focus on key systems that enable different parts of the health service to work together. To lead this sector-wide approach a National Information Board has been established, and to advance the implementation of this Five Year Forward this board will publish a set of ‘road maps’ laying out who will do what to transform digital care. Key elements will include: • Comprehensive transparency of performance data; to help health professionals see how they are performing compared to others and improve, to help patients make informed choices, and to help CCGs commission the best quality care. • An expanding set of NHS accredited health apps that patients will be able to use to organise and manage their own health and care • Fully interoperable electronic health records so that patients’ records are largely paperless. Patients will have full access to these records and will retain the right to opt out of their record being shared electronically. The NHS number, for safety and efficiency reasons, will be used in all settings, including social care. • Family doctor appointments and electronic and repeat prescribing available routinely on-line everywhere. • Bringing together hospital, GP, administrative and audit data to support quality improvement, research, and the identification of patients who most need health and social care support. • Take steps to build the capacity of all citizens to access information, and train our staff so that they are able to support those who are unable or unwilling to use new technologies.
Accelerate useful health innovation - continue to support the work of the National Institute for Health Research (NIHR) and the network of specialist clinical research facilities in the NHS and develop the active collection and use of health outcomes data, offering patients the chance to participate in research; and, working with partners, ensuring use of NHS clinical assets to support research in medicine.
Drive efficiency and productive investment - it has previously been calculated that a combination of a) growing demand, b) no further annual efficiencies, and c) flat real terms funding could, by 2020/21, produce a mismatch between resources and patient needs of nearly £30 billion a year. To sustain a comprehensive high-quality NHS, action will be needed on all three fronts: 1. Demand - this Forward View makes the case for a more activist prevention and public health agenda: greater support for patients, carers and community organisations; and new models of primary and out-of-hospital care.
Page 5 271 The Five Year Forward View: October 2014
2. Efficiency – previously estimated annual net efficiency gains of 0.8% are now seen as inadequate. A 1.5% net efficiency increase each year over the next Parliament should be obtainable if the NHS is able to accelerate some of its current efficiency programmes; but it should be recognised that some programmes that have contributed over the past five years will not be indefinitely repeatable. The ambition is for the NHS to achieve 2% net efficiency gains each year for the rest of the decade, possibly increasing to 3% over time. This would represent a strong performance compared with the NHS's own past, compared with the wider UK economy, and with other countries' health systems. 3. Funding - NHS spending has been protected over the past five years, and this has helped sustain services however, pressures are building. Depending on the combined efficiency and funding option pursued, the desired effect is to close the £30 billion gap by one third, one half, or all the way. Decisions on these options will inevitably need to be taken in the context of how the UK economy overall is performing, during the next Parliament.
3 Recommendation The Governing Body is requested to note for information the summary of the key messages of the Five Year Forward View.
Page 6 272 The Five Year Forward View: October 2014
Appendices Appendix A The Five Year Forward View
Page 7 273 FIVE YEAR FORWARD VIEW
October274 2014 CONTENTS
Foreword…..page 2
Executive summary…..page 3
Chapter One – Why will the NHS need to change?.....page 7
Chapter Two – What will the future look like? A new relationship with patients and communities…..page 10
- Getting serious about prevention…..page 10 - Empowering patients…..page 13 - Engaging communities…..page 14 - The NHS as a social movement…..page 15
Chapter Three – What will the future look like? New models of care…..page 17
- Emerging models…..page 17 - One size fits all?.....page 18 - New care models….page 20 - How we will support local co-design and implementation…..page 26
Chapter Four – How can we get there?.....page 29
- We will back diverse solutions and local leadership…..page 29 - We will create aligned national NHS leadership…..page 29 - We will support a modern workforce…..page 30 - We will exploit the information revolution…..page 32 - We will accelerate useful health innovation…..page 33 - We will drive efficiency and productive investment…..page 36
275
FOREWORD
The NHS may be the proudest achievement of our modern society.
It was founded in 1948 in place of fear - the fear that many people had of being unable to afford medical treatment for themselves and their families. And it was founded in a spirit of optimism - at a time of great uncertainty, coming shortly after the sacrifices of war.
Our nation remains unwavering in that commitment to universal healthcare, irrespective of age, health, race, social status or ability to pay. To high quality care for all.
Our values haven’t changed, but our world has. So the NHS needs to adapt to take advantage of the opportunities that science and technology offer patients, carers and those who serve them. But it also needs to evolve to meet new challenges: we live longer, with complex health issues, sometimes of our own making. One in five adults still smoke. A third of us drink too much alcohol. Just under two thirds of us are overweight or obese.
These changes mean that we need to take a longer view - a Five-Year Forward View – to consider the possible futures on offer, and the choices that we face. So this Forward View sets out how the health service needs to change, arguing for a more engaged relationship with patients, carers and citizens so that we can promote wellbeing and prevent ill-health.
It represents the shared view of the NHS’ national leadership, and reflects an emerging consensus amongst patient groups, clinicians, local communities and frontline NHS leaders. It sets out a vision of a better NHS, the steps we should now take to get us there, and the actions we need from others.
2
276 EXECUTIVE SUMMARY
1. The NHS has dramatically improved over the past fifteen years. Cancer and cardiac outcomes are better; waits are shorter; patient satisfaction much higher. Progress has continued even during global recession and austerity thanks to protected funding and the commitment of NHS staff. But quality of care can be variable, preventable illness is widespread, health inequalities deep-rooted. Our patients’ needs are changing, new treatment options are emerging, and we face particular challenges in areas such as mental health, cancer and support for frail older patients. Service pressures are building.
2. Fortunately there is now quite broad consensus on what a better future should be. This ‘Forward View’ sets out a clear direction for the NHS – showing why change is needed and what it will look like. Some of what is needed can be brought about by the NHS itself. Other actions require new partnerships with local communities, local authorities and employers. Some critical decisions – for example on investment, on various public health measures, and on local service changes – will need explicit support from the next government.
3. The first argument we make in this Forward View is that the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health. Twelve years ago Derek Wanless’ health review warned that unless the country took prevention seriously we would be faced with a sharply rising burden of avoidable illness. That warning has not been heeded - and the NHS is on the hook for the consequences.
4. The NHS will therefore now back hard-hitting national action on obesity, smoking, alcohol and other major health risks. We will help develop and support new workplace incentives to promote employee health and cut sickness-related unemployment. And we will advocate for stronger public health-related powers for local government and elected mayors.
5. Second, when people do need health services, patients will gain far greater control of their own care – including the option of shared budgets combining health and social care. The 1.4 million full time unpaid carers in England will get new support, and the NHS will become a better partner with voluntary organisations and local communities.
6. Third, the NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally but with some services in specialist centres, organised to support people with multiple health conditions, not just single diseases.
277
7. England is too diverse for a ‘one size fits all’ care model to apply everywhere. But nor is the answer simply to let ‘a thousand flowers bloom’. Different local health communities will instead be supported by the NHS’ national leadership to choose from amongst a small number of radical new care delivery options, and then given the resources and support to implement them where that makes sense.
8. One new option will permit groups of GPs to combine with nurses, other community health services, hospital specialists and perhaps mental health and social care to create integrated out-of-hospital care - the Multispecialty Community Provider. Early versions of these models are emerging in different parts of the country, but they generally do not yet employ hospital consultants, have admitting rights to hospital beds, run community hospitals or take delegated control of the NHS budget.
9. A further new option will be the integrated hospital and primary care provider - Primary and Acute Care Systems - combining for the first time general practice and hospital services, similar to the Accountable Care Organisations now developing in other countries too.
10. Across the NHS, urgent and emergency care services will be redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services. Smaller hospitals will have new options to help them remain viable, including forming partnerships with other hospitals further afield, and partnering with specialist hospitals to provide more local services. Midwives will have new options to take charge of the maternity services they offer. The NHS will provide more support for frail older people living in care homes.
11. The foundation of NHS care will remain list-based primary care. Given the pressures they are under, we need a ‘new deal’ for GPs. Over the next five years the NHS will invest more in primary care, while stabilising core funding for general practice nationally over the next two years. GP-led Clinical Commissioning Groups will have the option of more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services. The number of GPs in training needs to be increased as fast as possible, with new options to encourage retention.
12. In order to support these changes, the national leadership of the NHS will need to act coherently together, and provide meaningful local flexibility in the way payment rules, regulatory requirements and other mechanisms are applied. We will back diverse solutions and local leadership, in place of the distraction of further national structural reorganisation. We will invest in new options for our workforce, and raise our game on health technology - radically improving patients’ experience of interacting with the NHS. We will
4
278
improve the NHS’ ability to undertake research and apply innovation – including by developing new ‘test bed’ sites for worldwide innovators, and new ‘green field’ sites where completely new NHS services will be designed from scratch.
13. In order to provide the comprehensive and high quality care the people of England clearly want, Monitor, NHS England and independent analysts have previously calculated that a combination of growing demand if met by no further annual efficiencies and flat real terms funding would produce a mismatch between resources and patient needs of nearly £30 billion a year by 2020/21. So to sustain a comprehensive high-quality NHS, action will be needed on all three fronts – demand, efficiency and funding. Less impact on any one of them will require compensating action on the other two.
14. The NHS’ long run performance has been efficiency of 0.8% annually, but nearer to 1.5%-2% in recent years. For the NHS repeatedly to achieve an extra 2% net efficiency/demand saving across its whole funding base each year for the rest of the decade would represent a strong performance - compared with the NHS' own past, compared with the wider UK economy, and with other countries' health systems. We believe it is possible – perhaps rising to as high as 3% by the end of the period - provided we take action on prevention, invest in new care models, sustain social care services, and over time see a bigger share of the efficiency coming from wider system improvements.
15. On funding scenarios, flat real terms NHS spending overall would represent a continuation of current budget protection. Flat real terms NHS spending per person would take account of population growth. Flat NHS spending as a share of GDP would differ from the long term trend in which health spending in industrialised countries tends to rise as a share of national income.
16. Depending on the combined efficiency and funding option pursued, the effect is to close the £30 billion gap by one third, one half, or all the way. Delivering on the transformational changes set out in this Forward View and the resulting annual efficiencies could - if matched by staged funding increases as the economy allows - close the £30 billion gap by 2020/21. Decisions on these options will be for the next Parliament and government, and will need to be updated and adjusted over the course of the five year period. However nothing in the analysis above suggests that continuing with a comprehensive tax- funded NHS is intrinsically un-doable. Instead it suggests that there are viable options for sustaining and improving the NHS over the next five years, provided that the NHS does its part, allied with the support of government, and of our other partners, both national and local.
5
279
CHAPTER ONE Why does the NHS need to change?
Over the past fifteen years the NHS has dramatically improved. Cancer survival is its highest ever. Early deaths from heart disease are down by over 40%. Avoidable deaths overall are down by 20%. About 160,000 more nurses, doctors and other clinicians are treating millions more patients so that most long waits for operations have been slashed – down from 18 months to 18 weeks. Mixed sex wards and shabby hospital buildings have been tackled. Public satisfaction with the NHS has nearly doubled.
Over the past five years - despite global recession and austerity - the NHS has generally been successful in responding to a growing population, an ageing population, and a sicker population, as well as new drugs and treatments and cuts in local councils’ social care. Protected NHS funding has helped, as has the shared commitment and dedication of health service staff – on one measure the health service has become £20 billion more efficient.
No health system anywhere in the world in recent times has managed five years of little or no real growth without either increasing charges, cutting services or cutting staff. The NHS has been a remarkable exception. What’s more, transparency about quality has helped care improve, and new research programmes like the 100,000 genomes initiative are putting this country at the forefront of global health research. The Commonwealth Fund has just ranked us the highest performing health system of 11 industrialised countries.
Of course the NHS is far from perfect. Some of the fundamental challenges facing us are common to all industrialised countries’ health systems:
• Changes in patients’ health needs and personal preferences. Long term health conditions - rather than illnesses susceptible to a one-off cure - now take 70% of the health service budget. At the same time many (but not all) people wish to be more informed and involved with their own care, challenging the traditional divide between patients and professionals, and offering opportunities for better health through increased prevention and supported self-care.
• Changes in treatments, technologies and care delivery. Technology is transforming our ability to predict, diagnose and treat disease. New treatments are coming on stream. And we know, both from examples within the NHS and internationally, that there are better ways of organising care, breaking out of the artificial boundaries between hospitals and primary care, between health and social care, between generalists and specialists—all of which get in the way of care that is genuinely coordinated around what people need and want. 6
280
• Changes in health services funding growth. Given the after-effects of the global recession, most western countries will continue to experience budget pressures over the next few years, and it is implausible to think that over this period NHS spending growth could return to the 6%-7% real annual increases seen in the first decade of this century.
Some of the improvements we need over the next five years are more specific to England. In mental health and learning disability services. In faster diagnosis and more uniform treatment for cancer. In readily accessible GP services. In prevention and integrated health and social care. There are still unacceptable variations of care provided to patients, which can have devastating effects on individuals and their families, as the inexcusable events at Mid-Staffordshire and Winterbourne View laid bare.
One possible response to these challenges would be to attempt to muddle through the next few years, relying on short term expedients to preserve services and standards. Our view is that this is not a sustainable strategy because it would over time inevitably lead to three widening gaps:
The health and wellbeing gap: if the nation fails to get serious about prevention then recent progress in healthy life expectancies will stall, health inequalities will widen, and our ability to fund beneficial new treatments will be crowded-out by the need to spend billions of pounds on wholly avoidable illness.
The care and quality gap: unless we reshape care delivery, harness technology, and drive down variations in quality and safety of care, then patients’ changing needs will go unmet, people will be harmed who should have been cured, and unacceptable variations in outcomes will persist.
The funding and efficiency gap: if we fail to match reasonable funding levels with wide-ranging and sometimes controversial system efficiencies, the result will be some combination of worse services, fewer staff, deficits, and restrictions on new treatments.
We believe none of these three gaps is inevitable. A better future is possible – and with the right changes, right partnerships, and right investments we know how to get there.
That’s because there is broad consensus on what that future needs to be. It is a future that empowers patients to take much more control over their own care and treatment. It is a future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals, between physical and mental health, between health and social care, between prevention and treatment. One that no longer sees expertise locked into often out-dated buildings, with services fragmented, patients 7
281
having to visit multiple professionals for multiple appointments, endlessly repeating their details because they use separate paper records. One organised to support people with multiple health conditions, not just single diseases. A future that sees far more care delivered locally but with some services in specialist centres where that clearly produces better results. One that recognises that we cannot deliver the necessary change without investing in our current and future workforce.
The rest of this Forward View sets out what that future will look like, and how together we can bring it about. Chapter two – the next chapter – outlines some of the action needed to tackle the health and wellbeing gap. Chapter three sets out radical changes to tackle the care and quality gap. Chapter four focuses on options for meeting the funding and efficiency challenge.
BOX 1: FIVE YEAR AMBITIONS ON QUALITY
The definition of quality in health care, enshrined in law, includes three key aspects: patient safety, clinical effectiveness and patient experience. A high quality health service exhibits all three. However, achieving all three ultimately happens when a caring culture, professional commitment and strong leadership are combined to serve patients, which is why the Care Quality Commission is inspecting against these elements of quality too.
We do not always achieve these standards. For example, there is variation depending on when patients are treated: mortality rates are 11% higher for patients admitted on Saturdays and 16% higher on Sundays compared to a Wednesday. And there is variation in outcomes; for instance, up to 30% variation between CCGs in the health related quality of life for people with more than one long term condition.
We have a double opportunity: to narrow the gap between the best and the worst, whilst raising the bar higher for everyone. To reduce variations in where patients receive care, we will measure and publish meaningful and comparable measurements for all major pathways of care for every provider – including community, mental and primary care – by the end of the next Parliament. We will continue to redesign the payment system so that there are rewards for improvements in quality. We will invest in leadership by reviewing and refocusing the work of the NHS Leadership Academy and NHS Improving Quality. To reduce variations in when patients receive care, we will develop a framework for how seven day services can be implemented affordably and sustainably, recognising that different solutions will be needed in different localities. As national bodies we can do more by measuring what matters, requiring comprehensive transparency of performance data and ensuring this data increasingly informs payment mechanisms and commissioning decisions.
8
282
CHAPTER TWO What will the future look like? A new relationship with patients and communities
One of the great strengths of this country is that we have an NHS that - at its best - is ‘of the people, by the people and for the people’.
Yet sometimes the health service has been prone to operating a ‘factory’ model of care and repair, with limited engagement with the wider community, a short-sighted approach to partnerships, and under- developed advocacy and action on the broader influencers of health and wellbeing.
As a result we have not fully harnessed the renewable energy represented by patients and communities, or the potential positive health impacts of employers and national and local governments.
Getting serious about prevention
The future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health. Twelve years ago, Derek Wanless’ health review warned that unless the country took prevention seriously we would be faced with a sharply rising burden of avoidable illness. That warning has not been heeded - and the NHS is on the hook for the consequences.
Rather than the ‘fully engaged scenario’ that Wanless spoke of, one in five adults still smoke. A third of people drink too much alcohol. A third of men and half of women don’t get enough exercise. Almost two thirds of adults are overweight or obese. These patterns are influenced by, and in turn reinforce, deep health inequalities which can cascade down the generations. For example, smoking rates during pregnancy range from 2% in west London to 28% in Blackpool.
Even more shockingly, the number of obese children doubles while children are at primary school. Fewer than one-in-ten children are obese when they enter reception class. By the time they’re in Year Six, nearly one-in-five are then obese.
And as the ‘stock’ of population health risk gets worse, the ‘flow’ of costly NHS treatments increases as a consequence. To take just one example – Diabetes UK estimate that the NHS is already spending about £10 billion a year on diabetes. Almost three million people in England are already living with diabetes and another seven million people are at risk of becoming diabetic. Put bluntly, as the nation’s waistline keeps piling on
9
283
the pounds, we’re piling on billions of pounds in future taxes just to pay for preventable illnesses.
We do not have to accept this rising burden of ill health driven by our lifestyles, patterned by deprivation and other social and economic influences. Public Health England’s new strategy sets out priorities for tackling obesity, smoking and harmful drinking; ensuring that children get the best start in life; and that we reduce the risk of dementia through tackling lifestyle risks, amongst other national health goals.
We support these priorities and will work to deliver them. While the health service certainly can’t do everything that’s needed by itself, it can and should now become a more activist agent of health-related social change. That’s why we will lead where possible, or advocate when appropriate, a range of new approaches to improving health and wellbeing.
Incentivising and supporting healthier behaviour. England has made significant strides in reducing smoking, but it still remains our number one killer. More than half of the inequality in life expectancy between social classes is now linked to higher smoking rates amongst poorer people. There are now over 3,000 alcohol-related admissions to A&E every day. Our young people have the highest consumption of sugary soft drinks in Europe. So for all of these major health risks – including tobacco, alcohol, junk food and excess sugar - we will actively support comprehensive, hard-hitting and broad-based national action to include clear information and labelling, targeted personal support and wider changes to distribution, marketing, pricing, and product formulation. We will also use the substantial combined purchasing power of the NHS to reinforce these measures.
Local democratic leadership on public health. Local authorities now have a statutory responsibility for improving the health of their people, and councils and elected mayors can make an important impact. For example, Barking and Dagenham are seeking to limit new junk food outlets near schools. Ipswich Council, working with Suffolk Constabulary, is taking action on alcohol. Other councils are now following suit. The mayors of Liverpool and London have established wide-ranging health commissions to mobilise action for their residents. Local authorities in greater Manchester are increasingly acting together to drive health and wellbeing. Through local Health and Wellbeing Boards, the NHS will play its part in these initiatives. However, we agree with the Local Government Association that English mayors and local authorities should also be granted enhanced powers to allow local democratic decisions on public health policy that go further and faster than prevailing national law – on alcohol, fast food, tobacco and other issues that affect physical and mental health.
10
284
Targeted prevention. While local authorities now have responsibility for many broad based public health programmes, the NHS has a distinct role in secondary prevention. Proactive primary care is central to this, as is the more systematic use of evidence-based intervention strategies. We also need to make different investment decisions - for example, it makes little sense that the NHS is now spending more on bariatric surgery for obesity than on a national roll-out of intensive lifestyle intervention programmes that were first shown to cut obesity and prevent diabetes over a decade ago. Our ambition is to change this over the next five years so that we become the first country to implement at scale a national evidence-based diabetes prevention programme modelled on proven UK and international models, and linked where appropriate to the new Health Check. NHS England and Public Health England will establish a preventative services programme that will then expand evidence-based action to other conditions.
NHS support to help people get and stay in employment. Sickness absence- related costs to employers and taxpayers have been estimated at £22 billion a year, and over 300,000 people each year take up health-related benefits. In doing so, individuals collectively miss out on £4 billion a year of lost earnings. Yet there is emerging evidence that well targeted health support can help keep people in work thus improving their wellbeing and preserving their livelihoods. Mental health problems now account for more than twice the number of Employment and Support Allowance and Incapacity Benefit claims than do musculoskeletal complaints (for example, bad backs). Furthermore, the employment rate of people with severe and enduring mental health problems is the lowest of all disability groups at just 7%. A new government-backed Fit for Work scheme starts in 2015. Over and above that, during the next Parliament we will seek to test a win-win opportunity of improving access to NHS services for at-risk individuals while saving ‘downstream’ costs at the Department for Work and Pensions, if money can be reinvested across programmes.
Workplace health. One of the advantages of a tax-funded NHS is that - unlike in a number of continental European countries - employers here do not pay directly for their employees’ health care. But British employers do pay national insurance contributions which help fund the NHS, and a healthier workforce will reduce demand and lower long term costs. The government has partially implemented the recommendations in the independent review by Dame Carol Black and David Frost, which allow employers to provide financial support for vocational rehabilitation services without employees facing a tax bill. There would be merit in extending incentives for employers in England who provide effective NICE recommended workplace health programmes for employees. We will also establish with NHS Employers new incentives to ensure the NHS as an employer sets a national example in the support it offers its own 1.3 million staff to stay healthy, and serve as “health ambassadors” in their local communities.
11
285
BOX 2.1: A HEALTHIER NHS WORKPLACE
While three quarters of NHS trusts say they offer staff help to quit smoking, only about a third offer them support in keeping to a healthy weight. Three quarters of hospitals do not offer healthy food to staff working night shifts. It has previously been estimated the NHS could reduce its overall sickness rate by a third – the equivalent of adding almost 15,000 staff and 3.3 million working days at a cost saving of £550m. So among other initiatives we will: ● Cut access to unhealthy products on NHS premises, implementing food standards, and providing healthy options for night staff. ● Measure staff health and wellbeing, and introduce voluntary work-based weight watching and health schemes which international studies have shown achieve sustainable weight loss in more than a third of those who take part. ● Support “active travel” schemes for staff and visitors. ● Promote the Workplace Wellbeing Charter, the Global Corporate Challenge and the TUC’s Better Health and Work initiative, and ensure NICE guidance on promoting healthy workplaces is implemented, particularly for mental health. ● Review with the Faculty of Occupational Medicine the strengthening of occupational health.
Empowering patients
Even people with long term conditions, who tend to be heavy users of the health service, are likely to spend less than 1% of their time in contact with health professionals. The rest of the time they, their carers and their families manage on their own. As the patients’ organisation National Voices puts it: personalised care will only happen when statutory services recognise that patients’ own life goals are what count; that services need to support families, carers and communities; that promoting wellbeing and independence need to be the key outcomes of care; and that patients, their families and carers are often ‘experts by experience’.
As a first step towards this ambition we will improve the information to which people have access—not only clinical advice, but also information about their condition and history. The digital and technology strategies we set out in chapter four will help, and within five years, all citizens will be able to access their medical and care records (including in social care contexts) and share them with carers or others they choose.
Second, we will do more to support people to manage their own health – staying healthy, making informed choices of treatment, managing conditions and avoiding complications. With the help of voluntary sector partners, we will invest significantly in evidence-based approaches such as group-based education for people with specific conditions and self- management educational courses, as well as encouraging independent peer-to-peer communities to emerge.
A third step is to increase the direct control patients have over the care that is provided to them. We will make good on the NHS’ longstanding 12
286
promise to give patients choice over where and how they receive care. Only half of patients say they were offered a choice of hospitals for their care, and only half of patients say they are as involved as they wish to be in decisions about their care and treatment. We will also introduce integrated personal commissioning (IPC), a new voluntary approach to blending health and social care funding for individuals with complex needs. As well as care plans and voluntary sector advocacy and support, IPC will provide an integrated, “year of care” budget that will be managed by people themselves or on their behalf by councils, the NHS or a voluntary organisation.
Engaging communities
More broadly, we need to engage with communities and citizens in new ways, involving them directly in decisions about the future of health and care services. Programmes like NHS Citizen point the way, but we also commit to four further actions to build on the energy and compassion that exists in communities across England. These are better support for carers; creating new options for health-related volunteering; designing easier ways for voluntary organisations to work alongside the NHS; and using the role of the NHS as an employer to achieve wider health goals.
Supporting carers. Two thirds of patients admitted to hospital are over 65, and more than a quarter of hospital inpatients have dementia. The five and a half million carers in England make a critical and underappreciated contribution not only to loved ones, neighbours and friends, but to the very sustainability of the NHS itself. We will find new ways to support carers, building on the new rights created by the Care Act, and especially helping the most vulnerable amongst them – the approximately 225,000 young carers and the 110,000 carers who are themselves aged over 85. This will include working with voluntary organisations and GP practices to identify them and provide better support. For NHS staff, we will look to introduce flexible working arrangements for those with major unpaid caring responsibilities.
Encouraging community volunteering. Volunteers are crucial in both health and social care. Three million volunteers already make a critical contribution to the provision of health and social care in England; for example, the Health Champions programme of trained volunteers that work across the NHS to improve its reach and effectiveness. The Local Government Association has made proposals that volunteers, including those who help care for the elderly, should receive a 10% reduction in their council tax bill, worth up to £200 a year. We support testing approaches like that, which could be extended to those who volunteer in hospitals and other parts of the NHS. The NHS can go further, accrediting volunteers and devising ways to help them become part of the extended NHS family – not as substitutes for but as partners with our skilled employed staff. For example, more than 1,000 “community first responders” have been recruited by Yorkshire Ambulance in more rural 13
287
areas and trained in basic life support. New roles which have been proposed could include family and carer liaison, educating people in the management of long-term conditions and helping with vaccination programmes. We also intend to work with carers organisations to support new volunteer programmes that could provide emergency help when carers themselves face a crisis of some kind, as well as better matching volunteers to the roles where they can add most value.
Stronger partnerships with charitable and voluntary sector organisations. When funding is tight, NHS, local authority and central government support for charities and voluntary organisations is put under pressure. However these voluntary organisations often have an impact well beyond what statutory services alone can achieve. Too often the NHS conflates the voluntary sector with the idea of volunteering, whereas these organisations provide a rich range of activities, including information, advice, advocacy and they deliver vital services with paid expert staff. Often they are better able to reach underserved groups, and are a source of advice for commissioners on particular needs. So in addition to other steps the NHS will take, we will seek to reduce the time and complexity associated with securing local NHS funding by developing a short national alternative to the standard NHS contract where grant funding may be more appropriate than burdensome contracts, and by encouraging funders to commit to multiyear funding wherever possible.
The NHS as a local employer. The NHS is committed to making substantial progress in ensuring that the boards and leadership of NHS organisations better reflect the diversity of the local communities they serve, and that the NHS provides supportive and non-discriminatory ladders of opportunity for all its staff, including those from black and minority ethnic backgrounds. NHS employers will be expected to lead the way as progressive employers, including for example by signing up to efforts such as Time to Change which challenge mental health stigma and discrimination. NHS employers also have the opportunity to be more creative in offering supported job opportunities to ‘experts by experience’ such as people with learning disabilities who can help drive the kind of change in culture and services that the Winterbourne View scandal so graphically demonstrated is needed.
The NHS as a social movement
None of these initiatives and commitments by themselves will be the difference between success and failure over the next five years. But collectively and cumulatively they and others like them will help shift power to patients and citizens, strengthen communities, improve health and wellbeing, and—as a by-product—help moderate rising demands on the NHS.
So rather than being seen as the ‘nice to haves’ and the ‘discretionary extras’, our conviction is that these sort of partnerships and initiatives are 14
288
in fact precisely the sort of ‘slow burn, high impact’ actions that are now essential.
They in turn need to be matched by equally radical action to transform the way NHS care is provided. That is the subject of the next chapter.
BOX 2.2: SUPPORT FOR PEOPLE WITH DEMENTIA
About 700,000 people in England are estimated to have dementia, many undiagnosed. Perhaps one in three people aged over 65 will develop dementia before they die. Almost 500,000 unpaid carers look after people living with dementia. The NHS is making a national effort to increase the proportion of people with dementia who are able to get a formal diagnosis from under half, to two thirds of people affected or more. Early diagnosis can prevent crises, while treatments are available that may slow progression of the disease.
For those that are diagnosed with dementia, the NHS’ ambition over the next five years is to offer a consistent standard of support for patients newly diagnosed with dementia, supported by named clinicians or advisors, with proper care plans developed in partnership with patients and families; and the option of personal budgets, so that resources can be used in a way that works best for individual patients. Looking further ahead, the government has committed new funding to promote dementia research and treatment.
But the dementia challenge calls for a broader coalition, drawing together statutory services, communities and businesses. For example, Dementia Friendly Communities – currently being developed by the Alzheimer’s Society – illustrate how, with support, people with dementia can continue to participate in the life of their community. These initiatives will have our full support—as will local dementia champions, participating businesses and other organisations.
15
289
CHAPTER THREE What will the future look like? New models of care
The traditional divide between primary care, community services, and hospitals - largely unaltered since the birth of the NHS - is increasingly a barrier to the personalised and coordinated health services patients need. And just as GPs and hospitals tend to be rigidly demarcated, so too are social care and mental health services even though people increasingly need all three.
Over the next five years and beyond the NHS will increasingly need to dissolve these traditional boundaries. Long term conditions are now a central task of the NHS; caring for these needs requires a partnership with patients over the long term rather than providing single, unconnected ‘episodes’ of care. As a result there is now quite wide consensus on the direction we will be taking.
• Increasingly we need to manage systems – networks of care – not just organisations. • Out-of-hospital care needs to become a much larger part of what the NHS does. • Services need to be integrated around the patient. For example a patient with cancer needs their mental health and social care coordinated around them. Patients with mental illness need their physical health addressed at the same time. • We should learn much faster from the best examples, not just from within the UK but internationally. • And as we introduce them, we need to evaluate new care models to establish which produce the best experience for patients and the best value for money.
Emerging models
In recent years parts of the NHS have begun doing elements of this. The strategic plans developed by local areas show that in some places the future is already emerging. For example:
In Kent, 20 GPs and almost 150 staff operate from three modern sites providing many of the tests, investigations, minor injuries and minor surgery usually provided in hospital. It shows what can be done when general practice operates at scale. Better results, better care, a better experience for patients and significant savings.
In Airedale, nursing and residential homes are linked by secure video to the hospital allowing consultations with nurses and consultants both in 16
290
and out of normal hours - for everything from cuts and bumps to diabetes management to the onset of confusion. Emergency admissions from these homes have been reduced by 35% and A&E attendances by 53%. Residents rate the service highly.
In Cornwall, trained volunteers and health and social care professionals work side-by-side to support patients with long term conditions to meet their own health and life goals.
In Rotherham, GPs and community matrons work with advisors who know what voluntary services are available for patients with long term conditions. This “social prescribing service” has cut the need for visits to accident and emergency, out-patient appointments and hospital admissions.
In London, integrated care pioneers that combine NHS, GP and social care services have improved services for patients, with fewer people moving permanently into nursing care homes. They have also shown early promise in reducing emergency admissions. Greenwich has saved nearly £1m for the local authority and over 5% of community health expenditure.
All of these approaches seem to improve the quality of care and patients’ experience. They also deliver better value for money; some may even cut costs. They are pieces of the jigsaw that will make up a better NHS. But there are too few of them, and they are too isolated. Nowhere do they provide the full picture of a 21st century NHS that has yet to emerge. Together they describe the way the NHS of the future will look.
One size fits all?
So to meet the changing needs of patients, to capitalise on the opportunities presented by new technologies and treatments, and to unleash system efficiencies more widely, we intend to support and stimulate the creation of a number of major new care models that can be deployed in different combinations locally across England.
However England is too diverse – both in its population and its current health services – to pretend that a single new model of care should apply everywhere. Times have changed since the last such major blueprint, the 1962 Hospital Plan for England and Wales. What’s right for Cumbria won’t be right for Coventry; what makes sense in Manchester and in Winchester will be different.
But that doesn’t mean there are an infinite number of new care models. While the answer is not one-size-fits-all, nor is it simply to let ‘a thousand flowers bloom’. Cumbria and Devon and Northumberland have quite a lot in common in designing their NHS of the future. So do the hospitals on the
17
291
outer ring around Manchester and the outer ring around London. So do many other parts of the country.
That’s why our approach will be to identify the characteristics of similar health communities across England, and then jointly work with them to consider which of the new options signalled by this Forward View constitute viable ways forward for their local health and care services over the next five years and beyond.
In all cases however one of the most important changes will be to expand and strengthen primary and ‘out of hospital’ care. Given the pressures that GPs are under, this is dependent on several immediate steps to stabilise general practice – see Box 3.1.
BOX 3.1: A new deal for primary care
General practice, with its registered list and everyone having access to a family doctor, is one of the great strengths of the NHS, but it is under severe strain. Even as demand is rising, the number of people choosing to become a GP is not keeping pace with the growth in funded training posts - in part because primary care services have been under-resourced compared to hospitals. So over the next five years we will invest more in primary care. Steps we will take include:
• Stabilise core funding for general practice nationally over the next two years while an independent review is undertaken of how resources are fairly made available to primary care in different areas. • Give GP-led Clinical Commissioning Groups (CCGs) more influence over the wider NHS budget, enabling a shift in investment from acute to primary and community services. • Provide new funding through schemes such as the Challenge Fund to support new ways of working and improved access to services. • Expand as fast as possible the number of GPs in training while training more community nurses and other primary care staff. Increase investment in new roles, and in returner and retention schemes and ensure that current rules are not inflexibly putting off potential returners. • Expand funding to upgrade primary care infrastructure and scope of services. • Work with CCGs and others to design new incentives to encourage new GPs and practices to provide care in under-doctored areas to tackle health inequalities. • Build the public’s understanding that pharmacies and on-line resources can help them deal with coughs, colds and other minor ailments without the need for a GP appointment or A&E visit.
18
292
Here we set out details of the principal additional care models over and above the status quo which we will be promoting in England over the next five years.
New care model – Multispecialty Community Providers (MCPs)
Smaller independent GP practices will continue in their current form where patients and GPs want that. However, as the Royal College of General Practitioners has pointed out, in many areas primary care is entering the next stage of its evolution. As GP practices are increasingly employing salaried and sessional doctors, and as women now comprise half of GPs, the traditional model has been evolving.
Primary care of the future will build on the traditional strengths of ‘expert generalists’, proactively targeting services at registered patients with complex ongoing needs such as the frail elderly or those with chronic conditions, and working much more intensively with these patients. Future models will expand the leadership of primary care to include nurses, therapists and other community based professionals. It could also offer some care in fundamentally different ways, making fuller use of digital technologies, new skills and roles, and offering greater convenience for patients.
To offer this wider scope of services, and enable new ways of delivering care, we will make it possible for extended group practices to form – either as federations, networks or single organisations.
These Multispecialty Community Providers (MCPs) would become the focal point for a far wider range of care needed by their registered patients.
• As larger group practices they could in future begin employing consultants or take them on as partners, bringing in senior nurses, consultant physicians, geriatricians, paediatricians and psychiatrists to work alongside community nurses, therapists, pharmacists, psychologists, social workers, and other staff.
• These practices would shift the majority of outpatient consultations and ambulatory care out of hospital settings.
• They could take over the running of local community hospitals which could substantially expand their diagnostic services as well as other services such as dialysis and chemotherapy.
• GPs and specialists in the group could be credentialed in some cases to directly admit their patients into acute hospitals, with out-of-hours
19
293
inpatient care being supervised by a new cadre of resident ‘hospitalists’ – something that already happens in other countries.
• They could in time take on delegated responsibility for managing the health service budget for their registered patients. Where funding is pooled with local authorities, a combined health and social care budget could be delegated to Multispecialty Community Providers.
• These new models would also draw on the ‘renewable energy’ of carers, volunteers and patients themselves, accessing hard-to-reach groups and taking new approaches to changing health behaviours.
There are already a number of practices embarking on this journey, including high profile examples in the West Midlands, London and elsewhere. For example, in Birmingham, one partnership has brought together 10 practices employing 250 staff to serve about 65,000 patients on 13 sites. It will shortly have three local hubs with specialised GPs that will link in community and social care services while providing central out-of-hours services using new technology.
To help others who want to evolve in this way, and to identify the most promising models that can be spread elsewhere, we will work with emerging practice groups to address barriers to change, service models, access to funding, optimal use of technology, workforce and infrastructure. As with the other models discussed in this section, we will also test these models with patient groups and our voluntary sector partners.
New care model – Primary and Acute Care Systems (PACS)
A range of contracting and organisational forms are now being used to better integrate care, including lead/prime providers and joint ventures.
We will now permit a new variant of integrated care in some parts of England by allowing single organisations to provide NHS list-based GP and hospital services, together with mental health and community care services.
The leadership to bring about these ‘vertically’ integrated Primary and Acute Care Systems (PACS) may be generated from different places in different local health economies.
• In some circumstances – such as in deprived urban communities where local general practice is under strain and GP recruitment is proving hard – hospitals will be permitted to open their own GP surgeries with registered lists. This would allow the accumulated surpluses and investment powers of NHS Foundation Trusts to kick- start the expansion of new style primary care in areas with high health inequalities. Safeguards will be needed to ensure that they do 20
294
this in ways that reinforce out-of-hospital care, rather than general practice simply becoming a feeder for hospitals still providing care in the traditional ways.
• In other circumstances, the next stage in the development of a mature Multispecialty Community Provider (see section above) could be that it takes over the running of its main district general hospital.
• At their most radical, PACS would take accountability for the whole health needs of a registered list of patients, under a delegated capitated budget - similar to the Accountable Care Organisations that are emerging in Spain, the United States, Singapore, and a number of other countries.
PACS models are complex. They take time and technical expertise to implement. As with any model there are also potential unintended side effects that need to be managed. We will work with a small number of areas to test these approaches with the aim of developing prototypes that work, before promoting the most promising models for adoption by the wider NHS.
New care model - urgent and emergency care networks
The care that people receive in England’s Emergency Departments is, and will remain, one of the yardsticks by which the NHS as a whole will be judged. Although both quality and access have improved markedly over the years, the mounting pressures on these hospital departments illustrate the need to transition to a more sustainable model of care.
More and more people are using A&E – with 22 million visits a year. Compared to five years ago, the NHS in England handles around 3,500 extra attendances every single day, and in many places, A&E is running at full stretch. However, the 185 hospital emergency departments in England are only a part of the urgent and emergency care system. The NHS responds to more than 100 million urgent calls or visits every year.
Over the next five years, the NHS will do far better at organising and simplifying the system. This will mean:
• Helping patients get the right care, at the right time, in the right place, making more appropriate use of primary care, community mental health teams, ambulance services and community pharmacies, as well as the 379 urgent care centres throughout the country. This will partly be achieved by evening and weekend access to GPs or nurses working from community bases equipped to provide a much greater range of tests and treatments; ambulance services empowered to make more decisions, treating patients and making referrals in a more flexible way; and far greater use of pharmacists.
21
295
• Developing networks of linked hospitals that ensure patients with the most serious needs get to specialist emergency centres - drawing on the success of major trauma centres, which have saved 30% more of the lives of the worst injured.
• Ensuring that hospital patients have access to seven day services where this makes a clinical difference to outcomes.
• Proper funding and integration of mental health crisis services, including liaison psychiatry.
• A strengthened clinical triage and advice service that links the system together and helps patients navigate it successfully.
• New ways of measuring the quality of the urgent and emergency services; new funding arrangements; and new responses to the workforce requirements that will make these new networks possible.
New care model – viable smaller hospitals
Some commentators have argued that smaller district general hospitals should be merged and/or closed. In fact, England already has one of the more centralised hospital models amongst advanced health systems. It is right that these hospitals should not be providing complex acute services where there is evidence that high volumes are associated with high quality. And some services and buildings will inevitably and rightly need to be re-provided in other locations - just as they have done in the past and will continue to be in every other western country.
However to help sustain local hospital services where the best clinical solution is affordable, has the support of local commissioners and communities, we will now take three sets of actions.
First, NHS England and Monitor will work together to consider whether any adjustments are needed to the NHS payment regime to reflect the costs of delivering safe and efficient services for smaller providers relative to larger ones. The latest quarterly figures show that larger foundation trusts had EBITDA margins of 5% compared to -0.4% for smaller providers.
Second, building on the earlier work of Monitor looking at the costs of running smaller hospitals, and on the Royal College of Physicians Future Hospitals initiative, we will work with those hospitals to examine new models of medical staffing and other ways of achieving sustainable cost structures.
Third, we will create new organisational models for smaller acute hospitals that enable them to gain the benefits of scale without necessarily having to centralise services. Building on the recommendations of the 22
296
forthcoming Dalton Review, we intend to promote at least three new models:
• In one model, a local acute hospital might share management either of the whole institution or of their ‘back office’ with other similar hospitals not necessarily located in their immediate vicinity. These type of ‘hospital chains’ already operate in places such as Germany and Scandinavia.
• In another new model, a smaller local hospital might have some of its services on a site provided by another specialised provider – for example Moorfields eye hospital operates in 23 locations in London and the South East. Several cancer specialist providers are also considering providing services on satellite sites.
• And as indicated in the PACS model above, a further new option is that a local acute hospital and its local primary and community services could form an integrated provider.
New care model - specialised care
In some services there is a compelling case for greater concentration of care. In these services there is a strong relationship between the number of patients and the quality of care, derived from the greater experience these more practiced clinicians have, access to costly specialised facilities and equipment, and the greater standardisation of care that tends to occur. For example, consolidating 32 stroke units to 8 specialist ones in London achieved a 17% reduction in 30-day mortality and a 7% reduction in patient length of stay.
The evidence suggests that similar benefits could be had for most specialised surgery, and some cancer and other services. For example, in Denmark reducing by two thirds the number of hospitals that perform colorectal cancer surgery has improved post-operative mortality after 2 years by 62%. In Germany, the highest volume centres that treat prostate cancer have substantially fewer complications. The South West London Elective Orthopaedic Centre achieves lower post-operative complication rates than do many hospitals which operate on fewer patients.
In services where the relationship between quality and patient volumes is this strong, NHS England will now work with local partners to drive consolidation through a programme of three-year rolling reviews. We will also look to these specialised providers to develop networks of services over a geography, integrating different organisations and services around patients, using innovations such as prime contracting and/or delegated capitated budgets. To take one example: cancer. This would enable patients to have chemotherapy, support and follow up care in their local community hospital or primary care facility, whilst having access to world-leading facilities for their surgery and radiotherapy. In line with 23
297
the UK Strategy for Rare Diseases, we will also explore establishing specialist centres for rare diseases to improve the coordination of care for their patients.
New care model - modern maternity services
Having a baby is the most common reason for hospital admission in England. Births are up by almost a quarter in the last decade, and are at their highest in 40 years.
Recent research shows that for low risk pregnancies babies born at midwife-led units or at home did as well as babies born in obstetric units, with fewer interventions. Four out of five women live within a 30 minute drive of both an obstetric unit and a midwife-led unit, but research by the Women’s Institute and the National Childbirth Trust suggests that while only a quarter of women want to give birth in a hospital obstetrics unit, over 85% actually do so.
To ensure maternity services develop in a safe, responsive and efficient manner, in addition to other actions underway – including increasing midwife numbers - we will:
• Commission a review of future models for maternity units, to report by next summer, which will make recommendations on how best to sustain and develop maternity units across the NHS.
• Ensure that tariff-based NHS funding supports the choices women make, rather than constraining them.
• As a result, make it easier for groups of midwives to set up their own NHS-funded midwifery services.
New care model – enhanced health in care homes
One in six people aged 85 or over are living permanently in a care home. Yet data suggest that had more active health and rehabilitation support been available, some people discharged from hospital to care homes could have avoided permanent admission. Similarly, the Care Quality Commission and the British Geriatrics Society have shown that many people with dementia living in care homes are not getting their health needs regularly assessed and met. One consequence is avoidable admissions to hospital.
In partnership with local authority social services departments, and using the opportunity created by the establishment of the Better Care Fund, we will work with the NHS locally and the care home sector to develop new shared models of in-reach support, including medical reviews, medication reviews, and rehab services. In doing so we will build on the success of
24
298
models which have been shown to improve quality of life, reduce hospital bed use by a third, and save significantly more than they cost.
How will we support the co-design and implementation of these new care models?
Some parts of the country will be able to continue commissioning and providing high quality and affordable health services using their current care models, and without any adaptation along the lines described above.
However, previous versions of local ‘five year plans’ by provider trusts and CCGs suggest that many areas will need to consider new options if they are to square the circle between the desire to improve quality, respond to rising patient volumes, and live within the expected local funding.
In some places, including major conurbations, we therefore expect several of these alternative models to evolve in parallel.
In other geographies it may make sense for local communities to discuss convergence of care models for the future. This will require a new perspective where leaders look beyond their individual organisations’ interests and towards the future development of whole health care economies - and are rewarded for doing so.
It will also require a new type of partnership between national bodies and local leaders. That is because to succeed in designing and implementing these new care models, the NHS locally will need national bodies jointly to exercise discretion in the application of their payment rules, regulatory approaches, staffing models and other policies, as well as possibly providing technical and transitional support.
We will therefore now work with local communities and leaders to identify what changes are needed in how national and local organisations best work together, and will jointly develop:
• Detailed prototyping of each of the new care models described above, together with any others that may be proposed that offer the potential to deliver the necessary transformation - in each case identifying current exemplars, potential benefits, risks and transition costs.
• A shared method of assessing the characteristics of each health economy, to help inform local choice of preferred models, promote peer learning with similar areas, and allow joint intervention in health economies that are furthest from where they need to be.
• National and regional expertise and support to implement care model change rapidly and at scale. The NHS is currently spending several
25
299
hundred million pounds on bodies that directly or indirectly could support this work, but the way in which improvement and clinical engagement happens can be fragmented and unfocused. We will therefore create greater alignment in the work of strategic clinical networks, clinical senates, NHS IQ, the NHS Leadership Academy and the Academic Health Science Centres and Networks.
• National flexibilities in the current regulatory, funding and pricing regimes to assist local areas to transition to better care models.
• Design of a model to help pump-prime and ‘fast track’ a cross-section of the new care models. We will back the plans likely to have the greatest impact for patients, so that by the end of the next Parliament the benefits and costs of the new approaches are clearly demonstrable, allowing informed decisions about future investment as the economy improves. This pump-priming model could also unlock assets held by NHS Property Services, surplus NHS property and support Foundation Trusts that decide to use accrued savings on their balance sheets to help local service transformation.
BOX 3.2: FIVE YEAR AMBITIONS FOR MENTAL HEALTH
Mental illness is the single largest cause of disability in the UK and each year about one in four people suffer from a mental health problem. The cost to the economy is estimated to be around £100 billion annually – roughly the cost of the entire NHS. Physical and mental health are closely linked – people with severe and prolonged mental illness die on average 15 to 20 years earlier than other people – one of the greatest health inequalities in England. However only around a quarter of those with mental health conditions are in treatment, and only 13 per cent of the NHS budget goes on such treatments when mental illness accounts for almost a quarter of the total burden of disease.
Over the next five years the NHS must drive towards an equal response to mental and physical health, and towards the two being treated together. We have already made a start, through the Improving Access to Psychological Therapies Programme – double the number of people got such treatment last year compared with four years ago. Next year, for the first time, there will be waiting standards for mental health. Investment in new beds for young people with the most intensive needs to prevent them being admitted miles away from where they live, or into adult wards, is already under way, along with more money for better case management and early intervention.
This, however, is only a start. We have a much wider ambition to achieve genuine parity of esteem between physical and mental health by 2020. Provided new funding can be made available, by then we want the new waiting time standards to have improved so that 95 rather than 75 per cent of people referred for psychological therapies start treatment within six weeks and those experiencing a first episode of psychosis do so within a 26
300
fortnight. We also want to expand access standards to cover a comprehensive range of mental health services, including children’s services, eating disorders, and those with bipolar conditions. We need new commissioning approaches to help ensure that happens, and extra staff to coordinate such care. Getting there will require further investment.
27
301
CHAPTER FOUR How will we get there?
This ‘Forward View’ sets out a clear direction for the NHS – showing why change is needed and what it will look like. Some of what is needed can be brought about by the NHS itself. Other actions require new partnerships with local communities, local authorities and employers. Some critical decisions – for example on investment, on local reconfigurations, or on various public health measures – need the explicit support of the elected government.
So in addition to the strategies we have set out earlier in this document we also believe these complementary approaches are needed, and we will play our full part in achieving them:
We will back diverse solutions and local leadership
As a nation we’ve just taken the unique step anywhere in the world of entrusting frontline clinicians with two thirds – £66 billion – of our health service funding. Many CCGs are now harnessing clinical insight and energy to drive change in their local health systems in a way that frankly has not been achievable before now. NHS England intends progressively to offer them more influence over the total NHS budget for their local populations, ranging from primary to specialised care.
We will also work with ambitious local areas to define and champion a limited number of models of joint commissioning between the NHS and local government. These will include Integrated Personal Commissioning (described in chapter two) as well as Better Care Fund-style pooling budgets for specific services where appropriate, and under specific circumstances possible full joint management of social and health care commissioning, perhaps under the leadership of Health and Wellbeing Boards. However, a proper evaluation of the results of the 2015/16 BCF is needed before any national decision is made to expand the Fund further.
Furthermore, across the NHS we detect no appetite for a wholesale structural reorganisation. In particular, the tendency over many decades for government repeatedly to tinker with the number and functions of the health authority / primary care trust / clinical commissioning group tier of the NHS needs to stop. There is no ‘right’ answer as to how these functions are arranged – but there is a wrong answer, and that is to keep changing your mind. Instead, the default assumption should be that changes in local organisational configurations should arise only from local work to develop the new care models described in chapter three, or in response to clear local failure and the resulting implementation of ‘special measures’.
28
302
We will provide aligned national NHS leadership
NHS England, Monitor, the NHS Trust Development Authority, the Care Quality Commission, Health Education England, NICE and Public Health England have distinctive national duties laid on them by statute, and rightly so. However in their individual work with the local NHS there are various ways in which more action in concert would improve the impact and reduce the burden on frontline services. Here are some of the ways in which we intend to develop our shared work as it affects the local NHS:
• Through a combined work programme to support the development of new local care models, as set out at the end of chapter three. In addition to national statutory bodies, we will collaborate with patient and voluntary sector organisations in developing this programme.
• Furthermore, Monitor, TDA and NHS England will work together to create greater alignment between their respective local assessment, reporting and intervention regimes for Foundation Trusts, NHS trusts, and CCGs, complementing the work of CQC and HEE. This will include more joint working at regional and local level, alongside local government, to develop a whole-system, geographically-based intervention regime where appropriate. NHS England will also develop a new risk-based CCG assurance regime that will lighten the quarterly assurance reporting burden from high performing CCGs, while setting out a new ‘special measures’ support regime for those that are struggling.
• Using existing flexibilities and discretion, we will deploy national regulatory, pricing and funding regimes to support change in specific local areas that is in the interest of patients.
• Recognising the ultimate responsibilities of individual NHS boards for the quality and safety of the care being provided by their organisation, there is however also value in a forum where the key NHS oversight organisations can come together regionally and nationally to share intelligence, agree action and monitor overall assurance on quality. The National Quality Board provides such a forum, and we intend to re- energise it under the leadership of the senior clinicians (chief medical and nursing officers / medical and nursing directors / chief inspectors / heads of profession) of each of the national NHS leadership bodies alongside CCG leaders, providers, regulators and patient and lay representatives.
We will support a modern workforce
Health care depends on people — nurses, porters consultants and receptionists, scientists and therapists and many others. We can design innovative new care models, but they simply won’t become a reality unless we have a workforce with the right numbers, skills, values and 29
303
behaviours to deliver it. That’s why ensuring the NHS becomes a better employer is so important: by supporting the health and wellbeing of frontline staff; providing safe, inclusive and non-discriminatory opportunities; and supporting employees to raise concerns, and ensuring managers quickly act on them.
Since 2000, the workforce has grown by 160,000 more whole-time equivalent clinicians. In the past year alone staff numbers at Foundation Trusts are up by 24,000 – a 4% increase. However, these increases have not fully reflected changing patterns of demand. Hospital consultants have increased around three times faster than GPs and there has been an increasing trend towards a more specialised workforce, even though patients with multiple conditions would benefit from a more holistic clinical approach. And we have yet to see a significant shift from acute to community sector based working – just a 0.6% increase in the numbers of nurses working in the community over the past ten years.
Employers are responsible for ensuring they have sufficient staff with the right skills to care for their patients. Supported by Health Education England, we will address immediate gaps in key areas. We will put in place new measures to support employers to retain and develop their existing staff, increase productivity and reduce the waste of skills and money. We will consider the most appropriate employment arrangements to enable our current staff to work across organisational and sector boundaries. HEE will work with employers, employees and commissioners to identify the education and training needs of our current workforce, equipping them with the skills and flexibilities to deliver the new models of care, including the development of transitional roles. This will require a greater investment in training for existing staff, and the active engagement of clinicians and managers who are best placed to know what support they need to deliver new models of care.
Since it takes time to train skilled staff (for example, up to thirteen years to train a consultant), the risk is that the NHS will lock itself into outdated models of delivery unless we radically alter the way in which we plan and train our workforce. HEE will therefore work with its statutory partners to commission and expand new health and care roles, ensuring we have a more flexible workforce that can provide high quality care wherever and whenever the patient needs it. This work will be taken forward through the HEE’s leadership of the implementation of the Shape of Training Review for the medical profession and the Shape of Care Review for the nursing profession, so that we can ‘future proof’ the NHS against the challenges to come.
More generally, over the next several years, NHS employers and staff and their representatives will need to consider how working patterns and pay and terms and conditions can best evolve to fully reward high performance, support job and service redesign, and encourage
30
304
recruitment and retention in parts of the country and in occupations where vacancies are high.
We will exploit the information revolution
There have been three major economic transitions in human history – the agricultural revolution, the industrial revolution, and now the information revolution. But most countries’ health care systems have been slow to recognise and capitalise on the opportunities presented by the information revolution. For example, in Britain 86% of adults use the internet but only 2% report using it to contact their GP.
While the NHS is a world-leader in primary care computing and some aspects of our national health infrastructure (such as NHS Choices which gets 40 million visits a month, and the NHS Spine which handles 200 million interactions a month), progress on hospital systems has been slow following the failures of the previous ‘connecting for health’ initiative. More generally, the NHS is not yet exploiting its comparative advantage as a population-focused national service, despite the fact that our spending on health-related IT has grown rapidly over the past decade or so and is now broadly at the levels that might be expected looking at comparable industries and countries.
Part of why progress has not been as fast as it should have been is that the NHS has oscillated between two opposite approaches to information technology adoption – neither of which now makes sense. At times we have tried highly centralised national procurements and implementations. When they have failed due to lack of local engagement and lack of sensitivity to local circumstances, we have veered to the opposite extreme of ‘letting a thousand flowers bloom’. The result has been systems that don’t talk to each other, and a failure to harness the shared benefits that come from interoperable systems.
In future we intend to take a different approach. Nationally we will focus on the key systems that provide the ‘electronic glue’ which enables different parts of the health service to work together. Other systems will be for the local NHS to decide upon and procure, provided they meet nationally specified interoperability and data standards.
To lead this sector-wide approach a National Information Board has been established which brings together organisations from across the NHS, public health, clinical science, social care, local government and public representatives. To advance the implementation of this Five Year Forward View, later this financial year the NIB will publish a set of ‘road maps’ laying out who will do what to transform digital care. Key elements will include:
• Comprehensive transparency of performance data – including the results of treatment and what patients and carers say – to help health 31
305
professionals see how they are performing compared to others and improve; to help patients make informed choices; and to help CCGs and NHS England commission the best quality care.
• An expanding set of NHS accredited health apps that patients will be able to use to organise and manage their own health and care; and the development of partnerships with the voluntary sector and industry to support digital inclusion.
• Fully interoperable electronic health records so that patients’ records are largely paperless. Patients will have full access to these records, and be able to write into them. They will retain the right to opt out of their record being shared electronically. The NHS number, for safety and efficiency reasons, will be used in all settings, including social care.
• Family doctor appointments and electronic and repeat prescribing available routinely on-line everywhere.
• Bringing together hospital, GP, administrative and audit data to support the quality improvement, research, and the identification of patients who most need health and social care support. Individuals will be able to opt out of their data being used in this way.
• Technology – including smartphones - can be a great leveller and, contrary to some perceptions, many older people use the internet. However, we will take steps to ensure that we build the capacity of all citizens to access information, and train our staff so that they are able to support those who are unable or unwilling to use new technologies.
We will accelerate useful health innovation
Britain has a track record of discovery and innovation to be proud of. We’re the nation that has helped give humanity antibiotics, vaccines, modern nursing, hip replacements, IVF, CT scanners and breakthrough discoveries from the circulation of blood to the DNA double helix—to name just a few. These have benefited not only our patients, but also the British economy – helping to make us a leader in a growing part of the world economy.
Research is vital in providing the evidence we need to transform services and improve outcomes. We will continue to support the work of the National Institute for Health Research (NIHR) and the network of specialist clinical research facilities in the NHS. We will also develop the active collection and use of health outcomes data, offering patients the chance to participate in research; and, working with partners, ensuring use of NHS clinical assets to support research in medicine.
32
306
We should be both optimistic and ambitious for the further advances that lie within our reach. Medicine is becoming more tailored to the individual; we are moving from one-size-fits-all to personalised care offering higher cure rates and fewer side effects. That’s why, for example, the NHS and our partners have begun a ground-breaking new initiative launched by the Prime Minister which will decode 100,000 whole genomes within the NHS. Our clinical teams will support this applied research to help improve diagnosis and treatment of rare diseases and cancers.
Steps we will take to speed innovation in new treatments and diagnostics include:
• The NHS has the opportunity radically to cut the costs of conducting Randomised Controlled Trials (RCTs), not only by streamlining approval processes but also by harnessing clinical technology. We will support the rollout of the Clinical Practice Research Datalink, and efforts to enable its use to support observational studies and quicker lower cost RCTs embedded within routine general practice and clinical care.
• In some cases it will be hard to test new treatment approaches using RCTs because the populations affected are too small. NHS England already has a £15m a year programme, administered by NICE, now called “commissioning through evaluation” which examines real world clinical evidence in the absence of full trial data. At a time when NHS funding is constrained it would be difficult to justify a further major diversion of resources from proven care to treatments of unknown cost effectiveness. However, we will explore how to expand this programme and the Early Access to Medicines programme in future years. It will be easier if the costs of doing so can be supported by those manufacturers who would like their products evaluated in this way.
• A smaller proportion of new devices and equipment go through NICE’s assessment process than do pharmaceuticals. We will work with NICE to expand work on devices and equipment and to support the best approach to rolling out high value innovations—for example, operational pilots to generate evidence on the real world financial and operational impact on services—while decommissioning outmoded legacy technologies and treatments to help pay for them.
• The Department of Health-initiated Cancer Drugs Fund has expanded access to new cancer medicines. We expect over the next year to consult on a new approach to converging its assessment and prioritisation processes with a revised approach from NICE.
• The average time it takes to translate a discovery into clinical practice is however often too slow. So as well as a commitment to research, we are committed to accelerating the quicker adoption of cost-effective innovation - both medicines and medtech. We will explore with 33
307
partners—including patients and voluntary sector organisations—a number of new mechanisms for achieving this.
Accelerating innovation in new ways of delivering care
Many of the innovation gains we should be aiming for over the next five or so years probably won’t come from new standalone diagnostic technologies or treatments - the number of these blockbuster ‘silver bullets’ is inevitably limited.
But we do have an arguably larger unexploited opportunity to combine different technologies and changed ways of working in order to transform care delivery. For example, equipping house-bound elderly patients who suffer from congestive heart failure with new biosensor technology that can be remotely monitored can enable community nursing teams to improve outcomes and reduce hospitalisations. But any one of these components by itself produces little or no gain, and may in fact just add cost. So instead we need what is now being termed ‘combinatorial innovation’.
The NHS will become one of the best places in the world to test innovations that require staff, technology and funding all to align in a health system, with universal coverage serving a large and diverse population. In practice, our track record has been decidedly mixed. Too often single elements have been ‘piloted’ without other needed components. Even where ‘whole system’ innovations have been tested, the design has sometimes been weak, with an absence of control groups plus inadequate and rushed implementation. As a result they have produced limited empirical insight.
Over the next five years we intend to change that. Alongside the approaches we spell out in chapter three, three of the further mechanisms we will use are:
• Develop a small number of ‘test bed’ sites alongside our Academic Health Science Networks and Centres. They would serve as real world sites for ‘combinatorial’ innovations that integrate new technologies, bioinformatics, new staffing models and payment-for-outcomes. Innovators from the UK and internationally will be able to bid to have their proposed discovery or innovation deployed and tested in these sites.
• Working with NIHR and the Department of Health we will expand NHS operational research, RCT capability and other methods to promote more rigorous ways of answering high impact questions in health services redesign. An example of the sort of question that might be tested: how best to evolve GP out of hours and NHS 111 services so as to improve patient understanding of where and when to seek care, while improving clinical outcomes and ensuring the most appropriate 34
308
use of ambulance and A&E services. Further work will also be undertaken on behavioural ‘nudge’ type policies in health care.
• We will explore the development of health and care ‘new towns’. England’s population is projected to increase by about 3 to 4 million by 2020. New town developments and the refurbishment of some urban areas offers the opportunity to design modern services from scratch, with fewer legacy constraints - integrating not only health and social care, but also other public services such as welfare, education and affordable housing. The health campus already planned for Watford is one example of this.
We will drive efficiency and productive investment
It has previously been calculated by Monitor, separately by NHS England, and also by independent analysts, that a combination of a) growing demand, b) no further annual efficiencies, and c) flat real terms funding could, by 2020/21, produce a mismatch between resources and patient needs of nearly £30 billion a year.
So to sustain a comprehensive high-quality NHS, action will be needed on all three fronts. Less impact on any one of them will require compensating action on the other two.
Demand
On demand, this Forward View makes the case for a more activist prevention and public health agenda: greater support for patients, carers and community organisations; and new models of primary and out-of- hospital care. While the positive effects of these will take some years to show themselves in moderating the rising demands on hospitals, over the medium term the results could be substantial. Their net impact will however also partly depend on the availability of social care services over the next five years.
Efficiency
Over the long run, NHS efficiency gains have been estimated by the Office for Budget Responsibility at around 0.8% net annually. Given the pressures on the public finances and the opportunities in front of us, 0.8% a year will not be adequate, and in recent years the NHS has done more than twice as well as this.
A 1.5% net efficiency increase each year over the next Parliament should be obtainable if the NHS is able to accelerate some of its current efficiency programmes, recognising that some others that have contributed over the past five years will not be indefinitely repeatable. For example as the economy returns to growth, NHS pay will need to stay broadly in line with private sector wages in order to recruit and retain frontline staff. 35
309
Our ambition, however, would be for the NHS to achieve 2% net efficiency gains each year for the rest of the decade – possibly increasing to 3% over time. This would represent a strong performance - compared with the NHS' own past, compared with the wider UK economy, and with other countries' health systems. It would require investment in new care models and would be achieved by a combination of "catch up" (as less efficient providers matched the performance of the best), "frontier shift" (as new and better ways of working of the sort laid out in chapters three and four are achieved by the whole sector), and moderating demand increases which would begin to be realised towards the end of the second half of the five year period (partly as described in chapter two). It would improve the quality and responsiveness of care, meaning patients getting the 'right care, at the right time, in the right setting, from the right caregiver'. The Nuffield Trust for example calculates that doing so could avoid the need for another 17,000 hospital beds - equivalent to opening 34 extra 500-bedded hospitals over the next five years.
Funding
NHS spending has been protected over the past five years, and this has helped sustain services. However, pressures are building. In terms of future funding scenarios, flat real terms NHS spending overall would represent a continuation of current budget protection. Flat real terms NHS spending per person would take account of population growth. Flat NHS spending as a share of GDP would differ from the long term trend in which health spending in industrialised countries tends to rise a share of national income.
Depending on the combined efficiency and funding option pursued, the effect is to close the £30 billion gap by one third, one half, or all the way.
• In scenario one, the NHS budget remains flat in real terms from 2015/16 to 2020/21, and the NHS delivers its long run productivity gain of 0.8% a year. The combined effect is that the £30 billion gap in 2020/21 is cut by about a third, to £21 billion.
• In scenario two, the NHS budget still remains flat in real terms over the period, but the NHS delivers stronger efficiencies of 1.5% a year. The combined effect is that the £30 billion gap in 2020/21 is halved, to £16 billion.
• In scenario three, the NHS gets the needed infrastructure and operating investment to rapidly move to the new care models and ways of working described in this Forward View, which in turn enables demand and efficiency gains worth 2%-3% net each year. Combined with staged funding increases close to ‘flat real per person’ the £30 billion gap is closed by 2020/21.
36
310
Decisions on these options will inevitably need to be taken in the context of how the UK economy overall is performing, during the next Parliament. However nothing in the analysis above suggests that continuing with a comprehensive tax-funded NHS is intrinsically undoable – instead it suggests that there are viable options for sustaining and improving the NHS over the next five years, provided that the NHS does its part, together with the support of government. The result would be a far better future for the NHS, its patients, its staff and those who support them.
BOX 5: WHAT MIGHT THIS MEAN FOR PATIENTS? FIVE YEAR AMBITIONS FOR CANCER
One in three of us will be diagnosed with cancer in our lifetime. Fortunately half of those with cancer will now live for at least ten years, whereas forty years ago the average survival was only one year. But cancer survival is below the European average, especially for people aged over 75, and especially when measured at one year after diagnosis compared with five years. This suggests that late diagnosis and variation in subsequent access to some treatments are key reasons for the gap.
So improvements in outcomes will require action on three fronts: better prevention, swifter access to diagnosis, and better treatment and care for all those diagnosed with cancer. If the steps we set out in this Forward View are implemented and the NHS continues to be properly resourced, patients will reap benefits in all three areas:
Better prevention. An NHS that works proactively with other partners to maintain and improve health will help reduce the future incidence of cancer. The relationship between tobacco and cancer is well known, and we will ensure everyone who smokes has access to high quality smoking cessation services, working with local government partners to increase our focus on pregnant women and those with mental health conditions. There is also increasing evidence of a relationship between obesity and cancer. The World Health Organisation has estimated that between 7% and 41% of certain cancers are attributable to obesity and overweight, so the focus on reducing obesity outlined in Chapter two of this document could also contribute towards our wider efforts on cancer prevention.
Faster diagnosis. We need to take early action to reduce the proportion of patients currently diagnosed through A&E—currently about 25% of all diagnoses. These patients are far less likely to survive a year than those who present at their GP practice. Currently, the average GP will see fewer than eight new patients with cancer each year, and may see a rare cancer once in their career. They will therefore need support to spot suspicious combinations of symptoms. The new care models set out in this document will help ensure that there are sufficient numbers of GPs working in larger practices with greater access to diagnostic and specialist advice. We will 37
311
also work to expand access to screening, for example, by extending breast cancer screening to additional age groups, and spreading the use of screening for colorectal cancer. As well as supporting clinicians to spot cancers earlier, we need to support people to visit their GP at the first sign of something suspicious. If we are able to deliver the vision set out in this Forward View at sufficient pace and scale, we believe that over the next five years, the NHS can deliver a 10% increase in those patients diagnosed early, equivalent to about 8,000 more patients living longer than five years after diagnosis.
Better treatment and care for all. It is not enough to improve the rates of diagnosis unless we also tackle the current variation in treatment and outcomes. We will use our commissioning and regulatory powers to ensure that existing quality standards and NICE guidance are more uniformly implemented, across all areas and age groups, encouraging shared learning through transparency of performance data, not only by institution but also along routes from diagnosis. And for some specialised cancer services we will encourage further consolidation into specialist centres that will increasingly become responsible for developing networks of supporting services.
But combined with this consolidation of the most specialised care, we will make supporting care available much closer to people’s homes; for example, a greater role for smaller hospitals and expanded primary care will allow more chemotherapy to be provided in community. We will also work in partnership with patient organisations to promote the provision of the Cancer Recovery Package, to ensure care is coordinated between primary and acute care, so that patients are assessed and care planned appropriately. Support and aftercare and end of life care – which improves patient experience and patient reported outcomes – will all increasingly be provided in community settings.
38
312
ABBREVIATIONS
A&E Accident & Emergency AHSCs Academic Health Science Centres AHSNs Academic Health Science Networks BCF Better Care Fund CCGs Clinical Commissioning Groups CQC Care Quality Commission CT Computerised Tomography EBITDA Earnings before interest, taxes, depreciation and amortisation GP General Practitioner HEE Health Education England IPC Integrated Personal Commissioning IVF In Vitro Fertilisation LTCs Long term conditions NHS IQ NHS Improving Quality NHS TDA NHS Trust Development Authority NIB National Information Board NICE National Institute for Health and Care Excellence NIHR National Institute of Health Research PHE Public Health England RCTs Randomised Controlled Trials TUC Trades Union Congress WHO World Health Organisation
39
313 314
Item 6.1
Committee Audit Committee, 5 November 2014 Minutes
From Peter Brokenshire, Lay Member Governance - WFCCG
Key highlights Part 1:
1. The usual examination of the risks and the Board Assurance Framework (BAF) were made where the additions and removals to the directorate risk registers and the BAF were noted. A discussion around the need to strengthen the moderation process, through the Executive management meetings, of risks reported through the BAF took place along with a consideration as to whether the CCG’s risk management maturity was sufficiently advanced to commence reporting on zero tolerance risks.
2. Review of the progress on policy approvals and updates noting that the process is well established.
3. Review of the Information Governance Tool Kit progress noting that the key risk areas identified from the 2013/14 submission have been identified and are being proactively managed.
4. Review of progress against the Internal Audit plan. The associated Internal Audit report advised on 4 recent audits that had been completed of which two (BAF and Budgetary Control & Financial reporting) had received ‘green’ ratings.
5. Review and agreement of the Procurement Deep Dive report including a discussion of the challenges associated with the management of Conflicts of Interest particularly within the GP Network environment.
Part 2:
1. An update on the process for selection of the Internal Auditors for 2015/16.
315
Minutes of the Waltham Forest Clinical Commissioning Group Audit Committee (Part 1) - Draft
Date: Wednesday, 5 November 2014 Time: 10am –12 noon Venue: Kirkdale House
Members Present: Peter Brokenshire OBE (PB) Chair, Lay Member Audit & Governance Alan Wells,(OBE (AW) Lay Member PPI, CCG Vice-Chair Dr Rizwan Hasan, (RH) Consultant Member
In Attendance: CCG Officers Les Borrett (LB) Director of Financial Strategy Justin Roper (JR) Deputy Director of Integrated Governance David Pearce (DP) Head of Governance
Auditors John Elbake (JE) Baker Tilly Clive Makombera (CM) Baker Tilly
Item Action
83/14 Apologies for absence Introductions were made and apologies for absence were noted from:
Mark Trevallion, Baker Tilly and Zeb Alam, NELCSU. 84/14 Minutes of the meeting held on 3 September 2014 The minutes were agreed as read. PB 85/14 Matters Arising See table.
86/14 Risk Register DP presented the WFCCG directorate risk register summary status report at end October 2014.
The report identified the key changes in the risk profiles since the last report to the Audit Committee and provided an explanation of the reasons behind such changes.
AW noted that the rating of the Care Home risk reported through the Quality and Governance Directorate had been reduced. This had led to the risk being removed from the BAF. Recognising the ongoing risks associated with Care Homes AW sought assurance that the reduction in risk rating was supported with sufficient evidence. RH also drew attention to ‘Winterbourne’ and advised that the risk should not be removed. JR advised that a rolling programme of assurance visits to Care Homes was now well established which had not previously been in place and that any specific issues raised during visits were followed up by the CCG. DP advised that whilst the risk rating had been reduced it still remained as a high rated risk and that it continued to be managed through the Quality and
Audit Minutes 5 November 2014 Page 3161 of 5
Governance directorate risk register. The risk had been removed from the BAF as it was now rated below the Risk Register to BAF escalation threshold. DP noted that as the CCG was continuing to mature in its risk management processes it was an opportune time to introduce Zero Tolerance reporting on the BAF and that the Care Homes risk was an example of such a risk that would be recorded. PB agreed with the LB approach. LB agreed to raise the issue of Zero Tolerance reporting with the Executive Team.
PB observed that the number of risks reported through the Strategic Commissioning Directorate was greater than those reported through the Quality and Governance Directorate and questioned if this was reasonable given the nature of the CCG’s business. AW suggested that a moderation process at the Executive team level would be useful to ensure a greater degree of consistency in risk rating scores (but not withstanding the individual directors responsibilities to rate ‘their’ risks) and numbers reported. LB agreed to raise the issue of a moderation process at Executive level with LB the Executive Management team.
The Audit Committee noted the contents of the report.
87/14 Board Assurance Framework (BAF) DP presented the draft BAF as at end October 2014.
DP advised that 4 risks had been removed from the BAF since the last report to the Audit Committee. • The CCG fails to achieve its planned surplus due to non- achievement of its £10.4M QIPP plan. This risk has been removed
since the projected end year delivery of QIPP is at 91.4 percent of plan based on latest activity data and its overall and continuing favourable financial position. The risk continues to be managed through the Finance directorate.
• Outstanding Serious Incidents (SIs): Barts Health Trust and North East London Foundation Trust have a significant number of SIs that have not been managed within the National Framework for Reporting and Learning from Serious Incidents timeframe. This risk has been removed as Barts Health and North East London Foundation Trust current reported status (September 2014) is that Barts Health have 0 outstanding reports and NELFT have 19 outstanding reports. NELFT have established processes that have significantly reduced back log
to sustainable levels.
• NHS Waltham Forest Clinical Commissioning Group does not have assurance that all Care Homes are providing safe quality care to patients. This risk has been removed as there is a robust quality DP assurance visit plan in place that covers all Care Homes and the plan is on track. Both of these risks continue to be managed through the Quality and Governance directorate
• NHS Propco may charge rent and implement a lease agreement to community based services that use Propco estates from which to deliver services. This risk has been removed following a re-
Audit Minutes 5 November 2014 Page 3172 of 5
evaluation of the risk impact. The risk continues to be managed through the Strategic Commissioning directorate.
DP advised that there has been one new risk added to the BAF since the last report to the Audit Committee. The risk relates to patients whose Continuing Health Care needs have changed and may not be receiving the correct care. The risk is being managed through the Quality and Governance directorate.
PB questioned the pooled budget impact that related to the Better Care Fund (BCF) reported risk. LB advised that whilst there was some impact it was not material. LB further advised that the CCG’s arrangements associated with the governance of its BCF have received positive external recognition following a national review of BCF plans. PB asked when pooled funds would be released. LB advised that there were a number of outstanding issues with the Local Authority - where joint working arrangements are seen as supportive - that were still being worked through but at this point in time the release of funds was anticipated 2015/16.
RH noted the increase in the rating of the Barts Health related risk to risk score 20. LB advised that this was necessary following Barts Health’s continuing failure to meet projected targets. AW asked if there was a WELC response to the Barts Health issues. LB noted that there were ongoing discussions between CCG’s and Barts Health with regard to supporting delivery of the Trust’s RTT trajectory and financial performance. Some CCG’s have agreed to reinvest any fines for RTT failures in Q3 and Q4, subject to the Trust meeting a revised improvement target. The WFCCG Governing Body have agreed to consider such a proposal but only based on meeting the RTT target for Whipps Cross by March, which the Trust have subsequently confirmed is not possible. AW noted that the imposing of financial levies would not necessarily improve the Barts Health situation.
The Audit Committee noted the contents of the report.
88/14 Policy Tracker DP presented the Policy Tracker showing the latest status of the CCG’s policies.
DP informed the Committee that the next policies due for review were the Health & Safety Policy which had recently been added to the tracker, and the Development of Policies and Procedures policy. The Complaints policy was now overdue and was in its final draft stage ahead of circulation for DP Executive approval.
DP noted that it was unclear if the scope of policies being reviewed covered the full scope of the Audit committee remit. CM agreed to check the list against other CCGs and advise. CM
The Audit Committee noted the contents of the report.
89/14 Information Governance Tool (IGT) kit tracker for 2014/15 DP presented an update on the progress to date on the plan for monitoring progress against the 2014/15 IGT.
Audit Minutes 5 November 2014 Page 3183 of 5
DP advised that good progress was being made against all areas of the IG DP toolkit although there were 4 requirement areas that had been slightly delayed. These related to policy updates and data mapping activities which were in hand albeit the complexities of data mapping did present some risk.
The Audit Committee noted the contents of the report. 90/14 Internal Audit Progress Report CM presented the latest progress against the Internal Audit plan including final reports on (i) BAF, (ii) Patient Engagement, (iii) Prescribing (iv) CM Budgetary Control and Financial Reporting. AW noted that the report was not clear between the areas of Patient Engagement and Patient Experience. CM agreed to review the report and address any potential sources of confusion prior to reissuing the report.
CM presented 3 historical CSU reports. JR noted that the historical age of the reports made their value questionable at this time. CM acknowledged the historical nature of the reports and advised that the process for following up CM recommendations made within the reports would be reviewed and reported back to the next Audit Committee.
AW asked what assurances could be given that the recommendations made in the reports had been addressed, for example what assurances were in place in relation to the purchase order vs non-purchase order process. LB LB advised that reports were available and that he would prepare a report to show the latest purchase order to non-purchase order status.
The Audit Committee noted the contents of the report.
91/14 Deep Dive Reviews PB presented the report from the Procurement Deep Dive review 9 June 2014.
The Audit Committee agreed the contents of the report.
PB drew attention to the Baker Tilly report on management of Conflicts of Interest (CoIs). The Audit Committee reviewed the report and noted the challenges of managing CoIs in the GP network environment. CM noted the importance of transparency in managing CoIs.
92/14 Development to Governance Assurance Sources PB presented the latest development to the Governance Assurance plan and noted for some of the CCG’s Corporate Objectives there are no apparent sources of assurance against their delivery.
PB advised that for 2015/16 the Assurance Plan should cover all Corporate Objective areas.
AW advised that it would be necessary to distinguish those areas that the Internal Audit process covered and those that it didn’t. This would then inform the overall Assurance Plan for 2015/16.
The Audit Committee agreed to review at next meeting and acknowledged that this would form the main agenda item at that meeting. DP
Audit Minutes 5 November 2014 Page 3194 of 5
93/14 Any Other Business Nothing to report. 94/14 Next Meeting The next meeting will take place at 10 am on 7 January 2014. Venue Kirkdale House.
Signed …………………………………………… Date ………………………….
Audit Minutes 5 November 2014 Page 3205 of 5
Minutes of the Waltham Forest Clinical Commissioning Group Audit Committee (Part 2)
Date: Wednesday, 5 November 2014 Time: 10am –12 noon Venue: Kirkdale House
Members Present: Peter Brokenshire OBE (PB) Chair, Lay Member Audit & Governance Alan Wells OBE (AW) Lay Member PPI, CCG Vice-Chair Dr Rizwan Hasan (RH) Consultant Member
In Attendance: CCG Officers Les Borrett (LB) Director of Financial Strategy Justin Roper (JR) Deputy Director of Integrated Governance David Pearce (DP) Head of Governance
Item Action
01/14 Update on 2015/16 Procurement Process for Internal Audit Providers LB advised that there were 2 bidders for the Internal Audit Provider. Following evaluation of the bids there was no discernible difference between LB them and this meant that there was to be an interview panel early December 2014 to aid the selection process. LB advised that he was a member of the interview panel and would advise the Audit Committee of the outcome at its next meeting 7 January 2015.
Signed …………………………………………… Date ………………………….
.
Audit Minutes 5 November 2014 Page 3211 of 1
Item 6.2
Committee CCG Reference Group – 6 November 2014 Minutes
From Alan Wells, Chair of the Group - WFCCG
Key highlights Primary Care Strategy A PowerPoint presentation explaining the key points of the Primary Care Strategy. The Reference Group got into three groups to give their thoughts/discussions and feedback on the three key areas of the strategy, i.e.1 Proactive care, 2 Accessible care, 3 Co-ordinated care. Meetings in 2014/15 An informal meeting with the governing body was requested, and to share Reference Group contact details within the group. AS confirmed she would also forward-plan another governing body / Reference Group meeting for next year.
322
CCG Reference Group
Date and Thursday 6 November 2014 6-8pm time:
Venue: Boardroom B&C Kirkdale House, Leytonstone, London, E11 1HP
Attendees: Grainne Anthony Alli Anthony Sylvia Debreczeny Lynn Eaton Alex Kafetz Nadine Adams-Austin Joan Fratter Caroline White Dada Imarogbe Justin Roper Ellie Sahin Anna Sullivan Ana da Cunha Lewin Neil Collins Ousmane Diop
Apologies: Alan Wells Janet Tisson Roger Clifton Allan Anderson Sanna Butt Sue Comitti
Agenda Item Action
1. Welcome and apologies
Apologies were noted as indicated above.
2. Conflicts of interest No new conflicts were declared.
3. Minutes of the last meeting These were agreed as an accurate record. Justin Roper and Caroline Gilmartin have offered an informal meeting around Urgent Care procurement. Joan Fratter asked whether Mental Health would be covered. Justin confirmed that the Urgent Care procurement covered the following services: 111; Walk in
323 CCG Reference Group Thursday 6 November 2014
centres; Urgent Care Centres; GP out of hours and single point of access. These services provided for all health needs, and as such did cover mental health specifically. The group has expressed that Caroline Gilmartin explained these new contracts must be ready by 2015 and asked what the time scale is. Justin confirmed that the handover is planned for September 2015. (Subsequent to meeting, confirmation has been received that contracts are planned to be awarded in July 2015.) The group asked whether the Better Care Fund had improved the expanding of the rapid response team. Justin was asked whether that would be incorporated, or be a separate service under Urgent Care. Justin responded that a further meeting can address the questions separately.
4. Primary Care Strategy
Anna Sullivan presented a PowerPoint presentation explaining the key points of the Primary Care Strategy. The Reference Group got into three groups to give their thoughts/discussions, and feedback on the three key areas of the strategy, i.e.: 1. Proactive care; 2. Accessible care; and 3. Co-ordinated care. It was mentioned that most comments had been provided from patients and should also be from carers. There were discussions around integrated care, computer records and communications between GPs and hospitals. The group who had the proactive category gave their 3 priorities as: 1. Early Diagnosis and self-management. 2. GP practices understanding their patients, and targeting specific conditions based on this understanding. 3. Active involvement in patient groups etc. The group who had the accessible category gave their 3 priorities as: 1. Waiting times. 2. Accessibility modifications e.g. online-check in service and modifications for disabled patients. 3. Training to make services more accessible, e.g. IT training for GPs and customer service training for receptionists. The group who had the co-ordinated care category gave their 3 priorities as: 1. Improving communications. 2. Information to ensure people are seen in the right place, at the right time. 3. Health professionals taking responsibility for particular areas, e.g. named nurse model in the community.
5. Meetings in 2014/15
Alex queried whether an informal meeting with the governing body would be useful, and to
share Reference Group contact details within the group.
324 Page 2 of 3
CCG Reference Group Thursday 6 November 2014
Anna confirmed she had actioned the earlier request to establish if Reference Group members were happy to share contact details with one another – not everyone responded to confirm whether they were happy for their information to be shared in this way. Given attendees at this meeting are happy for their contact details to be shared within the group, Anna will action this and ask people not at the meeting whether they would like to participate too. She will also forward-plan another governing body / Reference Group meeting for next year.
6. AOB
The group were advised of a “Self Help Pharmacy Project” being held on Wednesday 12th November 2014 from 9:30am at the Walthamstow Assembly Hall. Neil Collins requested that Anna continue to send out emails with information regarding NHS England and events which he finds useful. Anna agreed to review how Reference and Rapid lists are used for communication, as there have been varying requests for different amounts and types of information.
Justin had advised the group that the CQC inspection at Whipps Cross will be on 11th November 2014. Justin had thanked the group for their support and attendance at the Annual General Meeting. Details of next meeting: TBC. Anna Sullivan to forward-plan meetings for 2015.
325 Page 3 of 3
Item 6.3
Title of report Performance and Quality Committee – October 2014
From Dr Kapoor, Chair of the Committee - WFCCG
Purpose of report The purpose of this report is to present NHS Waltham Forest Clinical Commissioning Group’s (WFCCG) Governing Body with the minutes of the Performance and Quality Committee minutes from October 2014.
Recommendations The Governing Body is asked to note contents of the minutes.
Performance NHS Waltham Forest CCG scorecard: Positive • Paediatric Asthma • Cancer two week wait figures at 92.7% target 93% • Personal Health Budgets achieved plan to make offers • Friends and Family Test at Whipps Cross has shown significant improvement in August • Clostridium.Difficile (Cdiff) remains within trajectory
Negative • Referral To Treatment RTT figures deteriorated in August • A&E Whipps Cross failed the 95% standard for beginning October • Dementia diagnosis rate has not improved • IAPT remains a risk as below target Cancer Lack of Breast Screening One Stop services was highlighted. Informal proposal from Barts Health regarding Breast Triple Assessment Clinic at Whipps Cross for Waltham Forest Clinical Commissioning Group (WFCCG) to consider looking at diverting patients to the St Bart’s Hospital site. Formal proposal from Barts has been requested. Accident and Emergency (A&E) Whipps Cross failed the 95% standard in the last two weeks, where the previous week figures were at 97%. Q2 figures are showing at 92.5%. BH overall 94%. The main reason is bed occupancy. There was a reduction in the length of stay during September but this has now increased back to longer stays, with an increase in over 85 year olds and young adults.
326 Performance and Quality Committee – October 2014
Dementia It was highlighted that the targets may have been set too high and that there may need to be a reduction in targets. It was agreed to look at the number of patients referred but not taking up the offer of memory clinic and their reasons for declining the service. Friends and Family Test (FFT) The Whipps Cross FFT score recovered in August (82) from the sharp fall in in June (29). The large fall in the FFT score in June was due to a large number of negative responses with relation to A&E. C.Difficile Although within trajectory looking at BH year end there could be over 71 cases across Barts Health. Current level being 39 cases 6 months in.
Risk implications If not the quality and performance of provider services are not effectively monitored and managed to reduce risk and meet targets then this could lead to: • Some patients not receiving the quality care WFCCG commissions and therefore have a poor experience and risk of harm
• Inhibit WFCCG from achieving its corporate objectives
• Reputational risk
Financial implications None identified within the report.
Equality analysis Equality impacts are identified in the individual reported risks.
Other committees/groups, including the CCG Reference Group and Rapid Feedback Group (Please include detail of when the group were involved and in what capacity) • WFCCG Performance and Quality Committee
327
Performance and Quality Committee Meeting
Date: Wednesday 8 October 2014
Time: 11.00am – 13.00pm
Venue: Boardroom, Kirkdale House, Leytonstone
Chair: Dinesh Kapoor (DK
Attendees: Alan Wells (AW) Dr Tonia Myers (TM) Helen Davenport (HD) Lorraine Smailes (LS) Justin Roper (JR) Carl Edmonds (CE) Les Borrett (LM) David Willmott (DW)(CSU) Annetta Toudji (AJ) CSU Sue Maughn (SM) (CSU) Enrico Panizzo (EP) CSU Diane Clements (DC) James Driver (JD)
Apologies: Dr Mayank Shah (MS) Korkor Ceasar (KC)
Agenda items 1.0 Welcome and apologies DK
The chair welcomed attendees and noted apologies.
2.0 Declaration of interest register DK
Declaration of Interest (DoI) recorded. No amendments
3.0 Minutes of last meeting and matters arising. DK
It was requested from the last minutes that Whipps Cross Clinical Forum minutes will be brought to this committee. HD explained that only draft minutes will be available when the committee takes place. It was agreed that draft minutes will be included within the monthly papers going forward. Agreed minutes can be found on the shared drive. There were three outstanding actions in relation to Mental Health that JR is required to action. • A progress report to be completed on how follow up treatment is managed to include information regarding low referral rates
328
Meeting notes and actions Performance and Quality Committee Wednesday 8 October 2014
• IAPT information to be communicated to GPs. A mystery shopper to be arranged in relation to referral process. • Contact Psychiatric Liaison to understand if they can assist the referrers in completing a self-referral including whether there are other options in making a self-referral. AT provided the figures of children with respiratory conditions admissions over the last quarter. A comparison was requested against last year’s figures. A deep dive was requested to take place to understand the delay in results. DW advised this has not yet been carried out due to issues around a possible risk which has been on- going since June 2014 where MCVs with GPs in Waltham Forest are not being approved. HD advised that this is not acceptable as other boroughs are not having the same issues. HD will be picking this up at Clinical Quality Review Meeting (CQRM) and Whipps Cross Clinical Forum. The next step would be for an SPR and contract query notice to be issued. DW will pick up the outstanding action and report back in next 2 weeks.
Actions Deadline Owner
GP Alert system to be discussed at locality meetings. JR to 30 October JR follow up with Holly Carey. 2014
Whipps Cross Clinical Forum draft minutes to be included within 3 November DC committee papers 2014
Mental Health outstanding actions to be completed. JR to speak 22 October JR to Chris Soltysiak. 2014
Respiratory condition admission figures for children to be 6 November AT compared to last year 2014
A deep dive report to be carried out on 6 patients, 2 from each 24 October DW locality to assist the committee with understanding the reason for 2014 delays.
Future meeting dates to be discussed going forward from 6 November HD/DK/DC February 2015 2014
4.0 Chair’s Report
DK provided chair’s monthly report. Whipps Cross Clinical Forum – 10 September, DK spoke in relation to on-going GP complaints where no response has been received from Barts Health (BH). Paediatric beds – A time line has been requested. This was also discussed at BH CQRM along with GP Alert systems. The first CCG AGM took place on Wednesday 24 September and was noted to be a positive and successful meeting. Performance and quality questions raised by the public were resolved by the CCG staff to the public’s satisfaction. DK attended the Leabridge Ward Meeting, Wednesday 1 October. HD advised the committee that obstetricians and midwives presented the very positive outcome of the Induction of Labour pilot at the Whipps Cross Clinical Forum. Caesarean section rate at WX site is now one of the lowest in London.
329 Page 2 of 6
Meeting notes and actions Performance and Quality Committee Wednesday 8 October 2014
5.3 Cancer – Breast one stop clinic at Whipps Cross SM
It was agreed that Cancer will be a standing agenda item. SM presented the position paper around Breast Triple Assessment Clinic at Whipps Cross. The trust has put together a proposal for Waltham Forest Clinical Commissioning Group (WFCCG) to consider. SM explained the proposal in detail and asked if the CCG would be happy to divert patients to the BH site? HD explained that it was inappropriate for Barts Health to request the CSU to communicate the proposal on their behalf. JD confirmed that a meeting took place in May with the London Cancer Board where the issue of lack of Breast Screening One Stop services was discussed. AW explained that it was unacceptable for this proposal to be accepted when patients were already expected to cope with such a poor service. HD explained that provision of this service is set out in the National Service Framework. HD requested that the formal letter for the proposal be sent directly to WFCCG. SM to action. Discussions took place around the moving of patients to BH site, how do we select which patients are to be moved? Is this a temporary or permanent arrangement? HD requested that the risk be assessed and documented on the CCG Risk Register. HD and LS will carry out a quality assurance visit on the Breast screening services at Whipps Cross supported by SM. JD advised that Dr Naheed Khan-Lodhi is the Clinical Director for cancer who should be invited to the next committee.
Actions Deadline Owner
Cancer to be included on agenda going forward November DC 2014
Proposal for changes to breast screening services to be sent October 2014 SM directly to WFCCG
Dr Naheed Khan-Lodhi to be invited to November committee November DC/JD 2014
5.0 Performance LB
EP provided an update on the WF scorecard. The report provides the progress against key performance and quality targets in 2014/15. EP highlighted significant risks Integrated Care – flagged red made active saving but is below target Dementia Diagnosis rate – Not improved, will be taken to Finance Committee Improving Access to Psychological Therapies (IAPT) – Remains a risk. At the end of August there were 196 referrals below target, improvement from June but a risk for Q2. District Nursing – non urgent referrals should be seen within 24 hours. NELFT raised issues considering a target of 95% or 96%. Medication errors – overall improvement in August.
330 Page 3 of 6
Meeting notes and actions Performance and Quality Committee Wednesday 8 October 2014
Positive Paediatric Asthma Cancer 2 week wait figures at 92.7% target 93%. Personal Health Budgets (PHB) achieved plan to make offers. Friends and Family good figures in August. Clostridium.Difficile (Cdiff) remains within trajectory. Referral To Treatment (RTT) – Figures have deteriorated during August with 3 care pathways incomplete.
52 Week Wait – A slightly better position 71 at BH. August 89, 25 of which were Whipps Cross.
Accident and Emergency (A&E) Whipps Cross failed the 95% standard in the last two weeks, where the previous week figures were at 97%. Q2 figures are showing at 92.5%. BH overall 94%. The main reason is bed occupancy. There was a reduction in the length of stay during September but this has now increased back to longer stays, with an increase in over 85 year olds and young adults.
Dementia – EP advised that targets were set higher, which makes it harder for us to reach. There are discussions around lowering the targets already set. HD required clarity on how do we support GPs confirming diagnosis and setting up pathways. TM confirmed the process and explained the procedure that takes place when going through the memory clinic. It was agreed that we need to understand the number of patients referred but not taking up the offer of memory clinic and their reasons for declining the service. Chris Soltysiak, Dementia Lead will action.
AW suggested that the committee should conduct a “deep dive” into each of the Performance Targets to understand the extent of the work the CCG was undertaking and if the CCG could do further work to improve the targets. It was agreed that the next Performance and Quality Committee will focus only on Scorecard. EP and CE will meet before the next committee to discuss who will be invited to the next meeting on 12 November.
Actions Deadline Owner
Understanding patients referred for memory clinic but declining October 2014 CS the service
Performance Scorecard to be reviewed by way of Deep Dive. October 28 CE/EP Responsible staff to be invited to November meeting. CE & EP 2014 to meet ahead of meeting and discuss and invite the relevant staff.
331 Page 4 of 6
Meeting notes and actions Performance and Quality Committee Wednesday 8 October 2014
5.2 Optimising Out Patients Referrals: Peer Review CE
CE presented a report to the committee. The purpose of the report was to demonstrate the positive impact that Peer Review visits undertaken from June until August 2014, is having.
The committee agreed that an update was not required until the second phase had been carried out in 6 months.
6.1 Quality Report DW
DW confirmed there are on-going outstanding issues around Whipps Cross where a meeting with Deborah Kelly took place to talk through strategies and improving works and on-going issues with Accident and Emergency (A&E). DW confirmed the outcomes of the meeting will be circulated to HD.
Friends and Family Test (FFT): The Whipps Cross FFT score recovered in August (82) from the sharp fall in June (29). The large fall in the FFT score in June was due to a large number of negative responses on the A&E part of the survey.
C.Difficile: DW would like to raise this as a note of caution. Looking at BH year end there could be over 71 cases (WELC pod). We are already at 39 cases 6 months in. DW will keep the committee updated with BH performance against target. An annual report is being complied on the last 6 months.
DW confirmed that from month 6 reports will be changing providing more narrative data. Actions Deadline Owner
Outcomes of meeting with Deborah Kelly to be sent to HD October 2014 DW
6.2 Patient Experience Report JW
JR presented the report providing details of the outcome of NHS Choice’s survey. JR will look at the comparison of the mental health hospitals.
Partnership of East London Cooperative (PELC) is not part of NHS Choices. LS advised the committee that she now sits on the PELC Clinical Quality Review Meeting where the issue of patient experience was discussed in great detail relating to NHS Choices. Actions Deadline Owner
Review NHS choices at the Mental Health Hospitals November JR 2014
332 Page 5 of 6
Meeting notes and actions Performance and Quality Committee Wednesday 8 October 2014
6.3 Quality Assurance Visit LS
LS confirmed since the fourth Quality Assurance Visit to Mary Ward at Whipps Cross BH have agreed that the ward will be closed. The closure will be phased as each patient is discharged and each bed will be closed.
The Patients Association Gold Standard Framework project continues. The project lead will attend the Performance and Quality meeting in January 2015 to provide a progress report on the outcome of the project.
Actions Deadline Owner
Invite Patients Association project lead to January 2015 meeting 30 October JR 2014
Details of next meeting: Date: Wednesday 12 November 11am Venue: Boardroom B/C Kirkdale House
333 Page 6 of 6
Item 6.4
Committee Medicines Management Committee Minutes 8 October 2014 Minutes
From Ada Onyeagwara – Head of Medicines Management – WFCSU
Key highlights
Attached are the minutes of the Medicines Management Committee held on 8 October 2014
Key Points for the governing body:
• WF CCG Vitamin D patient information leaflet approved • NELFT Depression pathway approved • Initiated discussion around prescribing indicators for QIPP 15/16 • Options for the provision and access of end of life drugs in Waltham Forest were discussed with plan agreed • GP forums with a focus on dermatology taking place • Agreement to compile a database for drug shortages in Waltham Forest which will be made available to practices • Action plans agreed for the top 3 overspending practices in each locality within Waltham Forest • Pilot in 3 practices agreed to see if reception staff can support GPs in highlighting common ScriptSwitch messages for patients on repeat prescriptions
334
Waltham Forest Medicines Management Committee
Wednesday 8th October 2014 Boardroom, Kirkdale House, 7 Kirkdale Road, Leytonstone, E11 1HP 2:00- 4:00pm Present
Dr. Mayank Shah MS Waltham Forest CCG Clinical Director – Chair
Dr. Thaven Chetty TC Prescribing Lead for Leyton/Leytonstone Consortium
Dr. Imran Kazi IK Prescribing Lead for Chingford Consortium
Dr. Munir Ali Zubair MAZ Prescribing Lead for Walthamstow Consortium
Head of Medicines Management – Head of Medicines Management Ada Onyeagwara AO Team for Waltham Forest
Tunde Ajibola TA Medicines Management Team Administrator Waltham Forest
Depen Gudka DG Prescribing Advisor Waltham Forest Medicines Management Team
Senior Prescribing Advisor Waltham Forest Medicines Management Kay Saini KS Team
Senior Prescribing Advisor Waltham Forest Medicines Management Hassan Serghini HS Team
Mayur Patel MP Local Pharmaceutical Committee Representative for Waltham Forest
Apologies
Dr. Prakash Kawar PK Local Medical Committees Representative for Waltham Forest
Carol Greening CG Assistant Director of Clinical Pharmacy Barts Health NHS Trust
Helen Davenport HD Director of Nursing, Quality and Governance Waltham Forest CCG
335
14/10/01 Welcome and Apologies
The Chair opened the meeting and introductions were made.
Apologies were received from: Dr. Prakash Kawar, Carol Greening and Helen Davenport.
14/10/02 Declaration of interest
There were no conflicts of interest declared for items on the agenda.
14/10/03 Minutes and Matters Arising
The minutes of the previous meeting in September 2014 were approved by the Committee as accurate.
Matters arising:
Following an internal audit of all the MM work streams, the auditors recommended that the MMC actions are RAG rated according to the level of risk they are likely to pose. The committee was advised to discuss and agree a process to ensure consistency in assessing the risk for any actions, which follow the MMC meeting. It was suggested that we adopt a similar process to that followed by the board.
ScriptSwitch – ScriptSwitch responded to an enquiry raised by the committee to allow prescription clerks to be able to view ScriptSwitch messages, when generating repeat prescriptions. In an email communication, ScriptSwitch advised against the proposal by the committee, stating that there are clinical governance risks associated with this arrangement.
The committee felt the initial enquiry had not been fully answered and further discussed this matter and suggested a pilot scheme to assess the impact on the workload in practices, in allowing prescription clerks to be able to view ScriptSwitch messages.
The committee suggested that the locality leads including the chair, will pilot the scheme in their individual practices.
The top 3 missed savings will be identified from the ScriptSwitch practice report. It was agreed that the prescription clerk will inform the prescriber whenever a message relating to any of the three drugs selected for the practice is flagged on the system, whilst generating a repeat script. The prescriber will review the requests and make a clinical decision. The data will be presented at a future MMC meeting for review.
Action MMC 82 – Locality leads and chair to implement pilot scheme
Oral Nutrition Supplement guidance – The committee is not in a position to approve the ONS guidance until the document has been approved at the NELFT Drugs and Therapeutics Committee, in line with the current NELFT governance process.
Review of the action tracker – see attached tracker for full details
MMC 71 - Drug monitoring list developed by BHR CCG – It was agreed at NELMMN to use the drug monitoring list produced by UK Medicines Information (UKMI) as opposed to that developed by BHR CCG.
Page 2 of 6 336
MMC 72 - NELFT PSDs – Final approved versions of the Patient Specific Directions for influenza, pneumococcal and shingles have been hosted on the WF GP intranet.
MMC 74 - CSS Gynaecology overspend – Dr. Khan (Clinical lead for the colorectal and Gynaecological CSS) was presented with prescribing data for CSS Gynaecology for the purpose of reviewing and ensuring that any prescribing undertaken by the service was appropriate.
14/10/04 Vitamin D
• Vitamin D leaflet - MMC approved Patient Information Leaflet subject to amendments pertaining to advice on sun exposure. Following this amendment the document will be sent to the communications team for consultation and approval. Once the document has been ratified, this will be made available to practices via the Waltham Forest intranet.
ACTION MMC 83 - MMC to send document to communications team for approval
• Vitamin D Guidance – Updated Vitamin D guidance was presented to MMC. These draft guidelines are based on NOS guidelines in terms of defining deficiency and insufficiency. It was agreed by the Committee that the draft guidelines will be sent to the rheumatology department based in Barts Health. All comments will be collated and presented back to the MMC at a later meeting.
• Vitamin D products - A draft document was presented to the MMC outlining the various vitamin D products that are available on the market. There was discussion around the legalities of prescribing unlicensed vitamin D over licensed products. The committee agreed that prescribing of vitamin D should not be encouraged for maintenance therapy. However, where there was a clinical justification, GPs would have access to all the information at the point of prescribing to make an informed decision. Switching all current Valupak vitamin D prescribing over to the licensed products would act as a cost pressure against the prescribing budget.
14/10/05 End of life Care
• A document produced by Emma Tempest (Palliative consultant), in collaboration with Dr. Munesh Mistry and Dr. Mary Crowe (End of Life GP leads) was presented for review and approval. The MMC agreed to the proposal of commissioning a service to provide End of Life Care drugs.
• Four proposals were presented to the committee which include the following:
1. Access via GP out of hours (PELC). Currently, PELC has a link to a pharmacy in Waltham Forest that holds the necessary drugs.
2. Access via hospitals – drugs will be made available via local hospitals.
3. Via community pharmacists – A service commissioned via a number of community pharmacies in Waltham Forest.
4. Drug box which will contain drugs for a planned discharge.
Page 3 of 6 337
The various options were discussed by the committee and it was agreed that options 3 and 4 were fit for purpose. These options would be explored further and detailed in a document that will be presented to the MMC in a future meeting. The MMC were open to the possibility of sponsorship from external organizations such as The Macmillan foundation.
ACTION MMC 84 – MMT to prepare and present detailed document at a later MMC
14/10/06 Finance • Dashboard
July 2014 data was presented to the committee. Indicators that were not yet delivering savings as expected were identified as the following: laxatives, wound dressings, respiratory and oral nutrition. In order to support practices in these areas the following actions have been implemented.
− Laxatives – guidelines were approved at the last MMC − Wound dressings – wound care formulary was launched in September − Respiratory - TEVA presented an early draft of a poster on inhaler devices to support practices in selecting the most appropriate devise when reviewing inhaler technique. The MMT are further exploring other educational material in supporting practices with asthma reviews. − Oral Nutrition – being highlighted at current GP forums.
Budget
A breakdown of the Month 4 savings data was presented to the committee. The report shows that at Month 4 there is a forecast underspend of £413k while the QIPP savings are half of what was expected at M4 - work is underway to address this issue − QIPP delivered savings of £49k for M4
− Savings from the rebate schemes registered to will next be available in December Year to Date savings are £258,590 which shows that we are ahead of our forecast YTD savings of £210k. The MMC was informed of potential cost pressures coming from the Cat M changes.
• QIPP
QIPP ideas – A summary of potential QIPP ideas for 2015/16 was presented and discussed with the committee. MMC asked that the list be brought back to the committee for a full discussion after it has been discussed at the GP locality meetings.
Branded generics list - also to be brought back to MMC for a full discussion.
Feedback from Stoma meeting – MMT had a meeting with the stoma nurses at Whipps Cross that provide a service to patients in Waltham Forest. The current service was reported to be robust and managed well with two nurses that cover Waltham Forest. Following on from the meeting, prescribing data relating to stoma will be analysed and anomalies will be discussed with the stoma team, who will then advise about appropriateness. The committee requested that the practices in Waltham Forest provide an up to date list of all patients
Page 4 of 6 338
registered at the practice receiving prescriptions for stoma, in order to ensure the stoma care team have reviewed these patients.
Budget
CSS service reports – Summary of CSS and CHS month 3 service report was presented to the committee. Breakdown of the CSS service report shows that CSS gynaecology service is currently overspent by 151%. This has been escalated to the contracts team for review. The clinical lead for the service has also informed the MMT that a review of their prescribing is underway to address the issues and to review the possibility of a formulary.
ScriptSwitch – ScriptSwitch report for September 2014 was presented to the committee. Total savings of £29k was generated from ScriptSwitch in September, of which £4k has been already reported via savings made on the dashboard.
The offer rate for acute prescribing was 10.61% which was higher than the National offer rate 8%. Acceptance rate for Acute was 29.76% which was lower than the national acceptance rate of 28%.
Offer rate for repeat prescribing was 11.48% which was higher than the national offer rate of 9%. The repeat prescription acceptance rate was 16.15% which again was lower than the national acceptance rate of 28% but was higher than last month’s repeat acceptance rate of 13.99%.
A list of the top 10 missed savings was presented to the MMC.
14/10/07 JPG
• Jaydess (levonorgestrel 13.5mg) - A new intrauterine delivery system that can be used to provide long-acting reversible contraception for up to three years has been added to the formulary at Barts Health.
• Headache guidelines devised together by the neurological team was presented for comments. The guidelines include various unlicensed treatments used for the treatment of headache. There were shared care guidelines included in the document to support the prescribing of each drug in Primary Care. The committee expressed reservations about recommending unlicensed treatment/ products to their GP colleagues.
14/10/08 NELMMN
One of the objectives of the NELMMN advisory group was to produce a unified formulary across all the sectors. It was agreed in the early discussions that both inner London and outer London would be involved in devising the formulary. Outer London CCGs have agreed to be involved in this piece of work, however are not willing to contribute equally in terms of the funding towards this project. The Committee discussed the options going forward and agreed that there is value in ensuring that Outer London CCGs are still involved in devising this formulary. However, it was recommended that the finance team at Waltham Forest further explore the reason as to why there has been an unequal split of funding contribution towards this work stream.
Page 5 of 6 339
14/10/09 NELFT
Depression pathway was presented and approved by the MMC.
14/10/10 LPC update
Colecalciferol complaint – The MMT received a complaint from a GP whereby he prescribed Hux D3 for a patient and the pharmacist dispensed a different brand of Colecalciferol. MMC have requested for more information to be able to investigate this matter further.
ACTION MMC 85 – MMT to investigate further
Database for drug shortages – At the last GP forum, the issue of out of stock medicines was raised and it was requested that the MMT devise a mechanism of communicating drug shortages to the practices. The LPC representative is to forward information that pharmacists receive to assist the MMT to inform prescribers of current out of stock medicines.
ACTION MMC 86 – LPC rep to forward drug shortage list to MMT
14/10/11 LMC update
There was no update given.
14/10/12 NICE update
One clinical guideline on bipolar which is to go to NELFT DTG.
14/10/13 AOB
• Medication error reporting - The MMC are still awaiting information for medication error reports from Barts Health. • 7 day prescriptions – It was reiterated that 7 day prescriptions are only going to be issued if there is a clinical need deemed necessary by the prescriber. The Committee advised that pharmacists should not insist on 7 day scripts and should be providing a compliance aid to a patient, where there is a clinical need as part of the Disability Discrimination Act specified in the Pharmacy contract.
Date of next meeting: Wednesday 12th November 2014 Boardroom, Kirkdale House, 7 Kirkdale Road, Leytonstone, E11 1HP 2:00- 4:00pm
Page 6 of 6 340
Item 6.5
Committee Planning & Innovation Meeting 8 October 2014 Minutes
From Alan Wells, Chair of the Committee - WFCCG
Key highlights Diabetes Strategy & Care Pathway
The correct version of the pathway would be circulated. It was confirmed that Dr Davison would be providing expertise and a letter would be sent to GPs outlining clear criteria to refer patients. It was agreed that the pilot BC (Business Case) should state that all concerns have not been addressed. The Committee were happy to give their approval in principle, subject to approval from Finance & QIPP, and dedicated project manager would be included as part of the business case.
Colorectal Business Case
The Committee wanted a change to the referral criteria and the first appointment/straight to test, and were happy to support the BC with the above changes.
Childhood Immunisation Quality Improvement Scheme
The Committee were happy to agree the scheme in principle but note the concerns if the networks are unable to implement the scheme. JM would lead on this scheme.
Obesity Tier 3 Services
There was concern that the services would be provided in 2 locations rather than 3. The Committee wanted to know the cost involved if there were 3 locations, or if it is to be only 2, then they would like to ask for 1 of them to be in a particular location. If joint procurement takes place with Newham, WF patients could go to locations in Newham that might me more convenient.
Sickle Cell Services
An investment of £122k would increase nursing, increase GP sessions from 3 to 5. Approval was given to invest and take the service out of CSS and have it as part of the NELFT contract. The Committee were happy to approve, the BC should go to the Finance & QIPP for funding approval.
341
Action Log Planning and Innovation Committee Date: 08.10.14 Time: 16:00 – 18:00 Venue: Kirkdale House, Board Room B&C
Chair: Alan Wells
Attendees: Apologies:
Anwar Khan Ian Clay Abdul Sheikh Naheed Khan-Lodhi Tonia Myers Caroline Gilmartin Mayank Shah Syed Ali Dinesh Kapoor Jane Mehta James Driver Munir Ali-Zubair
Agenda Item Action Required Person Date to be Responsible completed DK/AK Topic 2 Terms of Reference & Membership Minutes of last meeting / DK confirmed it was the ToR for CEPN that he had Matters arising requested from AK. AK informed the meeting that the September 2014 ToR are still evolving and they agreed to take the discussion outside of this meeting.
The minutes of the last meeting were agreed.
Topic 3 AW commented that the draft paper was not up to Diabetes required standard. CG confirmed that it had been Strategy & Care revised, the correct version of the pathway would be CG Pathway circulated.
CG tabled an updated front sheet. She suggested dedicated project management. There is an underinvestment in diabetes. Final version to go to P&I for clinical aspects and F&Q for finance sections to be approved.
CG asked the Committee to approve the tiered approach for diabetes and for a pilot.
It was confirmed that Dr Davison would be providing expertise and a letter would be sent to GPs outlining clear criteria to refer patients.
342
It was agreed that the pilot BC should state that all concerns have not been addressed. Next F&Q and P&I The Committee were happy to give their approval in Committee principle, subject to approval from F&Q, and dedicated Meetings project manager would be included as part of the business case.
Topic 4 AK declared his interest as he is a community provider Colorectal of this service. AW confirmed he didn’t need to leave Business Case the room.
AK clarified that we do not pay twice for referrals and that when patients are seen with suspicious symptoms, the colonoscopy is carried out and there is no delay.
JD to check PDR data for the cost of the straight to test pathway. JD
The Committee wanted a change to the referral criteria and the first appointment/straight to test, and were happy to support the BC with the above changes.
Topic 5 The CDs were advised to declare an indirect interest in Childhood this topic as they were part of networks who would Immunisation benefit from this scheme. AW advised they were Quality allowed to take part in the discussion. Improvement Scheme AK questioned how the risks would be mitigated if Networks were not set up in time, and would like to see a view on how to implement the scheme this year.
SA informed the meeting that the 95% target is difficult to reach as Eastern European patients are immunised in their own country.
DK would like to see the local authority public health/CCG joint plan.
The Committee were happy to agree the scheme in principle but note the concerns if the networks are unable to implement the scheme. JM would lead on JM this scheme.
Topic 6 There was concern that the services would be provided Obesity Tier 3 in 2 locations rather than 3. The Committee wanted to Services know the cost involved if there were 3 locations, or if it is to be only 2, then they would like to ask for 1 of them NK to be in a particular location.
If joint procurement takes place with Newham, WF patients could go to locations in Newham that might me more convenient.
343
The Committee were happy to support in principle.
Topic 7 There were issues of the service contract for this Sickle Cell service being out of date, and there was no clear line of Services supervision. These issues are being addressed. The business case seeks to invest in the service. If patients are seen in the community there will be saving as less would be seen in emergency. An investment of £122k would increase nursing, increase GP sessions from 3 to 5.
Approval was given to invest and take the service out of CSS and have it as part of the NELFT contract. Next F&Q The Committee were happy to approve. The BC should CE Committee go to the F&Q for funding approval. Meetings
Topic 8 • SA informed the Committee that the Diabetic UK AOB day had been excellent.
• JM informed the Committee that the 5 year business plan would be on the agenda from the next meeting.
344
Item 6.6
Committee Finance and QIPP Committee – October 2014 Minutes
From Peter Brokenshire, Chair of Committee - WFCCG
Key highlights
• The M5 forecast QIPP savings have improved from £9.1m to £9.4m against a plan of £10.4m.
• At the end of M6 Waltham Forest CCG is forecasting a year-end surplus.
• The committee approved a £250k investment proposal to improve the dementia diagnosis rate in Waltham Forest.
• The committee approved a £70k investment to review high cost continuing healthcare patients with a view to identifying potential inefficiencies.
• The committee approved a business case for a Tier 3 Weight Management Service. The CCG procurement panel is to decide on route to market.
• The committee made a number of recommendations related to a proposal for extended primary care from FedNet and proposed that the business case be considered at the November Governing Body meeting.
345
Meeting Finance and QIPP Committee Date and time 14.10.14 Boardroom B&C Kirkdale House 12.30-2.00pm Chair Peter Brokenshire (PB) Attendance: Les Borrett (LB), Dr A. Sheikh (AS), Sharon Yepes-Mora (SYM), Ian Clay (IC), Jane Mehta (JM), Brenda Pratt (BP), Enrico Panizzo (EP),
Dr.S. Ali (SA), Apologies: In attendance: Natalie Keefe (NK), Chris Soltysiak (CS), Dr Paul Russell (PR), Nuzhat Anjum (NA), Dr Sanjoy Kumar (SK), Vijay Bagga (VB)
Action Points Agenda item Action Who 1. Notes of last Agreed. meeting and matters
arising
2. Month 5 QIPP EP presented the M5 QIPP report to the members. report The overall forecast savings have improved from £9.1m to £9.4m. This reflected improved actual performance on integrated care and an improved position on Barts Health productivity. Integrated care forecast had been improved to £2.1m. BP noted there was some risk that savings reduce over winter. EP noted that a number of smaller projects had reduced forecasts due to delayed implementation, including Ambulatory Care, CSS, Health Coaches, Pathology Duplication, but that these should deliver savings later in the year and into 2015/16. 3. Month 6 Finance LB presented the finance report to members. Despite Report QIPP gap the CCG is forecasting an improved
financial position, with a predicted surplus of £7m.
The key risk remains data quality from Barts Health and the fact that whilst the Barts Health against Waltham Forest CCG has improved and is almost break-even, Tower Hamlets are forecasting an £8m over-performance. LB noted that there was a disjuncture between the CCG financial position and CCG performance and that options were being considered to spend non- recurrent money to improve performance against priority targets. 4. Dementia CS and PR presented a proposal to improve the Investment Proposal diagnosis of dementia in Waltham Forest and to enable the CCG meet its performance target of 67%. Approximately an additional 250 patients need to be identified. The proposal was for non-recurrent 1
346
investment to support GPs identify patients and update their registers as well as recurrent investment to increase capacity at the memory service and to commission support from the Alzheimer’s society. Total proposed investment was for £250k. The committee approved the proposed investments. 5. CHC Assessments KH presented the proposal for £70k investment in a targeted review of high cost patients. KH noted that the review process would be around two months. The committee approved the investment proposal. 6. Tier 3 Weight NK presented the business case. NK confirmed that Management the activity figures were based on best estimates of eligible patients and that there were not many examples of similar services nationally. It was noted that the £230k proposed investment was an indicative figure and that the procurement process would determine the market price. The committee approved the business case. It was agreed that the CCG procurement panel would decide on the best route to market. 7. Extended Primary SK and VB presented the extended primary care Care proposal. The proposal would offer more GP
appointments and the scope for longer appointments. Access to primary care is a local and national issue. LB highlighted a requirement for greater clarity regarding the phasing of the activity plan from commencement assuming that it would take some time in order to generate awareness and demand. LB also requested clarity about how financial risks would be shared between the CCG and the network in the event of activity levels below plan. This might take the form of some options depending on various activity scenarios and how payment would be linked to activity. LB requested assurance that registration with the HSCIC would not delay implementation of the project. VB noted that this was not a requirement for choose and book but agreed to check. JM requested further evidence for the stated activity assumptions which would help assess the potential risks around planned activity levels. It was agreed that there was scope for joint work regarding potential pre-launch communications strategies.
IC queried the additional clinical benefit of the extra 1.5hrs to be offered during weekdays and noted the risk that practices may reduce their opening hours. SK confirmed that part of the project would be to
Page 2 of 3
347
review operating models at the 3 month stage to ensure that they fit around demand and convenience
for patients.
There is a need to monitor attendance by practice at the hubs. SK agreed that the collaborative has a role to challenge each practice’s attendance patterns, the
the system is not affordable if duplicating payment.
LB queried how FedNet would employ staff and SK confirmed that they have specialist advice and would use a company to issue contracts but would have to honour contractual rights.
FedNet will employ local GPs with local knowledge and anecdotally have tested the market and there is a strong interest from GPs and receptionists in posts. VB stated that NHS Property Services have committed to make St James Health Centre fit for purpose by December however the CCG requested further assurance. PB questioned the impact on the urgent care procurement. JM advised that it has been flagged up as part of the procurement and the expectation is that the pilot will take out of the urgent care pathway patients who should be seen in primary care.
The pilot will be included in the 111 directory of services. Although supporting the pilot in principle, it was not approved by the Committee, as there were still unanswered questions that need to be resolved including the ramp up and phasing of the pilot, funding and the financial risk share. The proposal will be determined at part two of the October Governing Body. A formal business case will be presented at the November Governing Body meeting. JM The CCG will write formally to FedNet in response to the proposal setting out further questions and suggestions. The letter is to be sent by close of play Thursday 16 October. FedNet to respond in full by JM Monday 20 October.
The response will inform the paper that will be tabled JM / LB at the Governing Body and presented by LB.
8. QIPP 15/16 project SYM reported that there is slippage on the plan submission of investment proposals and business cases for 2014/15 QIPP schemes. The project plan is managed by the QIPP Planning Working Group. 9. Any Other Business None. 10. Date of next 19 November 2014 – 12.30 to 2.00pm meeting
Page 3 of 3
348
Item 6.7
Committee October IT Committee Minutes Minutes
From Dr Mayank Shah, Chair of Committee, WFCCG
Key highlights Additional funding for IT Agreed to draw up outline of proposals for IT to take to CCG Board. Emis Implementation Rollout to 11 out of 12 practices completed last practice being rolled out to today 15/10/14 (making 26 out of 45 practices, 58% list size, on Emis Web) Vision / SystmOne to Emis Web migration - Agreement from 7 practices to migrate early (before ‘connectedness’ decision Sept 2015 - 5 Vision, 2 SystmOne) Leaving 11 remaining practices (8 SystmOne, 3 Vision).
2 way connection to Barts - MIG / HIE Project manager (James McLintock) has started - First workshop for all key parties planned 22 October to confirm requirements.
Top 13 IT Improvements – GP IT review visits Rachel Reynolds is visiting practices and looking at the ‘As Is’ IT position of each practice in relation to contractual obligations (online patient access and GP2GP) and Top priorities highlighted by GPs, identifying training requirements and getting action points – 14 practices visited to date. Summary Care Record One of the interdependencies for 8am – 8pm extended GP services is use of SCR for those home practices not on Emis Web - Great progress from Christine CSU – of 12 practices that needed SCR switched on, now only have 5 Practices (1 Microtest, 3 SystmOne, 1 Vision) not switched on – meetings / training for these is arranged.
Pathology – requesting tests and receiving results electronically Project slipped by a month, 1 practice (Lyndhurst) has got through proof of concept. Queens Road medical centre – wrong information at tquest – Chingford medical practice NELFT firewall – can’t connect – tquest and NELFT issue. Will do another 3 pilots – as not confident to roll out remotely.
Information Governance Risk Reduced risk from red to amber Protocol document issued for review and comment.
Communications and Engagement Information relating to IT strategy published on website.
349 Good News Story drafted, members to review, then it will be published on web site.
Business Case for further Migration to Emis Web Moving non-Emis to Emis Web is significantly more complex than Emis LV or Emis PCS to Emis Web – there are additional costs for migration for document management migration – peripherals such as patient call in and patient check in Criteria for the Sept 2015 decision agreed. Document Management 3 levels of sophistication for document management exist – Emis web – scanned in and filed against patient record – Systmone – bit OCR & read coding – Docman Intellisence – more functionality A number of issues were raised during migration to EMIS Web. Agreed that a costed business case is to be produced for November IT Committee to consider.
350 IT Committee Notes and Actions
Venue: Board Room, Kirkdale House; Date: 15th October Attendance Chair: Dr Mayank Shah (MS) Clinical Director, Dr D Kapoor (DK) Clinical Director, Alan Wells OBE (AW) Lay Member, Les Borrett (LB) Director of Financial Strategy, John Higton (JH) Prederi, Gary McGuinness (GM) GP IT Service Manager CSU, Carl Edmonds (CE) Dept Director of Commissioning, Nina Worley (NW) Prederi, Dr Phil Koczan (PK) GP Advisor, David Pearce (DP) Head of Governance, Joan Fratter (JF) Patient rep/WF resident, Natalie Keefe (NK) Senior Commissioning Manager, Philip Woolley (PW) GP IT Support Manager, Chloe Davies (CD) Business Support Officer, Bhagi Shah (BS), Prederi
Apologies: none received
Actions from last meeting: • JH spoke to John Sadler who is working on inventory of what GP practices have in place to enable NHSE to see how are doing regards to patient online requirements JH working with JS and a number of CCGs • Anglia CSU can support SystmOne training in WF, will be a group session – Action: DK to inform SystmOne user group. May have to reciprocate with some CSU EMIS training • MS had spoken to Drs Thaven Chetty and Amish Patel – both amenable to joining online patient access group / being ‘Digital lead’. Action: NW to set up initial meeting • Choose and Book: NK noted date has been deferred to spring, practices have been notified • Handsworth practice needs to take new hardware to allow for software upgrades and seek assurance from builders that it won’t be damaged. Action: GM to inform the practice • GM confirmed that drives will be securely wiped – a certificate will be provided.
Key points, updates, issues raised, debated and challenged
Agenda item: additional funding for IT brought forward
• AW keen to invest further in supporting migration to EMIS, could be capacity issues within practices – discussion around possible options for investment, NW noted practices wanted to move next financial year – after QOF. • Suggestion to bulk buy training for next year, although auditors would not be keen • Suggestion to move practices on NELFT network on to dedicated N3 connection Action: JH to lead on drawing up outline of proposals for MS to take to CCG Board.
IT strategy implementation update
• NW – 11/12 practices have rolled out, last going today.
• Manor Practice, consider migration to run April –June, issues preventing immediate migration:
351 o Microtest MD queried whether CCG could force a practice to change software – referred to BMA and HSCIC waiting to receive copies of emails
o Current issue Microtest not hosted – planned for end Q1 2015
o Microtest working with healthcare gateway – for MIG accreditation in next couple of weeks.
Vision / SystmOne to Emis Web migration
• Agreement from 7 practices to migrate early
o 5 Vision, 2 SystmOne (Lyndhurst Vision 11/12, Churchill Vision Mid April, Queens Road SystmOne end April, Dhital SystmOne Early May, Hampton Vision Mid May, Bailey Vision End May, Higham Hill Early June)
o Scheduled in 3 per month from April – as per first phase rollout 2 led by CSU one by Emis (free of charge) - next slot now mid-June
o Remaining practices (11 - 3 Vision, 8 SystmOne) One practice having a demo and another verbal request but not followed up (one each SystmOne Handsworth & Vision Green Man)
• Updated Business case with costs and decision criteria for Sept 2015 on agenda.
Barts MIG / HIE
• PM started – James McLintock – reporting into NK and CE
• First workshop for all key parties planned 22 October to confirm requirements
• This morning attended Barts / Healthcare Gateway MIG potential developments – considering using the MIG to deliver clinical documents directly to the GP system and development of the MIG to share care plans – come back to this in document management agenda item
• Attending MIG / HIE Steering group Friday.
Summary Care Record
• One of the interdependencies for 8am – 8pm extended GP services is use of SCR for those home practices not on Emis Web
352 • Great progress from Christine (CSU) – of 12 practices that needed SCR switched on, now only have 5 Practices (1 Microtest, 3 SystmOne, 1 Vision) not switched on:
o 2 have met with Christine and agreed to switch on SCR – just need to agree a date
o 1 meeting booked to discuss and agree a date
o 1 PM off sick – Ecclesbourne – SystmOne
o 1 Manor practice with wider issues.
GP IT Reviews
• Rachel visiting practices – informing them of obligations, identifying training requirements and getting action points. Most are happy with Saxon.
• DK noted EMIS online help is frustrating. GM advised there is an Emis national user group meeting which he attended and EMIS also have issues with their online help – and will be re-launching online help and search engine.
Roll out of lab tests – Pathology
• NK: project slipped by a month, 1 practice (Lyndhurst) has got through proof of concept. Queens Road medical centre – wrong information at tquest – Chingford medical practice NELFT firewall – can’t connect – tquest and NELFT issue. • NK noted Newham also experiencing problems. • Meeting Monday CCG, CSU, Barts network team, Barts project manager. • Will do another 3 pilots – as not confident to roll out remotely.
IG Risk update
• Reduced risk from red to amber • Protocol document issued for review and comment • Waiting for LMC – chased – might need some help to escalate • We had set up an information sharing group to progress – one more meeting and then close • Using NHSE proposed sharing agreement template (for tier 2 data sharing documents for MIG, Integrated Care and Networks) • Agreed: to reduce this risk from 16 to 8 • Action: NW to update the risk log.
353
Communication/ Engagement update
• Information published on website. Action: JF to give feedback offline. • Separate paper issued at meeting – Good News Story, members to review Action: All - Feedback comments to NW offline – then it will be published on web site.
Business Case for further migration to EMIS Web
• Costs projected for migration £341k, following experience of migrations so far and lessons learnt, we now know more about technologies – MIG, DTS, Tquest and minor changes around GPSoC budget for next financial period projected £411k
• Moving non-Emis to Emis Web is significantly more complex than Emis LV or Emis PCS to Emis Web – there are additional costs for migration for document management migration – peripherals such as patient call in and patient check in
• MIG and Barts and Cerner – still other uncertainties – moving to greater complexity – MIG information sharing – Therefore Bhagi proposed that we put some contingency of 10% above the £411k to cater for some unknowns increase to £450k next financial year
• For the Sept 2015 decision - We need to ensure that the test is for product based decision – capability – significant improvement in connectivity and reduce risk;
o Have to work off the shelf – proper service level agreement, helpdesk, has to be a commercial product – need to go through an assurance test with HSCIC
o Choice we make should help us improve clinical care – training and user groups
o Products must be additive – must be layered what other functionality we will have available.
• Agreed: criteria
• Action: DK would raise at SystmOne user group
Document Management
GM: 3 levels of sophistication for document management, number of issues raised during migration to EMIS Web:
o Emis web – scanned in and filed against patient record
o SystmOne – bit OCR & read coding
354 o Docman Intellisence – more functionality • All vision practices use docman (as Vision doesn’t have internal document management) – can continue to use docman – or they can move away and use native Emis - £3k one off cost • Agreed / Action: A costed business case to be produced for November IT Committee Nina / Gary • Agreed to include MIG potential functionality for sending Barts letters within the business case as this is the preferred option for the future • Need to ensure that the CCG position regarding who is picking up cost and ongoing costs • Need to talk to Emis re their element of the £3,000 cost (£1,500) • Action: GM to contact Emis • Need to understand the functional differences separate from the costs • Need to recognise if the practice did make an investment initially • Docman – licence fees • Agreed: CSU Phil Woolley - to do what is pragmatic for sites, that have recently migrated to Emis Web that are having document management issues, whilst waiting for the strategy.
AOB • Should there be patient representative on Implementation group –Action: LB to take to implementation group next Tue • PC hardware rollout 35 done 13 outstanding – scheduling around go live for Emis Migrations
• Action: Natalie – where are we with approval for Allum check in and call in order as they have successfully gone live with Emis Web today – feedback to Phil
• Action: Issue with security – need something from the CCG – medical students and school leavers – Phil Woolley to draft something and be issued for CCG • A GP has sent an email to a number of other GPs – inappropriately criticising Saxon – we need to protect the practice and supplier - Action: Nina take to IT Implementation group as an action to draft a reminder of email etiquette and who should be contacted in the first instance if there are IT problems
• Patient’s access to records – how many switched on – information was in the last IT committee pack in the CSU quarterly update – and also will be in the response after Rachel has completed visits.
355 Action Lead Timeline 1. Inform SystmOne user group of training opportunity DK 21.10.14 2. Invite Drs Chetty and Patel to initial meeting for online access NW ASAP group / Digital 3. Update Handsworth practice re new equipment GM ASAP 4. Proposal seeking further investment to support IT strategy JH 20.10.14 5. IG risk re-scored – update risk register NW 19.11.14 6. Feedback offline to NW comments on IT communications on JF 24.10.14 website 7. Send feedback on comms/engagement paper – good news All 24.10.14 story 8. Migration to EMIS- business case criteria to be added to DK 21.10.14 SystmOne user group agenda 9. Document management - costed business case to be GM 19.11.14 produced for IT Committee 10. Contact Emis re their element of the £3,000 cost (£1,500) for GM 19.11.14 migration of documents 11. Should we have a patient rep at implementation group/ group LB 21.10.14 membership 2014-15 12. Update on Allum check in and call in order – feedback to PW NK 21.10.14 13. Draft detailed comms on governance issues due to medical PW 31.10.14 students and school leavers using clinical systems 14. Draft comms on email etiquette PW 21.10.14 15. Update on patient access online – next quarterly update Dec GM 17.12.14
Next meeting: 19th November 15:30, Board Room, Kirkdale House
356
Item 6.8
Committee Walthamstow Locality Commissioning Meeting – October 2014 Minutes
From Dr A Sheikh, Clinical Director - WFCCG
Key highlights
• Improving referral or uptake of services for:
- Health Checks
- Substance Misuse
- IAPT
- Retinal Screening
- Dementia
• Primary Care Strategy
• WFCCG Borough Summary Report
• WGCCG QIPP Report
• Clinical Director updates
- Urgent Care / Cancer - Optimisation Referral Scheme - CSS - IT Report - Prescribing
357
Item 6.9
Committee Leyton-Leytonstone Locality Meeting – November 2014 Minutes
From Dr Syed Ali, Chair of Locality, WFCCG
Key highlights
• Clinical Director Update:
- Dr Syed Ali provided an update on CVD and Diabetes - Dr Dinesh Kapoor provided an update on Performance and Quality - Dr John Samuel provided an update on mental health
• Month 5 QIPP and Borough Report
• Estates Strategy
• Commissioning Intentions
• Patient Participation Groups
• Voluntary Targeted Services for First Time Mothers
• Barts Health Pathology Issues.
358
Item 6.10
Committee Chingford Locality Commissioning Meeting – November 2014 Minutes
From Dr Tonia Myers, Clinical Director - WFCCG
Key highlights
• Family Nurse Partnership- Voluntary targeted service for first time mothers
• Bart’s Health Pathology issues
• Commissioning Intentions summary
• Patient Participation Groups (PPGs)- Feedback on how to make these more effective from members
• WFCCG Borough Summary Report
• WFCCG QIPP Report
• CCG/ Clinical Directors update
- Dementia Identification Scheme
- Flu jabs- Increasing uptake
• Update on Networks
359 Governing Body forward plan - November 2014 to September 2015 (Standard items are in blue) 26/11/2014 28/01/2015 25/02/2015 25/03/2015 27/05/2015 24/06/2015 22/07/2015
GENERAL BUSINESS GENERAL BUSINESS GENERAL BUSINESS GENERAL BUSINESS GENERAL BUSINESS GENERAL BUSINESS GENERAL BUSINESS Chair's update Chair's update Chair's update Chair's update Chair's update Chair's update Chair's update Questions from Members Questions from Members Questions from Members Questions from Members Questions from Members Questions from Members Questions from Members and Public and Public and Public and Public and Public and Public and Public GOVERNANCE GOVERNANCE GOVERNANCE GOVERNANCE GOVERNANCE GOVERNANCE GOVERNANCE BAF BAF BAF BAF BAF Communications Annual Report Committee Annual Report Better Care Together (formerly ICB) ToR
IG Update IG Toolkit FoI Update PERFORMANCE AND PERFORMANCE AND PERFORMANCE AND PERFORMANCE AND PERFORMANCE AND PERFORMANCE AND PERFORMANCE AND QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY P&Q Report P&Q Report P&Q Report P&Q Report P&Q Report P&Q Report P&Q Report Annual Safeguarding Annual Public Health Children Report Report Annual Report CHC
Annual LAC Report
FINANCE AND QIPP FINANCE AND QIPP FINANCE AND QIPP FINANCE AND QIPP FINANCE AND QIPP FINANCE AND QIPP FINANCE AND QIPP Finance Report Finance Report Finance Report Finance Report Finance Report Finance Report Finance Report Second draft 2015/16 First draft 2015/16 budget budget 2015/16 budget Better Care Fund - S75 Annual Report IFR STRATEGY AND STRATEGY AND STRATEGY AND STRATEGY AND STRATEGY AND STRATEGY AND STRATEGY AND PLANNING PLANNING PLANNING PLANNING PLANNING PLANNING PLANNING Final Transforming Services Changing Lives Case for Change for sign- Planning and Innovation off Committee Annual Report IT Strategy IT Committee Annual Implementation Update Report Estates Strategy Final Primary Care Strategy
Draft Urgent Care Strategy
Appointments to the Urgent Care Procurement Governing Body Report Extended Primary Care Finance and Performance Access Procurement Pipeline Update Primary Care Co- Commissioning
Care Quality Commission (CQC) Inspection
360