Wednesday 10 July 2019, 2.00 pm Committee Room 4, City Hall, The Queen's Walk, London, SE1 2AA

Agenda

1 Welcome, Introductions from New Members and Apologies

2 Declaration of Interests

3 Minutes of the Previous Meeting held on 3 April 2019 (Pages 1 - 6)

4 Matters Arising and Actions List (Pages 7 - 8)

ITEMS FOR DISCUSSION AND DECISION

5 London Health and Care Vision (Pages 9 - 38)

6 London Estates Strategy (Pages 39 - 110)

ITEMS FOR UPDATE

7 Thrive LDN: Progress Update (Pages 111 - 116)

8 Health Inequalities Strategy (HIS) update (Pages 117 - 122)

9 London Health Board Conference (Pages 123 - 126)

10 Any Other Business

REPORTS FOR NOTING

a Children and Young People's Mental Health in Schools update (Pages 127 - 132)

b Learning Disability Mortality Review Programme (Pages 133 - 138)

11 Dates of Future Meetings

 Wednesday 2 October 2019 (LHB Conference)  Wednesday 8 January 2020 (12pm)

Agenda Item 3

MINUTES

Meeting: London Health Board Date: Wednesday 3 April 2019 Time: 2.00 pm Place: Committee Room 5, City Hall, The Queen's Walk, London, SE1 2AA Copies of the minutes may be found at: https://www.london.gov.uk/moderngovmb/ieListMeetings.aspx?CommitteeId=438

Members present: Sadiq Khan, Mayor of London (Chair) Dr Tom Coffey, Mayoral Health Advisor Cllr Ruth Dombey, Leader, London Borough of Sutton Professor Yvonne Doyle, Regional Director, Public Health England Daniel Elkeles, Chief Executive, Epsom and St Helier Foundation Trust Sir Sam Everington OBE Chair, London-wide Clinical Commissioning Council Philip Glanville, Mayor, London Borough of Hackney Sir David Sloman, Regional Director NHS England and NHS Improvement, London Cllr Richard Watts, Leader, London Borough of Islington

Apologies: John Brouder, Chair, Cavendish Square Group (London Mental Health Trusts) Cllr Ray Puddifoot, Leader, London Borough of Hillingdon Cllr Danny Thorpe Leader, Royal Borough of Greenwich

In attendance: Geoff Alltimes, Co-Chair, London Estates Board (presenting item 6) Nick Bowes, Mayoral Director for Policy, GLA Dr Vin Diwakar, Medical Director, NHS England and Improvement (presenting item 5) Mary Harpley, Chief Officer, GLA Kirstin Lambert, Senior Board Secretary (clerk) Dick Sorabji, Director of Policy and Public Affairs, London Councils Will Tuckley, Co-chair, SPB and Chief Executive London Borough of Tower Hamlets (co- presenting item 5) Gus Wilson, London Health Board Secretariat Manager, GLA

City Hall, The Queen’s Walk, London SE1 2AA Enquiries: 020 7983 4100 minicom: 020 7983 4458 www.london.gov.uk Page 1 London Health Board Wednesday 3 April 2019

1 Welcome and Introductions (Item 1)

1.1 The Chair welcomed attendees to the meeting, including Cllr Ruth Dombey and Sir David Sloman who were attending their first London Health Board meeting.

1.2 The Chair noted Professor Yvonne Doyle was leaving her post as London Regional Director of Public Health England in May to take up the post of National Medical Director at Public Health England, and extended thanks for her help and support during her role as the Mayor’s statutory health adviser and for her leadership on public health in London as Director of PHE London.

1.3 Apologies for absence were received from Cllr Ray Puddifoot, Cllr Danny Thorpe and John Brouder.

2 Declarations of Interest (Item 2)

2.1 There were no declarations of interest.

3 Minutes of the Previous Meeting (Item 3)

3.1 DECISION The minutes of the previous meeting were agreed as an accurate record.

4 Matters and Actions Arising (Item 4)

4.1 The Board received a report setting out completed and outstanding actions arising from previous meetings.

4.2 Tom Coffey and Sir Sam Everington provided an update on item 4d Violence Prevention: A Public Health Approach. It was noted that a recent violence reduction health roundtable meeting had confirmed a senior responsible officer to act as the key link between the Violence Reduction Unit and NHS partners. It was also noted CCG chairs would be asked to discuss the various issues with their Health and Wellbeing Boards and that conversations were ongoing around how to involve health and care providers to further progress the issues.

4.3 DECISION: The Board noted the update.

Page 2 London Health Board Wednesday 3 April 2019

5 Renewed Health and Care Vision for London (Item 5)

5.1 Will Tuckley, Sir David Sloman and Dr Vin Diwaker introduced a paper reporting on progress on the development of a Health and Care Vision for London. It was noted the Health Conference in October 2018 had affirmed the aspiration for London to be the world’s healthiest city and that the commitment to achieving this was real. The Healthy London Partnership and partners, overseen by the Strategic Partnership Board, had in recent months undertaken a significant amount of work including engagement with over 300 professionals. Key questions asked during the engagement centred on whether the goals and aspirations were right; how to engage beyond the professional community; and what collaboration is needed between public bodies across London and the community and voluntary sector to ensure successful delivery.

5.2 The Board noted the significance of having a joint health and care strategy and expressed its support for the emerging vision. There was discussion regarding how to ensure that the vision is realised and progress measurable so that residents see tangible change. It was suggested that granular plans for each of the priorities should be developed to enable Londoners to see what is planned to be delivered. It was also noted that there needed to be a real integration of services, both horizontally between health and care services and vertically into communities. London Councils expressed that it would be important to ensure that borough leaders and Cabinets were also connected as part of the collaborative approach.

5.3 The Board discussed the need for a tailored approach in recognition of the diversity of London’s boroughs. London Councils members emphasised the need to identify social determinants affecting health and care at neighbourhood level and take a localised borough and sub-regional approach in order to achieve real transformation. NHS partners agreed that one model would not fit all and noted there would likely be the need to develop several models while taking a proportionate and balanced approach.

5.5 Partners discussed changes to the way in which services are being delivered and the benefits and opportunities presented by social prescribing. There were good examples of success in this area in boroughs such as Hackney and Tower Hamlets, including the establishment of pro-active multidisciplinary teams which meet monthly and proactively work with communities, with the effect of reducing pressure on NHS institutions and resources. The ambition was for all Londoners to have access to social prescribing.

5.6 Board members expressed a view that school readiness should form one of the vision priorities. It was noted that research supports that the first 1,000 days of a child’s life can be critical in determining health and physical wellbeing, the development of speech and language skills, social and emotional development and learning skills, and that where this is sub-standard it can be very difficult for a child to catch up and have potentially long-term effects into adulthood. It was noted that the Mayor’s Healthy Early Years Programme was helping to support these aims and reduce health inequalities by rewarding achievements in child

Page 3 London Health Board Wednesday 3 April 2019

health, wellbeing and development and seeking the participation of London’s 13,000 early years settings. The importance of supporting the recruitment and retention of health and care workers was also emphasised, and it was suggested that consideration be given to including this within the vision priorities.

5.7 The Board agreed that an update on the vision and priorities be brought back to the Board at its next meeting on 10 July 2019.

5.8 DECISION That the report and discussion be noted.

6 London Health and Care Estates Strategy (Item 6)

6.1 Geoff Alltimes introduced the report which provided an update on the London Health and Care Estates Strategy including progress made and current challenges. It was noted that the interim strategy incorporated extensive feedback received since Autumn 2018, and that further work was needed to align the strategy with the NHS Long Term Plan and strategic priorities of the new NHS England and NHS Improvement regional office. The draft capital investment pipeline for London had identified over 500 projects requiring £8 billion of capital over the next 10 years, and surplus land opportunities of approximately £2 billion, potentially releasing land for 12,500 new homes. A key challenge to realising these opportunities was the ability to commit to long-term plans as the funding was released in waves.

6.2 Board members discussed the need to present a strong vision to the Treasury to help speed up the release of funding and enable long-term planning. It was agreed there was a need to continue the implementation of big projects alongside progressing ‘quick win’ opportunities including the development of small sites and the merger of facilities such as general practices and community centres. Local authorities had demonstrated an ability to react quickly to identify and realise opportunities, although it was noted that finalising agreements could be challenging. It was also noted that the design of new health and care facilities was important to effect service transformation, as clinical care was increasingly being delivered in a different way.

6.3 It was noted there was a need for wider communication to build consensus for this work to ensure that Londoners understood the aims of the Estates programme. The purpose was to free up land for new homes while ensuring services are delivered collaboratively and efficiently, applying the Mayor’s six tests.

6.4 It was noted that the Strategy was expected to be finalised and shared with partners in upcoming months and would be considered by the Board at its next meeting.

6.5 DECISION: That the report and discussion be noted.

Page 4 London Health Board Wednesday 3 April 2019

7 Thrive LDN (Item 7)

7.1 Mayor Philip Glanville introduced a paper providing an update on recent and upcoming Thrive LDN activity in London. Since its public launch 18 months ago there had been growing interest in Thrive LDN amongst a wide range of agencies and various third sector organisations resulting in a rapid growth in activity covering partnerships, projects and initiatives across London boroughs. Highlights included the establishment of the Young London Inspired partnership which supports opportunities for young Londoners at greater risk of poor mental health, The Right to Thrive project, working with communities to understand how inequality and discrimination affect mental health and wellbeing, plans for the creation of an initial cohort of 50 Thrive LDN Champions and the planned launch of a multi-agency Information Sharing Hub. Mayor Glanville highlighted links to the work of the VRU including suicide prevention work, and the rollout of youth mental health first aid training to seek to ensure every school has a representative by 2021.

7.2 The Board commended the achievements to date and expressed its support for work under way. It was requested a further progress update be presented to the Board at its next meeting.

7.3 DECISION: That the report and discussion be noted.

8 London Health Inequalities Strategy: Progress update (Item 8)

8.1 Professor Yvonne Doyle introduced the report which provided an update on progress on the statutory London Health Inequalities Strategy launched in October 2018. There was a wide range of work under way, linking to the work on the Health and Care vision. Highlights included the convening of London’s Child Obesity Taskforce, publication of a draft social prescribing vision for London, a ban on unhealthy food advertising on London’s transport network, London becoming the first global city to exceed UNAIDS 95-95-95 ambitions for HIV identification, diagnosis and treatment, and the upcoming launch of the Ultra-Low Emission Zone on 8 April.

8.2 It was noted that smoking was another area of high health inequality with a much higher uptake of smoking amongst deprived communities. An Illegal Tobacco campaign was planned for the summer to target the issue of children buying tobacco and forming an addiction. Partners also noted that malnutrition was a significant problem. The Health team was producing stakeholder guides for specific audiences, including local government and the health and care system, focussing on the five aims of Healthy Children, Healthy Minds, Healthy Places, Healthy Communities and Healthy Living, outlining practical actions that can be taken to address the issues.

8.3 DECISION: That the discussion and report be noted.

Page 5 London Health Board Wednesday 3 April 2019

9 Dates of future meetings (Item 9)

9.1 The next meeting of the Board was scheduled for 2pm on 10 July 2019 at City Hall. The Board noted the next Health Conference was scheduled for 2 October 2019.

10 Any Other Business (Item 10)

10.1 There was none.

Page 6 Agenda Item 4

London Health Board

Date of meeting: 10 July 2019

Title of paper: Actions Arising

To be presented by: Chloe Newbold, Board Coordinator

Cleared by: Dr Nick Bowes, Mayoral Director, Policy Dr Tom Coffey, Mayor’s Health Advisor

Classification: Public

1 Executive Summary

1.1 This report updates the Board on actions arising from its previous meetings.

2 Recommendation

2.1 The Board is asked to note the updates.

3 Actions Arising from Previous Meetings

3.1 Actions arising from the meeting on 19 April 2018.

Agenda Item Action Status 5a. Strategic Final allocation framework and details of In progress Partnership any unallocated or flexible funding for the Board Work current financial year, and options for its Plan use, would be circulated/ presented to the Board Will Tuckley / Dr Jane Cummings

Page 7 3.2 Actions arising from the meeting on 18 December 2018.

Agenda Item Action Status 5a London's It was agreed that a further update be In progress – new primary provided to the Board at an appropriate update to be care strategy time, to include a focus on estates. provided at a future Dr Jonty Heaversedge meeting. 6a. Dementia Board partners expressed their full In progress Friendly London support for the work of the Alzheimer’s (ongoing) Society including their willingness to become dementia friends and work to help the Society to meet a target for 75% of their organisation’s staff to become dementia friends by 19 September 2019 when the second Dementia Friendly London Summit was scheduled to take place. All 6b. Borough The Chief Officer of GLA and Dementia In progress - update leadership on Champion, Mary Harpley, agreed to lead to be provided at a creating on bringing an update on this work to a future meeting. dementia future Board meeting at an appropriate friendly time. communities Mary Harpley

3.3 Actions arising from the meeting on 3 April 2019.

Agenda Item Action Status 5. Renewed The Board agreed that an update on the Complete: On 10 Health and Care vision and priorities be brought back to July 2019 agenda at Vision for the Board at its next meeting. Item 5 London 7. Thrive LDN The Board requested a further progress Complete: On 10 update be presented to the Board at its July 2019 agenda at next meeting. Item 8

4 Next Steps

4.1 Outlined elsewhere within this report.

Appendices:

None.

Page 8 Agenda Item 5

Date of meeting: 10 July 2019 Agenda item: 5 Title: London’s Health and Care Vision Presented by: Will Tuckley, Chief Executive, Tower Hamlets and SPB Co-Chair Sir David Sloman, London Regional Director, NHS England and Improvement Author: Dick Sorabji, Corporate Director of Policy and Public Affairs, London Councils Dr Vin Diwakar, London NHS Regional Medical Director Paul Plant, Interim Regional Director, PHE London Cleared by Dr Tom Coffey, Mayoral Health Advisor Status: For discussion Classification Public

1 Purpose of this paper

1.1 Partners have described a shared ambition to make London the healthiest global city. This paper reports progress on the development of a Health and Care Vision for London in support of that aim, and it shares an emerging description of the vital purpose of our partnership in delivering that shared ambition.

1.2 Since the meeting of the London Health Board (LHB) in April a process of professional engagement and co-development has been undertaken to help focus our Vision on a set of ambitious and impactful proposals that will animate and energise our work together. This covers 10 priority areas requiring strong London-wide collaboration, and it also considers the importance of London-level support to enable greater integration and collaboration at borough and neighbourhood levels. This paper presents some of the early outputs of that work in order to test the content before a more detailed process of engagement, policy development and planning.

1.3 Moving from aspiration to action will require increasing detail about the practical changes that need to be enacted across our partnership in the coming three, five and 10 years. To undertake that work in advance of the launch of the Vision will require effective engagement. This includes active involvement of organisational leaders across the partnership, as well as incorporating outputs of the extensive public engagement that health and care partnerships are undertaking for example in response to the NHS Long Term Plan. The paper sets out a high- level proposal to enable purposeful institutional and public engagement within the short timeframe, and without duplication of existing local processes.

Page 9

2 Recommendation(s)

2.1 This report seeks the views of LHB members to guide and refine further development work. In particular, the Board is asked:

a) to comment on the emerging narrative, highlighting points of strength and areas for refinement, as the basis for further development; b) to consider the 10 priority areas and the ideas emerging from professional engagement, and to give a view about whether these are the right areas upon which to focus; and c) to comment on the proposed approach to engagement, highlighting any further specific activities that are necessary and feasible within the timeframe.

3 Context and progress

3.1 Building on the Better Health for London report (2014), London’s NHS, Public Health England, Health Education England, London Councils (representing London’s Boroughs), local borough partnerships and the Mayor of London have been working together to devise a set of shared commitments to make London the healthiest global city. To further these goals and build on our collective work London’s health and care partners entered into Health Devolution Agreement with national bodies.

3.2 In July 2018, a progress report was presented to the Strategic Partnership Board (SPB) which assessed the improvements made and outstanding challenges faced by the partnership. In response to that review – and in anticipation of the likely changes in context created by the NHS Long Term Plan, the Social Care Green Paper, and the Prevention Green Paper – the SPB initiated work to renew the partnership’s Vision, and to establish a set of actions to refocus the work of the partnership in order to move ever closer to becoming the healthiest global city.

3.3 Since the initiation of the work we have established guiding principles and we are continuing to refine an emerging narrative that helps to frame our purpose, priorities and practical actions. Significant engagement has taken place in the early development of the Vision involving over 300 health and care professionals across multiple forums.

3.4 Following the April LHB meeting, professional expertise has been engaged to further define priority London wide population health commitments, measures and delivery plans. Over 100 experts have been involved in this process including London’s Directors of Children’s Services, Directors of Adult Services, Directors of Public Health and clinical leaders across the capital. Professional expert panels have also developed evidence compendiums bringing together data analysis, research and case studies from other global cities to support each priority.

Page 10

Figure 1: Summary of the process and progress in developing our Vision

4 Emerging themes, priorities and potential actions

4.1 Outline narrative themes

4.1.1 Healthy cities enhance quality of life, improve productivity, increase capacity for learning, strengthen families and communities, support sustainable habitats and environments and contribute to security, poverty reduction and social inclusion. Our partnership has a shared ambition for London to be the healthiest global city, and the best global city in which to receive health and care. 4.1.2 Our shared ambition is underpinned by our organisations’ respective and collective responsibilities to make a difference to: the health of Londoners; the health and care services in London; and how we collaborate. Our shared partnership is underpinned by a recognition that no single organisation alone can effectively address the opportunities and challenges we face: shared action makes us greater than the sum of our parts and better able to address priority issues that require pan-London solutions, and to support pan-London actions that enable closer and more effective partnerships at system, borough and neighbourhood levels. 4.1.3 Our shared commitment to improving health is framed using a life course approach, with the aim to ensure that all Londoners can start well, live well and age well. Our shared understanding of improving health and care services in London is to support primary prevention, community action, and self-care; to engender integrated community models; and to support effective specialist

Page 11

services and networks. And our shared commitment to collaborate effectively is based on recognising that we need aligned and reciprocal support across the partnership to address the real and urgent challenges we face in establishing sustainable services, whilst ensuring that decisions about health and care are devolved to the most appropriate level.

Figure 2: Emerging framework for our Vision

4.2 Potential priorities and practical actions

4.2.1 There are some issues that demand collective action at a London level to improve health outcomes, either because they are by nature less constrained by local geography – for example air quality – or because there are significant scope or scale benefits that emerge from acting collectively. Our work to date has highlighted ten priority areas for pan-London action, which are listed below. These are explored in more detail in the Appendix, which provides a summary of the emerging output of our professional engagement. These emerging outputs could be further developed into a set of ambitious and more granular proposals for inclusion within the Vision.

Page 12

Figure 3: Outputs from professional engagement: for consideration when developing partnership commitments and plans – N.B. early stage draft for discussion

Priority area and Possible local actions Possible city-wide actions possible commitments Reduce childhood • All London hospitals adopting • Support for all London primary obesity the new version of hospital schools to adopt a ‘water only’ food standards. policy. Commit to achieving a • Local areas taking up the • Expanding the junk food 10% reduction in Healthy Early Years London, advertising ban in boroughs proportion of children and the Healthy Schools. and on NHS sites. obese in year 6 and London across their borough • Partnering with TfL to increase reverse the trend in • Traffic light labelling for child the proportion of Londoners those who are friendly food retailers. achieving two ten-minute overweight. • Create more self-management periods of walking or cycling opportunities to support each day. children and families with • Introduce a network of water maintaining a healthy weight. fountains, refill cafes and restaurants to improve access to water. Improve the emotional • London’s local authorities • Youth mental health first aid wellbeing of children establishing Thrive LDN hubs. instructors in every London and young Londoners • Enhanced CAMHS pathways borough to ensure that every across STP footprints. London state school has London is a city with • NHS Trailblazer pilots, access to a Youth Mental environments that establishing mental health Health First Aid trainer by support children teams servicing schools in 2021. reaching a good level of London boroughs. • ThriveLDN ‘Are we OK development • Partner with the Mental Health London?’ campaign to open a cognitively, socially and Foundation to deliver three conversation with Londoners emotionally; and when ‘Thriving Community about inequality, mental health needed effective child prevention pilots. and wellbeing. and adolescent mental • ‘Perfectly Norman’ storytelling • Establish a suicide prevention health services are sessions designed to get multi-agency information available 24/7. parents and children talking sharing hub. about mental health. • Young Londoners grants to increase social action in young Londoners that are at greater risk of poor mental health. Create Healthy • Expand the number of healthy • Continue to build the ‘Stop Environments neighbourhood super-zones Smoking London’ portal to tackling a range of make it an asset for Londoners All Londoners live and environmental factors in addition to a new marketing work in health including food. campaign. reinforcing • Implement the ‘Healthy Streets • Explore Pan-London approach environments. Approach’ to help make to illegal tobacco control and walking, cycling and public counterfeit alcohol including transport the most attractive enforcement team. daily transport options. • Expand London’s self- • Increase access to Individual management support offer for Placement and Support (IPS) people struggling with MH and for those with severe mental. MSK conditions that impact on employment.

Page 13

health illnesses to find and • Work with London employers retain employment to support 750,000 Londoners • Increase access to receive the Healthy Workplace apprenticeships. Award accreditation scheme. Improve air quality • Local authorities mobilising the • Extending London’s ULEZ TfL Healthy Streets beyond central London for all Commit to improving framework, and new NICE vehicles and London-wide for access to healthier air guidance on air pollution. lorries, coaches and buses. and spaces by X% so • Local authorities working with • From 2020, all newly Londoners are able to schools and families on the manufactured private hire breathe safe air, both in impact of air pollution on their vehicles (less than 18 months and out of the home. health. old) presented for licensing for • Specific Air Quality Policies the first time must be zero being included in all local emission capable. plans. • NHS fleet will use low- • Installing at least 2500 new emissions engines and all charging points across the NHS sites will phase out capital by 2022. primary heating from coal and • All new developments are oil fuel. required to ensure adequate • Deliver a major expansion in secure cycle storage is electric vehicle infrastructure, available for each new home with at least 300 rapid charge built. points by 2020. • All health and care partnerships to take a networked, multidisciplinary approach to asthma care for all ages. Improve mental health • Local multiagency suicide • Continuing Thrive London ‘Are plans. you OK London?’ campaign. Commit to London • Developing increased • London rollout of Good being a city that alternative forms of provision Thinking digital mental health promotes positive for those in crisis. and wellbeing service. wellbeing, achieves an • Meeting specific waiting time • Implementing the pan-London X% increase in timely targets for emergency mental s136 model of care in access to mental health health services, providing a partnership with the NHS, services for Londoners 24/7 community-based mental Police, local authorities and from every background health crisis response and the voluntary sector. and makes progress mental health liaison service in • Projects to tackle stigma and towards zero suicides. all A&Es. improve mental wellbeing, • Providing an additional including Time to Change. 110,000 people with severe • Promoting good mental health mental health problems per in the workplace, including year with a physical health through the London Healthy check. Workplace Charter. • Continuing to increase local access to perinatal support and IAPT. Reduce the • Knife crime action plans • ‘London Needs You Alive’ city- prevalence and impact developed and implemented in wide media campaign. of violence each borough. • Evaluating local programmes • Education and community and sharing best practice outreach programmes focused evidence-based models

Page 14

City-wide health on crime and violence across the health and care commitment in reduction. system. development. • Focused action on violence • Commissioning bespoke against women and girls support models for vulnerable individuals at risk. • Reviewing NHS specialised pathways (e.g. criminal justice and mental health) to ensure appropriate support is available for individuals at risk. • Funding through the Young Londoners Fund to local projects that combat youth violence. Improve the health of • Hospitals meeting the duty to • Delivering the Mayor’s Rough homeless people refer people who are homeless Sleeping Plan of Action and or at risk of homelessness to the Government’s Rough Commit to reducing the the local authority for support. Sleeping Strategy numbers of rough • Implementing the homeless commitments. sleepers on the street. health commissioning • Commission integrated ‘step- London’s ambition is for guidance for London. down’/intermediate health and no rough sleepers to die • Conduct a joint local homeless care services for homeless on the streets. health needs assessment. people who require • Commission and provide continuation of care following services in line with the discharge from hospital. homeless and inclusion health • Develop regional and sub- standards and homeless regional solutions to deliver health commissioning safe and effective homeless guidance for London. hospital discharge taking a • Provide local leadership to ‘Housing First’ approach. champion, support and be • Convene the London accountable for delivery. Homeless Health Board to provide leadership and strategic oversight. Improve sexual health • National full funding for routine • Increase general public local commissioning of PrEP awareness of HIV today and Lead the way to having to help achieve ‘zero new HIV impact of stigma through a zero new HIV infections, infections’. pan-London campaign. zero preventable deaths • Optimise current patient • Build on the London borough and zero stigma by pathways and adoption of pan-London HIV collaborative 2030 as set out by the NICE guidance including opt and the Do it London Fast Track Cities out testing and TasP. campaign to make best use of commitment. • Maintaining access to a range existing community of free contraception for key knowledge, experience, and Reduce rates of STI populations. access to target underserved infections and address • Designing new models of care communities. sexual health to create a trusted, high • Ensure heath, care and inequalities in London quality, integrated and government organisations are by ensuring access to personalised care model. stigma-free, including training equitable, flexible, high- • Implement new and innovative for key staff groups and quality services. prevention technologies. services. • Engaging leaders and influencers throughout the health and care economy in the fight against HIV –

Page 15

including advocating to keep HIV education part of PHSE curriculum. Improve the quality of • Every London borough • Reducing variation in life for ageing working towards becoming a diagnosis rates across Londoners dementia-friendly community. London, going beyond the • Improving pathways and national ambition. Commit to becoming integrated working. • Shape dementia services so the first dementia • More active focus on that people with dementia friendly capital city by supporting people in the receive effective diagnosis, 2022. community. treatment and care. • Cancer screening campaigns • Maximise screening uptake Commit to increase to raise awareness and target (particularly bowel), screening participation in cancer hard-to-reach groups. changes (e.g. FIT, HPV), to screening programmes implement best practice so that more people are surveillance and increase diagnosed as early as population health awareness. possible.

Improve care and • Proactively identify patients • Reducing variation in End of support at the end of who should be receiving Life Care Services across life palliative care to ensure that London and targeting all people at the end of their personalised care planning in Commit to delivering life have high quality and target groups to reduce personalised end of life compassionate care with inequalities (i.e. homeless and care so that more personalised plans in place. people with learning people die in their place • Promote ‘Coordinate my Care’ disabilities). of their choice. (CMC) to ensure that • Continue to support the important information about development and people at the end of their life implementation of CMC in all and their preferences for the care settings, aligned to the care they wish to receive is digital infrastructure within the recorded and known. Local Health and Care Record Exemplar (LHCRE) programme.

4.2.2 There are other actions, that are best enacted at neighbourhood or borough level, but which can be supported by partnership action to make integration and collaboration easier. Building on the pilots established under the Devolution Agreement, NHS and local authority commissioners of health and care services have been exploring at a borough and multi-borough level how best to join-up, plan and improve the way they work together so that patients and residents receive the best care possible. Aligned with this, the NHS Long Term Plan emphasises the need for the NHS to be more joined-up and coordinated in its care; more proactive in the services it provides; and more differentiated in its support offer to individuals. To achieve this, local NHS organisations will increasingly focus on population health and partnerships with local authority- funded services, within new Integrated Care Systems (ICSs) everywhere. 4.2.3 To make this possible the NHS has embarked on fundamental changes to its operating strategy. Within the confines of current legislation, the NHS is working to unify strategy across different organisations and give priority to the benefits of collaboration. Proposals for future legislative change may ultimately accelerate

Page 16

this process. A case is under development for primary legislative change which will further enable collaboration and the integration of care. 4.2.4 The opportunity for more ambitious and effective joint working across the NHS and local government in London is being explored. Delivered in a sustainable manner, this has the potential to accelerate the move towards a population health approach; to better embed place leadership in the development of health and care services; and to bring together all parts of London government to support enhanced levels of health amongst Londoners. 4.2.5 It will be important to ensure that the opportunities for faster improvement through collaboration do not lead to inappropriate standardisation of approach and that solutions address the needs of specific communities across London. 4.2.6 Work to deliver this approach has been initiated and will continue through the summer. It will inform the place-based approach described above and be incorporated into the final Vision report. It is anticipated that the outcomes of this work will in turn be reflected in the five-year plans developed for the NHS Long Term Plan.

4.3 Based on the emerging narrative, themes and potential priorities described above we are planning to structure the content of the Vision to include the five following sections: a) our achievements as partnerships in terms of meaningful changes for Londoners; b) our renewed vision and strategy and what that will mean for Londoners at each spatial level; c) a focussed number of specific commitments that will be delivered working together as partnership across the city with our plans to deliver them; d) a statement of principles on how the boroughs and the NHS work together at each spatial level; and e) outcome measures that allow us to make international comparisons.

5 Next steps

5.1 The next stage in developing London’s health and care vision is to move from defining the goals towards agreeing how these goals will be achieved. This depends on agreement around two types of challenge.

5.2 Firstly, there are a range of enabling systems, resources and capabilities on which further progress is required. There is already significant agreement that these include accelerating prevention, development of estates, workforces, digitally enabled care, regulatory and payment systems and adequate funding for both health services and care services.

5.3 Secondly, there is a need to identify the extent to which collaboration across London public services can accelerate progress towards the goal of the healthiest global city. This will be built on the technical discussions referred to above.

Page 17

5.4 The planning for wider engagement with Londoners is under development as proposals for population health commitments are defined.

5.5 Partners and system leaders, health and care professionals and experts have shaped the work to date, with further testing and refining of priority commitments for a renewed health and care vision for London since the last LHB meeting. This has included input from local authorities, the GLA, clinical and operational NHS staff and PHE to draw together the proposed London-wide commitments, measures to track progress and the emerging delivery plan.

5.6 Wider public engagement planning will build on the public engagement undertaken for the development of the Mayor’s Health Inequalities Strategy, the Devolution MOU, STP planning, the Better Health for London report and review, Thrive LDN’s Londoners said report and the Great Weight Debate. Wider public engagement should aim to:

a) ensure people living and working in London, and the organisations that support them, are able to influence London’s health and care priorities; b) gain support for the priorities and commitments; and c) identify actions that are important to Londoners to inform delivery planning.

5.7 A proposed timeline for public engagement is set out below:

Ongoing Public engagement to Early public conversations raise awareness engagement to via STPs, Launch of and keep promote the Boroughs, London Vision Londoners work partner Oct 2019 talking about May - July channels etc health July - Oct Oct onwards

5.8 Priority groups have been mapped and engagement with these groups could be done via NHS and borough leads, both through existing forums on Long Term Plans, with support provided such as engagement toolkits that local areas can localise and adapt to engage local populations. 5.9 The LHB conference on 2 October 2019 will be used to launch the refreshed London Vision. A communications and engagement group with representatives from all partner organisations has been established to plan and deliver the LHB conference. Existing communications collateral such as films and footage will be used where possible; further resource would need to be identified if bespoke material is required. 5.10 A strategic communications plan for the London health and care vision will also be developed by HLP to ensure there is continued awareness and promotion of the London’s health and care priorities, using this engagement and

Page 18

communication as a public health intervention in itself. This will ensure the priorities are kept at the forefront of the minds of those leading the system, and will enable consideration of how we might target priority groups to improve Londoners health. 5.11 The LHB is asked to consider the high-level approach to engagement described above and the emerging priorities as the basis for this engagement ahead of the launch at the LHB conference in October 2019 and comment on whether other methods or channels of engagement should be considered. 5.12 Work is also underway with colleagues from PHE to develop a dashboard for agreed shared commitments to population health improvements. An annual strategic review, similar to the Take Care New York approach1, is being developed so that progress can be reviewed through both quantitative data and ongoing engagement with Londoners. This will help partners to understand where challenges remain and where opportunities lie. The metrics and annual strategic review will be aligned to the Health Inequalities metrics and reporting. This work will include further consideration of how we measure our goal to be the world’s healthiest global city.

Appendices: • Appendix 1: Summary outputs from professional engagement to date (subject to further development).

1 Take Care New York is the City's ‘blueprint’ to improve every community's health, especially among those groups with the worst health outcomes. An annual progress report is compiled which looks at indicators of health as well as wider determinants of health. The progress report describes trends in indicators over time at a city-wide level and in ‘Very High-Poverty Neighbourhoods’.

Page 19

Appendix 1: Summary outputs from professional engagement to date – subject to further development

Reduce Childhood Obesity

London commits to achieving a 10% reduction in proportion of children obese in year 6 and reverse the trend in those who are overweight

Childhood obesity is a complex global challenge with rates increasing across the world. This trend is particularly worrying as excess weight in children is associated with a high likelihood (60%) of obesity in adulthood and includes both short- and long-term health consequences. Some of the most significant effects are the increased risk of cardiovascular diseases (esp. heart disease and stroke), diabetes, musculoskeletal disorders (esp. ostearthritis), and some cancers (colon, breast, endometrial), which increase the chance of premature death and disability. Across major global cities, London has the highest childhood obesity rate. In 2016/17, more than one-in-five of London’s children were overweight (BMI 25-30) or obese (BMI > 30) (23.1% boys, 21.5% girls) in Reception (4-5 years), around half of whom (10.9% boys, 9.6% girls) were obese. These numbers markedly increase by Year 6 (10-11 years) with two-in-five of children being overweight or obese (41.1% boys, 35.9% girls) and 26.2% of boys and 21.0% of girls being obese. Notably, by Year 6 only slightly more than half of children (59.9%) have a healthy weight. London, with a childhood obesity prevalence of 23.6% has the highest rate in England, which is significantly above the national rate (20.0%), slightly higher than New York (21%), and much higher than Hong Kong (7%), Madrid (2%), or São Paolo (7%). This rate in London has consistently been increasing since 2007/08, especially for children in Year 6. Importantly, social inequalities and deprivation tend to result in significantly higher rates of childhood obesity. In Reception, London’s children from most deprived regions have 7.7 percentage points (243%) higher obesity rates than those from least deprived areas, a difference that rises to 15.0 percentage points (219%) by Year 6. These differences are most likely due to the availability of cheap junk foods high in sugar that may disproportionately target families aiming to maximise calorie density per cost. Obesity in Year 6 is most prevalent among boys of Bangladeshi (33.0%), Pakistani (30.4%) and other Asian (28.8%) ethnicities, and girls of Black Caribbean (30.2%), Black African (29.2%), and other Black (27.3%) ethnicities. For all but Black Caribbean, Black African, and other Black (27.3%) ethnicity groups, obesity prevalence is higher among boys than girls (aged 10-11). In November 2018, after overwhelming support from Londoners, the Mayor of London confirmed a ban on junk food advertising on the London transport network (TfL) to tackle childhood obesity and promote a healthy lifestyle. London’s first Child Obesity Taskforce is tasked to halve the percentage of London’s children who are overweight at the start of primary school and obese at the end of primary school by 2030, and to reduce the gap between child obesity rates in the richest and poorest areas in London and are currently working on more similarly impactful policies.

Appendix: Summary outputs – Illustrative for discussion Page 20

This initiative is encouraging, yet developing broader partnerships will be crucial to ensuring healthy environments for London’s children to be and stay healthy. We will achieve our commitment through:

Local action: City-wide action:

• All London hospitals adopting the new • Support for all London primary schools to version of hospital food standards adopt a ‘water only’ policy • Local areas taking up the Healthy Early • Expanding the junk food advertisement Years London, and the Healthy Schools ban in boroughs and on NHS sites London across their borough • Partnering with TfL to increase the • Traffic light labelling for child friendly food proportion of Londoners achieving two retailers ten-minute periods of walking or cycling • Create more self-management each day opportunities to support children and • Use the London Environment Strategy to families with maintaining a healthy weight introduce a network of water fountains, refill cafes and restaurants to improve access to water

And continuing to learn from good practice:

The Daily Mile is a project by the Daily Mile Foundation, which has been supported and developed with many local councils across London, including the Borough of Richmond (one of the lowest obesity rates) and the Borough of Tower Hamlets (one of the highest obesity rates). The Daily Mile is implemented in schools and encourages children to run or jog, at their own pace, for 15 minutes every day. An evaluation of the Daily Mile intervention showed that a 7-month long intervention increases physical activity by 9 min/day, reduces sedentary time by 18 min/day and reduces skinfolds by 1.4 mm, as a proxy for obesity, in school children.

A partnership between We Are What We Do, Create London, and the London Borough of Newham in East London piloted Box Chicken, a healthy alternative to fast food outlets in close proximity to four secondary schools, for four weeks. The purpose of the test was to offer school children a healthier alternative to fried chicken at a low price under a youthful brand. After the test pilot, an evaluation concluded that the project had great potential for growth, as it did end up with healthier recipes that 95% of customers found tasty, 76% found to be good value for money, and 90% wanted to keep returning to, while making a profit over the trial period.

How will we track progress? National London Trend Indicator average average Low birth weight of term babies 2.82 3.01 Reception: Prevalence of overweight including 22.4% 21.8% obesity Reception: Prevalence of severe obesity 2.4% 2.9% Year 6: Prevalence of obesity (including severe 34.3% 37.7% obesity) 242 (32% Number of children and young people included in of the total the audit with Type 2 diabetes by country and TBC in England region, 2017/18 and Wales)

Appendix: Summary outputs – Illustrative for discussion Page 21

Improve the emotional wellbeing of children and young Londoners

London is a city with environments that support children reaching a good level of development cognitively, socially and emotionally; and when needed effective child and adolescent mental health services are available 24/7

Young Londoners are experiencing alarming levels of poor mental health. As half of all mental health problems manifest by age 14, and 75% manifest before the age of 24, children and young people need to prioritised to reduce the number experiencing poor mental health and also to ensure good mental well-being in London’s future adults.

Suicide is the leading cause of death in young Londoners, accounting for 14% of deaths in 10-19 year olds. Furthermore, 9% of London’s 5-19 year olds have a mental health disorder and over a quarter of these children self-harm.

Poor mental health is both a consequence of inequality and disadvantage, as well as the cause of it. Mental illness is particularly prevalent in Figure 1: A heat map showing highest risk young people that suffer from inequalities such as for poor mental health in London by borough poverty, neglect and school absenteeism as well as London’s youth LGBT+ community.

London’s children and young people also experience challenges when accessing care. Access to specialist children and young people’s mental health services in London continue to be too difficult and access rates are lower than other parts of the country. Prioritising funding and availability of mental health resources is therefore more urgent than ever.

The mental health of London’s children and young people remains a priority for the Mayor of London, local leaders and the NHS – particularly focussed on prevention and intervening early but also ensuring specialist care is available when needed by the most vulnerable young Londoners.

Appendix: Summary outputs – Illustrative for discussion Page 22

We will achieve our commitment through:

Local action: City-wide action:

• London’s local authorities establishing • Youth mental health first aid instructors in every London borough to ensure that every Thrive LDN hubs London state school has access to a Youth • Enhanced CAMHS pathways across Mental Health First Aid trainer by 2021 STP footprints • ThriveLDN ‘Are we OK London?’ campaign • NHS Trailblazer pilots, establishing to open a conversation with Londoners mental health teams servicing schools in about inequality, mental health and London boroughs wellbeing • Partner with the Mental Health • Establish a suicide prevention multi-agency Foundation to deliver three ‘Thriving information sharing hub Community prevention pilots • Young Londoners grants to increase social • ‘Perfectly Norman’ storytelling sessions action in young Londoners that are at designed to get parents and children greater risk of poor mental health talking about mental health

And continuing to learn from good practice:

London partners across the GLA, London Councils, the NHS and PHE, working with charities and others launched Thrive LDN in 2017 - a citywide movement to bring Londoners and organisations together to help make the city a happier, l healthier place to live and work. Since 2017, Thrive LDN has already supported a variety of local actions targeting London’s children and young people, including the Youth Mental Health First Aid schools programme and facilitating community sessions that encourage young people to talk about mental health, increase awareness and reduce stigma. The Young People’s Health and Wellbeing Service in Lewisham demonstrates how partnerships between the NHS and local authorities can productively address the mental health needs of CYP. The service supports key areas of CYP needs (emotional wellbeing, substance misuse and sexual health) offering face to face and online clinical support to any young person aged 10-19. Providing flexible outreach for families that may experience barriers to accessing care, the service focuses on evidence based interventions, including both short term support as well as referrals. With 251 counselling hours in Q4 alone in 18/19, the online portion is currently being piloted across five other boroughs of SEL.

How will we track progress? National Indicator London average Recent trend average School Readiness: the percentage of children achieving a good level of 71.5 73.8 development at the end of reception Number of schools with Healthy N/A TBC Schools London Bronze awards

NHS CYP Access Standard TBC TBC

Appendix: Summary outputs – Illustrative for discussion Page 23

Create Healthy Environments

All Londoners have opportunities to live a healthy life and kick harmful habits

London is a major global city with huge potential to give people access to oppotuntiies to live a healthy life through their their work, leisure and environment. Some of the most important aspects of living in London that must be tackled through partnerships rather than single targeted interventions relate to deprivation and its impact on health and welbeing including the higher chances of obesity among deprived populations, smoking, alcohol and other substance misuse, as well as workplace health and wellbeing.

Over the past 5 years, London has reduced its smoking rate which, while lowest nationally, has been declining at a slower rate and has not yet reached the global standard set out in Better Health for London, which aimed for it to decrease to 13% (London change 2015-18: 17.1% → 14.6%; England: 18.4% → 14.9%). Worryingly, smoking is most common among youth (25-34 years) and much more prevalent among people in routine and manual occupations when compared to those in managerial and professional employment. Further redcing smoking rates is crucial as it remains the leading cause of premature mortality in Lodnon. Similarly, while measures of alcohol consumption and related deaths in London are lower than the rest of the UK, much remains to be done to reduce dependency, morbidity and mortality related to its misuse.

Over the past 5 years, London has reduced its smoking rate which, while lowest nationally, has been declining at a slower rate and has not yet reached the global standard set out in Better Health for London, which aimed for it to decrease to 13% (London change 2015-18: 17.1% → 14.6%; England: 18.4% → 14.9%). Worryingly, smoking is most common among youth (25-34 years) and much more prevalent among people in routine and manual occupations when compared to those in managerial and professional employment. Further reducing smoking rates is crucial as it remains the leading cause of premature mortality in London. Similarly, while measures of alcohol consumption and related deaths in London are lower than the rest of the UK, much remains to be done to reduce dependency, morbidity and mortality related to its misuse.

Evidence suggests that Londoners spend more time at work than the rest of the UK and therefore it is therefore vital that workspaces are healthy environments where people can thrive. While many good campaigns have been introduced to that end such as the London Healthy Workforce Charter and organisations and businesses offer more flexibility at work than ever before, more partnered action must be developed to use good practices at a larger scale and ensure healthy and supportive workplaces across London.

The Mayor of London, to address some of these trends, has introduced a ban on advertising junk foods in London’s transport network in 2018, drafted a London Plan and started the Stop Smoking London campaign.

Appendix: Summary outputs – Illustrative for discussion Page 24

We will achieve our commitment through: Local action: City-wide action:

• Expand the number of healthy • Continue to build the ‘Stop Smoking neighbourhood superzones tackling a London’ portal to make it an asset for range of environmental factors including Londoners in addition to a new marketing food campaign • Implement the ‘Healthy Streets Approach’ • Explore Pan-London approach to illegal to help make walking, cycling and public tobacco control and counterfeit alcohol transport the most attractive daily including enforcement team transport options in London • Expand London’s self-management • Increase access to Individual Placement support offer for people struggling with and Support (IPS) for those with severe MH and MSK conditions that impact on mental health illnesses to find and retain employment employment • Work with London employers to support • Increase access to apprenticeships 750,000 Londoners receive the Healthy Workplace Award accreditation scheme in their workplace by 2020

And continuing to learn from good practice:

The Mayor of London presented a draft London food strategy in 2018 hoping to address the creation of a healthy food environment for children and adults. While the Mayor has introduced a ban on advertising on London’s transport network, local councils have taken the lead in banning hot food takeaways near schools, and limiting their concentration within a certain stretch of the street, diversifying options available to people eating out. Islington, for example, has proposed that hot food takeaways (Class A5) will be resisted within 200m of primary and secondary schools and when 4% or more total units in Local Shopping Areas are in A5 use.

The Health and Wellbeing Board of the London Borough of Barnet, which brings together local and regional authorities, as well as representatives of NHS England, primary care providers and Healthwatch, continue their work to improve wellbeing of its residents in the workplace. Many changes need to happen at the workplace level, and the Barnet Council leads the way, being awarded the London Healthy Workplace Charter excellence accreditation in 2016. To this aim, they developed and delivered a wide range of actions that addressed mental health, diabetes, cardiovascular health and fitness. For example, the Council introduced blood pressure checks, lunch and learn sessions, mental health awareness stalls, among others.

How will we track progress? National London Indicator average average % of physically active adults (19+) (Active Lives Survey) 66.0% 64.6% Smoking prevalence in adults (Annual Population Survey) 14.9% 14.6% Hypertension: QOF prevalence (all ages) 13.9% 11.0% Proportion of the population meeting the recommended ‘5-a-day’ on a 54.1% 54.8% ‘usual day’ (adults) Alcohol-specific mortality (persons) 10.6 7.9 Sickness absence – the percentage of working days lost due to sickness 1.1 1.0 absence Gap in employment rate between those in contact with secondary mental 66.2 68.2 health services and the overall employment rate

Appendix: Summary outputs – Illustrative for discussion Page 25

Improve Air Quality

We commit to improving access to healthier air and spaces by X% so Londoners are able to breathe safe air, both in and out of the home

The quality of London’s air is dangerously and illegally poor. Over 2 million Londoners live in areas that exceed legal limits on nitrogen dioxide, including 400,000 children. High levels of damaging pollutants are harming our health and quality of life, particularly affecting lung development in our children and reducing life expectancy.

Over 9,000 Londoners’ lives end sooner than they should each year because of air pollution, and around 20 per cent of primary schools are located in parts of London that breach legal air pollution limits.

Air pollution is linked to the development of asthma and can cause chronic conditions such as cardiovascular disease and lung cancer. It is also to blame for children in parts of our city growing up with stunted lungs. Worryingly, some of the worst pollution hotspots are around schools and research shows that London’s most deprived communities are among the hardest hit – meaning that poverty and pollution are combined, limiting the life chances of too many young Londoners.

The Mayor of London wants our city to have the best air quality of any major world city. In early 2019, the GLA introduced the world’s first Ultra Low Emission Zone (ULEZ) with proposals to further extend its boundaries; we have low emission neighbourhoods and new hybrid and zero-emission double-decker buses on our roads. Similarly, many London boroughs have adopted 20mph speed limits. Public awareness and understanding is increasing, and by involving schools and communities this contributes to an integrated model of action, particularly in understanding and managing asthma.

Despite the actions outlined, air quality continues to remain the most pressing environmental threat to the future health of Londoners. It is also a key contributor to inequalities across the capital. Reducing air pollution levels isn’t easy and we need support from all partners to address this challenge as well as coordination of all levels – local, sub-regional and city-wide.

Appendix: Summary outputs – Illustrative for discussion Page 26

We will achieve our commitment through:

Local action: City-wide action:

• Local authorities mobilising the TfL Healthy • Extending London’s ULEZ beyond central

Streets framework, and new NICE London for all vehicles and London-wide

guidance on air pollution for lorries, coaches and buses

• Local authorities working with schools and • From 2020, all newly manufactured families on the impact of air pollution on private hire vehicles (less than 18 months their health old) presented for licensing for the first time must be zero emission capable • Specific Air Quality Policies being included in all local plans • NHS fleet will use low-emissions engines and all NHS sites will phase out primary • Installing at least 2500 new charging points across the capital by 2022 heating from coal and oil fuel • Deliver a major expansion in electric • All new developments are required to ensure adequate secure cycle storage is vehicle infrastructure, with at least 300 available for each new home built rapid charge points by 2020

• All health and care partnerships to take a networked, multidisciplinary approach to asthma care for all ages

And continuing to learn from good practice:

Ealing has introduced a community-based education and action plan intervention across the borough to help children and parents manage asthma. Face-to-face interventions take place in homes, schools, primary healthcare settings and community centres and include staff training, one-to-one and group self-management drop-ins, facilitating ‘Asthma Friendly Schools’, consultant led events for GPs and public awareness campaigns. Ealing borough saw a 40% reduction in emergency asthma admissions for children under 19 over the time period of the programme, and 95% of local doctors and nurses reported improved confidence in offering self- management advice to children with asthma and their parents/carers

Bart’s NHS Trust has a long-standing partnership with the City of London Cooperation and Newham, Tower Hamlets and Waltham Forest boroughs to improve local air quality. The partnership has included training over 300 clinical staff to give appropriate guidance to vulnerable patients and engaging with over 1000 people at Bart’s hospitals to give advice on how to reduce their exposure to poor air quality. Actions have also included installing green infrastructure and air quality assessments at Bart’s sites, the Trust has committed to reducing emissions from its own transport and the local boroughs putting in place emission restrictions near the many hospital sites

How will we track progress? National Indicator London average Recent trend average Fraction of mortality attributable to particulate air 5.1 6.5 pollution

Admissions for asthma for young people aged 10 to 137.6 153.9 18 (Persons, 10-18 yrs)

Appendix: Summary outputs – Illustrative for discussion Page 27

Improve mental health

We commit to London being a city that promotes positive wellbeing, achieves an X% increase in timely access to Mental Health services for

Londoners from every background and makes progress towards zero suicides

The estimated prevalence of mental ill health in London is 2 million: that’s 13 of us on the average bus and more than 100 of us on the average tube. 14 Londoners die each week from suicide. The Metropolitan Police service records an average of 2,400 mental health incidents per month and up to 140 Londoners per 100,000 were detained under the Mental Health Act in 2017/18. These staggering figures show we must work harder to prevent mental illness and provide a range of support for Londoners to access to prevent people reaching crisis point.

There is high variability between mental health services and the efficacy and efficiency of those services across London. For example, contacts with mental health crisis teams varied 41 fold between the boroughs with the highest and lowest number in December 2018.

Poor mental health is both a consequence and a cause of inequalities. There is a long list of factors that influence mental illness, including ethnicity, economic status, physical/long-term health conditions and social factors. We also know there are differences in access to treatment, with people from black and minority ethnic groups more likely to enter the mental health services when in crisis, more likely to be referred via the courts or the police rather than by a GP, and to receive medication rather than Figure 2: Risk of poor mental health talking therapies. across London’s local authorities on the basis of assessed inequalities The Mayor of London wants to improve mental health and wellbeing for Londoners, and London’s Health Inequalities Strategy sets out key actions to achieve this, including implementing plans to help tackle income inequality as a cause of poor mental health, providing funding with partners of Thrive and supporting citywide initiatives to reduce suicides.

Despite progress having been made in recent years in recognising the pressing need for parity of esteem with physical illness, mental ill-health and the associated health inequalities and stigma continue to be a major and growing concern for London. Preventing mental illness, improving wellbeing and ensuring people have the best possible outcomes from access to high quality treatment when and where they need it isn’t easy and we need support from all partners to address this challenge as well as coordination of all levels – local, sub-regional and city-wide.

Appendix: Summary outputs – Illustrative for discussion Page 28

We will achieve our commitment through:

Local action: City-wide action:

• Local multiagency suicide plans • Continuing Thrive London ‘Are you OK • Developing increased alternative forms of London?’ campaign

provision for those in crisis • London rollout of Good Thinking digital

• Meeting specific waiting time targets for mental health and wellbeing service emergency mental health services, • Pan-London s136 model of care in providing a 24/7 community-based mental partnership with the NHS, Police, local health crisis response for adults and older authorities and the voluntary sector adults and all-age mental health liaison service for all A&Es/inpatient wards • Projects to tackle stigma and improve • Providing an additional 110,000 people mental wellbeing, including Time to with severe mental health problems per Change year with a physical health check • Promoting good mental health in the • Continuing to increase local access to workplace, including through the London perinatal support and IAPT Healthy Workplace Charter •

And continuing to learn from good practice:

Lambeth Together, Living Well Alliance: Lambeth Clinical Commissioning Group (CCG) and Lambeth Council have joined with a group of providers to create the Living Well Network Alliance. The group of providers under a 7-10 year alliance contract, work with commissioners to lead, co-ordinate and, in large part, deliver support and services for those experiencing mental health issues in Lambeth. A key feature of the partnership is the Living

Well Network Hub, the ‘front door to mental health services’ in Lambeth, where staff from South London and Maudsley Foundation trust, Certitude, Look Ahead, Thames Reach, Clapham Family Practice and Lambeth Council are available to support local people with their wellbeing and mental health. The partnership working is supported by monthly Collaborative breakfast meetings to discuss current initiatives, share learning and help find new solutions.

Good Thinking: London’s digital mental wellbeing service, Good Thinking has directed around 300,000 Londoners towards self-care support to tackle sleep, anxiety, stress and depression. Over 120 online resources are signposted to through Good Thinking. Data from one resource, Be Mindful, demonstrated that users saw a 23% reduction in stress, 41% reduction in anxiety and 37% reduction in depression.

How will we track progress?

Indicator National average London Recent trend Suicide: age-standardised rate per 100,000 population (3 9.6 8.6 year average)

Adults in contact with secondary MH services who live in 57.0% 61.0% Not available stable and appropriate accommodation

IAPT Referrals Moving to Recovery 51.5% 51.7%

Rates of Detention Under the MH Act - 9,700 Not available

Appendix: Summary outputs – Illustrative for discussion Page 29

Reduce the prevalence and impact of violence

NB - City-wide health commitment in development

The level of violent crime in London is unacceptably high. Too many lives have been tragically cut short, and more have been changed forever by injury and grief. Violent incidents have risen for several consecutive years across the Country. In London in 2018, one third of homicide victims were aged 16-24 and three out of every five deaths involved a knife.

With increasing rates of deaths due to violence, the severity of attacks has continued to worsen. Since 2015/16, King’s College hospital saw 63% more adults treated for knife wounds; a trend echoed in other major trauma centres across the capital. Our NHS clinicians have also noted higher numbers of Figure 3: London violence against the person data victims presenting with multiple, rather than single or double, puncture wounds.

Statistics also revealed a huge disproportionality in the ethnicity of both victims and perpetrators. Black Londoners are more likely to say they feel personally affected by crime (44% compared to 32% of non-black Londoners) and this is supported by evidence on knife crime, where 26% of victims and 46% perpetrators are black. A picture of inequality is also exposed; the areas most affected by violence are boroughs in London with the most significant deprivation.

Violence is increasingly regarded as a public health issue that impacts on the health and wellbeing of the population as well as individuals. It contributes to health inequalities and causes ill-health through fear, injury and loss, affecting Londoners and our communities. It is also contagious, with clusters of incidents linked in time, by place, or by the groups of people affected. To tackle this effectively we need to understand and address its root causes.

There are known risk factors for involvement in violence, which overlap with risk factors for other adverse physical and mental health outcomes. London’s health and care system has a key role to play in the violence reduction agenda; and with other partners can lead and deliver a public health approach that understands the root causes of violence and how it can be prevented.

A range of evidence-based intiatives are already occurring including in healthcare settings, in schools, and with organisations and groups that work directly with young people in their communities. We must continue this momentum to extend actions and address service gaps to ensure we cater to London’s most vulnerable and those at risk.

Appendix: Summary outputs – Illustrative for discussion Page 30

Local and city-wide partnerships can help us reduce violence in London through the actions outlined below.

We will achieve our commitment through:

Local action: City-wide action:

• Knife crime actions plans developed • ‘London Needs You Alive’ city-wide and implemented in each borough media campaign • Education and community outreach • Evaluating local programmes and programmes focused on crime and sharing best practice evidence-based violence reduction models across the health and care system • Focused action on violence against • Commissioning bespoke support models women and girls for vulnerable individuals at risk

• Reviewing NHS specialised pathways (e.g. criminal justice and mental health) to ensure appropriate support is available for individuals at risk • Funding through the Young Londoners Fund to local projects that combat youth violence

And continuing to learn from good practice:

Project Future is a community based, youth led mental health and well-being service that seeks to transform mental health delivery for young men aged 16-25, who are involved in offending and affected by serious youth violence in Haringey. Project Future is a partnership project between Mind in Haringey, Barnet, Enfield and Haringey NHS Mental Health Trust and Haringey Council. Project Future has been co-produced with the young men themselves who are entrenched in cycles of poverty and offending, and who are not able to access regular services.

City-wide action - In response to rising levels of violence across the capital, the Mayor of London has set up a Violence Reduction Unit (VRU) bringing together representatives from the voluntary and community sector and specialists in health, education, enforcement and local government to adopt a public health approach to reducing violence across the capital. London’s NHS is committed to violence reduction as a priority area and has recently appointed a NHS Senior Responsible Officer and Clinical Director to develop and steer a regional violence reduction programme that supports interventions at local, sub-regional and London level and is aligned to the Mayor’s VRU. How will we track progress? National London Indicator Trend average average Violent crime (including sexual violence) - hospital 43.4 44.4 admissions for violence

Violence Against the Person offences TBC TBC

Appendix: Summary outputs – Illustrative for discussion Page 31

Improve the health of homeless people

London commits to reducing the numbers of rough sleepers on the street. London’s ambition is for no rough sleepers to die on the streets

People experiencing homelessness are some of the most vulnerable and isolated people in our society and have some of the poorest health outcomes. They are more likely to die young, with an average age of death of 44 for men and 42 for women (ONS, 2018). Physical and mental health problems, as well as substance misuse, can contribute towards and are exacerbated by homelessness.

The number of people seen sleeping rough on the streets in London has doubled in the last 10 years and represents 27% of the total in England, with 7,487 people seen sleeping rough in London 2017/18. For every person sleeping rough there are estimated to be 13 times as many ‘hidden homeless’ who are sofa-surfing, living in cars, squats or in other precarious situations. There is also a growing number of households in local authority arranged temporary accommodation in London - 54,280 households in 2017/18.

London’s profile also presents unique challenges, with higher numbers of people who are less able to access support as well as those with no recourse to public funds. In 2017 40% of people sleeping rough in London were from the UK compared to 82% in the rest of England and 30% were from EU countries compared to 12% in the rest of England. The stigma associated with homelessness, exclusion from mainstream society, lack of access to support services and the inability of those services to meet such complex needs, means these needs often go unmet.

As a result, people experiencing homelessness are high users of urgent care settings, where on average they access hospital services four times more often and inpatient services eight times more often than the general population(Department of Health, 2010). There is widespread and growing concern about the number of homeless people discharged from hospital without their underlying housing and health problems being addressed, and the rise in homeless deaths. Instances of patients leaving hospital with nowhere to go rose by nearly a third (to 8,758 discharges) from 2014 – 2018 in England, with the largest increases in London (The Guardian, 2019).

The Government’s Rough Sleeping Strategy aims to half the number of rough sleepers in England and Wales by 2022 and to eliminate rough sleeping by 2027. The Mayor of London’s Rough Sleeping Plan of Action sets out a wide ranging plan to prevent and reduce rough sleeping in the capital.

The development of the London Vision and STP plans presents an opportunity for the health and care system in London to come together and look at this issue in a way that hasn’t happened before – to find new ways of serving this population in an informed, effective and compassionate way.

Appendix: Summary outputs – Illustrative for discussion Page 32

We will achieve our commitment through:

Local action: City-wide action:

• Hospitals meeting the duty to refer • Deliver the Mayor’s Rough Sleeping people who are homeless or at risk of Plan of Action and the Government’s homelessness to the local authority for Rough Sleeping Strategy support commitments • Implementing the homeless health • Commission integrated ‘step- commissioning guidance for London down’/intermediate health and care services for homeless people who • Conduct a joint local homeless health needs assessment require continuation of care following

• Commission and provide services in line discharge from hospital with the homeless and inclusion health • Develop regional and sub-regional standards and homeless health solutions to deliver safe and effective commissioning guidance for London homeless hospital discharge taking a • Provide local leadership to champion, ‘Housing First’ approach support and be accountable for delivery • Convene a London Homeless Health Board to provide leadership and strategic oversight and monitor progress

And continuing to learn from good practice:

The Healthy London Partnership, along with Healthwatch London and homeless charity, Groundswell, produced ‘my right to access healthcare’ cards to help people experiencing homelessness overcome barriers registering and receiving treatment at GP practices. 75,000 cards have been distributed across shelters, day centres, food banks, drop in centres and other community and voluntary organisations across London since December 2016. HLP have worked with Pathway, a homeless health charity, to create an eLearning training package for GP receptionists and practice managers.

No Second Night Out (NSNO) is a London-wide partnership project, rolled out in 2012 across all boroughs following a successful pilot, aiming to ensure that those who find themselves sleeping rough in London for the first time need not spend a second night on the streets. To do so, NSNO takes note of London’s rough sleepers via London Outreach teams or through the StreetLink platform and, following a comprehensive assessment in one of their three 24-hour assessment hubs or two staging posts, provides a Single

Service Offer. Since the launch of the program, 75% of all new rough sleepers accessing

NSNO did not spend a second night out and helped 6,943 people to exit rough sleeping across London. How will we track progress? National Indicator London average average Deaths of homeless people in London (per 100,000 total 1.2 2.0 population) Number of people sleeping rough in London (2017/18) 4,677 7,484

Appendix: Summary outputs – Illustrative for discussion Page 33

Improve sexual health

London will lead the way to having zero new HIV infections, zero preventable deaths and zero stigma by 2030 as set out by the Fast Track Cities commitment. To reduce overall rates of STI infections and address sexual health inequalities in London by ensuring access to equitable, flexible, high-quality services.

Sexual health is an important public health issue that impacts on people’s broader wellbeing Poor sexual and reproductive health and ongoing transmission rates of HIV have major impacts on population mortality, morbidity and wider wellbeing. Sexual relationships are an intensely private matter, but have a significant impact on the wellbeing of the whole adult population and of wider society. If not successfully treated, STIs can lead to a number of conditions such as pelvic inflammatory disease, ectopic pregnancy, infertility and cervical cancer. Sexual and reproductive ill health is concentrated in many vulnerable and marginalised communities, and improving sexual and reproductive health and HIV outcomes will address these major health inequalities. London’s rate of STI diagnoses is 83 per cent higher than any other region in England, while 17 of the 20 local authorities with the highest rates of STIs are in the capital. The chance of contracting an STI in London is considerably higher than any other UK city with a rate of infections that is 65% higher than the national average. Younger people, people from Black ethnic groups and men who have sex with men (MSM) are at increased risk of sexual ill health. We need to build on work to increase choice and convenience of access of contraceptive methods, such as the C-Card Scheme, which enables young Londoners to pick up free condoms. The newly launched sexual health e-service for London (SHL) is another opportunity to expand free and easy access to sexual health testing via the internet and local venues. Major strides have been made in responding to HIV in London but there is more we can do HIV remains an important public health problem in London. In 2017, an estimated 38,600 people were living with HIV in London, representing 38% of all people living with diagnosed or undiagnosed HIV in the UK. An estimated 1,549 London residents were newly diagnosed with HIV in 2017, accounting for 39% of new diagnoses in England. In January 2018, the Mayor of London, Public Health England, NHS England and London Councils signed a joint declaration to achieving the UNAIDS targets. The initial targets are for cities to reach ‘90-90-90’ (90% of people with HIV diagnosed, 90% on ART treatment and 90% virally suppressed) and then 95-95-95, with the ultimate goal of ‘getting to zero’. London is already a world leader in its response to HIV: it is currently the only city to have exceeded the second target milestone of ‘95-95-95’, with the most recent statistics from 2017 at 95%-98%-97% respectively. This puts London in a unique position to accelerate its progress and be the first world city to end its HIV epidemic. Despite being a world leader, we still have our challenges

Appendix: Summary outputs – Illustrative for discussion Page 34

London still has high rates of late diagnosis of HIV (35% between 2015-17), which results in poorer health outcomes for these individuals, including premature death. In addition to this, most new HIV infections are passed on from persons unaware of their infection.

We need to combat stigma which has significant impacts on testing and treatment adherence and reaching underserved groups of Londoners with high rates of late diagnosis and lower HIV awareness. London also has a population of people living well with HIV, but who have greater need for support for some wider determinants of health and an ageing HIV population which requires more support for managing co-morbidities and other unrelated conditions as they get older. We will achieve our commitment through:

Local action: City-wide action:

• National full funding for routine local • Increase general public awareness of commissioning of PrEP to help achieve HIV today and impact of stigma through ‘zero new HIV infections’ a pan-London campaign • Optimise current patient pathways and • Build on the London borough pan- adoption of NICE guidance including London HIV collaborative and the Do it London campaign to make best use of opt out testing and TasP existing community knowledge, • Maintaining access to a range of free experience, and access to target contraception for key populations underserved communities • Designing new models of care to • Ensure heath, care and government create a trusted, high quality, organisations are stigma-free, including integrated and personalised care training for key staff groups and services model • Engaging leaders and influencers • Implement new and innovative throughout the health and care economy, prevention technologies including advocating to keep HIV education part of PHSE curriculum11

And continuing to learn from good practice:

The London boroughs of Lambeth, Southwark and Lewisham (LSL), like other boroughs across the capital, have seen a rise in the number of new diagnoses of HIV and other STIs among gay men. In response, these three boroughs commissioned the first qualitative research in the UK into ‘chemsex’, sometimes referred to as ‘party and play’ or ‘sex when you’re wired.’ The research involved new analysis of gay men’s health surveys, as well as one-to-one interviews and focus groups. Its aims were to not only to identify risk-taking behaviour, but also establish the reasons behind that behaviour in order to help commissioners identify possible future interventions

How will we track progress? National Indicator London average average Syphilis diagnostic rate /100,000 12.5 38.7 New STI diagnoses (exc chlamydia aged <25) /100,000 794 1547 Gonorrhoea diagnostic rate /100,000 78.8 228.4 HIV testing coverage (total, %) 65.7% 72.3% HIV late diagnosis % (PHOF indicator 3.04) 41.10% 35.20% New HIV diagnosis rate / 100,000 aged 15+ 8.7 21.7

Appendix: Summary outputs – Illustrative for discussion Page 35

Improve the quality of life for ageing Londoners

There is significant potential to improve the quality of life of Londoners as we grow older, through action to improve healthy life expectancy and through targeted work in later life on wellbeing and proactive care. London is becoming a City that better supports and empowers older people to stay well through its communities and amenities, world class health and care services, and support for personal capacity to maximize the opportunities for London through things like social prescribing. Dementia

London commits to becoming the first dementia friendly capital city by 2022

In London, 72,000 people are estimated to be living with dementia and of these, 4,200 are under- 65. If current trends continue, there will be a 40 per cent increase in the people living with this condition by 2025. The dementia diagnosis rate is currently 73%, which means it is predicted that there are currently 20,000 people in London who have dementia but no diagnosis (65+ years). Good progress has been made in the last 3-5 years from a diagnosis rate of 54% however there is wide ranging variation in rates across CCGs. In May 2018, organisations in London pledged to make London a dementia-friendly capital city by 2022. The GLA, London Health Board and Alzheimer’s Society are working with partners to achieve: 2,000 organisations that are more dementia friendly, and 500,000 Dementia Friends taking action, big or small, to improve the everyday lives of people affected by dementia. Every London borough is working towards becoming a dementia-friendly community, with meaningful involvement of people affected by dementia. Our ambition is that people affected by dementia in Greater London - no matter who they are or where they live - should be able to enjoy the best possible quality of life. We will achieve our commitment through:

Local action: City-wide action: • Every London borough working towards • Reducing variation in diagnosis rates across becoming a dementia-friendly community London, going beyond the national ambition • Improving pathways and integrated working • Shape dementia services so that people with dementia receive effective diagnosis, • More active focus on supporting people in treatment and care the community

How will we track progress? National Indicator Date London average average Dementia: Recorded prevalence (aged 65 2018 4.33 4.50 years and over) Deaths in Usual Place of Residence: People 2017/18 68.5 56.2 with dementia (aged 65 years and over) Dementia: Residential care and nursing 2018 68.2 48.9 home bed capacity (aged 65 years and over)

Appendix: Summary outputs – Illustrative for discussion Page 36

Cancer

Commit to increase participation in cancer screening programmes so that more people are diagnosed as early as possible

There are an estimated 2.5 million people living with cancer in the UK in 2015, rising to 4 million by 2030. The number of people living with cancer in the UK in 2015 has increased by over a million people since 2010. In London, 231,740 people were living with and beyond cancer in 2017. The prevalence data demonstrates the growing need for health and care systems to respond to the rise in diagnoses of cancer and improving survival rates. In order to deliver the ambitions for cancer (set out in the NHS Long Term Plan) so that 75% of all cancers will be diagnosed at Stage 1 and 2 by 2028, it will be essential to maximise the uptake and effectiveness of screening programmes. Cancer screening aims to reduce the numbers of deaths from breast, cervical and bowel cancer by: • finding pre-cancerous signs of cervical and bowel cancer and treating these • identifying and treating early signs of breast, cervical and bowel cancer, leading to a greater chance of survival and less aggressive treatments. Currently, cancer screening coverage is generally lower in London than the national average, with wide variation between and within CCGs. Coverage and uptake are typically lower in urban and deprived communities, and in certain groups within society, including Black, Asian and Minority Ethnic groups, people with physical or learning disabilities and LGBT+ communities.

We will achieve our commitment through:

Local action: City-wide action: • Campaigns to raise awareness and • Maximise screening uptake (particularly

target hard-to-reach groups. bowel), screening changes (e.g. FIT, HPV), to implement best practice

surveillance and increase population health awareness

How will we track progress? National London Indicator Date average average Cancer screening coverage – cervical 2018 71.4 64.7 cancer Cancer screening coverage – breast 2018 74.9 69.3 cancer Cancer screening coverage – bowel 2018 59 50.2 cancer

Appendix: Summary outputs – Illustrative for discussion Page 37

Improve care and support at the end of life

London commits to delivering personalised end of life care so that more

people die in the place of their choice.

Around 47% of deaths in England take place in hospital despite this being the least preferred location by patients. There is also considerable variation in the likelihood of dying in hospital by region and a considerably higher proportion of hospital deaths in our capital city. Our children and young people are also dying in emergency departments and hospital wards, with a significantly lower proportion in London dying at home.

For three-quarters of these people, death does not come suddenly and involves a progressive decline in functioning and frequent interactions with health professionals. During this time, many receive some form of end of life care, designed to ease any pain or distress caused by their symptoms, and to maximise their quality of life until the moment of their death. However, for some this care isn’t received – we need to ensure our Londoners are supported at the end of their life and where possible they die in their preferred place.

We will achieve our commitment through:

Local action: City-wide action:

• Proactively identify patients who should • Reducing variation in End of Life Care be receiving palliative care to ensure Services across London and targeting that all people at the end of their life personalised care planning in target have high quality and compassionate groups to reduce inequalities (i.e. care with personalised plans in place homeless and people with learning • Promote ‘Coordinate my Care’ (CMC) to disabilities) ensure that important information about • Continue to support the development people at the end of their life and their and implementation of CMC in all care

preferences for the care they wish to settings, aligned to the digital receive is recorded and known infrastructure within the Local Health and Care Record Exemplar (LHCRE) programme

How will we track progress? Date National London Indicator average average Percentage of deaths that occur in 2017 46.0% No data hospital (all ages)

% of people that have a CMC record TBC TBC TBC

Appendix: Summary outputs – Illustrative for discussion Page 38 Agenda Item 6

Date of meeting: 10 July 2019 Agenda item: 6 Title: London Estates Strategy Presented by: Geoff Alltimes, Co-Chair of the London Estates Board Author: Sue Hardy, Programme Director, London Estates Delivery Unit Cleared by Dr Nick Bowes, Mayoral Director, Policy Status: For Discussion Classification Public

1 Purpose of this paper

1.1 This paper seeks to achieve endorsement from the London Health Board (LHB) to publish the first London Health and Care Estates Strategy, a key requirement of the London Estates Board (LEB) as it progresses through the devolution gateways from an advisory body to one that makes capital investment decisions in London.

1.2 There have been significant changes made to the strategy since it was shared with over 200 stakeholders for comment and contribution in August 2018. The changes address many of the useful comments received through the consultation exercise, they also reflect the London Estates Delivery Unit (LEDU) and LEB progress over the last few months. Additionally, the strategy has been updated to reflect alignments with national policy and funding developments, such as the publication of the NHS Long Term Plan and the announcements of the wave 4 STP capital awards.

2 Recommendation(s)

2.1 The Board is asked:

2.1.1 to note the progress made on the development of the London Health and Care Estates Strategy; and

2.1.2 to endorse the strategy ahead of publication.

3 Context

3.1 The London Health and Care Estates Strategy, developed by the LEB, is a first for London. The strategy brings together the locally-led work of London’s five Sustainability and Transformation Partnerships (STPs). London’s shared strategy describes how by coming together, the partners involved with deciding the future of health and care facilities can work in a more organised and transparent way to transform the quality of the facilities in which our patients receive care.

Page 39

4 Key updates to the London Health and Care Estates Strategy following consultation with partners and stakeholders

4.1 Governance & engagement – governance and engagement arrangements that reflect the phased progression of the LEB from an advisory forum to a formal decision making body. It shows that these arrangements and the associated engagement activities ensure that a transparent, representative and accountable system is in place.

4.2 Performance measurement - KPIs for the LEDU/LEB have been set that reflect the key objectives of releasing land no longer required for clinical use, delivering transformation in the health and care estate and supporting the delivery of thousands of new homes in London.

4.3 Investment criteria - principles that will underpin investment decision making has been clarified with recognition that the detailed approach and process will be agreed with partners.

4.4 Interdependence between Primary and Acute Care - a much clearer and repeated message of the inextricable link between delivering transformation in the acute and primary care sectors is made.

4.5 Priorities for action – LEB and LEDU workstreams focus on supporting a more efficient project and business case development approvals process, improving utilisation of the estate, developing capacity and competency in STP estates management and helping the development of innovative delivery and funding solutions. Work to undertake joint asset planning and delivery with STPs, GLA and Department of Health and Social Care is in progress.

4.6 Capital Investment Pipeline – the strategy refers to the high level investment requirements of the five STPs as set out in their estate strategies produced in July 2018. This information has provided the LEB and LEDU with oversight of the investment pipeline for London, however due to the outcome of the wave 4 STP capital bidding round, the recent HM Treasury’s finance infrastructure review and the national requirement for STPs to revisit their plans, the pipeline continues in its development and will be managed as an iterative piece of work.

4.7 NHS Long Term Plan (LTP) - the close alignment of the estates strategy with the LTP is drawn out and referenced throughout the strategy and underpins the core principles of the LEB and LEDU vision.

4.8 Naylor Review – the strategy now provides a stronger reference and alignment with the key recommendations from Sir Robert Naylor’s review of the management of NHS estate. The LEB and GLA are kept closely informed of Sir Robert’s work for the NHS Property Board.

Page 40

4.9 STP capital funding awards - the aggregate position is given with regard to the scale of application for wave 4 funding and the expected outcomes such as recurrent revenue savings, land released for development of new homes. This is set against the outturn position of very few projects being successful and the much reduced opportunity to deliver savings and land for homes. The use of financial metrics on a project by project basis to award funding highlighted as fundamentally different approach to the pan London view that is needed and would be operated by the LEB.

5 Next steps

5.1 Upon endorsement of the London Health and Care Estates Strategy by members of the LHB, the strategy will be formally published and will enable the LEB to move to phase III of the devolution gateway (shadow decision making) .

Appendices:

• Appendix 1: London Health and Care Estates Strategy

Page 41 This page is intentionally left blank London’s Estates Matter

The London Estates Board: Health and Care Estates Strategy

June 2019 Final draft

Page 43 This document will be reviewed annually. The London Estates Board: Health and Care Estates Strategy 1 Contents

Foreword 4 Executive Summary 6

SECTION 1 The vision and purpose of London’s Health and Care Estates Strategy 13

1.1 Vision and purpose 14 1.2 Context 16

SECTION 2 Bringing together London’s sub-regional estates strategies 21

2.1 Clinical priorities determining locally-led estates strategies 22 2.2 Enabling a fit for purpose primary care, community and mental health estate 25 2.3 Enabling a fit for purpose acute estate 29 2.4 Delivering estates transformation London-wide 32

Page 44 2 SECTION 3 Outcomes and approach to delivery 36

3.1 Outcomes of the London Estates Board 37 3.2 Progress and next steps for delivery 41

SECTION 4 Governance and engagement 44

4.1 Governance 45 4.2 Engagement 49

Appendices 50

Appendix A: London demographics and housing needs 51 Appendix B: London joint prioritisation framework 55 Appendix C: London-wide and local STP governance and delivery arrangements for estates 61

Glossary 67

Page 45 3 Foreword

London has some of the world’s most through the London Health and Care Devolution advanced facilities, but it also has some Memorandum of Understanding1, to deliver our of the worst GP and hospital buildings in vision of providing Londoners with exemplar health and care facilities. The London Estates Britain. Some primary care buildings are so Board (LEB) sits at the centre of this approach, dilapidated and inaccessible that they have where all London and national partners meet with been deemed beyond repair. Whilst some wider organisations to develop and agree plans to hospitals are aspiring to build the most transform London’s health and care estate. technologically-advanced facilities, others This strategy has been developed to help all are just trying to keep the rain out. partners meet our collective ambitions to: People are at the heart of health and care services. • Meet the health needs of a growing population The quality of care we offer across London (circa 780,000 within the next 10 years2). depends first on the dedication and skills of staff but it also depends on the quality of the premises • Improve the health outcomes and care in which they work. experience of patients and their families in fit for purpose facilities. NHS owned land and buildings in London is valued • Enhance the working environment of our at more than £11 billion, covering a footprint three dedicated health and care staff. times the size of Hyde Park. This London Health and Care Estates Strategy describes how we plan • Support and accelerate changes in health and not only to fix the roof in challenging times, but care service model delivery to reflect and drive how we will transform the quality of the facilities best practice. in which Londoners receive care. Our vision is for London to have a world class health and care • Deliver significant improvements in value for service estate that reflects and adds to its stature as money through lower estate maintenance costs. a leading global city in the 21st century. To achieve Recognising our health is impacted by access this, we estimate £8 billion of new investment is to housing, jobs and the quality of our living required over the next 10 years. environment, this strategy supports increased London’s health and care partners have united benefits by embracing estate solutions that span all to create this strategy to respond to the estates of London’s public services, recognising: challenge. Built bottom-up from across our capital • How co-locating professionals supporting it reflects the dedication and collaboration of people with multiple health conditions can make health and care leaders, including NHS England & collaboration easier and care more accessible. Improvement, London’s 32 Clinical Commissioning Groups and providers, the five Sustainability and • How fit for purpose premises can improve the Transformation Partnerships, Public Health England links between London’s great hospitals and the (London region), the Mayor of London and London local primary and community care that is needed Councils representing London’s 32 boroughs and before and after hospital treatment. the City of London Corporation. This strategy sets out how we will use the new powers secured

1 London Health and Care Devolution Memorandum of Understanding, November 2017 2 Sub-national population projections for England, ONS May 2018

Page 46 4 The London Estates Board: Health and Care Estates Strategy • Sharing the property development skills, Please be assured, this is a live document and legal powers, access to finance and the only the beginning of our journey to ensure every planning powers of the Mayor and London Londoner receives treatment in a world class borough councils to accelerate and enhance facility. As we develop and strengthen our working delivery plans. practices, collaborative approaches and priorities, we will share updates to our strategy. • Connecting up the estates strategies of all London public services to maximise We hope you will see the scale of London’s opportunities for delivering more jobs, housing, ambition in the pages that follow and that this community and health facilities for Londoners. strategy provides a focus supporting on-going • Releasing surplus NHS land to support the conversations with all Londoners. delivery of an estimated extra 12,500 Finally, as independent sschair of the LEB, I would new homes. like to express my gratitude to Board members and • Working with the NHS, GLA and London partners involved in creating this first unified health borough councils to invest in the delivery of and care estates strategy for London. The Board housing for Londoners and for health and remains committed to working with and through care staff. our partners, strengthening our collaboration to ensure that our shared vision is realised. • Promoting good physical and mental health and wellbeing and reduce health inequalities Geoff Alltimes through great design of our built environment. Independent Chair, London Estates Board The scale of the task means we must be ambitious. For a chance of success we need all our partners to give their full commitment to collaboration and to being open to challenge and new ways of working. Through this new unified approach and sharing of common purpose, as this first pan London estates strategy demonstrates, we can improve the delivery of high quality primary, community, mental health and social care premises, a fit for purpose hospital estate and the sustainability of an exemplar health and care system.

We are also committed to be ever more ambitious. The LEB is ready to move into phase 3 of operation (shadow decision-making), with the longer-term ambition of seeking partners’ support for the transition to phase 4 (full decision-making).

Page 47 The London Estates Board: Health and Care Estates Strategy 5 Executive Summary

Page 48 6 The London Estates Board: Health and Care Estates Strategy Executive Summary: London’s First Health and Care Estates Strategy

This is the first London-wide health and care The London context estates strategy in the 70 year history of the NHS. It marks a turning point in how London’s London has an unrivalled concentration of health health partners, alongside national partners, providers that can rightly claim to be world leaders want and need to work together. To provide a in their field delivering their services from state of sustainable, fit for purpose estate, one which is the art facilities. London’s NHS estate value at £11 capable of supporting the delivery of our clinical billion is also unequalled and presents very real needs, we need to stop working in organisational opportunities for transformation. However, too silos, take a long term and holistic view of acute many provider sites in London have been identified and primary care estates and ensure policy and by the Care Quality Commission (CQC) as being funding decisions that have a major impact on the deficient in providing a safe environment for health condition of our estate are taken in London, care delivery and as Sir Robert Naylor observed, by London. ‘constant restructuring in the NHS has resulted in fragmented ownership and management Vision and purpose structures and decision making’.

The London Estates Board’s vision is for all The scale of the NHS estate in London only serves Londoners, regardless of their background or to exacerbate the resultant coordination and where they live, to have access to a world class alignment challenge from this fragmentation. This health service in world class facilities. This requires strategy actively addresses this fragmentation, sufficient numbers of skilled and dedicated staff being built bottom up from the extensive and and fit for purpose buildings and facilities. Premises intensive work amongst London’s health and care that should reflect and add to London’s stature as a partners it evidences the many shared estates leading global city. issues and delivery priorities across London. It very forcefully highlights the clinical and estate priorities We know this is an ambitious vision given the of the primary, community, mental health and current condition of our estate. We also recognise acute sectors and the inextricable link that needs that transformation on this scale requires a to be made and managed more than ever between fundamental change in how we do business these parts of the system. in London, within the NHS and with the wider 3 public sector. This London Health and Care Estates Echoing the NHS Long Term Plan’s focus on the Strategy is designed to help us achieve our vision need for more out of hospital health care, close by mapping how we will collaboratively use the integration of providers and delivery at scale, powers secured through the London Health and this strategy shows how partners are taking a Care Devolution Memorandum of Understanding holistic, London-wide view of the NHS and the (MoU) to drive forward our detailed work plans wider public sector estate. Partners are beginning for NHS estate transformation across London. It the process of building better relationships and a is a live document and will be updated to reflect system wide approach to deliver the much needed progress and new priorities, as well as acting as a estates priorities. key tool in measuring our own success

3 NHS Long Term Plan January 2019

Page 49 The London Estates Board: Health and Care Estates Strategy 7 Beyond the challenge of fragmentation, London Furthermore, data for London’s hospital trust estate shares some health estates issues with the rest indicates that whilst London accounts for 18% of of the UK, such as the need to better utilise occupied floor space across England, it accounts existing capital assets and maximising the use of for 32% of the reported backlog maintenance technology to mitigate the need for additional cost. This is closely related to the fact that 41% of space. More critically however we have many London’s estate was built before 1965 compared unique and persistent issues, built up over time to 29% for the rest of England; even more tellingly, due to the sheer scale of London’s population and 21% of London’s NHS estate was built before 1948 demographics and the nature, scale and condition whilst for the rest of England this was just 11%. of the primary and acute health estate. Current estimates indicate that £8 billion will be needed over the next 10 years to transform the It has been estimated that a third of London’s London health and care estate into fit for purpose primary care infrastructure needs to be rebuilt with facilities (see Figure A). many practices operating from Victorian premises.

We know this is an ambitious vision given the current conditionWe know this of is ouran ambitious estates vision given the current condition of our estates.

It has been estimated that Furthermore, even more tellingly, Current estimates indicate that was built compared to of London’s NHS estate of London’s primary 21% care infrastructure 41% before 29% for was built before bn 1/3 needs to be rebuilt the rest of £8 whilst for the 1948 will be needed 1965 England rest of England with many practices operating of London’s over the next 10 years to We know this is an ambitious vision given the current condition of our estates. this was 2 from Victorian premises. estate just 11% transform the London health and care estate into It has been recognised that transformation on this scale requires a fundamental change fit for purpose facilities 3 It has been estimated that Furthermore, even more tellingly, Current estimates in how we do business in London, within the NHS and with the wider public sector. indicate that was built compared to of London’s NHS estate of London’s primary 21% care infrastructure 41% before 29% for was built before bn 1/3 needs to be rebuilt the rest of £8 whilst for the 1948 will be needed 1965 England rest of England with many practices operating of London’s over the next 10 years to this was from Victorian premises. estate just 11% transform the London health and care estate into It has been recognised that transformation on this scale requires a fundamental change fit for purpose facilities 3 in how we do business in London, within the NHS and with the wider public sector. It has been recognised that transformation on this scale requires a fundamental change in how we do business in London, within the NHS and with the wider public sector.

Figure A: The scale of the challenge

Page 50 8 The London Estates Board: Health and Care Estates Strategy Historically, nationally determined priorities and associated funding models and metrics have not Common priorities are seen across the resulted in London receiving its ‘fair share’ of five estates strategies: funding for estates improvements that reflect London’s unique needs and priorities. Tellingly, • Improve and maintain existing this approach has failed to address or halt the buildings, for example the critical decline in quality of London’s estate. Added to this, maintenance work required at Whipps ONS projections show that both London’s total Cross University Hospital described in the population and the proportion of those aged 60 North East London (NEL) plan. and over, typically the most intensive users of health • Redesign and redevelopment of and care services, are expected to be the fastest community and primary care estate: growing in England. As the latest round of NHS for example in North Central London England & Improvement project funding awards (NCL), Locality Planning to support shifting indicate, traditional funding approaches also of services into community and primary continue to fail to materially address the needs of care, reducing reliance on acute services. London’s NHS estate. • Develop new sites and buildings to This persistent mismatch of need and funding support new models of hospital care, highlights the critical requirement for funding for example a key feature of future North arrangements for London to be allocated according West London (NWL) service provision to London’s needs and priorities, in a planned will be out of hospital hubs. Primary, and sustainable manner with receipts generated community, mental health, social care in London being re-invested in the capital. It and acute providers will come together to highlights the importance of the London Estates deliver integrated, patient-centred services Board securing a devolved and long term capital in the hubs. budget to coordinate this. • Make better use of existing assets, Clinical and estate priorities for example South East London’s (SEL) plan involves reducing the amount of Each of the London’s five Sustainability and under-utilised space at a number of sites, Transformation Partnerships (STP) have developed including at the Sunshine House CHP sub-regional estates strategies to deliver clinical facility in Peckham. best practice models of care, consistent with the • Co-ordinated approaches to using NHS Long Term Plan and their individual locally the public sector estate, for example determined estates priorities. There are wide Croydon, Kingston, Merton and inequalities in health across STPs, for example a Sutton councils in South West London woman living in Tower Hamlets is expected to live (SWL) all participate in One Public for just 56 years in good health compared to 70 Estate partnerships. years on average if she lived in Richmond upon Thames. Notwithstanding the need to reflect local conditions and drivers, it is possible to take Figure B: Common priorities across London’s a London-wide view, as set out in Figure B, to five STP estate strategies determine common plans and approaches.

Page 51 The London Estates Board: Health and Care Estates Strategy 9 The role of the London Estates Board LEDU will review STP, commissioner and provider (LEB) and London Estates Delivery Unit competencies and capacities to support business (LEDU) case submissions at pace and at scale. • Portfolio and building operational toolkits – the Successful estates transformation will be driven LEDU will work with London-wide and national more quickly and cost effectively by a collective partners to establish protocols and toolkits that and collaborative approach between London’s will help partners develop and run their estate health and public sector partners. This is being more cost effectively. made possible through the establishment of the LEB (2016) and more recently the LEDU (2018). • Capital investment plan management – the LEDU Both play a pivotal and catalytic role in delivering has begun the process of establishing an assured an agreed workplan that is focussed on addressing capital investment plan requirement for London the key issues highlighted in this pan London that details where and when funding is needed, estates strategy: and for what type of development in order to deliver the clinical priorities. This plan, the first • Estates data – the LEDU will work to compile for London, will be refreshed on an annual basis a reliable, robust and interoperable data and will be used to support the London bid for collection, storage and analysis approach. a devolved and long-term budget and equally This will aid regional and London-wide importantly will be used to allocate and manage estates planning. the programme of transformation against London determined priorities. • A devolved capital budget – the LEB as a unified partnership will work with national partners to • A voice for London – the experiences and secure a long-term capital budget for London, priorities of London’s health estate will be much against which strategic plans can be made and stronger when delivered together through the managed. In securing a devolved capital budget, LEB, ensuring more cost effective involvement the LEB will help regional delivery partners plan and better outcomes. The LEB will be measured with confidence. on its success in bringing partners together and acting as the voice for London on health and • Innovative, strategic and planned delivery – care estates matters at the national table. whilst the LEB will work to secure a long-term assured, devolved capital budget for London, it • Better engagement with provider is very likely to be insufficient to meet even the organisations – the LEB and LEDU will support already known capital investment need. The providers with the development of their LEB working with local partners will identify transformation plans, releasing surplus land, innovative property delivery routes, funding generating capital for reinvestment, tackling sources, and legal structures that will enable backlog maintenance challenges, alongside transformation of the estate at pace. This facilitating partnership working that draws on approach will meet clinical needs and address their experience and expertise to up-skill other health inequalities by also generating valuable organisations in London. social outcomes, such as affordable housing and community amenities. More details on the LEB and LEDU’s approach to collaborative working and decision-making are • Business case support – the LEDU will support outlined in section 2.4. STPs through training and sharing best practice to develop ‘right first time’ business cases. The

Page 52 10 The London Estates Board: Health and Care Estates Strategy Outcomes of the London Estates Board Governance for London’s estates transformation The success of the LEB’s work will be measured against the strength of its performance to generate The London Health and Care Devolution visible and quantifiable value for money outcomes, Memorandum of Understanding (MoU) was establishing and managing the first requirement signed in November 2017. The MoU confirmed for London, as well as on its success in bringing a commitment from national and local partners partners together and acting as a voice for London to work together to accelerate health and care on health and care estates matters. transformation for the benefit of Londoners. Critically, the scope of the MoU went beyond The LEB must deliver against three overarching committing partners to take ‘a shared strategic requirements to be judged successful: approach to estates planning’ and also included • Support delivery of £8 billion of investment in NHS capital investment decision-making powers. health and care estate by 2028 The LEB was formally established in 2016 on the • Support release of surplus land (circa £2 billion) back of partners’ recognition of the need for for alternative use transparent and collaborative working on London’s NHS estate. The LEB has 4 phases of progression • Support delivery of 12,500 new homes for (Figure C); advisory, strategic; shadow decision- Londoners by 2028 making and formal decision-making. The transition The immediate priority for the LEB is to support across the phases is managed by clear criteria, the successful delivery of the wave 1-3 projects governance and partner agreement. and wave 4 schemes (outlined in Figure I, page 24) which were awarded funding in January 2019.

Page 53 The London Estates Board: Health and Care Estates Strategy 11 LEB phases of progression

I II III IV 4 phases of progression C Y N N G I G G D O O O R A L I I N E N T E S S I S R M I I A K I K I V A R C C R E E H T O M A S M A S F D A D D

Phase LEB brings Brings strategic estates Begins making Decisions start overview together partners functions, building a recommendations to be taken by LEB in a single forum. London view from local to national representatives at Focuses on and sub-regional organisations on board meetings. developing estates strategies and some captial relationships, enabling a wider public investent decisions capabilities sector approach and (including business and data. non-binding case approvals). recommendations.

Figure C: LEB phases of progression

The LEB has already demonstrated its competence, Given the real and important progress to date it firstly as an advisory and currently as a strategic is envisaged by partners that the LEB will move forum. Much has been achieved to date including to phase III, shadow decision-making, during supporting STPs to develop their estates strategies, 2019/20. During this phase the LEB will establish all of which were rated ‘Good’ or ‘Strong’ during the structures and resources to enable it to the recent national review process and therefore make timely and robust recommendations for provide a sound basis for investment planning and NHS capital investments. With the final phase the foundation of this estates strategy. of progression, formal decision-making, being achieved in 2020/21. The LEDU is in the process of establishing a capital investment plan for London, the first of its kind, The challenge is great but with a commitment which will be phased, prioritised and agreed by and willingness from all partners to work partners. This will provide a concrete basis for together, we will transform the London health financial planning and funds management across and care estate from its current condition to one London. The LEDU has also established close of which Londoners can be justly proud of for working relationships with local partners and is decades to come. increasingly seen as the single point of contact for London-wide estates data and as the voice for London, both of which are evidenced by its role in the recently launched Primary Care Estates Review.

Page 54 12 The London Estates Board: Health and Care Estates Strategy Section 1

The vision and purpose of London’s Health and Care Estates Strategy

Page 55 13 1.1 Vision and purpose

This strategy brings together the substantial to deepen and embed collaborative approaches to work undertaken across London to establish addressing the many estates challenges. Critically, what we need for and from our health and for the first time it provides partners with the power to take health and care estate investment and care estate. A shared commitment to decisions for London, in London. This strategy is an partnership working underpins the plans articulation of that commitment and a roadmap to and is needed to ensure our vision becomes deliver our shared vision. a reality. London faces unique health and care challenges Strategic vision due to its demographic scale and make-up, its position as a world leader for medical research and cutting-edge treatment as well as having a London’s NHS has enormous and very visible vast and valuable estate with substantial backlog physical estate challenges. These reflect years maintenance needs. This diversity of need and of underinvestment, rising maintenance opportunity is also true across, and even within costs, fragmented funding and management individual London boroughs. Between 2012 and arrangements coupled with insufficient skills and 2014, the average life expectancy in Barking and resources to address these deficiencies. Dagenham was 77.5 years for men compared to The scale of our vision to overcome these 83.4 years in Kensington and Chelsea. The same long-term systemic and cultural barriers and study showed that women in Tower Hamlets could to transform the quality of our NHS estate is expect 30 years of ill health, while men in Enfield 5 necessarily ambitious. experience fewer than 12. Therefore, whilst there is one shared vision, there is not one London Londoners deserve a health and care estate that solution. means all Londoners are treated in world class facilities, which reflect and add to London’s This is why this London Health and Care Estates position as a leading global city in the 21st century. Strategy builds from the bottom up. It draws on evidenced local need, as set out in the plans and Purpose of the strategy priorities from the estate strategies of London’s five sub-regional Sustainability and Transformation London partners have long recognised the benefits Partnerships (STPs), and aligns these with the new of working together, and in December 2015, powers and approaches made possible by the formally committed to work more closely to support devolution MoU. all Londoners to lead healthier, independent lives, This has led to an ambitious shared vision, a clear prevent ill health and make the best use of health 4 set of objectives, effective collaboration principles, and care assets. a detailed programme of work to transform Significant progress has been made but more is health and care estate across London, and strong needed and at a faster pace if the shared vision is to governance arrangements for the London Estates become a reality. The 2017 London Health and Care Board (LEB). Devolution Memorandum of Understanding (MoU) provides that opportunity by supporting partners

4 Better Health for London: Next Steps 2015 5 Life Expectancy at Birth and at Age 65 by Local Areas in England and Wales: 2012 to 2014, ONS, 4 November 2015

Page 56 14 The London Estates Board: Health and Care Estates Strategy Objectives and investment principles Releasing estate for non-NHS use whilst retaining ownership can generate on-going revenue streams A clear set of objectives have been established that and provide potential for later NHS use, if needed. reflect the clinical estate priorities of the NHS Long Alternatively, surplus building(s) and land can be Term Plan6 (LTP) and those of our local partners. released of to the market to generate lump sums. The LEB partners will therefore work together to: The revenue generated from asset release needs to be re-invested in London for investment in the NHS • Improve the health outcomes and care estate. We see this long-term approach as the only experience of patients and their families route to securing a financially sustainable future for • Deliver patient-focused and joined up health a world class health and care system for London. and care for all The strategy also describes London’s clear and • Ensure effective and efficient use of the health joined up approach to capital investment decisions.7 care estate The approach has been designed to enable and ensure a robust and transparent translation of our • Generate capital and sustainable revenue to objectives into approval decisions and successful reinvest in our estate project delivery. As set out in Figure D, all projects • Deliver homes for healthcare workers and must first meet the three ‘hurdle criteria’ as well as Londoners being considered against our four core principles of: quality and patient benefits, financial sustainability, • Deliver sustainable and health promoting asset efficiency, strategic clinical fit. environments • Optimise the opportunities of the wider public

O sector estate b je ct iv e We believe there is significant opportunity to s H make vast improvements in the way current NHS ud e for on d Valu ey le C buildings and land are used to support these ri C te or r e ia priorities. By releasing NHS estate that is surplus Pr in uality c ip to requirement and working with other public Patient le estate owners, we can invest in London’s health Benefit s Strategic inancial and care system whilst simultaneously providing Clinical Sustainability

it

jobs, homes, community facilities and a built A

e

f

l

f

b Asset o

a r

r

environment that reduces health inequalities and Efficiency d

e a

v

b

i

l

l

e e supports health and well-being across London. D

To achieve this we are taking a 10-year and strategic view to ensure sensible and sustainable estates planning across London. This means evidencing where existing estate is clearly surplus or not fit for purpose and where new estate is needed to meet clinical need. Figure D: Capital investment decisions framework

6 NHS Long Term Plan, 2019 7 A detailed description is provided in appendix B

Page 57 The London Estates Board: Health and Care Estates Strategy 15 1.2 Context

London’s health and care estate has significant challenges which need to be recognised and addressed in order to 21% GP transform our facilities, tackle health NHSPS 39% inequalities and improve health and care CHP 9% for all. Provider

Mental Health A world leader 10% Public Health 3% Estate/Other 18% London has a significant concentration of specialist hospitals and facilities serving a local and national population. Many are linked to Figure E: Estate Property Ownership by service provider nationally and internationally renowned research and educational facilities. 1% 3% To maintain and make the most of this world leading position, the challenges faced by the 3% 7% health and care estate across London must be 16% addressed. This can only be done by drawing on GP the opportunities for greater partnership. NHSPS

CHP The current estate: value, ownership Provider and costs Mental Health

Public Health The NHS is one of the largest property owners in Estate/Other London with estate valued in excess of £11 billion.8 70% However, almost 40% of all the properties from which NHS services are delivered are held privately by GPs (Figure E). This means decision-making to Figure F: Estate Ownership by Floorspace support the NHS LTP and local partners’ ambitions to deliver on integrated primary, community and 2% 3% social care models is not within the full control of the NHS. 4% 7%7% 13% That said, approximately 70% of the floor area GP from which services are delivered is owned by NHSPS provider trusts9 (Figure F), and 71% of estate costs CHP is driven by this (Figure G). This means significant value and estate control rests with providers to Provider improve acute care utilisation and drive better, Mental Health more cost effective care outside of hospitals and in Public Health Estate/Other the community. 71%

8 London Health Commission – Better Health for London 2014 Figure G: Share of NHS Estate – Costs by Ownership 9 London Health Commission – Better Health for London 2014 Page 58 16 The London Estates Board: Health and Care Estates Strategy Drivers of change activity and staffing model underpinning the LTP, we have not built in as a core assumption How and where health care is delivered is potential offsets in hospital beds from increased changing as are the expectations of users. The investment in community and primary care’.12 NHS LTP and local partners clinical and estate • Integration of services: Recognising the strategies all reflect the need to meet growing and benefits of providing care via multi-disciplinary increasingly complex demand, take advantage of teams, bringing health and social care together technological advances, address health inequalities and working effectively across settings, national and improve health outcomes and experiences in and regional policy is increasingly focusing on a cost effective way. This strategy recognises how integration within and across multi-borough these and other drivers of change impact on the footprints. The Next Steps to the Strategic estate needs for London: Commissioning Framework13 signposts and • Demographics:10 London’s population grew supports ‘practices to develop and carry out by 1.5 million between 2001 and 2017. plans for collaborating at scale’. Likewise the ONS projections show that to 2026 London’s NHS 2018/19 Planning Guidance set out a plan population is expected to be the fastest growing for STPs to ‘evolve’ into Integrated Care Systems in England reaching 9.5 million by 2026, an (ICS). In these ICSs, ‘commissioners and NHS 8.8% increase. All boroughs will experience providers, working closely with GP networks, growth but in areas such as Barking Riverside local authorities and other partners, agree to and Old Oak and Park Royal, entire new take shared responsibility…for how they operate town developments are underway. Our older their collective resources for the benefit of population is also growing faster than the UK local populations’.14 Within London, many local average. Those aged 60 and over are the most and sub-regional systems are already taking intensive users of health and care services, given steps towards this integrated approach. Whilst their often complex needs. A highly diverse and teams can be virtual many will be ‘place based’, mobile population also has a direct impact on as envisaged by the LTP. The current largely how people use health services, for example fragmented primary and community care estate London GPs experience a high turnover of will need to be re-configured to better support patients compared to the rest of the country.11 this new joined up approach to service delivery. These are clearly complex trends and have • Technology: Increasingly technology is being significant implications for where and how care used to improve the delivery of health and care is provided in London in the future. services in London. This includes changing the • New care models: A major part of the NHS ways in which clinical and non-clinical care is LTP is to support local and sub-regional partners managed through digital interventions such as to deliver more care in the community and in self-monitoring apps for diabetes and changing people’s homes through community-based the way patients interact with, access and use hubs, thus reducing reliance on acute services health and care services, such as NHS Go 3 and delivering more patient centric service. initiative. Technological advance in population The LTP notes that ‘in the base-case funding, scale data analysis is also enabling the NHS to

10 Further details in appendix A 11 Sustainability and Transformation in London – An independent analysis of the October 2016 STPs, The King’s Fund, 2017 12 NHS Long Term Plan, January 2019 13 A vision for strengthening general practice collaboration across London, NHS, 2018 14 NHS 2018/19 Planning Guidance, February 2018 Page 59 The London Estates Board: Health and Care Estates Strategy 17 better understand and plan clinical services and deliver and manage the estate in a sustainable estate provision to meet the forecast health needs way. There is increasing recognition that of the population in general and identifiable sustainably designed and managed buildings groups at risk for particular conditions. This improve the patient experience, as well as includes sharing of information more effectively reducing the use of resources and connecting and could inform targeted screening for high-risk the NHS with local communities and the population cohorts. The Naylor review15 found environment. Therefore, the need for sustainable ‘current emerging opportunities for technology estate approaches applies to all providers. to transform care, such as online doctor services, Spending on resource reducing technology and remain at an early stage with unknown estates processes can generate positive financial returns implications. At present, there is little existing and reduce recurrent expenditure but will often evidence that emerging IT schemes will reduce the require upfront investment. need for buildings in the NHS. The potential for increasing the use of new technology to reduce Estates challenges estate costs and improve care is an area the LEB, through its partners and other organisations, will The quality of NHS estate is highly variable – need to keep under review to support the new London has some of the finest hospital buildings in models of care. the world but also some of the worst: • Workforce: Recruitment and retention of skilled • A significant proportion of the estate is old: staff is a recognised issue in delivering quality Across the entire NHS estate (acute, primary, health care. Estates solutions which support mental health and community) there are varying co-location of health and social care staff can conditions of quality and performance. The help address this by increasing collaboration Naylor review found that 18% of NHS provider and job satisfaction. Alongside this, the Homes trusts occupy significant estate that predates the for NHS Staff initiative will help to support formation of the NHS in 1948. Better Health for the recruitment and retention of workforce London found that for London this was 28%. in London by providing affordable housing in Additionally it found more than 40% of NHS appropriate locations.16 hospitals in London were over 30 years old.17 Reflecting under-investment and age of the • Sustainability: The NHS has faced and will estate it is estimated that £1.9 billion is needed in continue to face significant financial challenge. London just to deal with backlog maintenance.18 These financial challenges have led to under- Much of London’s primary care infrastructure, investment in estates and the use of allocated including GP practices, are in ‘poor’ or capital to support revenue positions. This has ‘unacceptable’ condition with a third of GP resulted in worsening estate quality, with rising surgeries needing to be rebuilt and 44% needing backlog maintenance pressures. repair.19 As buildings age and deteriorate, the • Environmental sustainability: NHS trusts are associated running costs also increase. required to produce Sustainable Development • Underutilisation: A high level assessment of Management plans setting out how they will capital efficiency highlighted that NHS assets

15 NHS property and estates: Naylor Review, DHSC 2017 16 Homes for NHS staff, NHS England & Improvement. https://improvement.nhs.uk/resources/homes-nhs-staff/ 17 London Health Commission – Better Health for London 2014 18 NHS ERIC 2017/18 data 19 London Health Commission – Better Health for London 2014 Page 60 18 The London Estates Board: Health and Care Estates Strategy may be under-utilised by around 15%.20 In support agreed system wide health priorities. London, there are examples of modern facilities, The development of the capital investment plan some built through private finance initiatives will enable the LEB to identify these priorities, that remain under-utilised.21 however, there is currently no mechanism for incentivising Trusts to relinquish surplus capital • Fragmented ownership: NHS estate for investment in other London estate priorities. ownership is highly fragmented, involving NHS trusts, NHS trust charities, local authorities, NHS property companies, GPs and private Opportunities to meet the needs organisations. This results in a lack of of Londoners coordinated decision-making and, given the diverse property interests, often impacts the As set out in this strategy, through devolution ability to enact change at pace. and partnership working we now have a unique opportunity to support delivery of new models Institutional issues of care that meet the wants and needs of our population, as set out in local and sub-regional plans. We also have the opportunity to support the Many decisions about health and service planning delivery of much needed new homes, new school and budgets are taken at national level. This can places and other community infrastructure. sometimes create unintended barriers to delivering the connected and tailored local services that This strategy brings together the conclusions Londoners want. For example: of these locally owned and developed estates • Organisations often work in silos with strategies. It summarises the work underway limited experience, capability and capacity across London, being developed collaboratively for estates planning and development: by organisations working in health and care, The Naylor review found that strategic estate to improve the use, quality, performance and planning has not been a priority as the NHS has utilisation of the existing: evolved. The review states ‘continuous reform • Primary, community and social care estate has eroded estates capabilities leaving the NHS with a lack of regional and national strategic • Acute estate estates capability’. This is as true in London as it • Mental health care estate is elsewhere. • Insufficient incentives for surplus property By bringing these strategies together we have release and unified strategic estate identified common themes around utilisation, planning: NHS processes for releasing of collaboration, investment and reinvestment. surplus property are based around single It has also been possible to draw out the organisational entities and do not encourage a interdependencies between improving primary, system wide appraisal of costs and benefits.22 community, mental health and social care which National partners agree in principle to NHS are critical to mitigating the demand for acute Trusts and Foundation Trusts in London retaining services, thus supporting service transformation. capital receipts, on the basis that the LEB These interdependencies are critically important. will identify how to reinvest these receipts to Consistent with the London Health Board’s

20 Productivity in NHS hospitals, Lord Carter DHSC, February 2016 21 London Health Commission – Better Health for London 2014 22 London Devolution Programme: Estates Technical Pack, 2017 Page 61 The London Estates Board: Health and Care Estates Strategy 19 review of the initial STP clinical strategies23 and Where estates proposals reflect significant the six ‘assurances’ requested by the Mayor of changes to service provision, patient, public and London24, we are clear that the estates strategies local government consultation will be expected, are intended to enable robust health and care consistent with statutory obligations.25 plans. These include strong clinical underpinning, considering the impact across the health and While these principles underpin the London care system, narrowing health inequalities and Estates Strategy, it is recognised that they will be financial sustainability. considered in detail at more local levels by the relevant organisations, stakeholders and citizens. Where estates proposals aim to redesign services away from acute settings, these must be considered in light of the drivers of change, including demographic population changes. Proposals may require phasing to ensure that required capacity increases in primary and community services are in place to enable care to move to these settings.

23 Minutes from the London Health Board – 5 October 2017 24 The Mayor’s Six Tests, GLA. https://www.london.gov.uk/what-we-do/health/champion-and-challenge/mayors-six-tests 25 Sustainability and Transformation in London – An independent analysis of the October 2016 STPs, The King’s Fund, 2017

Page 62 20 The London Estates Board: Health and Care Estates Strategy Section 2

Bringing together London’s sub-regional estates strategies

Page 63 21 2.1 Clinical priorities determining locally-led estates strategies

Locally-led work, drawn together at a Whilst there are unique individual responses in sub-regional level has built a strategic terms of timing and scale, the nature of estate picture for primary care, mental health and responses across London partners are similar and provide significant opportunity for joint working. acute estates needs across London. In July 2018, sub-regions were invited to submit Overview bids for STP wave 4 capital funding. Figure H illustrates the spread and type of London wave 4 The five London Sustainability and Transformation capital bid investment sites. The London STP initial Partnerships (STPs) have developed detailed health bid estimate was around £3 billion. Following and care estate strategies. This is in response to review by the LEDU and LEB, projects with a total best practice models of care, as set out in the requirement of £1.5 billion were then formally NHS LTP and their local demographic, health submitted. This was set against a total initial and organisational challenges. Building upon the national wave 4 funding pot of £1.6 billion. The collective and collaborative work being undertaken total funding available was subsequently reduced by healthcare professionals, cross-borough to £1.2 billion to address the NHS financial issues partnerships and local estate forums, the LEB has caused by collapse of Carillion. The wave 4 identified an overarching set of London wide health announcement27 in January 2019 means that a and care aspirations which require a significant large number of London projects did not receive estate response. These aspirations include: funding. The main rationale for schemes not being supported was that they did not perform • Prioritising illness prevention and early well against nationally set financial benchmarks. intervention The unfunded projects remain a priority for the • Strengthening and redesigning primary care and STPs and the LEB will work with partners to find community services alternative ways to fund and deliver these projects. Figure I illustrates the location and type of schemes • Improving care in priority service areas that have received wave 4 funding. • Transforming acute and specialised services • Reducing unwarranted variations in care • Improving productivity and efficiency • Supporting and developing the health and care workforce • Developing supporting infrastructure • Changes to incentives and organisational arrangements26

26 Sustainability and Transformation in London – An independent analysis of the October 2016 STPs, The King’s Fund, 2017 27 NHS England & Improvement, January 2019

Page 64 22 The London Estates Board: Health and Care Estates Strategy Key: NCL NWL SWL SEL NEL

Figure H: London’s wave 4 capital bid investment proposals

Page 65 The London Estates Board: Health and Care Estates Strategy 23 Key: NCL NWL SWL SEL NEL

Figure I: Successful wave 4 capital bid investment proposals in London

North West London South West London • Development of Endovascular Hybrid Theatre, • Patient Flow Transformation Programme St Mary’s Hospital South East London • Northwick Park Hospital Theatres • Bromley Health & Wellbeing Centre • Park Royal Mental Health Wards Reconfiguration • Patient Centric Supply Chain • Woodlands Mental Health Wards Reconfiguration, Hillingdon • SE London Estate Optimisation • Northwick Park Hospital Mental Health Wards • Consolidation of Streatham Common Reconfiguration Group Practice

North Central London • New Kidbrooke Sub-Hub

• St Pancras Hospital North East London was not awarded any wave 4 • Project Oriel project funding.

Page 66 24 The London Estates Board: Health and Care Estates Strategy 2.2 Enabling a fit for purpose primary care, community and mental health estate

At the heart of this pan London health and Out of hospital Mental Total care estates strategy is the transformation / Primary Care Health (£M) and delivery of community based integrated (£M) (£M) care, which will require significant NWL 217 33 250 collaboration and investment to implement. NCL 44 137 181 NEL 318 10 328 Delivering primary, community and mental SWL 167 251 418 health care at scale, as outlined in the General Practice Forward View28 and the recent NHS LTP, SEL 156 0 156 will support; a developed workforce; system London 901 431 1,332 partnerships; economies of scale; better care and new services; better quality improvements and Figure J: Estimated out of hospital/primary care and mental greater resilience. The London Primary Care Next health capital investment requirement in London Steps to the Strategic Commissioning Framework29 (Next Steps Framework) reinforces this need for New models of care and improving the at scale and integrated models of care if general primary care estate practice and community health providers are to meet the increasingly complex health needs of The Next Steps Framework notes that all London’s the population. STPs have identified that resilient, effective primary care is the foundation to the future of the A key factor impacting on the ability of GPs wider system. It notes that ‘STPs are beginning and other care providers to achieve this is to evolve into Integrated Care Systems’ in which the availability of flexible, fit for purpose commissioners and NHS providers work closely accommodation of the right size, right quality with the rest of the care system. It is expected that and in the right location. these new models of community care will help moderate demand for acute hospital services while Varying condition and quality also contributing to improving health outcomes and reducing health inequalities. Much of London’s primary care infrastructure is in need of refurbishment and further investment to improve the quality of services. Current estimates by the LEDU, based on detailed review with London’s STPs, indicate a need for investment in the region of £1.3 billion over the next 10 years (Figure J). This forecast investment figure reflects NCL’s strategic planning focus on Project Oriel and St Pancras Hospital. NCL STP is currently identifying additional out of hospital, and other primary and community and social care requirements.

28 General Practice Forward View, NHS 2017 29 London Primary Care Next Steps to the Strategic Commissioning Framework, NHS 2018 Page 67 The London Estates Board: Health and Care Estates Strategy 25 • Delivering primary care at scale: • Integrated models of care through The Next Steps Framework notes that there is a community hubs: Hubs aim to support holistic growing body of evidence that shows delivery health and wellbeing in community settings. of primary care through system partnerships Operating on an integrated and collaborative offers economies of scale, better care and new basis, these typically involve bringing together services, improved quality, greater resilience primary, community, mental health and social and wider workforce opportunities. It also can care services, with some services currently based deliver more appropriate care that is convenient in hospitals. and efficient for patients. These arrangements Hubs can be virtual but will often be ‘place also enable greater access to specialist support based’ providing an opportunity to co-locate in primary care, for example through delivering with other public services that support wellbeing consultant-led assessments and clinics in such as gyms, swimming pools, dance studios, general practice. library services, community meeting spaces, • Addressing specific mental health service cafés, job centres and debt advice services. challenges: The delivery of mental health These teams could be ‘wrapped round’ or services is changing with new integrated ‘aligned with’ groups of primary care practices. approaches between physical and mental health Funding constraints, silo working, the emergence services and moves towards more care being of new and complex health challenges that these delivered within the community, thus radically organisations were not set up to address, such changing the historic model of in-patient care. as an increasingly aging population and chronic To support this, the mental health estate needs ill health, means transforming partner working to become fit for purpose. For example, in NCL relationships is vital. the required level of capacity is being considered CCGs and local authorities have responsibility as part of a whole system approach across the for commissioning health and care services St Pancras and St Ann’s Hospital sites.30 for local populations and some good practice Across London, there is a move to increase examples of integration are emerging. access to primary care and for mental health Whilst the maturity of these models differs services to be delivered locally with the aim of significantly across London, both sub-regional reducing demand on the acute sector and to and pan London estate strategies recognise mitigate the need for additional mental health the importance of delivering a collaborative in-patient beds. For example, within SEL work approach to future estate investment. is underway to consider the future of mental health services, with discussions underway between Lewisham Hospital and South London and Maudsley NHS Foundation Trust.31

30 North Central London Devolution Pilot Outline Business Case November 2017 31 Our Healthier South East London – Sustainability and Transformation Partnership – STP Estates strategy submission July 2018 Page 68 26 The London Estates Board: Health and Care Estates Strategy Investment in the primary care estate The LEB operating as a forum for local and sub- regional London and national partners to plan and Given the nature and quality of much of London’s prioritise will play a pivotal and catalytic role in primary care estate, it is clear substantial delivering an estate that supports the advances in reorganisation and improvement in the quality primary community and mental health care. and type of accommodation to house GPs and community care clinical and non-clinical staff is A key role for the London Estates Delivery Unit to needed. Significant financial investment over a support this delivery is in its work with the GLA to sustained period of time is required to support and share and apply the knowledge and skills needed achieve the benefits of the new models of care. to develop innovative delivery solutions.

Substantial financial investment whilst necessary Illustrative approaches is not sufficient to deliver these new approaches. It will also require commitment, capability and Significant efforts are underway locally to address resource capacity to work together to deliver primary, community, mental health and social joined up estate planning and scheme delivery. care estate challenges and opportunities. The As the Naylor review commented, ‘most examples in Figure K are illustrative of further work fundamentally, integrating care and improving being progressed within the existing framework, the scale and consistency of primary care requires governance and resources available. More is a transformation in out-of-hospital care and the needed and is being developed through the estate used to deliver that care.’ opportunities provided by the LEB.

Page 69 The London Estates Board: Health and Care Estates Strategy 27 NCL: Camden and Islington NHS Foundation Trust – St Pancras Hospital estate redevelopment The redevelopment programme enables NWL: One Public Estate: transformation of the estate to enable delivery Collaborative Regeneration at of the Trust’s Clinical Strategy and national and Northwick Park local health strategies, through the development NEL: Whipps Cross The vision is to create a ground of health services and research facilities across the redevelopment breaking scheme that complements boroughs of Camden and Islington. It puts service the park and outer London setting, users at the centre, building more visible, more The Whipps Cross site is one delivering over 1,500 homes and accessible and more integrated services for people of the largest in the country at generating capital receipts to support locally alongside world class research facilities. almost 18 hectares, but rates the redevelopment of the hospital. The release of the St Pancras site will fund these as one of the most inefficient The project brings together four activities. Of the land released, up to 2 acres of the in terms of utilisation. The land-owning partners: the London site will be sold to Moorfields Eye Hospital NHS redevelopment of Whipps Cross North West Healthcare NHS Trust, Foundation Trust for the development of a new will allow the health system to the University of Westminster, eye care, research and education facility with the re-balance the way in which care Network Homes (a Registered Institute of Ophthalmology. is provided to meet the changing Provider) and the London Borough of needs of the population, Brent. Collectively the aligned with plans to develop partners have secured an integrated care system. £470,500 worth of funding The size and scale of the site via OPE for feasibility and presents significant opportunities master planning and a further for further redevelopment, £9.9m has been secured via the regeneration and commercial Housing Infrastructure Fund uses as well as the provision of a to improve local transport healthcare facility. links and infrastructure.

SWL: South West London and St George’s Mental Health NHS Trust – Springfield Hospital redevelopment SEL: Local health strategy and link to STP The Trust’s ambition is to create a centre of excellence NHS Southwark CCG worked closely with partner organisations, for mental health services by building new inpatient patients and clinicians to develop a service model for community- facilities in the London Borough of Wandsworth at based services and the business case for the development of a Springfield Hospital and to expand the community health centre at Dulwich Hospital. The new Dulwich Health Centre services provided to ensure care is delivered closer will bring together and build on services which are currently to home. The new inpatient buildings will be funded delivered from geographically diverse and/or substandard premises. by releasing parts of the site no longer needed for The centre will be one of the three proposed Community Health clinical care and this land will be used to deliver new Hubs in Southwark as described in both the STP Estates Strategy houses and providing extra green space for the local and the Southwark Local Estates Plan and will offer primary care, community. This is a major programme of investment in children’s non-specialist community services and out of hospital the local community, and is anticipated to complete by clinical consultations and community-based diagnostics. 2023. The business case is currently being considered by NHSI and DHSC.

Figure K: Examples of acute care investment schemes at STP level

Page 70 28 The London Estates Board: Health and Care Estates Strategy 2.3 Enabling a fit for purpose acute estate

London’s acute NHS estate supports world will remain unfit for purpose and will continue to renowned research and cutting-edge deteriorate’. These findings mirror the situation treatment. The estate includes some of the in London. NHS data indicates that addressing only the backlog maintenance needed across the finest and the worst quality in the country. estate in London alone would cost in the region of It requires significant investment to support £1.9 billion (Figure L).34 On the ground, estimates existing as well as future clinical need. by STPs and individual Trusts are much higher, possibly as much as double as NHS central data Acute estate size and value collection only includes the cost of the works. The reported backlog maintenance figure excludes The NHS is one of the largest owners of land and fees, decanting costs, VAT and other associated buildings in London. The physical footprint of costs Trusts would have to pay to carry out this London’s hospitals at around 398 hectares means maintenance and is therefore an underestimate of its larger than the City of London.32 The book value the actual costs. of the acute estate is estimated to be £9 billion33, with 70% belonging to acute hospital trusts. An analysis of ERIC data returns undertaken 35 The remaining 30% is owned by community and by NHSI and LEDU shows that whilst London mental health trusts. accounts for 18% of occupied floorspace across England, it accounts for 32% of the reported Varying quality and condition backlog maintenance cost for the whole of England. This highlights the importance of the LEB securing a devolved and long-term capital budget As noted above the quality of the NHS estate in for London, to be distributed according to needs London is highly variable. London has some of the and priorities. Further analysis by NHSI provides finest hospital buildings in the world, such as the some explanation for the relatively higher backlog facility at University College London Hospital on maintenance costs in London. An age profile Euston Road, and some of the poorest hospital analysis36 shows that 41% of London’s estate was facilities in the UK. Too many of our hospitals built before 1965 compared to 29% for the rest of assessed by the Care Quality Commission (CQC) England, even more tellingly 21% of London’s NHS have been rated as ‘needing improvement’ or estate was built before 1948 whilst for the rest of even ‘inadequate’. England this was just 11%. In terms of more recent The Naylor review found nationally that ‘without developments, the data shows that 48% of the investment in the NHS estate the Five Year Forward space in London was built since 1985 compared to View (5YFV) cannot be delivered, the NHS estate 56% across the rest of England.

Backlog NWL NCL NEL SEL SWL London Total (£m) 1,059 223 156 138 348 1,924 £/m2 870 231 178 134 539 407

Figure L: Backlog Maintenance spend needed by STP regions and London Source: ERIC data 2017/18 Note: (1) NWL backlog maintenance is significantly higher due to SaHF delays

32 London Health Commission – Better Health for London 2014 33 ERIC 2017/18 34 ERIC 2017/18 35 London Commissioning Region – Backlog Maintenance Analysis, NHSI 2019 36 ERIC 2017/18 Page 71 The London Estates Board: Health and Care Estates Strategy 29 Utilisation Improving hospital estate

A high-level assessment of capital efficiency (capital Across London, there are a multitude of acute turnover) suggests that NHS assets may be under- estate transformation proposals, varying in scope utilised by around 15%.37 If this capital could be and scale to reflect the health and care outcomes unlocked, it would be worth around £1.5 billion. being sought for local, national and international The majority of this potential value lies in acute populations, given the broad reach of research and hospital trusts where as much as £1–1.2 billion specialist services provided in London. could be surplus to requirements. The London sub-regional estates strategies bring Optimising the utilisation of these sites would have these together, recognising the interdependencies the added benefit of reducing running costs by with improving primary, community, mental around £200 million annually.38 health and social care (see Section 2.4). There are common themes in these proposals: The Naylor review identified the root causes of many of the acute estate problems, namely; under- • Consolidation of services across sites: investment at a local level has created a legacy of Some of the plans propose changes to hospital backlog maintenance; past failures to fully commit services in response to pressures around quality, capital allocations; continuous reform has eroded workforce and cost, through concentrating estates capabilities; the move to autonomous services in fewer hospitals to improve outcomes, local NHS organisations has reduced the scope such as ‘bringing together routine and for estates planning and a lack of knowledge of complex care onto single sites’.39 This reflects the size, property type, use, value and ownership a networked model where services across of the estate. Again these findings apply in full hospitals and community hubs are linked to in London where there is fragmented property concentrate activity, improving care outcomes ownership, complex rules and a knowledge gap while also freeing up valuable space within high- on how NHS bodies can and should participate cost acute sites.40 in joint ventures and other property development structures. This is exacerbated by a lack of a London-wide strategic overview of how the estate should be used to meet current and future clinical needs and filling this gap is a key focus for the LEB and the LEDU.

37 Operational Productivity and Performance in English NHS Acute Hospitals, An Independent Report for the Department of Health by Lord Carter, 2015 38 London Health Commission – Better Health for London 2014 39 Sustainability and Transformation in London – An independent analysis of the October 2016 STPs. The King’s Fund, 2017 40 Our Healthier South East London STP Page 72 30 The London Estates Board: Health and Care Estates Strategy • Re-profiling estate to recognise new models • Academic Health Science Centres: Using of care and meet health needs: While many the estate to enable the NHS and academia to hospitals will continue to be needed in the work collaboratively with industry to identify, future, not all the hospitals will need to provide adopt and spread innovation and best practice the same services that they do today. As part will be a focus for the LEB. The UK Government of the range of improvements and the move has identified Life Sciences and Healthcare as towards out-of-hospital services, the overall important sectors to generate new economic profile of the acute estate is likely to change. growth as well as increasing the quality of care However, the number of beds needed is not for patients within the NHS. Academic Health expected to decrease. This is reflected in the Science Networks focus on the needs of patients NHS LTP which notes ‘in the base-case funding, and local populations, support and work in activity and staffing model underpinning the partnership with commissioners and public LTP, we have not built in as a core assumption health bodies to identify and address unmet potential offsets in hospital beds from increased medical needs, whilst promoting health equality investment in community and primary care’.41 and best practice. • Supporting sustainable services for the Two examples of these networks already future: Investment in new facilities can underway in London are Imperial College provide a financially sustainable way to Health Partners and UCLPartners. address backlog maintenance and quality challenges. London’s acute hospitals deliver a The LEB acts to support the challenges identified number of world-leading services. The current by the Naylor review and enable the realisation of constraints posed by outdated and poor London’s estates transformation plans by creating estate potentially limit their ability to attain a London-wide view of clinical estate need and and retain in some circumstances ‘world class’ opportunity. The LEB will support investment status and reputation. Across the Sustainability decisions based on detailed local and sub-regional and Transformation Partnership plans, joint knowledge and robust project level business cases. approaches across a number of providers to The LEDU will connect the NHS with the GLA and maximise value and facilitate improvements other public sector estate owners to work together are underway. For example, as a part of a to share property development skills, access finance, wider estates change project within NCL, the participate in property development ventures, development of a new facility for Moorfields maximise the value of estate release and estate Eye Hospital should enable the Trust to development for adjacent and linked sites. It will continue to provide world-leading clinical also work to compile a land use database to increase services and research, currently constrained by visibility of surplus land redevelopment opportunities 42 the existing estate. and will provide information, advice and guidance on business case development.

41 NHS Long Term Plan, January 2019 42 North Central London Devolution Pilot Outline Business Case, November 2017 Page 73 The London Estates Board: Health and Care Estates Strategy 31 2.4 Delivering estates transformation London-wide

Successful estates transformation will be more integrated way. For example, in SEL work driven more quickly and cost effectively by a is underway to adapt buildings that are publicly collective and collaborative approach. subsidised in order to support coordinated and integrated health and care services. The opportunity provided by the LEB and There are also a variety of acute estate collaborative working to date has highlighted the transformation proposals across London to ensure large number of common priorities and issues the right services are located in the right places. across London’s primary, community, mental health These proposals are focused on consolidation of and social care and the acute estate. It has also services across sites and re-profiling of estates to shown the significant inter-dependencies between recognise new models of care, sustainability and community-based and acute estate plans, most addressing mental health challenges. For example, notably the critical role that improvements to the the redevelopment of Whipps Cross Hospital will primary, community, mental health and social care allow the health system to meet the changing estates play in mitigating demand pressures on the needs of the local population. acute estate.

Collaboration, capacity and Getting the most out of NHS land decision-making and buildings Greater efficiency and flexibility in how the NHS Over recent years, a more systematic approach estate is used will help reduce waste, improve has been taken to partnership working in London. usage and could generate capital and/or revenue For example, much of the London health and care to be reinvested into improvements in the quality system is now engaged with the One Public Estate of the London health and care estate. Through (OPE) programme. OPE works closely with health local, London and national partners working more and care estate owners to identify opportunities to closely together, looking at ways of re-purposing collaborate with the wider public sector, identifying and refurbishing existing buildings, investment ‘marriage value’43 from adjacent or complementary in new developments and co-location with other sites and enhancing development and site release public-sector services, we will have a clearer picture potential. To date, 22 of London’s 32 boroughs, of the condition and most cost effective purpose of along with public sector partners, including the NHS land and buildings in London. NHS and GLA have joined the OPE programme and formed OPE partnerships. The LEDU has formed This includes the ability to make the best use close working relationship with the GLA housing of existing high-quality estate for primary and and land team to further facilitate and embed joint community care services while also addressing the project design and delivery. estate that is in need of repair.

Across London, there is evidence at local level of a Under and inappropriate utilisation of acute range of collaborative approaches being developed hospital estate has a long and complex history, to improve delivery of primary, community, mental exacerbated by the fragmentation of the health and social care as well as strengthening organisations involved in running, commissioning collective decision-making. All five London STPs into and occupying NHS estates. Cross-borough have set out plans to redesign how primary and STP planning provide opportunities for care and community services are delivered in a

43 Marriage value refers to the enhanced value created by a co-ordinated approach to developing two or more property assets

Page 74 32 The London Estates Board: Health and Care Estates Strategy increased cooperation and coordination of these opportunities to create longer-term revenue parties, driving improved use of estates. streams from surplus assets and land to ensure a sustainable plan for health and care in London. The ability to work closely with London boroughs This route may carry greater risk and reduce and the GLA will also give new opportunities for: short-term financial gains but enables London to • A more transparent and open-book take a longer term, sustainable approach to estate approach to estates delivery, combined with a investment and maintenance. joined-up approach to the management of the This strategy relies on NHS Property Services wider public-sector estate, consistent with (NHSPS) and Community Health Partnerships OPE principles (CHP), wholly owned companies, to work with the • Effective deployment of resource and LEB to develop an approach for the investment capability at sub-regional and regional levels, and release of assets, which balances national and including to NHS Trust and Foundation Trusts London needs and priorities. where necessary While the deployment of capital in the NHS • Assurance that decisions prioritise optimisation from all sources combined must be equitable of the use of health and care estate over in relation to need across different parts of the organisational self-interest country, it is recognised that in London there is significant opportunity to optimise the use of The need for investment and valuable surplus assets to address the very visible reinvestment back into London needs. As noted above, asset optimisation will require upfront investment, the scale of which The LEB will work with partners to identify the will be driven by the fact that the cost of capital optimum opportunities to reinvest capital receipts investment is significantly higher than anywhere and revenue streams to support agreed system- else in the country. wide health estate priorities. This will require In summary, the principle of equity means up-front capital investment to release and deliver there must be recognition of the higher cost of primary and community care facilities across the developing buildings and services in London and the five London STPs in addition to reinvestment disproportionately large and complex make-up of of released capital, and clarity on future capital London’s health service demand. It is also recognised availability. This will be informed by London’s that incentives are needed to support the health capital investment plan. and care systems to release and optimise the use Re-investment needs to be part of a long-term of surplus land. National partners are committed to sustainable plan which recognises that capital working with the London system through the LEB to receipts from releasing assets alone will not solve explore opportunities to achieve this. all of the identified need. Money generated by the release of NHS land and buildings that are truly surplus to requirements can be invested back into London’s health and care system for effective transformation. However, working in partnership, the system must continue to explore

Page 75 The London Estates Board: Health and Care Estates Strategy 33 Further collaboration is needed and has been • Innovative, strategic and planned delivery made possible through the establishment of the – whilst the LEB will work to secure a long-term LEB and the LEDU which has a workplan focussed assured, devolved capital budget for London, it is on addressing key issues highlighted in this very likely to be insufficient to meet the already strategy so far: known capital investment need. The LEB working with local partners, such as the GLA, London • Estates data – in the history of the NHS boroughs, NHS Charities and One Public Estate, no single organisation has had or has taken will identify innovative property delivery routes, responsibility for ensuring comprehensive, funding sources, and legal structures that will consistent and interoperable datasets across, enable greater transformation of the estate at or even within, the primary and secondary pace. This approach will meet clinical needs and health care sectors. For example, there has also generate valuable social outcomes, such as to date been no official estimate of backlog housing and public/community amenities and maintenance requirements in the primary care reduce health inequalities. sector. The LEDU will work to compile a reliable, robust and interoperable data collection, storage • Business case support – the LEDU will support and analysis approach for London to aid sub- STPs through training and sharing best practice regional and London-wide estates planning. to develop ‘right first time’ business cases. The LEDU will review STP, commissioner and provider • A devolved capital budget – the LEB as a competencies and capacities. This will support unified partnership will work with national business case submissions at pace and at scale. partners to secure a long-term capital budget The LEDU will support engagement amongst for London, against which strategic plans partners at a practitioner level to help explore can be made and managed. No longer will solutions to common and complex business commissioners and providers have to react to case issues. one-off time limited national capital availability announcements which are subject to nationally • Portfolio and building operational toolkits determined allocation and single project – as articulated in this strategy, there are many financial benchmarks alone. Furthermore, common estate development issues facing national decisions often do not reflect London’s partners. Examples include how to secure CIL quantum of need or clinical and estate priorities & S106 funding and how to maximise use of and their interdependencies. They are instead individual buildings and the estate as a whole, dependent on the pendulum of national policy taking into account the diverse property spending priorities. In securing a devolved ownership arrangements. Whilst on a day-to- capital budget, the LEB will help regional day basis these can only be managed at a local delivery partners plan with confidence. level, the LEDU will work with London-wide and national partners to establish protocols and operational toolkits that will help partners develop and run their estate more cost effectively.

Page 76 34 The London Estates Board: Health and Care Estates Strategy • Capital investment plan management – the LEDU has worked with partners to establish an investment requirement for London that details where and when funding is needed, and what is required in order to deliver the clinical estate priorities. When complete, the capital investment plan, the first for London, will be refreshed on an annual basis and will be used to support the London bid for a devolved and long-term budget and equally importantly will be used to allocate and manage the programme of transformation against London determined priorities. The LEDU will also introduce a cloud-based Portfolio Management System to enable the effective delivery, tracking and risk profiling of the plan. • A voice for London – the NHS is a national organisation which impacts on the lives of everyone in the country. There are constant calls for policy reviews of the numerous aspects of the delivery of health and care services and almost all of these have an estates development requirement or impact. The experiences and priorities of London’s health estate partners will be much stronger when delivered together through the LEB, thus ensuring more cost effective involvement and better outcomes. This has already been demonstrated through the LEB’s involvement in the review of London’s primary care estate. This has brought more attention and associated expertise and resources to explore and address specific primary care estate issues in London.

Page 77 The London Estates Board: Health and Care Estates Strategy 35 Section 3

Outcomes and approach to delivery

Page 78 36 3.1 Outcomes of the London Estates Board

Joined-up strategic decision-making for • Support to develop and deliver sites, leveraging London will mean a more transparent and borough and GLA expertise and making London- collaborative way of working, with clear level support more accessible through the LEDU. improvements for all Londoners. • Clarity on capital availability, needs and plans to enable more effective health and care Collaborative working and collective consideration capital investment with greater certainty about of the public estate issues to drive outcomes under use of receipts to support financial planning. three themes: During the financial year 19/20, London and national partners will seek to finalise the capital 1. Partnerships investment plan for London.

The LEB will continue to enable whole-system • London is ready to control a delegated capital strategic estates planning by bringing London budget to support the delivery of the plan from partners together in a single forum to discuss financial year 2019/20. and overcome London-wide estate challenges • Progress in delivering this strategy is predicated and realise opportunities. in part on the availability and quality of data. The LEB will support a systematic commitment The LEDU provides a dedicated team to support to data collection and quality management health and care estates delivery across London. The via existing approaches (for example, Estates ability to draw on partner expertise, including from Return on Information Collection (ERIC) and the the GLA, Strategic Estates Planners, London boroughs Model Hospital toolkit) and new approaches and via the OPE programme means we can support: where cost effective. For example, through the • Collaborative decision-making to inform the LEDU, HUDU has recently completed a detailed best possible use of the London NHS and wider interactive mapping of all primary, community public estate. The LEB is ready to move into and mental health provider premises. The map phase III of operation (shadow decision-making) includes location, population served, estates from April 2019, with transition into phase IV development plans and funding position and (decision-making) by April 2020. allows analysis at local STP area. • Identification of opportunities for ‘marriage value’ from surplus public-sector sites. In 2019, all health and care estate business cases considered by the LEB will consider these potential opportunities. • Streamlined business case approvals process with key decision-makers at the LEB. In 2020, the LEB will be ready to be granted formal delegation of business case approval within delegated limits. Authority will be granted by national organisations to named members of the LEB, consistent with the limits described in the LEB Operating Framework.44

44 LEB operating framework, Page 14, November 2017 Page 79 The London Estates Board: Health and Care Estates Strategy 37 2. Improvements to the estate aims to deliver not only £500 million capital receipts by Financial Year 2022/23 but also an average annual Operational acute estate outcomes recurrent revenue opportunity of £300 million.

Facilities management has a direct bearing on Across England, the NHS and DHSC expect to patient experience, ensuring that premises are safe, free land sufficient for 26,000 homes by 2020. In welcoming, warm and clean environments for staff London, it is expected that surplus health land will and patients. The NHS in London spends over £2 enable the delivery of up to 12,500 homes by 2028. billion per annum maintaining and running its estate London’s ability to deliver on these ambitious targets and facilities and there are opportunities to achieve is largely dependent on its ability to secure the early efficiency savings via a number of initiatives, for and sufficiently scaled level of investment required example through reducing unwarranted variation in to enable system-wide transformation. energy costs. London will use its collective resources and assets to The LEB commits to supporting the objectives deliver housing at an affordable level, in particular described in Lord Carter’s Review45 to drive to support London’s public sector workforce. The improvement in operational efficiency: Mayor is investing £4.8 billion to start building 116,000 new affordable homes in London by 2022. • With all trusts (where appropriate) implementing a plan to operate with a maximum of 35% of 3.Enabling wider health and non-clinical floor space and 2.5% of unoccupied care outcomes or under-used space • Delivering this benchmark by April 2020, so that Transformation of the health estate is expected the estate is used in a cost effective manner to contribute to important wider and sustainable health outcomes including: Operational primary and community care • A radical upgrade in disease prevention and estate outcomes public health Ownership of this estate is fragmented across the • Greater control by the public of their own health public, private and voluntary sector. The LEB will support partnership working to ensure the diverse • Breaking down barriers in how care is provided estate owners have a common understanding of • Delivering new models of care the population need and how and where estate should be located and operated to best deliver on • Impact on reducing health inequalities NHS national and local service policies. • Delivering wider benefits to the local community, Capital receipts and release of land for housing such as training and employment, through the role of NHS facilities as anchor institutions The NHS and the Department of Health and Social Care (DHSC) are aiming to release surplus assets The LEB recognises that the built environment valued at £2 billion over the current Spending is a key determinant of health and wellbeing, Review period. The LEB’s ambition is to develop a therefore improving the health of communities and sustainable approach to estates transformation and reducing health inequalities will be a key priority

45 Operational Productivity and Performance in English NHS Acute Hospitals, An Independent Report for the Department of Health by Lord Carter, 2015 Page 80 38 The London Estates Board: Health and Care Estates Strategy when considering the redevelopment of surplus term delivery requirements, for example supporting NHS land. The LEB will work to ensure new NHS STPs to develop nationally accredited, robust health facilities have the potential to promote health and care estates strategies and moving the LEB and wellbeing and reduce health inequalities, from an advisory to a strategic forum. for example, through design, construction and facilities operation and co-location of community This is just the beginning. Much more is needed NHS facilities with a range of wider public services from partners in the remaining period of phase II to that support wellbeing (such as, leisure facilities make meaningful progress and enable subsequent and employment advisory services). progression phases to reach their targets. These phased progression targets provide clear milestones Key performance indicators (KPIs) against which the LEB’s progress can be measured and annual business planning supported. The LEB will rightly be measured by the strength of its performance. As a delivery as well as a strategic Phase II: Strategic forum, the LEB should be assessed on its ability to (January 2018–September 2019) generate visible and quantifiable value for money • Finalise the London Health and Care outcomes. It will also be measured on its success in Estates Strategy bringing partners together and acting as the voice for London on health and care estates matters at • Develop LEDU staffing and resources plan the national table. • Develop an assured 10-year annualised capital The LEB must deliver against three overarching investment plan for London requirements to be judged successful: • Develop an assured business planning and • Support delivery of £8 billion of investment in project approval process health and care estate by 2028 • Collaborative working with other public estate • Support release of surplus land (circa £2 billion) owners on five projects for alternative use • Support up-skilling of local health care teams • Support delivery of 12,500 new homes for across London to undertake and manage health Londoners by 2028 and care estates planning and delivery • Input into all strategic national health estates These long term but critical delivery requirements reviews and forums fully reflect the ambitions and recommendations set out in the Naylor review. These are necessarily Phase III: Shadow Decision Making supported by high level KPIs aligned with the LEB (September 2019–April 2020) phases of progression, as set out in the MoU. It is against these that the LEB will develop detailed • Support the transition of the LEB to full management and resourcing plans and track and investment decision-making by April 2020 report performance on an annual basis to partners. • Production of a land use database for all London Good progress has been made in phase I and NHS estate phase II to date, specifically in creating the conditions to support the LEB to deliver on its long

Page 81 The London Estates Board: Health and Care Estates Strategy 39 • Support projects amounting to £650 million of • Deliver or support 10 training courses per investment in health estate46 annum to up skill local health care teams to undertake/commission project business cases • Support delivery of 32 ha of land released for alternative uses • Meet NHSE/I business case turnaround times 90% of the time • Deliver 10 training courses to up-skill local health care teams to undertake/commission • Collaborative working with other public sector business cases estate owners on 10 new projects per annum • Achieve 50% increase in the number of business • Support delivery of 10,900 new homes cases judged to be ‘right first time’ for Londoners48 • Meet NHSE/I business case turnaround times • Bringing together and expand strategic estates 85% of the time planning and delivery resources • Collaborative working with other public estate • Input into all regional and national forums owners on 10 projects to ensure London’s needs and opportunities are understood • Support delivery of 1,600 new homes for Londoners47 Each of these high level KPIs will necessarily be 49 • Support up-skilling of local health care teams to underpinned by detailed SMART targets and a undertake and manage health and care estates management plan setting out activities, resourcing planning and delivery and monitoring arrangements. The targets and management plan will be agreed annually Phase IV: Full Decision Making alongside the LEB budget allocation decisions. (April 2020 onwards) • Supporting £2.3 billion per annum of investment • Annual updating of land use database • Annual refresh of the London Health and Care Estates Strategy • £100 million annual investment to reduce existing backlog maintenance through transformation schemes

46 This reflects schemes which are currently funded under waves 1, 2, 3 and 4, ETTF, CIL and S106 47 This reflects schemes which are currently funded under wave 1, 2, 3, and 4, ETTF, CIL and S106 48 This reflects schemes which are currently funded under wave 1, 2, 3, and 4, ETTF, CIL and S106 49 SMART – Specific, Measurable, Achievable, Realistic, Time-bounded Page 82 40 The London Estates Board: Health and Care Estates Strategy 3.2 Progress and next steps for delivery

Delivery of this strategy is not only sites programme; enhanced the efficiency, dependent on investment, but requires quality and transparency of approval processes skills, expertise and strong partnerships and decisions. This has ultimately accelerated approval of some schemes and projects from the to be in place. current 5–10 years average timescale. Progress to date Case study: St Ann’s Hospital Since 2015, health and care partners from over Successful collaborative working between the GLA, 100 local, regional and national organisations Haringey Council and Barnet, Enfield and Haringey have worked to develop and implement London’s Mental Health NHS Trust enabled the first use of Health and Care Devolution MoU. This work has the Mayor’s land fund to acquire part of the St highlighted the significant progress that we can Ann’s Hospital site on 31 March 2018. This deal – 50 facilitated through the LEB and LEDU – will enable make by working better together within London. the redevelopment of the hospital site delivering new • Supporting local and sub-regional estate state-of-the-art mental health facilities and deliver up to 800 new homes, with 50% being affordable. The planning arrangements: All five London STPs GLA will use in-house technical expertise to procure a have now developed live estates and capital development partner through London Development strategies with the support of SEP London, the Panel 2 (LDP2). LEB and LEDU. London-wide partnership support is in place to support strategic planning (such Case study: Northwick Park as the London-wide prioritisation framework – The LEB and GLA are working with London Northwest see appendix B) and for specific initiatives. For Healthcare NHS Trust, Network Housing, University example, significant work is underway at local, of Westminster, Brent Council and OPE to develop a sub-regional and London levels to determine deliverable master plan to bring forward surplus and what is meant by ‘a community hub’, from underused land for housing development that could deliver around 1,500 homes including student and both a clinical (i.e. the services within) and NHS staff accommodation. technical perspective (i.e. ensuring the delivery of fit for purpose, affordable new buildings or Case study: London Development Panel developments). Further work to develop and define the detailed technical arrangements are The GLA has procured a new development panel (LDP2) currently underway, led by the sub-regional to support public land owners in delivering residential- led development on their land. LDP2 is available to all estate leads and facilitated by SEP and the LEDU. public-sector bodies in London, including the NHS with a number of benefits, including: • Facilitating access to capital and new forms of funding: as described in appendix C. • Saving time and money on the procurement process • Improved joint working and governance arrangements to support estate • Assisting users to provide housing and spur economic growth transformation at pace: Collaborative working and a joined up strategic approach to • Opportunities for early market engagement planning between partners, including the NHS, through soft market testing with panel members. NHS charities, local government and the GLA, This can reduce risk and help to improve the success of a project have helped to develop and define a major

50 Health and Care Devolution – What is means for London November 2017

Page 83 The London Estates Board: Health and Care Estates Strategy 41 The opportunity going forward • Pursuing a joint approach to utilisation across the London estate: Planning across the The devolution agenda presents significant health and care system provides opportunities opportunities to enhance and facilitate health for increased cooperation and coordination estate improvements: of these parties, and the opportunity to drive improved utilisation of estates. The ability • Strengthened governance and delivery to work closely with London boroughs and arrangements within London to drive the GLA will give new opportunities for joint estate transformation at pace: The LEB is solutions to estates issues. This work is closely envisaged to take on greater decision-making linked to back office optimisation/consolidation over time. This would enable streamlined efforts. Non-clinical estates across London processes for development, review and approval are vast and present a major opportunity for of estate transformation proposals and a collaboration and reduction in revenue costs support function to develop business cases to to create headroom for investment in clinical enable faster delivery of schemes. The LEB is estates. We will aim to support acute providers committed to increasing the transparency of to reduce unoccupied or unutilised space across these processes to ensure that decisions on London to 2.5% by 2020. capital are taken in order to best meet London’s priorities. • Providing the right planning support: Town planning is essential in supporting delivery. • Access to technical support, skills and There are opportunities to ensure that health expertise: Significant in-house property objectives are built into, and recognised within, expertise resides within the wider London both the new London Plan and in local borough system. The GLA, local authorities, LEDU and plans. There are also opportunities to support SEP advisors, NHSPS and CHP and many Trusts prospective projects through the planning have extensive experience of developing capital process, from application through to development projects and programmes. The project delivery and HUDU a key LEB partner are London Development Panel (LDP2) brings available to provide expert advice and support. together the most experienced housing developers who have a track record of delivering in London. These could be leveraged to support planning, capital project development and delivery of NHS estate schemes.51

51 London Devolution: Estates Technical Pack – November 2017

Page 84 42 The London Estates Board: Health and Care Estates Strategy • Coordination and support – homes for in partnership between OPE, GLA and NHS staff: DHSC, NHS England & Improvement LEDU. Additionally, the pilot will lead to the are considering national guidance to support NHS development of a delivery toolkit which is providers to include key worker housing solutions scheduled for publication in July 2019. The LEB as part of their recruitment and retention and LEDU has engaged with the DHSC teams to strategy. In addition, DHSC has identified the encourage a flexible national policy that will be need to provide 3,000 homes for NHS Staff suitable to the health and care sector’s need for nationally. The national policy is exploring key staff housing in London. demand requirements, track record of delivery London NHS charities are the largest owners of and existing options against some alternative NHS staff accommodation in the capital. The potential delivery routes, as well as investment LEDU is working with estate owners to explore opportunities and constraints. the potential for such organisations to scale up To date, a MoU has been signed and £500,000 their investment in providing homes for staff in OPE funds have been awarded to support in order to support recruitment and retention a pilot project focussing on five exemplar sites across London. in London. This initiative is being delivered

The challenge is great but with a commitment and willingness from all partners to work together, through the LEB we will transform the London health and care estate from its current condition to one of which Londoners can be justly proud of for decades to come.

Page 85 The London Estates Board: Health and Care Estates Strategy 43 Section 4

Governance and engagement

Page 86 44 4.1 Governance

Through partnership working and a robust London Estates Board (LEB) governance process, this first overarching view of NHS estates in London will allow all The LEB was formally established in 2016 as a London and national partners to better plan result of partners’ recognition of the need for transparent and collaborative working on London’s and use NHS buildings and land. NHS estate. Since 2016, the Board has acted as a forum to facilitate priority discussions and to create Governance for London’s a mechanism to directly solve some of the estates estates transformation challenges facing London’s health and care system.

Reflecting detailed discussions on how to solve By enabling collaborative working by partners London’s health and care estates challenges, within and beyond London, the LEB aims to deliver: national and local partners signed the London • This estate strategy that supports holistic clinical Health and Care Devolution Memorandum of strategies within and across London Understanding (MoU)52 in November 2017. The MoU confirmed a commitment from national and • Faster and greater generation of capital for local partners to work together to accelerate health reinvestment into health and care in London and care transformation for the benefit through the release of surplus NHS land of Londoners. • Access to development and delivery Critically, the scope of the MoU went beyond opportunities, including innovative commitments to work together. In addition to financing mechanisms taking ‘a shared strategic approach to estates • Marriage value by realising the opportunities of planning’ it also included NHS capital investment NHS, NHS charity and adjacent surplus site(s) decision-making powers. In essence the MoU set with those owned by other public sector bodies out a roadmap to improve health and care by: utilising a One Public Estate (OPE) approach • Closer working within London and with • Decisions involving London’s NHS estates being national partners taken within London. The LEB will move to a • Better responding to London’s unique challenges decision-making forum for capital investment, and opportunities by taking more decisions for subject to national approval thresholds London in London In doing so, the LEB operates according to the The detailed governance and delivery following agreed key principles: arrangements for estates in London and at a local STP level can be found in appendix A. • Subsidiarity: decisions taken at the lowest appropriate level. • Robust governance: clear responsibility and accountability for decision making for project prioritisation, assessment, approval and delivery management.

52 London Health and Care Devolution Memorandum of Understanding, 2017 Page 87 The London Estates Board: Health and Care Estates Strategy 45 • Transparency: clear processes and criteria for London Estates Delivery Unit decision making. Established in 2018 to support the operational • Knowledge sharing: all partners delivery of LEB priorities and LEB members, the bringing the collective expertise of their London Estates Delivery Unit (LEDU) is a pan constituent organisations. London partnership of resource and expertise, including the Healthy Urban Development Unit Full membership is available via a dedicated (HUDU) and NHS Strategic Estates Planning Service webpage on the Healthy London Partnership (SEP). LEDU brings together regional and national website and is currently made up of: resource to enhance local programme and project • London’s five STP estates leads development and delivery capabilities. • Department of Health and Social Care The LEDU’s key tasks include working in partnership with: • HM Treasury • STPs to establish a robust capital investment • London Councils (social care responsibility) plan for London • NHS England & Improvement (London) • The Greater London Authority (GLA) Housing • Greater London Authority and Land team and other local government partners to take forward projects to deliver new • NHS Property Services homes for Londoners • Community Health Partnerships • The NHS in London and other national and central government partners to establish • Representation from devolution pilots robust and transparent business planning, • Cabinet Office project decision making processes and assurance frameworks • CCG commissioner representative • National and regional organisations to facilitate project development and delivery at pace and at scale

The LEDU brings together a network of relevant expertise and skills to enhance London’s capability and capacity to transform its health and care estate by driving the greatest value from the significant opportunities that exist.

Page 88 46 The London Estates Board: Health and Care Estates Strategy London Estates Board: Phases Figure M outlines this transitional approach from of progression Phase I to Phase IV.

The LEB has already demonstrated its competence Phase I: Advisory (Dec 2016–Dec 2017) as a strategic forum. As it matures further the In phase I, the LEB brought together the full range LEB will move towards a forum within which NHS of partners in a single forum for relationship capital investment decision-making – including development, capabilities assessments and data delegated business case approvals and capital gathering. It also supported STPs to create their allocation considerations – could be exercised, sub-regional estates plans. so far as statutory powers permit this, and within national approval thresholds. Phase II: Strategic (Jan 2018–September 2019) It is important to note that plans for the use of During phase II each London STP built upon its land in London will continue to be led at a local plans and prepared an estates strategy. Reviewed level by STP estates teams and developed through nationally, London’s STP estates strategies all scored local engagement with service users, staff and either ‘Good’ or ‘Strong’. During this phase the local communities. LEDU has worked with partners to develop this pan The coming together of London’s NHS estates plans London strategy (including capital investment plan will benefit Londoners. By collaborating through and prioritisation framework). This has involved the LEB, estates leads across London, alongside significant and on-going engagement with a wide local and national partners, will be able to identify range of stakeholders. The draft strategy was sent opportunities to improve health and care delivery out to over 200 stakeholders to ensure awareness by sharing and supporting each other. The LEB of and input by all into the strategy development. offers a more transparent and collaborative way of Meaningful and on-going engagement is the working and allows health and care organisations golden thread running through all LEB and to access resources and expertise not previously LEDU activities. Further detail on engagement available or easily accessible. during phase II is outlined in section 4.2.

The LEB will help STPs to develop innovative funding solutions to ensure London has the required premises, which is particularly important at a time when national capital is scarce. Decision- making will seek to achieve consensus so far as is possible, while respecting the views and statutory accountabilities of constituent organisations.

Page 89 The London Estates Board: Health and Care Estates Strategy 47 Phase III: Shadow Decision-making During phase III the LEB will: (September 2019–March 2020) • Update the operational framework The LEDU Programme Director has worked with • Develop MoU’s to reflect the commitments from members of the wider devolution team to prepare each partner required to implement the updated an outline proposal for formally progressing the operating framework LEB to phase III (shadow decision-making) from September 2019. • Develop and agree business case assurance process To support this transition legal and governance documents are being prepared. These documents • Begin making recommendations to national will reflect a review of the LEB membership organisations on capital allocations for London and clarity on those members with decision- • Begin making recommendations for investment making powers. This approach aligns with the decisions, including business case approvals recommendations of the Naylor review. Phase IV: Full Decision-making The current operational framework will (March 2020 onwards) also be updated to reflect partners’ roles and responsibilities. The processes of making recommendations and dispute resolutions tested and verified in phase III will be underpinned by all necessary legal and statutory processes and documentation reflecting the scope and responsibilities of the LEB, LEB Co-Chairs and other executives.

LEB phases of progression

I II III IV 4 phases of progression C Y N N G I G G D O O O R A L I I N E N T E S S I S R M I I A K I K I V A R C C R E E H T O M A S M A F S D A D D

Phase LEB brings Brings strategic estates Begins making Decisions start overview together partners functions, building a recommendations to be taken by LEB in a single forum. London view from local to national representatives at Focuses on and sub-regional organisations on board meetings. developing estates strategies and some captial relationships, enabling a wider public investent decisions capabilities sector approach and (including business and data. non-binding case approvals). recommendations.

Figure M: LEB phases of progression

Page 90 48 The London Estates Board: Health and Care Estates Strategy 4.2 Engagement

The LEB is uniquely placed in terms of its be developed and updated annually to reflect ability to involve stakeholder organisations progress and effectiveness of the strategy and to ensure meaningful and regular multi the engagement plan. As a key purpose of the LEB is to enable decision making for London in organisation communication. London, the approach to engagement has been Substantial engagement has been undertaken and will continue to be extensive and intensive to support the establishment of the LEB and the encompassing liaison with London and national operating framework which guides the remit and partners and wider stakeholders. focus of its work. Supporting the preparation LEB as a forum for national and local NHS of the STPs estates strategies, their NHS wave 4 partners and London local government partners is funding submissions and the development of its uniquely placed in terms of its ability to reach into strategy have all necessitated identification and stakeholder organisations to ensure meaningful engagement with a large range of stakeholders. and regular communication. Supported by To support the on going delivery of the strategy, the LEDU, this dialogue will ensure timely and a communications and engagement plan will appropriate health and care estate decisions for London are made in London.

1 February 18 May 13 June 21 Aug 14 September 25 October 14 December

Outline Strategy SPB includes a deep LED Steering LED Director End of extended ayor of London The LED Director is presented to the dive on estates and Group updates presents an update deadline for references the attended the London LEB for feedback the draft London following the 29 about LED London feedback on draft London Estates Accountable Officers on initial headings Estates Strategy is arch LEB and Estates Strategy at pan London estates Strategy in his meeting to report on and overarching brought to the 1 ay SPB. the Primary Care strategy. speech at the progress and structure. meeting for review. Capital Panel. London ealth proposed progression Board conference. to phase .

18 July 18 September 4 October & 15 November LED Steering Group An update is The LED ran workshops updates following 9 presented to the with STPs on developing the uly LEB. Borough eads of Comms Network. capital investment plan.

Feb Mar Apr May June July Aug Sep Oct Nov Dec Jan

29 March 9 July 6 August 25 September 30 November January

nitial document Draft of the London Draft London LED Director is LED Director and The LEB Co-Chair and developed by Estates Strategy is Estates Strategy on a panel with LEB Co-Chair LED Director hold Deloitte presented tabled at LEB for is circulated to Sir obert Naylor present an meetings with all 5 STPs to to LEB and input from members over 2 at the ealth update and A discuss the outcomes of subseuently only. This meeting people across Show talking at London wave 4 funding, future circulated to SPB. was scheduled to the health and about devolution Councils ealth governance arrangements embers are review the Wave 4 care system. and the LEB. and Wellbeing and readiness to support encouraged to share Capital Bids that STPs Board Chairs next phase of estates it with local forums were due to submit Network meeting. devolution. e.g. it was taken to with their STP CELC. Strategy on 16th uly. London Estates Board (LEB) London Estates Delivery Unit (LEDU) London Health and Care Strategic Partnership Board (SPB) Sustainability and Transformation Partnership (STP)

Figure N: High-level snapshot of LEB and LEDU engagement, February 2018 – January 2019

Page 91 The London Estates Board: Health and Care Estates Strategy 49 Appendices

Page 92 50 Appendix A: London demographics and housing needs

London is one of the most diverse cities in proportional increases can be seen in the older the world. Forty per cent of Londoners were population, particularly those aged 60 and over, born outside of the UK and there are over being the biggest users of health and care services. 300 languages spoken in London. Forty per Population projections by London cent of Londoners are from Black, Asian boroughs (2018–2028)55 and Minority Ethnic backgrounds and 1.2 million Londoners are disabled. Some of the • Three out of the 33 London boroughs have a very richest and very poorest people in the projected absolute growth of over 50,000, and country live in London, with over 600,00053 contribute over 20% to the overall growth in of London’s children living below the poverty London. These include: Newham at 72,279; Ealing at 56,875 and Tower Hamlets at 53,508 line and healthy life expectancy differing by up to 14 years between boroughs.54 • Only 6% of all boroughs have predicted growth lower than 10,000 (City of London at 1,394; Population projections Kensington and Chelsea at 7,695) • Over half of boroughs (58%) predict population Over the next 10 years, London’s population is growth of between 10,000 – 30,000 projected to increase by 883,334 – more than the current population of Amsterdam. The largest

Figure O: London’s population growth 2018–2028

53 Tackling child poverty and health inequality in London, GLA 54 Public Health England. Public Health Outcomes Framework; 2014-16 55 Analysis provided by London Healthy Urban Development Unit (HUDU) based on 2016 GLA Round Population Projections

Page 93 The London Estates Board: Health and Care Estates Strategy 51 Population projections by London sub- population increase across London. This STP regional area (2018–2028) accounts for the highest percentage of overall London growth. Tower Hamlets and Newham • NWL: The total projected population growth account for nearly half (47.6%) of the total of 221,487 amounts to 25.1% of total London STP population growth. NEL also includes the growth. Within NWL, Westminster has the City of London, which has the lowest projected highest projected growth (56,875 increase population growth across London. in population; 25.7% of total STP growth), • SEL: Overall growth is projected at 151,081, while Kensington and Chelsea has the lowest representing 17.1% of the total population projected growth (7,695 increase; 3.5% of total increase across London. The highest growth STP growth). borough is Greenwich, followed by Southwark • NCL: The total projected population growth is (with 27% and 22% of total STP population 93,678, which equates to 10.6% of the total growth respectively). London growth. More than half of the boroughs • SWL: Overall projected growth is 152,606, (60%) have projected growth between 10,001 representing 17.3% of the total population and 20,000 over the next 10-year period. Barnet increase across London. Over half (57.7%) of is projected to have the highest population this growth is located in two boroughs: Croydon growth in the NCL STP (8.6%). and Wandsworth. • NEL: Overall growth is projected at 264,483, which amounts to 29.9% of the total

Figure P: Map of London’s forecast population growth, 2018–2029 Page 94 52 The London Estates Board: Health and Care Estates Strategy Housing Targets Forward Plan

In partnership with boroughs, the Mayor has As part of his housing strategy, The Mayor of undertaken a Strategic Housing Land Availability London has set forward plans for the development Assessment to identify where the homes London of 30 Housing Zones in partnership with London needs can be delivered. Ten-year housing targets boroughs and their development partners. have been established for every borough, alongside opportunity area plans for longer-term delivery The Mayor is investing £4.8 billion to start building where the potential for new homes is especially 116,000 new affordable homes in London by 2022. high. The total housing target proposed in the draft London Plan over the next ten years is 649,350.

Figure Q: Opportunity Area

Page 95 The London Estates Board: Health and Care Estates Strategy 53 London Housing % of Housing % of Housing % of Total Total STP Area target large target small target non-self- housing % of from sites from sites from non contained unit London large small -self- sites target Draft sites sites contained Housing sites Target SWL 47,320 48.8% 49,530 51.1% 160 0.2% 97,010 15% SEL 72,320 59.6% 48,580 40% 430 0.4% 121,330 19% NWL 97,000 63.1% 55,090 35.9% 1,530 1% 153,620 24% NEL 132,480 70.1% 55,800 29.7% 820 0.4% 189,100 29% NCL 51,350 58.2% 36,730 41.6% 210 0.2% 88,290 14% Total 400,470 N/A 245,730 N/A 3,150 N/A 649,350 100%

Figure R: Draft GLA housing targets by London sub-regional areas (2018 – 2028)

South West

South East

North West

North East

North Central

0 50000 100000 150000 200000

Large Sites Small Sites Non Self Contained

Figure S: GLA Housing Target Site Composition by London STP region

Page 96 54 The London Estates Board: Health and Care Estates Strategy Appendix B: London joint prioritisation framework

Purpose Developing Approach

Prioritisation of investment projects is an on- Reflecting the current LEB progression going key task both locally and at a regional phase, partners are working to develop a level given that funds are inevitably limited. An London capital investment plan and prioritised agreed, transparent, widely understood and robust 10 year annualised capital investment approach to capital prioritisation is needed to programme. The framework shows a three ensure the most urgent health estate needs of stage development process reflecting the London are met as fully and as early as practicable. relevant partner roles and responsibilities.56 Assessment Local STEPs submit annual capital investment plan and refreshed estates strategy NEL NCL NWL SWL SEL

Annual London Capital 1. Fixed Point: Evaluation Scoring LEB London Prioritisation Panel criteria applied to all London STP Investment Plan incl. priorities (Long List) all STP Schemes

Back-log 2. Filter: Hurdle Criteria applied (Medium List) Maintenance Investment

3. Filter: Evaluation Criteria Scoring

Annual* London Prioritised Capital London Priorities: Final London recommended priorities to LEB (Short List for capital investment) Investment Plan

Figure T: Approach to development of the London Capital Investment Plan and investment prioritisation

56 The LEB leadership may request an extraordinary prioritisation panel meeting outside of ordinary schedule times if there is deemed to be a circumstance requiring a London review, such as a round of national capital bidding Page 97 The London Estates Board: Health and Care Estates Strategy 55 1. Producing the Prioritised Annual 2. Applying the hurdle criteria – Capital Investment Plan economic & financial criteria

Each STP based on their health and care estates In order to establish an appropriate ‘short list’ strategy will undertake a local prioritisation of transformational schemes that are considered exercise, updated annually, supported by associated to be sufficiently worked up, viable and capable scoring exercises to produce a ‘prioritised capital of being taken forward for delivery, the capital investment plan’. The capital investment plan investment plan will be assessed against 4 hurdle from each STP having been ratified and supported criteria on the basis of a pass/fail score. Each of through local governance arrangements will be the hurdle criteria is defined below (Figure U). submitted to the LEB. The plan will be categorised However, it should be noted that the hurdle criteria by service area to aid visibility with alignment with may be amended or added to in order to reflect clinical and wider priorities. the specific capital availability at a single point in time and the associated criteria to secure recurring The LEB Prioritisation Panel57 will be responsible or non-recurring capital. This assessment will be for evaluating the STP prioritised plan. In the first undertaken by the Prioritisation Panel. instance, the prioritisation panel will be brought together annually to undertake the scoring of the individual plans submitted by the five London STPs. This may need to be supplemented with ‘in year’ panel meetings to respond to NHS limited time funding initiatives or other circumstances.

Figure U: Hurdle criteria

57 The LEB Prioritisation Panel will be formed of elected representatives from the London partnership Page 98 56 The London Estates Board: Health and Care Estates Strategy Affordable – The Health system is able to 3. London Prioritisation framework demonstrate the proposal is affordable within their for Capital Investment – non current budgetary limits. financial criteria Economic Case – The scheme clearly demonstrates value for money. The value for The Framework also identifies five key criteria money (VfM) ratio should be greater than 1 with for evaluation of the capital investment plan to a positive net present value (NPV) to demonstrate determine the agreed London Prioritised Capital value for money, the higher the number the better Investment Plan. These evaluation criteria include: value for money. • Quality and Patient Benefits Financial Case – The scheme shows significant • Financial Sustainability revenue savings as a percentage of capital, i.e. a cumulative return on investment (RoI) over the • Asset efficiency asset life. This clearly needs to be positive but the • Strategic Fit higher the better, in the past the DHSC has used a benchmark of 4x revenue savings to capital. • Deliverability For lower value schemes we would expect to see appropriate payback periods. For the very largest These are the core criteria against which the annual schemes, payback may be over a longer period. investment plan is initially evaluated. We should consider this metric on a scheme by For this stage of the process each criteria has been scheme basis along with both NPV and RoI metrics allocated a weighting to ensure a balanced outcome as above. This will not form part of the hurdle during the prioritisation process. These weightings criteria, but will be considered as part of financial have been discussed and agreed by the London sustainability assessment within the framework regional NHS England & Improvement team. criteria (Figure V). At each prioritisation panel the shortlisted Deliverable – STPs will need to demonstrate that projects will receive a score between 1–10 the schemes they put forward have a good chance for the five criteria set out in the evaluation of being delivered with agreed timeframes. framework (see Figure V). Scoring guidance set out in Figure W and will be evidence based. Sustainability Transformation Partnerships will have single representation at the panel and are able to provide further information and detail on projects as necessary. An additional detail or representation cited at the panel session will need to be evidenced by the STP.

Page 99 The London Estates Board: Health and Care Estates Strategy 57 Deliverability - 5% Leadership to deliver Strategic fit - 15% Service and demand management Extent to which the scheme is free from complications such as: planning restrictions, Level of fit with STP plans, lack of available land, interdependencies with Support from local CCGs, other schemes. Support from NHSE (where appropriate), support Does the scheme have a robust plan in place from local communities and stakeholders. with clear milestones and delivery capacity? Does the scheme deliver service improvements? Does the organisation/system have a history of delivering change programmes? Does the scheme quantify demand reductions/ better management of service demand? Does the scheme evidence stakeholder engagement? Does the scheme deliver workforce productivity improvements?

Asset efficiency - 20% Estates efficiency Extent to which scheme ensures efficient use of estate. Quality and Extent to which the patient benefits scheme allows for - 40% release of surplus land. Transformation and patient benefits Ensuring there is clinical safety in the current estate. Financial sustainability Responding to CGC or other - 20% regulators concerns. Financial sustainability and value Ensuring clinical services are sustainable. for money Ability to deliver new models of care? Extent to which scheme covers own costs To what degree does the scheme transform the through releasing resource or more efficient use local health economy and patient service? of resource. Demonstrating that the scheme is affordable to the local health system, delivering a positive NPV and return on investment within a reasonable payback period.

Figure V: Prioritisation Framework Criteria for London Page 100 58 The London Estates Board: Health and Care Estates Strategy Criteria Score 1 Score 5 Score 10 Not supported by STP and not Supported by STP but lower Fully supported by STP and in prioritised list down on prioritised list prioritised in top 3 No commissioner support Major commissioners have 85% of commissioners have Strategic fit indicated informal support provided formal support Consultation/communication with communities and Consultation/communication Consultation/communication stakeholders have revealed with communities and with communities and major concerns stakeholders has not revealed stakeholders have shown high major concerns level of support Scheme makes no contribution to demand management Scheme contributes to Scheme a key part of demand demand management management Trust remains in bottom two Scheme ensures trust moved Scheme ensures trust moves quartiles of Carter estate KPIs to second quartile Carter on top quartile Carter estate estate KPIs KPIs Scheme does not lead to any Asset release of surplus land Scheme allows some release Scheme allows extensive efficiency of surplus land release of surplus land Scheme does not increase Scheme delivers either safety Scheme responds to CQC or patient safety or deliver new improvements (which may other external requirements models of care respond to external regulator Scheme increases patient safety Quality requirements) Patient experience unaffected and patient Scheme reshapes services to benefit OR ensure ongoing sustainability Scheme reshapes services and deliver new models of care to increase sustainability Scheme considerably improves and deliver new models of patient experience care and improves patient experience Scheme delivers wider benefits to the local community Scheme is unaffordable in Scheme delivers efficiencies Scheme delivers efficiencies revenue terms which at least partly cover which cover revenue revenue consequences of consequences of capital spend Scheme will require external Financial capital spend and can show capital funding Capital spend can be sustainability how remaining affordability gap will be bridged delivered from self-generated Scheme has a negative return sources (land sales, charity, on investment Scheme is neutral on rate of depreciation) return on investment Scheme can demonstrate Scheme will require external positive return on investment capital funding Planning is a major concern Some planning concerns Scheme is free from planning but advice is that they can concerns Insufficient land for scheme be overcome Land is available for the Deliverability Scheme depends on other Land is available or can be scheme projects which are outside the purchased for the scheme trust’s control Scheme does not depend on If there are dependencies, other projects these have been mapped and can be managed

Figure W: Scoring Bands for each criterion

Page 101 The London Estates Board: Health and Care Estates Strategy 59 LEB Prioritisation Panel

Panel representation is to be reviewed and ratified by the London Estates Board on an annual basis. Each member is to be elected/selected by the representative organisation. The LEB Prioritisation Panel includes: • Independent Chair • NHS England & Improvement London Finance Director • NHS England & Improvement Project Appraisal Unit • NHS England & Improvement Estates & Facilities London Director • Clinical Representative • STP Nominated Representative • LEDU Director • SEP London Director • Provider representative • London Councils representative

All Prioritisation Panel meetings will be documented and minuted and submitted to London Estates Board for final endorsement.

Page 102 60 The London Estates Board: Health and Care Estates Strategy Appendix C: London-wide and local STP governance and delivery arrangements for estates

London Health Board Political oversight; chaired by the Mayor of London

London Health and Care Strategic Partnership Board Strategic and operational leadership and oversight for London-level activities

Homes for Londoners Board London London Transformation London London Prevention Digital Funding Workforce Estates Board Partnership Partnership Oversight Board Board Board Group National Property Board

London Estates Delivery Unit

Figure X: London Estates Board and wider governance arrangements

Page 103 The London Estates Board: Health and Care Estates Strategy 61 The governance arrangements as detailed in the July 2018 STP estates strategies are set out below: s

Providers Commissioners Local Authorities g n d i e i k o Local Authority B Trust Boards Governing Bodiess x8 y M a

Cabinets r n o t o i

Health & Wellbeing s i a t u c

Boards e S t D

NWL STP Health Programe Joint NWL Health and Care Shadow Joint Committee** Provider Board* Board* Transformation Group

e r s (Commissioner and Provider (Provider, Commissioner and (Commissioner focused) (Provider focused) b l

a focused) Local Authority focused) n E

/

s d r

a Urgent and Emergency Care Board o B

e

m Clinical Board m a

g r DA1 DA2 DA3 DA4 DA5 o

r Strategic Provider and Digital Workforce

P Better care Programme Estate CCG CFO Portfolio Transformation Improving for people Better care Improving Executive* Committee* Group* Board Delivery Board health and with for older mental wellbeing long-term people health conditions services DA5 *Safe, high quality and sustainable hospital services p s Older people’s Workforce 5a NWL Testimonial o u r 2a care reference Design Authority Transformation a n d 5b G 4a n 1a 2b group Advisory Council y 5c r

i g 4b

e 1b 2c e s v 4c 5d i l D 1c 2d 3d a d HR Directors e 3a 4d Multiple working groups D 2e 3b 3e b e Network 3c c

Please note: Ÿ 3b repositioned to Accountable Care Systems enabler Ÿ DA5* does not have a programme board but links to the Provider Board/Strategic Estates Committee / Provider and CCG CFO Group / DA5 Programme Ÿ Executive and the STP Health Board depending on the workstream Ÿ Shadow Joint Committee ** The expectation from December 2018 is that this board will become shared decision making

Figure Y: North West London (NWL STP)

Page 104 62 The London Estates Board: Health and Care Estates Strategy Joint Health Regulators Health & Overview & NHSE/NHSI/CQC Wellbeing Scrutiny Boards Community and local OHSCs

Homes London London Land for London Health Board Commission Statutory Organisations

Provider Boards CCG Governing LA Committee/ Bodies Cabinets

London Health NCL STP NCL STP and Care Advisory Board Programme Board Strategic Partnership* Primary Care Health and Committee in Common LGA/GLA Care Cabinet

Finance and Activity HMT Modelling Group London Estates Board DHSC

NHS E/I NCL Estates Board

London Estates Delivery Unit Local Estates Entire Task and (assurance and Forums Finish Groups business case co-developent)

Figure Z: North Central London (NCL STP)

Page 105 The London Estates Board: Health and Care Estates Strategy 63 Regulators NHSE / NHSI / CQC

Strategic Partnership Board (London-wide)

NEL ELHCP Assembly System delivery boards: Commissioning (Meets quarterly, extended membership including BHR integrated care partnership board, Alliance (JCC) patient reps and stakeholders) City & Hackney Transformation programe board, WEL/Transforming Services Together ELHCP Executive Group (Monthly, includes single AO, NELCA chair, Director of NEL Strategic Commissioning, Chair of Clinical Senate and Clinical Senate Director of Public Health)

Provider Alliance and CEO ELHCP ELHCP Estates ELHCP Operational Delivery Transformation (Collaboration for Financial (Operating plan, (Strategy alignment, devo strategy strategy review delivery) alignment, review finance strategy, delivery) system productivity)

Local decision making will take place through CCG Governing Boards, provider trust boards and local authority HWB / OSC

Figure AA: North East London (NEL STP)

Page 106 64 The London Estates Board: Health and Care Estates Strategy Providers Commissioners Local Authorities Local & Joint OSCs Provider Boards Governing Bodies Cabinets

& Strategic Committies in Common Local Health decision making Statutory Bodies & Wellbeing Board

Patient & Collaborative Public Pre Board STP Programme Board Leadership Engagement Seminar Forum Group

Acute Provider Collaborative

Kingston & Richmond Croydon LTB Clinical Senate

Delivery LTB Finance & Activity Transformation Transformation Committee Sutton LTB Merton & Wandsworth LTB

Clinical transformation groups UEC Cancer Delivery Mental Health Local Maternity Learning Disability Other ad hoc as Transformation Group network System (TCP) network required e.g. MSK and Delivery Group

Care setting System enablers

Primary Care Integrated Care at South London SWL Digital & Local Workforce

support delivery SWL Estates Board network Home & in the Specialised Technology Action Board Community (RCBS) Commissioning SWL-wide networks to

Figure BB: South West London (SWL STP)

Page 107 The London Estates Board: Health and Care Estates Strategy 65 LEB SEL STP Executive Committee

SEL STP Estates LEDU Executive Delivery Group

SEL STP Estates Steering Group

LEPCC

Bexley Bromley Greenwich Lambeth Lewisham LEF Southwark LEF LEF LEF LEF LEF

A partnership of NHS providers and Clinical Commissioning Groups serving the boroughs of Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark with NHS England

Figure CC: South East London (SEL STP)

Page 108 66 The London Estates Board: Health and Care Estates Strategy Glossary

BLM Backlog maintenance KH Kingston Hospital NHS Foundation Trust CAPEX Capital expenditure LEB London Estates Board CBC Community-based care LEDU London Estates Delivery Unit CCG Clinical Commissioning Group LNWUHT London North West University CDEL Capital departmental expenditure limit Healthcare Trust CHP Community Health Partnerships LTP Long Term Plan CHS Croydon Health Services Trust MoU Memorandum of Understanding CIL Community Infrastructure Levy NCL North Central London CMH Central Middlesex Hospital NEL North East London CNWL Central and North West London NHS NHS National Health Service Foundation Trust NHSE NHS England CQC Care Quality Commission NHSE/I NHS England & Improvement DHSC Department of Health and Social Care NHSI NHS Improvement ELHCP East London Health and Care NHS LTP NHS Long Term Plan Partnership NHSPS NHS Property Services ERIC Estates Return Information Collection NWL North West London ETTF Estates and Technology Transformation PPP Public Private Partnership Fund ROI Return of Investment ESTH Epsom and St Helier University OPDC Old Oak and Park Royal Development Hospitals NHS Trust Corporation FYFV NHS Five Year Forward View OPE One Public Estate GLA Greater London Authority s106 Section 106 GP General Practitioner SEL South East London GSTT Guy’s & St Thomas Hospital Foundation SEP Strategic Estates Planning Trust SPB London Health and Care Strategic HDU High Dependency Unit Partnership Board HLP Healthy London Partnership STP Sustainability and Transformation HUDU Healthy Urban Development Unit Partnership ICHT Imperial College Healthcare NHS Trust SWL South West London ICS Integrated Care Systems VfM Value for Money ICU Intensive Care Units Wave Wave 1 – 4 capital investment funding 1 – 4

Page 109 The London Estates Board: Health and Care Estates Strategy 67 About this document Effective June 2019, due for review May 2020. This strategy document is written and prepared by the London Estates Board (LEB), in partnership with health and care partners and supported by the London Estates Delivery Unit (LEDU).

For more information You can stay up to date about the work of the London Estates Board and the London Estates Delivery Unit via the Healthy London Partnership website, where you can explore the programme’s FAQs and progress reports: www.healthylondon.org/our-work/london- estates-transformation/

London Estates Board c/o Greater London Authority 169 Union Street London Page 110 SE1 0LL Agenda Item 7

Date of meeting: 10 July 2019 Agenda item: 7 Title: Thrive LDN Presented by: Mayor Philip Glanville, Mayor of Hackney Author: Dan Barrett, Deputy Director, Thrive LDN Cleared by Mayor Philip Glanville, Mayor of Hackney Status: For noting

Classification Public

1 Purpose of this paper

1.1 The purpose of this paper is to update members on:

• Thrive LDN activity since the last meeting;

• Thrive LDN’s strategy development and Evaluation Framework; and

• Thrive LDN’s 2019 campaigns and festival plans.

2 Recommendation(s)

2.1 The Board is asked:

2.1.1 to note the update on Thrive LDN; and

2.1.2 to comment on any areas or potential opportunities where they can provide further support for the citywide movement and/or Thrive LDN team.

3 Context

3.1 Poor mental health is one of the biggest challenges facing London and prevalence is often much higher in the communities facing most inequalities. Thrive LDN is a citywide movement to ensure all Londoners have equal opportunity to good mental health. We are supported by the Mayor of London and all London Health Board partners.

4 Update on Thrive LDN Activity

4.1 Youth Mental Health First Aid: Over 70 courses have now been delivered, attended by over 1,000 teachers and school staff, so far in 2019. A further 30 courses have been arranged from September 2019. UCL Consulting have been appointed as the evaluation partner for the programme. A preliminary findings report will be published in April 2020.

Page 111

4.2 Thrive LDN Champions Leadership Programme: The training programme began in May, with approximately 50 voluntary Thrive LDN Champions attending. From Champions’ feedback at the initial training session, a list of ten masterclass sessions have been developed.

4.3 Mental Health Awareness Week 13-19 May: Thrive LDN supported partners’ various activities throughout the week, including the This is Me campaign to tackle stigma and discrimination in the workplace. The Mayor also highlighted the Londoners Said report on social media.

4.4 Student wellbeing: In partnership with University of London, The London Association of Directors of Public Health, National Union of Students and London and Partners, Thrive LDN has commissioned a mental health and wellbeing needs assessment of further education students in London. The report will be published in October.

4.5 Mental Health Transformation Board engagement: Dr Jacqui Dyer presented the Londoners Said report at the March Mental Health Transformation Board meeting. Professor Oliver Shanley and Jane Milligan, co-Chairs of the Mental Health Transformation Board, have written to the London Health Board to demonstrate the Board’s commitment to signposting all health and care partners in London to the report’s recommendations on how best to tackle inequalities and improve the mental health of Londoners. (see Appendix 1 – MHTB letter to LHB).

4.6 Violence Reduction Unit (VRU) engagement: Mayor Philip Glanville and Dr Jacqui Dyer, co-Lead of Thrive LDN, met with Sophie Linden, Deputy Mayor – Policing & Crime, and Lib Peck, Director of the Violence Reduction Unit, to scope out partnership working between Thrive LDN and the Violence Reduction Unit. Thrive LDN will continue to engage with the work of the VRU.

4.7 Thrive LDN team leadership changes: Una Carney left the Thrive LDN team in June. Una has been involved with Thrive LDN since its conception, first leading on Communications and Engagement before taking on leadership of the programme in April last year. Dan Barrett, Deputy Director of Thrive LDN, is now leading the team with support from Thrive LDN Advisory Group members.

4.8 The future of Thrive LDN hosting and alignment with the London Health and Care Vision and the London Improvement Transformation Architecture (LITA) review: As part of securing continued support for Thrive LDN and the team, Thrive LDN’s Advisory Group Chair has written to the co-Chairs of the Strategic Partnership Board asking for a meeting to discuss where Thrive LDN will sit in terms of the London Health and Care Vision. Advisory Group members will also be working with the LITA process to ensure the team currently hosted by Healthy London Partnership continues to get the support and resourcing needed to ensure the continued success and support of the programme.

Page 112

5 Strategy Development & Evaluation Framework

5.1 Ensuring all Londoners have an equal opportunity to good mental health: Thrive LDN commissioned Purpose, a specialist social movement incubator, to independently review Thrive LDN’s activities and approach to evaluation. The review involved co-creation workshops with the Thrive LDN team, Advisory Group and Leadership Team, Thrive LDN Champions, the Mayor’s Peer Outreach Team and regional and local partners and participants. The outputs, summarised in the Ensuring all Londoners have an equal opportunity to good mental health report (see: https://www.thriveldn.co.uk/wp- content/uploads/2019/06/Ensuring-all-Londoners-have-an-equal-opportunity-to- good-mental-health-1.pdf), have highlighted several important considerations for Thrive LDN:

• Participants would like Thrive LDN to have a greater focus on Perception change than in previous years.

• Participants aligned on a 2020 goal that would see Thrive LDN achieving change by growing local and regional networks to implement diverse activities and interventions across London communities.

• Participants valued participation and want to be more involved in developing and delivering campaigns and a citywide mental health festival.

• Participants wanted to see Thrive LDN do more to amplify the voices of Londoners affected by inequality and poor mental health.

5.2 Evaluation Framework: Following the co-creation workshops, the Thrive LDN team has reviewed Thrive LDN’s logic model and Evaluation Framework. Several additional evaluation activities have been implemented for 2019/20, as a result:

• The Thrive LDN team will undertake a baseline assessment of Londoners’ mental health and wellbeing using an assets-based approach, collect and analyse data on all Thrive LDN participants, as well as carry out a qualitative evaluation of participants from target groups to develop a deeper understanding of the Thrive LDN network and the contribution Thrive LDN is having to the lives of those we are engaging with.

• The Thrive LDN team, with colleagues from Public Health England (London), King’s College University and Greater London Authority, have established a Thrive LDN Evaluation Reference Group, to develop and implement a longer-term London-wide assessment of the outcomes and impact of Thrive LDN, and undertake a benefits realisation exercise to more clearly understand return on investment.

Page 113

5.3 Thrive LDN campaigns and festival: Planning is underway for Thrive LDN’s 2019 campaigns and festival. As highlighted from the co-creation process, Thrive LDN is supporting a more participatory approach to designing and developing plans this year. We would be delighted to welcome London Health Board members to two events:

• World Suicide Prevention Day event on 10 September: Thrive LDN Suicide Prevention Network will be hosting an event at City Hall on 10 September to mark World Suicide Prevention Day. The event will be an opportunity for partner organisations to share work they are leading in London to reduce the number of suicides.

• World Mental Health Day event on 10 October: The Mayor’s Peer Outreach Team will be leading on a youth-led mental health event at City Hall to mark World Mental Health Day on the 10 October. The event will include film screenings, presentations and discussions, workshops and creative activities.

6 Next steps

6.1 Members are also invited to consider how Thrive LDN can be highlighted at the London Health Board conference on 2 October as a good practice example of regional, sub-regional and local partnership working in London.

Appendices:

• Appendix 1 – Mental Health Transformation Board letter to the London Health Board

Page 114 Appendix 1

Professor Oliver Shanley OBE Sadiq Khan Nursing Directorate th Mayor of London 5 Floor Skipton House Chair of the London Health Board 80 London Road City Hall London The Queen's Walk SE1 6LH London SE1 2AA T: 011380 70334 E: [email protected]

26 April 2019

Dear Mayor Khan and London Health Board members

Supporting Thrive LDN’s Londoners Said report

London’s Mental Health Transformation Board recently received an update on the work of Thrive LDN. As co-chairs of the Board, we were particularly pleased to see the outcomes of the work undertaken in partnership with the Mental Health Foundation to ask Londoners how best to support their mental health and wellbeing.

Thrive LDN’s Londoners Said report contains very rich information and is a strong example of meaningful engagement with Londoners in boroughs with the highest risk of poor mental health. The Mental Health Transformation Board is committed to signposting all health and care partners in London to the report’s recommendations on how best to tackle inequalities and improve the mental health of Londoners.

More generally, we remain keen for London’s health and care partners to identify further areas where they can work with or align with the aspirations of Thrive LDN. Doing so will complement portfolios and business plans and build on the commitments to mental health and wellbeing in local areas whist responding to the feedback from Londoners on how best we as a system and city can help every Londoner to thrive.

There is a whole host of transformational work happening across London to improve mental health and the services provided for those who need support and help. Having a prevention agenda like Thrive LDN is key but we also need to ensure we are supporting Londoners with poor mental health too. We believe our collective efforts to make London a more mentally well city can ensure we are reaching and helping the most vulnerable citizens. The more we can work together as a city to ensure we help people with poor mental health or those experiencing illness the greater impact we can have.

NHS England and NHS Improvement Page 115

We share the ambitions for making London a healthier happier place for all. We hope you will continue to draw fully on the collective expertise and experience of the London Mental Health Transformation Board, so that we can further support the work of Thrive LDN to help us meet this ambition and also disseminate learning across London’s health and care system. We are also keen to share more of our work around transforming mental health for all Londoners with you and LHB members and are keen to keep you informed and up to date with progress and indeed highlighting some of the challenges we are facing. We look forward to our continued working together to make London a city where everyone has the opportunity to thrive.

Yours sincerely

Professor Oliver Shanley OBE Jane Milligan Regional Chief Nurse Accountable Officer, NHS North East London Commissioning Alliance; Senior Responsible Officer for Healthy London Partnership’s Mental Health Transformation Programme

Page 116 Agenda Item 8

Date of meeting: 10 July 2019 Agenda item: 8 Title: London Health Inequalities Strategy (HIS) update Presented by: Vicky Hobart on behalf of Paul Plant Author: Karen Steadman Cleared by Dr Nick Bowes, Mayoral Director, Policy Dr Tom Coffey, Mayoral Health Advisor Status: For noting Classification Public

1 Purpose of this paper

1.1 To update the London Health Board (LHB) on progress in delivering the London Health Inequalities Strategy (HIS) and work being undertaken to support the partnership to engage with the HIS and fulfil their commitments.

2 Recommendation(s)

2.1 The Board is asked to note and comment on progress in implementing the London HIS, including:

• Progress against the key performance indicators;

• Five new stakeholder guides;

• Five workshops to take forward complex issues in partnership; and

• Plans for a one year on event/ session on the London HIS to be aligned to the LHB conference on 2 October 2019.

3 Context

3.1 An overview of the London HIS was provided in the papers of the last London Health Board, and is a standing item on the Board’s agenda. The impact of the London HIS in reducing health inequalities is monitored through a set of population indicators that are reported on an annual basis.

3.2 The LHB Terms of Reference commit them to drive improvements in London’s health, care and health inequalities where political engagement at this level can uniquely make a difference. Oversight of implementation and delivery of the HIS is undertaken by the London Prevention Partnership Board (LPPB).

Page 117

4 Progress in implementing the London’s HIS and future opportunities

4.1 Appendix 1 provides an update on the Mayor’s key performance indicators for implementation of the London HIS.

4.2 Progress since the last meeting of the LHB includes:

• Publication of a set of stakeholder guides to the HIS – short summaries developed to communicate key messages and promote local action. These are tailored to different stakeholder groups (healthcare, local authorities, voluntary and community sector, organisations working with children and young people, and businesses), featuring examples of what partners are already doing to contribute to achieving the aims and objectives of the HIS. Available here: https://www.london.gov.uk/what-we-do/health/health- inequalities-strategy/stakeholder-guides

• Five HIS implementation workshops are planned to bring focus to and accelerate action on complex, pan-London problems which relate to the HIS. The theme and focus of the first two workshops has been confirmed through the LPPB.

Workshop 1 - Healthy Communities (26 June); Accelerating social prescribing in London.

Workshop 2 - Healthy Places (3 July); Hospital stays and beyond: supporting homeless people in London.

The focus of the final three workshops (Children, Minds, Living) is being developed with partners, and they will be held later in 2019.

Workshop 3 - Healthy Children (TBC); Suggested focus- breastfeeding and infant feeding, and/or parenting support to tackle health inequalities.

Workshop 4 - Healthy Minds (TBC); Suggest focus - mental health and wellbeing in schools.

Workshop 5 - Healthy Living (TBC); Suggested focus – smoking and illegal tobacco and/or alcohol harm reduction.

• The Mayor has written to Council Leaders and other stakeholders – to share the achievements at six months and raise awareness of the guides, the HIS workshops, and ongoing engagement opportunities.

Page 118

4.3 Partners continue to work across the health and care system to ensure health inequalities are reflected in the development of the London Health and Care Vision, and in NHS local plans. This includes considering how the work of the following workstreams will be reflected within the development of this work:

• Action to improve air quality; • London Child Obesity Taskforce; • London Violence Reduction Unit; • London social prescribing vision; • London HIV Fast Track Cities leadership group; • Thrive LDN, Goodthinking; • Dementia Friendly London; and • The London Healthy Early Years, Healthy Schools and Healthy Workplaces programmes.

4.4 Specific areas of work progressed in this quarter include: • Launch of the ULEZ to improve air quality in central London; • Launch of the refreshed London Healthy Workplace Award, aligned to the Mayor’s new Good Work Standard - including the new Micro Award (for business with less than 10 employees) and the new Communal Space Award (for organisation hosting and facilitating nomadic businesses); • Delivery of community development for health masterclasses in each sub- region; • Initiation meeting to develop a blueprint for the elimination of Hepatitis C in London; and • Partnership framework agreement with the City of Amsterdam’s Healthy Weight Programme Team, and agreement to host the first Global Summit for Cities on Child Obesity in London with the support of Guy’s and St Thomas’ Charity (plus other global partners).

4.5 The Board are particularly asked to note the work of the Mayor’s Child Obesity Taskforce in this period and their emerging recommendations.

4.6 The Taskforce have undertaken extensive cross-sectoral engagement; and heard from children and their families to understand what makes it difficult to grow up with a healthy weight in London.

4.7 The document sets out 10 aspirations which the Taskforce believe will impact on the child obesity epidemic in London, with a focus on the experience of London’s children and the environment in which they live. In summary the draft recommendations include:

1. Take action to reduce the number of children living in poverty in London. 2. Provide support to enable women to breastfeed for longer. 3. Build capacity and capability among professionals engaging with children in their earliest years to support children to maintain a healthy weight. 4. Utilise the National Child Measurement Programme (NCMP) to engage with parents as a ‘call to action’.

Page 119

5. Provide children with the opportunity to eat and drink healthily and be more active in learning settings. 6. Create more active, playful streets and spaces. 7. Offer free water everywhere. 8. Make London a 'Child Manipulation Free' city (through reducing exposure to advertising). 9. Transform food on offer in takeaways and out of home. 10. Fund 'Good Food' innovation and entrepreneurs in London.

The action plan will be published in September and detail on implementation is in development with partners. The findings of their initial engagement and research will be made publicly available over the summer. The Taskforce are actively involved in the development of the child obesity elements of the London Vision to support alignment.

5. Next steps

5.1 There will be a London HIS one year on event/session aligned with the annual LHB conference on the 2 October 2019. The Board is asked to share views on how this opportunity could best be used to further mobilise action in London to address health inequalities.

Appendices:

• Appendix 1 - HIS: Update on KPIs

Page 120

Appendix 1 - HIS: Update on KPIs

KPI Update (June 2019) Healthy Children: By 2020, A Since its launch in October 2018: minimum of 10% of London’s early years registered settings (approx. • 32 (97%) London Boroughs have confirmed or 1330) signed up to Healthy Early committing local HEYL resource. Years London (with a potential • 16/17 (94%) priority boroughs are confirmed or increase to 15% pending evaluation). committing local resource for HEYL. All 17 “priority” boroughs provide local • 1190 (89% of target) settings registered on the HEYL support for HEYL. website, of these: • 789 (66%) with HEYL First Steps award; • 83 (11%) HEYL Bronze award; • 33 (4%) HEYL Silver award; and • 3 (1%) HEYL Gold Award. Healthy Minds: By 2021, every state Over 100 instructors have been trained. school in London will have access to a 70 courses, attended by over 1,000 teachers and school trained mental health first aider, staff, have been delivered. including: A further 30 courses are being arranged from •100 youth mental health first aid September. trainers trained in 18/19 (recruited from local authorities and through the HSL network); and •2000 school staff and peer mentors trained in 18/19, focussing on secondary schools Healthy Places: By 2050, London will The Mayor launched the Ultra Low Emission Zone have the best air quality of any major (ULEZ) in central London on 8 April 2019. From 2021 the world city, going beyond the legal emission standards will apply to Inner London – covering requirements to protect human health a population of 3.8 million people. The ULEZ has the and minimise inequalities. strictest emission standards of any major global city and will be the largest zone of its type in Europe. In its first month of operation, the compliance rate with the ULEZ standards (on ‘typical’ days) was around 74 per cent in a 24-hour period. Compared to March, there were around 9,400 fewer older, more polluting, non- compliant vehicles seen in the zone on an average day since the start of the scheme. There has been approximately a 20% in nitrogen dioxide concentrations measured at roadside monitoring sites in the ULEZ zone since February 2017 when people started preparing for the T-charge and ULEZ.

Healthy Communities: By 2028, The London Vision for Social Prescribing was published social prescribing will be available for in June 2019. It was developed in partnership, led by the most vulnerable Londoners GLA and HLP, but with input from across sectors – including the VCS, and working closely with the NHS and local authorities.

Page 121

The Vision outlines three priorities for London in order to enable social prescribing to grow in the capital over the next 10 years. It focuses on three key areas for action: o Developing the social prescribing workforce development; o Supporting the VCSE sector; and o Improving digital connectedness. The Mayor continues to support social prescribing related activities in London through his many grant programmes – such as the Young Londoners Fund, Sports Unites, Culture Seeds and the Greener City Fund. HLP is working with the five London STP areas to support and develop social prescribing pilots. Each STP will receive £100,000 to fund personalisation/social prescribing pilots. A workshop on the social prescribing was held with senior representatives from across NHS/CCGs, Local authorities and the VCS on the 26 June 2019. A number of ‘scene setting’ reports commissioned by GLA and HLP over the year were published. These were used to inform the Vision, and relate to the roles of housing associations; Local Authorities, VCS; and Digital. They also address evaluation approaches. Healthy Living: By 2041, all TfL have identified the actions they need to take forward Londoners will do at least two periods to help achieve this target in an active people plan. This of ten minutes of active travel each includes research to better understand their audience, as day (e.g. walking, cycling) they need well as joint-working with boroughs and NHS partners to to stay healthy, with efforts focussed support Londoners to be more physically active. on supporting the most inactive. TfL’s Healthy Streets Officers and Liveable Neighbourhoods programme will also support delivery of this target. The Walking Action Plan and Cycling Action Plan provide further details of the range of work being done to support Londoners to walk and cycle in London.

Page 122 Agenda Item 9

Date of meeting: 10 July 2019 Agenda item: 9 Title: London Health Board Conference Presented by: Stephen Waring, Head of Health Policy and Partnerships Author: Gus Wilson, LHB Secretariat Manager Cleared by Dr Nick Bowes, Mayoral Director, Policy Status: For noting Classification Public

1 Purpose of this paper

1.1 This paper sets out proposals for the London Health Board (LHB) conference and Health Inequalities Strategy (HIS) partnership celebration event being held at City Hall on 2 October 2019.

2 Recommendation(s)

2.1 The Board is asked:

2.1.1 to note and comment on the proposals and next steps; and

2.1.2 to note opportunities for involvement in the programme.

3 Context

3.1 The LHB has commited to holding an annual conference bringing together leaders from across health and care in London to build on partnership work towards London becoming the world’s healthiest global city.

3.2 The last conference took place on 25 October 2018 with the Mayor and Simon Stevens giving keynote addresses followed by panel discussions involving London Health Board members. Dr Vin Diwakar led an interactive session on system priorities the outputs of which have been fed into the emerging health and care vision.

3.3 Previous events have built on the London Health Commission’s Better Health for London report (2014) and Better Health for London One year on (2015) and the progress made against the 10 ambitions.

3.4 As well as showcasing progress and good practice in health and health care including the commitments in the HIS, the event is an opportunity for partners to commit to a renewed health and care vision and bold partnership action to work together to make London the world’s healthiest global city.

4 Aim and purpose

4.1 The LHB 2019 Conference is a partnership event convened and hosted by the Mayor as chair of the Board. LHB members will be invited to play key roles

Page 123

during the event. The aim of the conference is to launch London’s ambitious new vision for health and care and to showcase partnership achievements over the year since the launch of the London Health Inequalities Strategy.

4.2 The event will again be held at City Hall, with the Chamber available for plenary sessions, the ‘Map Area’ for a market place of information stalls and for networking and interaction and committee rooms for break-out/parallel workshop sessions.

4.3 The purpose of the event is to: • enthuse and motivate Londoners around health and health care and tackling health inequalities; and • secure commitment from partners to work together to become the world’s heathiest global city and the city where people receive the best healthcare, and to align around key priorities for action.

4.4 The detailed themes and objectives of the event are still being developed. One option under consideration is to give the event a similar structure to the vision which is based on a life course approach of Start, Live and Age Well and across primary, secondary and tertiary prevention plus enablers like estates, digital, workforce and devolution. It is intended that health inequalities will be threaded throughout the programme.

4.5 The programme will be designed to bring together partners around the priorities and shared commitments to action described within the London Health and Care Vision. The event will be designed to offer key roles for all LHB members and partners.The intention is to hold an interactive session in the morning focussed on achievements to date and further mobilising action on the Health Inequalities Startegy followed by the formal LHB conference programme from 2 pm.

4.6 Leaders will be invited from across health and care, local politicians, voluntary and community sector (see appendix 1). The event will be public facing and media will be invited to cover proceedings. The plenary sessions will be webcast live and archived on the GLA website.

4.7 A range of materials will be made available on the day including: • Press release highlighting key announcements will be issued in advance; • Publication: London’s Health and Care vision; • Publication: London’s Health Inequalities Strategy partnership achievements one year on from publication; and • Conference fringe and market place with partners from across London invited to showcase.

5 Next steps

5.1 Partners will collaborate to plan, resource and deliver the event which will be led by GLA Health Team reporting to Stephen Waring and Dawn Carrington, HLP Communications Director as joint SROs. A project team to support delivery will be established from across the partnership.

Appendices: • Appendix 1: Suggested invitation list. Page 124

Appendix 1: Suggested invitation list

Invitees will include: • LHB members; • SPB members; • Council leaders; • London Councils; • Local Authority Chief Executives; • London Assembly members; • NHSE & I (London region); • Clinical Commissioning Group Chairs and Chief Officers; • STP leads; • Public Health England (London region); • Staff associations/ Trades Unions; • Health Education England; • Clinical Senate; • Think tanks (1 rep from IPPR, King’s Fund, Nuffield, Health Foundation); • Partner communication leads; • ADASS; • Directors of Public Health; • Thrive LDN Champions; • GLA; • London Estates Board members; • Acute and MH Trust CEs; • London wide Local Medical Committees; • Mental health leads; • Charity Chief Executives; • Directors of Children’s services; Business leaders; • Media; • Academic Health Science Networks; • London Child Obesity Taskforce; • Violence Reduction Unit; and • TfL, Police, London Fire Brigade.

We would expect an audience of c.200-250 key stakeholders on the day. All will be invited to attend the whole event.

Page 125 This page is intentionally left blank Agenda Item 10a

Date of meeting: 10 July 2019 Agenda item: 10a Title: Children and Young People’s Mental Health – Mental Health in Schools Author: Andy Martin, Programme Manager (CYP), Healthy London Partnership Beth McGeever, Programme Manager (CYPMH), NHS England and NHS Improvement (London region) Cleared by Professor Oliver Shanley, Regional Chief Nurse, NHS England and NHS Improvement (London region) Status: For noting Classification Public

1 Purpose of this paper

1.1 The purpose of this paper is to: • Provide an overview of progress for the London’s year one trailblazer areas; • Update on the next steps for the implementation of future waves of trailblazer areas in London; and • Update on Healthy London Partnership’s mental health in schools project including the mental health in schools toolkit.

2 Recommendation(s)

2.1 The Board is asked to note the progress being made in London to implement the ambitions of the children and young people’s mental health green paper and the Healthy London Partnership mental health in schools project.

3 Context

3.1 There is a children and young people’s mental health transformation programme being undertaken across London. The ambition for this transformation is set within Future in Mind (2015) and the NHS Five Year Forward View for Mental Health (2016). A subset of the transformation programme is focusing on mental health in schools.

3.2 In July 2018 the Government published its response to the consultation on the Green Paper ‘Transforming Children and Young People’s Mental Health’. The Green Paper had three core proposals: • A designated senior lead for mental health in all schools to oversee the approach to mental health and wellbeing. • Funding for mental health support teams, supervised by CAMHS staff, to provide extra capacity for early intervention and on-going help across groups of schools and colleges. • Piloting a four-week waiting time target for NHS CAMHS services.

Page 127

3.3 It was confirmed that these three proposals would be trialled in trailblazer areas with the first wave to be operational by the end of 2019.

3.4 The NHS Long Term Plan further strengthens the Government’s commitment to improving children and young people’s mental health services and enabling appropriate support for children and young people when they need it. An important element of this wider commitment is that over the next five years the NHS will fund new Mental Health Support Teams (MHSTs) working in schools and colleges to be rolled out to between 20% and 25% of the country by the end of 2023.

4 Implementing the ambitions of the Children and Young People’s Mental Health Green Paper in London

4.1 The London Region was allocated a fixed envelope of funding1 to deliver mental health support teams and pilot four week waiting time pilots in 2018/19 and 2019/20. CCGs which met a set of nationally defined pre-selection crtieria were invited to submit Expressions of Interest to become a year one trailblazer area. A total of 18 Expressions of Interest applications were submitted to the NHS England (London) regional team for review.

4.2 On 20 December 2018 the Department of Health and Social Care and Department for Education announced that there would be 25 trailblazer areas nationally in the first wave. London secured seven trailblazer areas, with at least one in each Sustainability and Transformation Partnership (STP) area. This equates to a total of 15 mental health support teams across London. London’s trailblazer areas are currently establishing the full complement of workforce and beginning to offer services to a selection of education settings, with the expectation that all teams will be fully operational by December 2019.

Number of education Four week waiting Number of MHSTs Trailblazer area and CCGs covered settings covered time pilot Bromley CCG 2 46 Yes Camden CCG 2 32 Yes Haringey CCG 2 36 Yes Hounslow CCG 2 20 No South London Health and Care Partnership 3 44 No (Merton, Wandsworth and Sutton CCGs) Tower Hamlets CCG 2 27 Yes West London CCG 2 30 No Total 15 235

1 London has been awarded £7,411,294 across 2018/19 and 2019/20 to support the roll out of 15 Mental Health Support Teams across seven areas, four of which are also piloting a a four week waiting time standard for access to children and young people’s mental health services.

Page 128

4.3 MHSTs have three key functions in education settings: • Delivering evidence based interventions for mild to moderate mental health issues. • Supporting the senior mental health lead in each education setting to introduce or develop a whole school or college approach to mental health and wellbeing. • Giving timely advice to school and college staff, and liaising with external specialist services, to help children and young people get the right support and stay in education.

4.4 It is important to note that the MHSTs are designed to augment the existing arrangements provided by and for schools, not to replace them. The baseline mapping report (section 5.6) undertaken through the Mental Health in Schools Project (Healthy London Partnership) assists in an understanding of the current services available.

4.5 MHSTs are comprised of Education Mental Health Practitioners (EMHPs), who complete a one year full time university course covering six modules. The course has been specifically designed to ensure that a large pool of potential learners are able to apply from both health and educational settings.

4.6 Higher level therapists supervise the EMHPs and more complex cases, supporting the whole school approach and evidence based interventions at individual level and for group work. They will receive specific supervisor training to provide support to EMHPs during and after their training programme.

4.7 Four trailblazer areas in London are testing approaches that could feasibly deliver four-week waiting times for access to NHS support, ahead of introducing new national waiting time standards for all children and young people who need specialist mental health services.

Governance 4.8 The London Region has established a joint programme, working alongside the Department for Education, Health Education England and Healthy London Partnership’s Children and Young People’s Mental Health Improvement Team to work with trailblazer areas to monitor and support implementation, and share learning across London.

2019/20 Trailblazer waves 4.9 In 2019/20, two further waves of mental health support teams will be established; with two cohorts of Education Mental Health Practitioners (EMHPs) commencing training in September 2019 and January 2020. For these further two waves of trailblazer areas, MHSTs will be fully operational in these areas in September 2020 and January 2021.

4.10 As part of the the 2019/20 selection process, specific consideration will be given to ensuring that mental health support teams are focussing on addressing a range of health inequalities across London.

Page 129

5 Healthy London Partnership Mental Health in Schools Project

5.1 During 2018 the Healthy London Partnership in collaboration with the Greater London Authority, established a Mental Health in Schools Project. Three resources were developed during this project and were published in November 2018. An overview of these resources is provided in sections 5.2, 5.6 and 5.10 of this report.

Mental health in schools toolkit

5.2 The toolkit, available on the Healthy London Partnersip website and via a link on the Healthy Schools (London) website, provides a wide range of information and guidance, for school leaders and staff, governing bodies, health care professionals and commissioners in health and Local Authorities, on how to promote emotional wellbeing and mental health within schools. The toolkit builds on existing materials available to schools and commissioners as well as outlining some of the new initiatives taking place across London.

5.3 A professional reference group was established to provide consultation on the development of the toolkit. The group included senior school staff, voluntary agency representatives, educational psychologists, CCG commissioners and local authority education staff.

5.4 The toolkit was publicised via: • a letter from the Mayor of London to all London schools; • a letter from Professor Oliver Shanley to all school nursing services; • the London Councils eBulletin; and • Healthy London Partnership communications.

Since publication of the toolkit there have been over 13,000 page views (as at April 2019).

5.5 Healthy London Partnership will continue to refresh and keep the toolkit up to date, including the availability of suitable mental health apps.

Baseline mapping report

5.6 The baseline mapping report provides an overview of the findings from a survey and mapping exercise, undertaken from May to August 2018, to support better understanding of current provision across London. This was undertaken across the three key organisations engaged in local transformation planning: • Clinical Commissioning Groups (CCGs). • Local Authorities, (through Directors of Children’s Services). • NHS Mental Health Provider Trusts.

5.7 The survey format was different for each of these organisations to reflect their distinct roles. Responses were received from 27 out of 33 local authority areas, a return rate of 82%. The extent and detail included means that there is a significant advance in the information available on what activity is taking place within schools.

Page 130

5.8 Key findings include: • In the majority of areas that submitted a response, there is evidence of a considerable range of activity to support emotional wellbeing and mental health within schools. • The nature of this activity varies considerably between boroughs. There are a wide range of initiatives, sometimes within the same geographical area. • There is a variation in the level of knowledge and awareness of services provided and commissioned by schools within the CCG and Local Authority. • The commissioning arrangements remain complex, particularly at the lower ranges of intervention. • Many initiatives are at early stages in their evaluation of effectiveness. • There is limited data about the numbers of CYP who are currently accessing services through schools and colleges.

5.9 A self assessment tool for CCGs to measure their progress in developing services through the children and young people’s mental health local transformation plan and their oversight through Health and Wellbeing Boards has been developed and is included on the mental health in schools toolkit.

Insights on young people’s perspectives on school mental health support in London

5.10 Young Minds, via their Amplified programme, were commissioned through the Healthy London Partnership to undertake a consultation exercise regarding what support young people want to be able to access in schools. The exercise involved a review of any existing consultations that had taken place with young people regarding the support they feel would be most helpful within schools.

5.11 A consultation event was held in July 2018 with young people from across London refining these messages. The report provides an overview of this process and the ten key messages provided by young people, summarised below: • Every pupil knows who is responsible for and can help with mental health issues. • Every adult in the school offers a good first response if I say or show I am struggling with my mental health. • Bullying is dealt with effectively. • Empower us to understand and take a role in caring for our mental health. • Extra support for pupils that are struggling. • Emotional and practical support during busy, stressful times. • A place to go on hard days. • Signposting to support in our area and beyond. • Pupil involvement in making the school more mentally healthy. • Recognising us as individuals.

Page 131

6 Next steps

6.1 The London Region expects to confirm London’s 2019/20 Trailblazer areas in early July 2019.

6.2 Healthy London Partnership through the continuation of their mental health in schools project will refresh and keep the toolkit up to date.

Appendices:

None.

Page 132 Agenda Item 10b

Date of meeting: 10 July 2019 Agenda item: 10b Title: Learning Disability Mortality Review Programme Author: Jemma Sharples (Learning Disability Nurse Advisor) and Emily Handley (LeDeR Regional Coordinator) Cleared by Professor Oliver Shanley OBE Status: For noting Classification Public

1 Purpose of this paper

1.1 This paper updates the London Health Board on the Learning Disability Mortality Review Programme (LeDeR).

2 Recommendation(s)

2.1 The Board is asked to note this paper and support the work underway.

3 Context

3.1 The LeDeR Programme is delivered by the University of Bristol. It is commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England. Work on the LeDeR programme commenced in June 2015. A key part of the LeDeR programme is to support local areas in England to review the deaths of people with learning disabilities aged four years and over and implement service improvements in response to the learning. It has been a requirement in London to review all eligible deaths since 1 May 2017.

3.2 The NHS long term plan sets out the priorities for the NHS for the coming 10 years. This includes a specific focus on the needs of people with a learning disability, autism or both. A key commitment is to reducing the premature mortality of people with a learning disability and continued funding for the LeDeR Programme.

4 The LeDeR Annual Report 2019

4.1 The third LeDeR annual report was published on the 21 May 2019. From 1 July 2016 - 31 December 2018, 4,302 ‘in scope’ deaths have been notified to the programme across England. https://www.hqip.org.uk/wp- content/uploads/2019/05/LeDeR-Annual-Report-Final-21-May-2019.pdf

4.2 The median age at death for people with learning disabilities (aged 4 years and over) who died from 1 April 2017-31 December 2018 was 59 years. For males it was 60 years; for females 59 years. The updated data suggests a disparity in the age at death for people with learning disabilities (aged 4 years and over) and the general population (all ages) to be 23 years for males and 27 years for females.

Page 133

4.3 There was a rise in deaths through autumn and early winter. Over a third (37%) of people who died from aspiration pneumonia did so between October – December.

4.4 The majority (79%) of ‘Do not attempt Cardio Pulmonary Resucitation’ (DNACPR) orders were appropriate, and correctly completed and followed. However, 19 reviews reported that the term ‘learning disabilities’ or ‘Down’s syndrome’ was given as the rationale for the DNACPR order.

4.5 The medical conditions most frequently cited anywhere in Part I of the Medical Certificate of Cause of Death were: pneumonia (25%), aspiration pneumonia (16%), sepsis (7%), dementia (syndrome) (6%), ischaemic heart disease (6%) and epilepsy (5%).

4.6 A third (33%) of reviews reported one or more examples of best practice. These were frequently in relation to:

• Strong, effective inter-agency working. • Person-centred care. • End-of-life care.

4.7 One in ten reviews (11%) noted that concerns had been raised about the person’s death. These were commonly in relation to:

• Delays in diagnosing and treating illness. • The quality of health and social care received by the person.

4.8 The report made 12 key recommendations which are targeted at a national level, however, in London we recognise that there is much that should and can be done at a local level to reflect on the learning coming out of the reviews and translate this into actions for improvements (Appendix 1).

Page 134

5 Key Statistics

5.1 LeDeR Performance Data - National Picture

% completed reviews nationally: 32% % reviews unallocated to a reviewer nationally: 37%

5.2 LeDeR Performance Data - London Picture

% completed reviews in London: 47% % reviews unallocated to a reviewer in London: 15% Page 135

5.3 The London region has a higher percentage of completed LeDeR reviews than nationally and a lower percentage of reviews awaiting allocation to a reviewer. There is, however, further work required to address the outstanding cases. The action plan below sets out how this will be addressed.

6 London Strategy

6.1 In London we are proactively engaging with the STPs and CCGs to address key issues with the delivery of the LeDeR Programme. We have an overview group in place, with membership that includes people with lived experience, which meets regularly to coordinate this work.

6.2 In 2018/19 the main focus in London was on: • Increasing the number of reviewers trained in London. • Monitoring and assurance on the number of allocated and completed reviews. • Supporting learning events. • Procurement of an independent company to complete 35 reviews in London. • Supporting areas to unblock information sharing barriers.

6.3 In 2019/20 the main focus will be: • Development of a GP Learning Disability Network, to increase engagement in primary care. • Supporting the National Learning Disability Programme to review and put a programme of work in place reduce the number of outstanding reviews. • Work with the London Safeguarding Adults Board ensuring enhanced alignment with safeguarding processes. • Assuring that CCGs have a robust plan in place to ensure that LeDeR reviews are undertaken within six months of the notification of death to the local area. • Assuring that CCGs have systems in place to analyse and address the themes and recommendations from completed LeDeR reviews. • Working with NHS England and NHS Improvement Clinical Networks to ensure support to meet the needs of people with Learning Disabilities is embedded within their programmes of work. • Supporting the development of learning and improvement initiatives in London.

7 Service Improvments

7.1 One of the LeDeR programme’s primary aims is to make sure that local learning from completed LeDeR reviews leads to prompt service improvements in local areas. Significant service changes across London have been implemented to date, to support people with a learning disability to live longer, healthier lives.

Page 136

Primary Care

Case Study 1 Camden CCG planned and funded a training session for GPs on the Mental Capacity Act, to improve their knowledge, skills and confidence when using the act. The session also promoted the use of a new template within GP record systems, to further support GP’s in writing up capacity assessments, best interests decisions, powers of attorney and deputyships.

Case Study 2 NHS Kingston and Richmond Clinical Commissioning Group working with Richmond Mencap and NHS England, produced a video for GPs and their teams about making the quality of care better for people with a learning disability and how they can help to reduce health inequalities. This has been shared with GP surgeries across England and is available here: www.youtube.com/watch?v=ZLn4qEM5X4c

Secondary Care

Case Study 1 Circle of Support meetings involving a learning disability liaison nurse and the patient’s circle of support, have been introduced by the London North West Healthcare NHS Trust for anyone with a learning disability, autism or both admitted for more than five days. This means that the person’s progress can be reviewed, treatment can be planned, and the right kind of support is in place before the person goes home. It also makes sure that people do not stay in hospital any longer than is necessary.

Case Study 2 Kingston Hospital has set up an Acute Care learning disability collaborative to improve access and support for people with a learning disability when they attend and are discharged from hospital. The work includes improved identification of people with a learning disability and brings together a range of local knowledge to support better care and resolve local issues.

8 Next steps

8.1 Work planned for 19/20 is included in section 6 above.

8.2 An additional £5m will be invested nationally by NHS England and NHS Improvement in 2019/2020 to address the unreviewed cases and increase the pace with which reviews are allocated and completed. The money will be invested in developing a dedicated workforce to undertake reviews and develop systems and processes to embed mortality review and quality improvement activity across the health and social care system.

Appendices:

• Appendix 1: Learning Disability Mortality Review Programme, Annual Report, May 2019, recommendations. Page 137

Appendix 1: Learning Disability Mortality Review Programme, Annual Report, May 2019, recommendations.

Page 138