1. Chief Executive S Introduction 5

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Commissioning Strategy Plan 2007/8-2011/12

PCT Name: Enfield Date 22 February 2008

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PCT details 1 1. Chief Executive’s introduction 5 2. Vision 7 3. Context 10 3.1. Population demographics 10 3.2. Population health needs 20 3.3. Existing models of care 23 3.4. Quality, health outcomes, and inequalities 25 3.5. Other challenges within the local health economy 33 3.6. Existing targets and national priorities 33

3.7. Provider Landscape 37

3.8. Financial situation 42 3.9. Activity Commissioned 45 3.10. Internal capabilities 48 4. Goals 52 5. Initiatives 60 5.1. Description and prioritisation against health outcomes, inequalities and strategic goals 62 5.2. Initiative capital requirements 62 5.3. Impact of initiative on quality and outcomes 62 5.4. Impact of initiative on activity levels 62 5.5. Impact of initiative on commissioning cost 62 5.6. Stakeholder engagement and risk 63 6. Overall Impact 64 6.1. Impact on quality, health outcomes, and inequalities 64 6.2. Impact on activity 66 6.3. Impact on provider landscape 67 6.4. Impact on finance 68 7. Implementation and monitoring 71 8. Declarations 78 8.1. Board statements 78 9. Annex – Further details of planned initiatives 79 9.1. Impact of initiative on commissioning cost 79 9.2. Initiative capital requirements 81

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9.3. Impact of initiative on activity levels 82 PCT details PCT name

Enfield PCT Holbrook House, Cockfosters Road, Barnet, Herts, EN4 ODR

Key contact at PCT (name, contact details)

Stephen Conroy, Deputy Chief Executive [email protected] Tel no: 020 8370 8134

Commissioning Strategy Plan date

November 2007

Document Control

Author/Editor Gail Hawksworth, Strategic and Operational Planning Manager

Owner/s Stephen Conroy, Deputy Chief Executive

File Ref Commissioning Strategy Plan 2007

Approver Role

Carolyn Berkeley Chairman

Tracey Baldwin Corporate Chief Executive

Stephen Conroy Deputy Chief Executive

Change History

Version Date Author/Editor Summary of Change

Draft Version 1 11 June 2007 Gail Hawksworth First working draft (with omissions)

Draft Version 2 27 June 2007 Glen Stewart Health Improvement sections completed

Draft Version 3 20 July 2007 Liz Wise and Gail Further amendments made throughout Hawksworth the document

Draft Version 4 3 August 2007 Liz Wise Further amendments made throughout the document, including goals and initiatives

Draft Version 7 17 September 2007 Liz Wise and Gail Further amendments made throughout Hawksworth the document following NHS London’s comments on 9 August 2007 and

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further comments from stakeholders.

Draft Version 8 19 September 2007 Liz Wise and Gail Further amendments made throughout Hawksworth the document following comments from stakeholders

Draft version 9 25 September 2007 Liz Wise and Glen Further amendment to health needs Stewart and equalities

Draft version 10 4 October 2007 Liz Wise and Gail Further amendments made throughout Hawksworth the document following comments from stakeholders

Final Draft 30 November 2007 Stephen Conroy and Gail Further amendments made throughout Hawksworth the document following Board approval of ‘Enfield PCT- getting health and healthcare right for the future’ the PCT’s operating plan

Final Draft 10 December 2007 Stephen Conroy and Gail Further amendments made throughout Hawksworth the document following comments received from NHS London

Resubmitted Final 20 February 2008 Stephen Conroy and Gail Further amendments made throughout Draft 22.02.08 Hawksworth the document following comments received from NHS London in January 2008.

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1. Chief Executive’s introduction

Chief Executive’s introduction

Enfield’s Commissioning Strategy Plan (CSP) sets out the vision, key objectives and initiatives that will deliver our goals over the next five years. The CSP is designed to give our local population, staff, partners and other key stakeholders a clear view of our Strategic Direction. The document also describes briefly our achievements to date. Enfield has a population of 289,604, with good transport links into central London. The Borough is very diverse, having more open green spaces in the north and more dense urban environments particularly in the south east.

Our population is relatively young, diverse in terms of socioeconomic factors and ethnicity. The population will become more diverse as the proportionate size the “white” population falls and other populations grow. Identifying the health needs of these population will be ongoing so as to be able to cater appropriately for their needs.

Our Vision (section 2) states how we intend to improve health and health care for the Enfield population and the document goes on to describe the goals and initiatives that will deliver our Vision. To address health and health inequalities, the PCT works closely with the London Borough of Enfield and has developed a robust Local Area Agreement that clearly identified the joint priorities to improve the health of the population. The development of our Commissioning Strategy Plan (CSP) is timely as we are revising with our partners in Local Government and the other statutory Authorities the targets within the new Local Area Agreement, ‘Working Better Together Transforming the delivery of Health Care Across the Children & Young People Partnership for Health Strategic Plan 2007-2010’. In terms of health services, the PCT primarily buys services from NHS providers and others to deliver healthcare to our population (our own provider unit manages a number of community services including community nursing, children’s services and a range of therapies and some specialist services). To improve the quality of health care services, the PCT is working with Barnet PCT, Haringey PCT, GPs, London Borough of Enfield, Barnet and Chase Farm Hospitals; North Middlesex University Hospital to develop a local clinical strategy to improve health services. The conclusion of the consultation ‘Your Health, Your Future’ clinical strategy across Barnet, Enfield and Haringey (BEH), our own primary care strategy, the recommendations in the White paper ‘Our Health, Our Care, Our Say’ and the forth coming London Health strategy provide the context for changes to the health services. Within this context we have developed a vision that meets the needs of patients and the public given changing lifestyles, new technology, advanced treatment and new and emerging diseases.

The PCT is also working with North Central London Sector partners, through working groups and networks that are overseen by NCLCG to develop the four agreed initiatives in the phased approach to improving healthcare locally.

Following a period of time in which Enfield PCT was ‘Turnaround’, we are now creating an accelerated development programme for our commissioning and provider teams in order to develop the organisations capability to deliver our vision. For 2007/2008, we have a budget of £368.1m, which we allocate to secondary care (acute hospitals), primary care (GPs, dentists, pharmacists, optometrists etc) mental health, prescribing drugs and improving the public health of our population. We have ambitious plans for our population, and the PCT’s commitment is to invest £10M in new primary care services over the next 5 years. But we are currently consuming more resources than we can afford evidenced by an overspend in 06/07 of £13m and an improved situation, but still forecasting a £10m overspend in 2007/08. We have an underlying debt of some £16m. In addition we are forecasting demographic and population changes that will also place pressures on resources. We therefore need to plan and secure services to achieve our stated goals and manage within our allocated resources. This Plan will allow us to match our monthly income with our monthly expenditure by the end of 2008/09 (called run rate balance). We aim to pay off our accumulated historic debt by the end of 2010/11.

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The PCT has considered the setting of its goals carefully, taking into account our local needs and service gaps, our partnership commitment to the LAA, DAAT and Children’s Trust development; the BEH Clinical Strategy and the emerging Healthcare for London Strategy. The PCT also has to deliver financial recovery and make rapid progress towards world class commissioning. At this point in time, the identification of our goals is heavily influenced by the PCT’s financial position. We have therefore focussed on examining ourselves against national benchmarks and best practice to identify where we can be more efficient. We have measured ourselves against the NHS indicator scorecard to see where our performance could improve against best practice in setting our Goals. We have also used the national programme budgeting data to see whether we spend disproportionately more on some areas than in others. This data, although still imperfect identifies that we are not outliers in any areas and so need to make reductions in spend across all areas of health provision rather than targeting any area specifically.

The BEH Clinical Strategy should be the main clinical driver for change in coming years and is nearing the end of the consultation period, and dependent on the outcome of the consultation in the New Year, the PCT would want to review its CSP during 2008/09 in the light on the outcome of the consultation. This will give us opportunity to take account of the emerging framework for World Class Commissioning, and if our medium term financial plan is accepted, then the PCT can be more ambitious in its plans to transform local health care services and improve health.

Having measured ourselves, researched best practice nationally and internationally we have identified six Goals that we must address:

1. Planned (Non urgent) care 2. Urgent care 3. Contracting and Procurement 4. Evidence Based Commissioning (including Prescribing) 5. Community and Specialist Services (including our Provider Division) 6. Staying Healthy- working with our partners

Each of these goals is supported by a series of initiatives that will deliver against our goals and move us towards our stated vision. We will work with our partners in general practice, community services, Barnet & Chase Farm and North Middlesex University Hospitals and the London Borough of Enfield to ensure that by focusing on these 6 goals we will dramatically improve health services for Enfield residents and free up wasted resources that could then be used to accelerate local improvements.

General Practice has an important role in delivering many of these improvement areas. General Practice and their primary care teams must rise to the challenges of integration, standardisation, equality and diversity, flexibility and responsiveness to local needs.

We continue to work with the PPI Forum, Overview and Scrutiny Committee, PBCs and other local providers and we will ensure that Patient and Public involvement is embedded in the detailed planning. The PCT will be carrying out health impact assessments for these changes and we are committed to involving our stakeholders as this work progresses.

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2. Vision

PCT’s vision Background

Enfield’s overall population is expected to be static with significant increase in those aged 45 – 65 years with an impact on increase in long-term conditions.

The “non white” population is expected to increase significantly particularly those who classify themselves as Black Africans, Chinese, Greek/Turkish and Kurdish communities with an impact on particular diseases such as diabetes, heart disease, stroke and sickle cell and also use of health services in the borough

Residents of Enfield have an above average life expectancy but our aim is to ensure that all residents have relatively good quality of life no matter which part of the borough they live in.

Adverse trends in health behaviours such as smoking and the rising prevalence of obesity, alcohol misuse and physical inactivity, which if unchecked, will lead to a marked increase in the burden of ill health

The gap in life expectancy particularly between men and women and men living in wards in Southgate compared to Edmonton.

The picture of health needs outlined above provide the clear reason for change that is needed in Enfield and this will be achieved through the implementation of this 5 year strategic commissioning plan and the PCT primary care strategy, the targets within the Local Area Agreement, and the changes agreed following the consultation “Your health, Your Future clinical strategy across Barnet, Enfield and Haringey.,

Enfield has:

 The fifth highest age standardised admission rate

 Exceeds the London Average on mortality from diabetes  Fifth lowest QOF scoring points for Coronary Heart Disease compared to London Boroughs.

Vision:

We are committed to providing high quality patient-centred care and enabling people in Enfield to lead longer and healthier lives and have access to excellent services. Our vision is:

“ We will improve the health and well being of our population by purchasing services and leading partnerships that deliver:"

Health and Well Being:

1. Prevent avoidable ill health, reduce health inequalities, promote healthy communities

2. Integrate care and partnership working (between health and social care, for example) to maximise the contribution of the entire workforce

Best Quality of Care

3. Bring care closer to home when appropriate (but having the right specialist services available in hospitals) to ensure that people get effective, timely and appropriate healthcare when they are sick

4. Provide the best quality care pathway in line with evidence based care, and improve the patient experience maintain high standards for all services.

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5. Enable local people to have a greater voice in determining the pattern of health services planned and purchased and increasing the ability of people to manage their own care.

6. Integrate care maximising workforce contribution

Value for All

7. By ensuring the best use of every pound invested in us by the tax payer and manage within the total financial resources available to us, for example effective use of workforce and buildings productively

8. Achieve Financial balance for the PCT and sustained financial stability for the local health economy.

Other Strategic Plans that will contribute to the vision:

Related strategic plans that are central to delivering the changes are:

 The North Central London Collaborative Commissioning Plan

 The BEH Clinical Strategy

 Care Closer to Home Making it Happen- A strategic Framework – joint strategic framework with LBE

 Primary care investment plan to be consulted on March 2008

 Every Child Really Does Matter - Enfield’s Local Area Agreement

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3. Context

3.1. Population demographics

Projected demographic trends commentary

3.1 Overall population:

Enfield is the most northern of London boroughs with a population of approximately 289, 604 although the number of people registered with a GP is currently 288,751. Numerically Enfield’s overall population is expected to remain relatively static in the next 5 years to 2012 with an expected overall increase of only 0.85% to 2012 from GLA population projections of 2006.

The ratio of males to females is also expected to remain relatively static falling from 48.47: 51.53 in 2006 to 48.29: 51.71 in 2012. This though hides significant change within the demographics of the borough. Whilst persons aged 15-44, 64-75 and 75+ all fall by approximately 2% the number of persons aged 45-64 is expected to rise by >8%. This represents a fall in the often healthy population (15-44) of 2065, a fall in persons 64+ of 902 and an increase in the number of people who are likely to require long term interventions (45-64) of 5237. This is likely to impact significantly upon the health economy. Therefore, in order to support the delivery of healthcare, we will take into account the following:

 The changing age profile of the population

 The geographical areas in which the population growth is expected and the link to deprivation

 Ethnic make-up of the population

Life Expectancy, mortality and main causes of deaths

On average male life expectancy is approximately 77.0 years with the highest in Grange ward (81.2) and the lowest in Edmonton Green (72.7), a difference of 8.5 years. The average male life expectancy in London is 76.4 years. The Major cause of deaths between 2002 and 2006 for males was malignant neoplasms (cancers) with cardiovascular disease being second biggest killer.

On average female life expectancy is 81.3 years with the highest in Highlands ward (86.2) and lowest in Upper Edmonton (77.8), a difference of 8.4 years. The average female life expectancy in London is 81.2 years. The Major cause of deaths between 2002 and 2006 for females was cardiovascular disease with cancers being the second biggest killer.

(Source London Health Observatory: Life Expectancy data 2001-2005)

An analysis of the rate of all causes of deaths in Enfield for those aged less than 75 years shows that Enfield has a lower rate of deaths than England.

In Enfield between 2003 and 2005 the infant mortality rate was 6.7 per 1000 live births. This is higher than the London rate of 5.2/1000 live births in the same period. The majority of infant deaths can be attributed to events occurring in pregnancy (immaturity at birth, congenital anomalies, ante and intrapartum conditions).

Immaturity at birth related conditions contribute to around 37% of infant deaths. All Cause Mortality (SMR): Under 75 years 2000-2004 is given below:

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80.0 R M

S 60.0

e n l k s y t k e e y D n g rs w s te il r n e r y e c s n e r n d n L e n e o d a a e w u a re o a o il u o n e e a t n g H P e o lb w t L h t b b t E e IE r r s T la th e l r e h S C n u th n s r F G G fo h u r il G B s g ld o J u o r G N s k g o o H a i ey e m o m e r c i m te H k fi d S d d n E e o H S h h a H d r n E E n to m C c s g l u E o n l in u th ie T er er P o a B u f p m P W o n w p d S E Lo U E

Source: London Health Observatory www.lho.org.uk

Major Causes of Death in Enfield for Men and Women, April 2002-March 2006

Male Female

Number % Number %

Injuries 124 2.9% 45 0.9%

Cardiovascular Disease 1095 25.7% 1192 24.2%

Cerebrovascular Disease 447 10.5% 677 13.7%

Communicable Diseases 52 1.2% 49 1.0%

Diabetes 64 1.5% 39 0.8%

Disease of Digestive System 179 4.2% 181 3.7%

Disease of Nervous System 125 2.9% 150 3.0%

Cancers 1155 27.1% 1084 22.0%

Mental Health* 83 1.9% 187 3.8%

Respiratory Diseases 642 15.1% 872 17.7%

Other 291 6.8% 453 9.2%

All Deaths 4257 4929

Estimated Change in Prevalence of Key Diseases

The prevalence of some diseases in the population of Enfield is expected to change. Some long-term conditions/diseases in the table below will be affected by changes in the population age structure particularly affecting those aged 45- 65 years where a significant growth is expected in the next 5 years. The growth in these

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key diseases such as diabetes, chronic obstructive airways disease, coronary heart disease and hypertension will also be affected by changes in lifestyle and risk factors such as smoking and obesity and the effectiveness and extent of investment in medical interventions.

The table below indicates prevalence of key disease groups:

Expected incidence growth

Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 (Baseline)

Disease group 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 (Prevalence)

Cancer 13298 13317 13336 13355 13375 13394

COPD 12760 12750 12769 12815 12862 12909

Asthma 20682 20712 20742 20772 20802 20832

Diabetes (1 & 2) 14146 14450 14755 15060 15651 15959

CHD 12449 12467 12485 12503 12521 12539

Hypertension (treated 29821 29637 29510 29524 29595 29666 prevalence)

Renal Replacement 107 117 130 143 157 Therapy – new patients based on a 10% annual growth in demand.

Socio-economic Status

Enfield has tremendous socio-economic variation with affluent suburban areas in the west and high levels of disadvantage in the south and east1. Four of the eastern wards are amongst the top 10% most deprived wards in the country whilst 17% of the residents of Hadley Wood are millionaires. Overall Enfield is in the bottom third of most deprived districts in England and is ranked eighteenth out of 33 London boroughs for deprivation. The concentration of house building in the east of Enfield also places particular pressures on services in this area. The Index of Multiple Deprivation (IMD) scores vary from 42.51 (Edmonton Green) to 10.16 Grange (Enfield). Enfield is ranked within the worst 6% for overcrowding in England and Wales and 30% of Enfield children live in poverty. The distribution of the population in Enfield means that children and young people are more likely to live in disadvantaged areas than the population as a whole. The proportion of children entitled to free school meals has increased and this is now above the average nationally and for statistical neighbours for both primary and secondary phases. Sixty two per cent of Enfield’s school children are from black and minority ethnic communities, with 37% having English as an additional language.

Unemployment in Enfield

Unemployment varies by both ward and ethnicity with higher levels generally recorded in the southeast of the

1 Working Better Together Transforming the Delivery of Health Care Across the Children & Young People Partnership for health STRATEGIC PLAN 2007-2010

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borough and amongst black and minority ethnic populations. In 3 wards unemployment was over 7.5%; (Edmonton Green - 10.5%, Upper Edmonton – 8.5% and Ponders End – 7.9%). In the five years 2001-2006 Enfield had the highest percentage increase in income support claimants of any local authority (13.7%).

Enfield’s 2005 working age population was estimated at 178,000 (91,800 males and 86,200 females). Calendar year 2006 data shows 139,700 were economically active (79,300 males and 60,400 females). 43,800 were recorded as economically inactive (15,200 males, 28,600 females). By occupation, 49.1% were classified into Standard Occupation Classification (SOC) 2000 Major Groups 1 – 3 (managers and senior officials 28,900, 21.6%), Professional occupations 18,900, 14.2%) and Associate professional and technical 17,800, 13.3%). 30,700 were placed in SOC Major Group 4-5; Administrative and secretarial (20,600, 15.4%) and skilled trades occupations ((10,100, 7.6%). 17,800 were placed in SOC 2000 major group 6-7. Personal service occupation (8,900, 6.7%) and Sales and customer services (8,800, 6.6%). A further 19,100 were placed in SOC 2000 group 8-9; Process, plant and machine operatives (4,200, 3.2%) and elementary occupations (14,900, 11.2%).

Using the indicator advised by GoL for the measurement of worklessness (e.g. claimants as a percentage of the estimated population of working age) between May 05 and Feb O7 Enfield worklessness stood at between 16.8 and 17.3%. Long-term unemployment (e.g. unemployed for over a year) has remained relatively constant at between 16-18% of claimants (1005 – 1145 persons, June 2005 – June 2007)

The number of people claiming a state pension has remained stable for the past five years ranging from 41,610 in 2002 to 41,465 in 2006.

Ethnicity

Enfield is very ethnically mixed with state school pupils recording themselves under 87 different ethnicities. As ethnic and cultural background may have a profound effect on their health and well being, analysis of different groups living in Enfield enables a better understanding of the population we serve. It is vital that services are delivered in a culturally appropriate manner.

Currently 68% of the population is classified as ‘white’. It is expected that this will fall as Enfield becomes more ethnically diverse. The ‘White’ population is expected to fall by 4.41%, Black Caribbean to rise by 9.7%, Black African by 17.5%, Chinese by 21.6% and ‘Other’ by 28.9%. This will include Enfield’s large Greek, Turkish, Turkish-Cypriot and Kurdish population as well as more recent migration from Eastern Europe.

This is shown in more detail in the table titled “Projected demographic trends commentary.”

Expected population growth (to be completed if applicable)

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Population segment

Persons 0-14 55663 55,714 55689 55760 55832 55840

Persons 15- 44 132942 133,634 133179 132485 131664 130877

Persons 45- 64 62964 64,045 65030 66028 67177 68201

Persons 64-74 18941 18,687 18589 18579 18454 18420

Persons 75+ 17630 17,524 17385 17274 17237 17249

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Persons All 288140 289,604 289872 290126 290364 290587

Growth (%)

Persons 0-14 0.09 -0.04 0.13 0.13 0.01

Persons 15- 44 0.52 -0.34 -0.52 -0.62 -0.60

Persons 45- 64 1.72 1.54 1.53 1.74 1.52

Persons 64-74 -1.34 -0.52 -0.05 -0.67 -0.18

Persons 75+ -0.60 -0.79 -0.64 -0.21 0.07

Persons All 0.51 0.09 0.09 0.08 0.08

Compound growth rate 2007/08 – 2011/12 (%) Persons 0-14 0.32

Compound growth rate 2007/08 – 2011/12 (%) Persons 15-44 -1.55

Compound growth rate 2007/08 – 2011/12 (%) Persons 45-64 8.32

Compound growth rate 2007/08 – 2011/12 (%) Persons 64-75 -2.75

Compound growth rate 2007/08 – 2011/12 (%) Persons 75+ -2.16

Compound growth rate 2007/08 – 2011/12 (%) Persons All 0.85

Male Population: Numerically Enfield’s male population is expected to remain relatively static in the next 5 years to 2012 with an expected overall increase of only 0.47% to 2012 from GLA population projections of 2006. Again though this hides significant change within the demographics of the male population of the borough. The male population aged 15-44 is expected to fall by >2.6% (1731) and the number of males age 64-75 by just under 4.5% (399) whilst the male population aged 45-64 is expected to grow by >8% (2447). The number of males aged 75+ is likely to grow by >3% (205). These changes are likely to lead to a net gain on the demands upon the health economy.

These figures mask much greater change that is expected in the ethnicity of the borough (see section below). Expected population growth (to be completed if applicable)

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2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Population segment

Males 0-14 28179 28215 28238 28284 28312 28307

Males 15- 44 65480 65699 65322 64812 64276 63749

Males 45- 64 30380 30918 31351 31823 32346 32827

Males 64-74 8941 8752 8693 8674 8589 8542

Males 75+ 6691 6728 6743 6754 6811 6896

Males All 139671 140322 140347 140347 140334 140321

Growth (%)

Males 0-14 0.13 0.08 0.16 0.10 -0.02

Males 15- 44 0.33 -0.57 -0.78 -0.83 -0.82

Males 45- 64 1.77 1.40 1.51 1.64 1.49

Males 64-74 -2.11 -0.67 -0.22 -0.98 -0.55

Males 75+ 0.55 0.22 0.16 0.84 1.25

Males All 0.47 0.02 0.00 -0.01 -0.01

Compound growth rate 2007/08 – 2011/12 (%) Males 0-14 0.45

Compound growth rate 2007/08 – 2011/12 (%) Males 15-44 -2.64

Compound growth rate 2007/08 – 2011/12 (%) Males 45-64 8.05

Compound growth rate 2007/08 – 2011/12 (%) Males 64-75 -4.46

Compound growth rate 2007/08 – 2011/12 (%) Males 75+ 3.06

Compound growth rate 2007/08 – 2011/12 (%) Males All 0.47

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Female Population: Again, numerically Enfield’s female population is expected to remain relatively static in the next 5 years to 2012 with an expected overall increase of 1.21% to 2012 from GLA population projections of 2006. Similar demographic changes to the male population though are seen: there is small change of –0.50% in number of females of child-bearing age (15- 44) (a fall of 334), a fall in the number of females aged 64-74 just over 1% (-122) and a very small fall in the number of females aged 75+ of 0.05% (-586). Again however there is a rise in the population aged 45-64 of over 8.5%, this equating to an extra 2790 females, which will increase the need for interventions for long-term conditions.

These figures mask much greater change that is expected in the ethnicity of the borough (see section on population ethnicity).

Expected population growth (to be completed if applicable)

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Population segment

Females 0-14 27484 27499 27451 27476 27520 27533

Females 15- 44 67462 67935 67857 67673 67388 67128

Females 45- 64 32584 33127 33679 34205 34831 35374

Females 64-74 10000 9925 9896 9905 9865 9878

Females 75+ 10939 10796 10642 10520 10426 10353

Females All 148469 149282 149525 149779 150030 150266

Growth (%)

Females 0-14 0.05 -0.17 0.09 0.16 0.05

Females 15- 44 0.70 -0.11 -0.27 -0.42 -0.39

Females 45- 64 1.67 1.67 1.56 1.83 1.56

Females 64-74 -0.75 -0.29 0.09 -0.40 0.13

Females 75+ -1.31 -1.43 -1.15 -0.89 -0.70

Females All 0.55 0.16 0.17 0.17 0.16

Growth (%)

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Compound growth rate 2007/08 – 2011/12 (%) Females 0-14 0.18

Compound growth rate 2007/08 – 2011/12 (%) Females 15-44 -0.50

Compound growth rate 2007/08 – 2011/12 (%) Females 45-64 8.56

Compound growth rate 2007/08 – 2011/12 (%) Females 64-74 -1.22

Compound growth rate 2007/08 – 2011/12 (%) Females 75+ -0.05

Compound growth rate 2007/08 – 2011/12 (%) Females All 1.21

Population Ethnicity

There is expected to be significant change in the ethnic make-up of Enfield in the next 5 years. All ethnicities except “White” are expected to grow by over 7%. By contrast the White population is expected to fall by 4.41%. By contrast the ‘other’ population is expected to grow by >28% (2355), the Chinese population by >21% (637) and the Black African population by over 17% (3050). The ‘other’ population is likely to include the Turkish, Turkish- Cypriot and Kurdish community which is variously estimated at some 35,000 in Enfield but under census categories, is coded as ‘white, other’. Overall the ‘white’ population is expected to fall by 8937 whilst all other ethnic categories combined are expected to grow by 13.69% (10, 986). These changes are likely to be due to external factors such as immigration policy changes particularly recent policy changes for Eastern Europe. These changes have implications for health and healthcare interventions e.g. the Black African population is associated with certain health conditions such as sickle-cell, stroke and hypertension and the Turkish community with very high smoking prevalences (approximately 50%).

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Population segment (Ethnicity)

All Ethnicities 282,928 283,338 283,747 284,157 284,566 284,976

White 202,702 200,583 198,644 196,869 195,246 193,765

Black Caribbean 17,119 17,476 17,818 18,148 18,469 18,775

Black African 17,416 18,172 18,850 19,455 19,991 20,466

Black Other 7,032 7,225 7,398 7,561 7,712 7,857

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Indian 12,484 12,698 12,903 13,101 13,294 13,480

Pakistani 2,056 2,099 2,137 2,171 2,203 2,231

Bangladeshi 4,219 4,320 4,417 4,507 4,589 4,667

Chinese 2,956 3,098 3,233 3,360 3,480 3,593

Other Asian 8,782 8,973 9,154 9,323 9,480 9,626

Other 8,162 8,694 9,193 9,662 10,102 10,517

Growth (%)

All Ethnicities 0.14 0.14 0.14 0.14 0.14

White -1.05 -0.97 -0.89 -0.82 -0.76

Black Caribbean 2.09 1.96 1.85 1.77 1.66

Black African 4.34 3.73 3.21 2.75 2.38

Black Other 2.73 2.40 2.20 2.01 1.87

Indian 1.72 1.62 1.54 1.47 1.40

Pakistani 2.10 1.81 1.59 1.47 1.24

Bangladeshi 2.40 2.24 2.04 1.81 1.70

Chinese 4.80 4.35 3.93 3.58 3.26

Other Asian 2.18 2.01 1.84 1.69 1.54

Other 6.52 5.74 5.10 4.56 4.10

Growth (%)

All Ethnicities 0.72

White -4.41

Black Caribbean 9.67

Black African 17.51

Black Other 11.72

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Indian 7.98

Pakistani 8.48

Bangladeshi 10.61

Chinese 21.56

Other Asian 9.62

Other 28.86

IMD by Ward and Locality 2004

Ward SOA Score Locality Average

Bush Hill Edmonton Park 12.05

Edmonton Edmonton Green 42.51

Edmonton Haselbury 29.09

Edmonton Jubilee 26.25

Lower Edmonton Edmonton 30.34

Upper Edmonton Edmonton 36.57 29.47

Enfield North Chase 21.52

Enfield Enfield North Highway 27.40

Enfield North Enfield Lock 25.98

Enfield North Ponders End 31.43

Enfield North Southbury 26.88

Enfield North Town 12.60

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(Enfield)

Enfield North Turkey Street 27.29 24.73

Southgate Bowes 23.51

Southgate Cockfosters 13.63

Grange Southgate (Enfield) 10.16

Southgate Highlands 13.91

Palmers Southgate Green 19.83

Southgate Southgate (Enfield) 11.77

Southgate Southgate Green 17.81

Winchmore Southgate Hill 15.54 15.77

Borough 22.67

3.2. Population health needs

Current population health status and projected needs 3.2 Population health needs

The overall population of Enfield is not projected to see a significant increase in the next 5 years however the age group between 45 and 65 years is projected to see a significant growth of >8% (5237). Enfield’s population is relatively young with most in the 15-45 years age group, the younger population residing mostly in the east of the Borough (Edmonton Locality) and the older population residing mostly in the west of the borough (Southgate Locality).

Enfield’s favourable life expectancy of 77.0 for males and 81.3 for females (compared to 76.4 and 81.2 in London and 76.3 and 80.8 nationally) masks significant inequalities across the borough. The difference in life expectancy between the most affluent wards (Grange, Highlands) and the least affluent wards (Edmonton green, upper Edmonton) is 8.5 for males and 8.4 for females.

Infant mortality rate was 6.7 per 1000 live births between 2003 and 2005. Although the actual numbers of deaths is small, this is still higher than the London rate of 5.2/1000 live births in the same period. The risk factors for infant mortality include, smoking in pregnancy and smoking in the environment, alcohol, teenage pregnancy, cot deaths and premature birth.

The most common cause of death in Enfield is cardiovascular disease (heart disease and stroke) followed by cancer and respiratory diseases. However, in line with national trends there is now a reduction in the total

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number of deaths from these diseases. Again, although rates are declining there are still large inequalities in mortality rates between wards e.g. the mortality rates from heart disease range from 60 per 100,000 to 140 per 100,100 in line with levels of deprivation across Enfield.

Smoking has a significant impact on ill health and death rates from major diseases such as heart disease, cancers, respiratory and circulatory diseases as outlined above. Although Enfield exceeded its target of helping 2063 residents quit smoking in 2006/07, the work to help more people give up is ongoing. Smoking is very prevalent in the Turkish, Turkish Cypriot and Kurdish community and hence is a local target for all partners in Enfield through the Local Area Agreement. The school survey on obesity carried out in 2006/07 amongst the reception and year 6s in Enfield schools showed that over 17.5% of pupils were classified as obese and 32% as overweight. Obesity is an indicator of future healthcare needs including heart disease, diabetes mellitus, hypertension, hyperlipidemia, some cancers and musculo-skeletal conditions. Although a number of interventions are in place as part of the effort to reduce obesity prevalence in both the childhood and adult population this is likely to remain a significant predictor of healthcare need.

Enfield has also seen an increase in the diagnoses of sexually transmitted disease especially chlamydia again mirroring areas of deprivation. In addition the HIV infections rate is rising, reflecting the trend in London. The rate of diagnosed and undiagnosed HIV infections amongst Black Africans and men who have sex with men is also rising in Enfield, similar to most London boroughs. Although teenage pregnancy rates in Enfield has continued to fall in the last two years, the rate remains higher than the England average and similar to the London average (Enfield: 46.2 per 1000 15 – 17 year old females in 2005). The challenge will be to continue our efforts in promoting a positive sexual health lifestyle and providing interventions that tackle the impact on Enfield’s residents. Local research indicates that the number of users of class A drugs in Enfield is 7477 (this number includes those who are currently not problematic) Enfield became an “intensive” Drug Interventions Programme borough in 2005-2006 and successfully introduced the Tough Choices programme (Testing on Arrest, Required Assessment and Restriction on Bail). In 2007/08, Enfield introduced a multiple provider system for drug services including a new Tier 3 service currently working towards providing treatment to an increased number of drug users and also improving retention in treatment for these drug users. Often drug users also present with alcohol problems.

Current alcohol treatment services in the London Borough of Enfield are extremely limited and are not meeting the needs of moderate to severe alcohol clients. Those whose consumption is above the above the threshold of 16 units (men) / 12 units (women).

The absence of an effective alcohol treatment system in the borough is having a severe impact for the PCT in terms of clinical governance issues, its reputation on the national stage, and in the local political arena.

Of the clients currently accessing Rugby House - the only Drug and Alcohol provision in the borough – over 50% are now assessed as having alcohol problems and many of these are above the Tier 2 threshold referred to above for which we are not currently commissioning care. This creates numerous clinical dilemmas for the staff working in this unit and PCT commissioners have been alerted to a number of serious clinical governance issues as a result. One consequence of this limited treatment process is that several alcohol clients do not present until they are very ill often with severe associated physical conditions and the only option available is to place them with a Tier 4 provider at a substantial cost for which funding has then to be found. These alcohol presentations are also impacting on the capacity available to our existing providers to provide services to Drug clients.

London Borough of Enfield is one of the only London Boroughs not to have a Tier 3 Alcohol treatment system and this has been the subject of a number of questions from the local MP for Southgate and other national political bodies.

Locally the Alcohol Harm Reduction Board and the Council themselves have made it known that they consider the lack of an alcohol treatment system in the borough a major care deficit in the borough.

The recent decision by the chair of the DAT to agree to the DAT becoming a DAAT and thus take on the responsibility of planning and performance management of Alcohol Treatment in the Borough provides an opportunity for Enfield PCT to work with the other stakeholders in commissioning the development of Alcohol

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treatment systems in the borough.

An Alcohol needs assessment for Enfield, carried out by Alcohol Concern in 2005, estimated that around 9000 adults in the borough are drinking at levels that will harm their health. In 2005-2006, Enfield patients with conditions directly related to alcohol misuse accounted for 4625 hospital bed days at Chase farm and North Middlesex university Hospitals. A one-month audit conducted in 2007 found that 50% of patients arriving at North Middlesex Accident and Emergency department (at its peak period) were drinking at levels that were hazardous to their health. The plan within the next 5 years will need to include additional interventions in the community to support people with drug and alcohol problems.

The review of mental health needs in Enfield in 2006, found that Edmonton Green and Lower Edmonton had the highest levels of mental health hospital admissions between 2003 and 2005. Young men in Enfield have a higher risk of committing suicide than any other group in the population. However, the suicide rate has decreased in Enfield since 1993 and in 2005 was lower than in London and England. The challenge in the 2008/09 and beyond is to reconfigure community mental health services to ensure that services match areas of need.

Although the NHS cervical screening programme coverage rate increased in 2005-2006 from 74.5% to 75.2%. Enfield was one of the few PCTs’ in London to have increased its coverage for that year. This increase will need to be maintained by ensuring adequate access to screening for women in the community particularly those from black and ethnic minority groups. Breast screening coverage has been less successful and has decreased from 71.5% in 2004 to 62.6% in 2006. This is likely to remain the same as a result of recent problems with the local breast screening service. Our challenge will be to ensure that the local service continues to be safe and maintains its access to women in the target screening age group.

Other health needs in Enfield include ongoing reduction of our levels of TB notifications which is presently below the national and London average, improving our childhood immunization coverage particularly MMR in the light of present increases in diagnosed cases of measles in North London and maintaining our high uptake of flu vaccinations for the over 65s as it has a positive impact on reducing excess deaths from Long term conditions.

Although the NHS cervical screening programme coverage rate increased in 2005-2006 from 74.5% to 75.2%. Enfield was one of the few PCTs’ in London to have increased its coverage for that year. This increase will need to be maintained by ensuring adequate access to screening for women in the community particularly those from black and ethnic minority groups. Breast screening coverage has been less successful and has decreased from 71.5% in 2004 to 62.6% in 2006. This is likely to remain the same as a result of recent problems with the local breast screening service. Our challenge will be to ensure that the local service continues to be safe and maintains its access to women in the target screening age group.

Other health needs in Enfield include ongoing reduction of our levels of TB notifications which is presently below the national and London average, improving our childhood immunization coverage particularly MMR in the light of present increases in diagnosed cases of measles in North London and maintaining our high uptake of flu vaccinations for the over 65s as it has a positive impact on reducing excess deaths from Long term conditions.

Summary of Key Points

Enfield’s population is relatively young, diverse in terms of socioeconomic factors and ethnicity. The population will become more diverse as the proportionate size the “white” population falls and other populations grow. Identifying the health needs of these population will be ongoing so as to be able to cater appropriately for their needs. Currently the identified health needs are:

 Cancer

 CVD and Stroke

 Renal

 End of life Care

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 Respiratory diseases

 Smoking cessation

 Childhood obesity

 Sexual Health including STD and teenage pregnancy

 Long term conditions including diabetes

It is vital that services are delivered in a culturally appropriate manner and we make progress in reducing health inequalities across the borough.

Enfield PCT will achieve its stated vision through year on year delivery of initiatives; these are current organised under the six key goals of improving planned care, urgent care, contracting and procurement, evidence based commissioning including prescribing, community and specialist services (including our Provider Division) and staying healthy (working with partners).

More information can be obtained from Enfield’s Public Health Report 2006/07 and Enfield PCT getting Health and Health care right for the Future.

3.3. Existing models of care

Existing models of care commentary The models of care in place to serve the Enfield population have seen little significant change for many years. There is an over-reliance on secondary care, for both urgent care and long term conditions. This is evidenced by NHS productivity metrics, which demonstrate high levels of out patient activity for the PCT, as well as by user feedback, which demonstrates lack of confidence in primary care access. As a result primary care is patchy and in places under-developed, with the areas N9, N18 and EN3 identified as underdoctored.

Acute Services Local secondary care acute services are delivered in three acute units managed by 2 trusts, Barnet & Chase Farm Hospitals and North Middlesex University Hospitals. Barnet & Chase Farm Hospitals, like Enfield PCT, are in financial turnaround and face performance challenges. The Healthcare Commission issued Barnet & Chase Farm Hospitals on 5 July 2007 a 3-month improvement notice for breaches of the hygiene code ordering immediate changes to its infection control practices. The code outlines compulsory duties to prevent and manage healthcare-associated infections such as MRSA and Clostridium difficile. It is expected that compliance will be attained by 30 September 2007.

The Barnet Enfield and Haringey clinical services strategy for the health economy sets consolidate elements of acute services on each site.

Primary Care GP services are provided by 62 practices with a total of 144 GP principals with an average list size of 1923 patients per primary care practitioners. GP prescribing is high in Enfield compared to neighbouring PCTs. For the period 2006/07 Enfield GPs wrote 3,166,286 prescription items and the first quarter of 2007/08 shows that they have written 817,102 prescription items. The quality of access and service in Primary Care is variable and the PCT has developed a balanced scorecard tool to monitor quality and cost effectiveness.

A Specialist Clinical Assessment Service that triages all routine non urgent GP referrals according to locally agreed criteria /pathways is in place and a number of clinical pathways have been implemented in primary care, for example:

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 GPs with special interest for providing care for people with skin problems and for those who require minor surgery  GPs and specialist nurses are looking after diabetics who were previously managed by hospital consultants in line with an agreed clinical pathway; development of a primary care diabetes team

A large number of A&E attendees could be seen in primary care and we jointly commission with Haringey PCT Chilvers MCCrea to run a nurse led Walk-in Centre adjacent to North Middlesex Hospital A&E and plan to fully develop a primary care urgent care model on the Chase Farm site. We commission out of hours services from Barndoc Ltd. The services they provide include telephone advice, appointments at Chase Farm Hospital (nurse and GP), home visits by GPs and also dental advice and referrals onto the PCT dental out of hours service.

Dental Practices: The PCT has 49 dental contracts, 2 of which are purely for orthodontics. There is adequate access to NHS dentistry and complaints are minimal. In 2006/07 EPCT contracted with 47 dental practices to provide 413,367 units of dental activity (UDAs). However only 398,745 were delivered at a cost of £9,720,225 at an average cost of £23.38 per UDA. All under performance> 4% is being repaid by the practices during 07/08.

5 out of the 13 contracts that significantly under performed in 2006/07 have already been reduced in 2007/08. However all contracts are currently being reviewed after 6 months.

Pharmacists: Currently there are 57 pharmacies in Enfield from whom PCT commissions essential, advanced and enhanced services, with a focus on quality and outcome in all cases. 24 pharmacies are undertaking medical reviews (advanced service) with 3 undertaking minor ailments, 34 smoking cessation, Emergency Hormonal Contraception and 5 flu. The PCT is also undertaking a pilot with the pharmacy in Forest Road and all GPs within the centre regarding anti-coagulations.

Optometrists: In Enfield there are 34 optical practices. These provide both private and General Ophthalmic Services which usually include sight tests, contact lenses and orthoptics (e.g. patients with squints, amblyopia or diplopia). Of these, four provide digital retinal screening for patients with Diabetes as part of the area-wide Retinal Screening Scheme. There are also four practices, which provide Low Vision Services for Blind and Partially Sighted people. The PCT is in discussions with the Local Optical Committee regarding a proposal for a pilot referral scheme for direct cataract referrals.

Specialist Acute Service (see NCL CC Plan) Cardiology Cardiology services are delivered in acute settings in line with the National Service Framework (NSF) for CHD. These services are primarily delivered via the Royal Free and UCLH on a networked pathway of care. This pathway is clinically overseen by the NC Sector Cardiac Network Board.

Cancer Cancer services are delivered in line with the Cancer Plan and Institute on Governance (IOG) guidance. Entry to the cancer pathway of care is generally via the 2 week suspect cancer referral route, which is well established. Access to services is measured under the cancer access targets. The development of cancer services is overseen clinically by the NCLCN. A sector cancer commissioning group aligns key cancer commissioning decisions to lead commissioning arrangements.

Renal Renal services are delivered with North Central Sector on a hub and spoke model of care and clinically delivered in line with the renal NSF. Following a public consultation the Royal Free became the main provider of care in 2004/5. The development of renal services is overseen by the sector’s renal network.

Enfield PCT Provider Division Enfield PCT directly manages a wide range of community and specialist services across the Borough. These are

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managed through a Care Group approach:  Adults & Older People (community nursing, intermediate care, community matrons, palliative care and musculo-skeletal/outpatients)  Children & Younger People (health visiting, school nursing, community paediatric team and children with special needs) and  Specialist Care Groups (sexual health and family planning, learning difficulties assessment and treatment / integrated community team). Services are delivered in a variety of settings - patient homes and community sites including new modernised primary care centres. Work is on going to achieve more flexible, proactive case management with a view to prevent admissions. Services are being further developed to ensure that they are modern, high quality and cost effective. Closer alignment to GP Clusters and integration with local authority and voluntary services is also a key aim.

3.4. Quality, health outcomes, and inequalities

Performance on increasing quality and health outcomes commentary

In the 2006-07 Annual Health Check, the PCT was assessed as fair on Quality of Services and weak on Use of Resources. It was judged as fully met on core standards having declared itself compliant on all but one of the healthcare standards. Existing targets were judged as partly met and new targets as weak. The PCT achieved its targets on smoking cessation, cancer waiting times and emergency access targets. All the NHS inpatient and outpatient waiting time targets were met, including the milestones towards the 18-week RTT target, although diagnostic waits were narrowly missed. However the 18-week RTT target remains a significant challenge and for 2007-08 the PCT is poorly placed nationally in terms of progress on the 18 weeks RTT targets and milestones. The PCT is working closely with Barnet and Chase Farm Hospitals Trust in the development of action plans to resolve this issue. Also included in the Annual Health Check, although not part of the overall rating, was an assessment of the PCT’s progress on development standards for public health – Enfield was assessed as good. In addition there were four service reviews, again not part of the overall rating but assessed as follows:

Diabetes Fair

Adult Community Mental Health Services Fair

Substance Misuse Services Fair

Tobacco Control Good

The Healthcare Commission carried out a National Review of Diabetes Services at the end of 2006. All 152 new PCTs participated in this review. The scores were on a 1-4 categorical scale and Enfield PCT achieved a score of 2. This means that our performance met minimum requirements and the reasonable expectations of patients and the public. The measures used in this review were derived from aspects of the Diabetes National Service Framework, Department of Health Standards for Better Health and relevant NICE guidelines as well as key issues raised in consultation with patients and health professionals.

The review of adult community mental health services was published in October 2006, Enfield PCT was assessed as fair on each of the following focus areas:

- Community services are accessible to people according to their presenting circumstances

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- Care arrangements focus on a range of needs and outcomes for people who use services

- People who use services and their carers where appropriate, are involved in decisions and are able to make choices about their care

Enfield received an overall assessment of fair in the review of substance misuse services. It was assessed as good in the following areas:

- Community prescribing services have procedures in place to ensure controlled drugs are administered and managed in accordance with best practice

- Pathways through treatment are clear, coordinated and continuous for service users

The following areas were assessed as fair:

- Service users have prompt, equitable and flexible access to community prescribing services

- Service users have a personalised care plan that incorporates a comprehensive assessment of their physical, psychological, social and legal needs and preferences

- Prescribing practice is in line with models of care for treatment of adult drug misusers and drug misuse and dependence – Guidelines on clinical management

- Service users have a personalised care plan that incorporates a comprehensive assessment of their physical, psychological, social and legal needs and preferences

- Services have systems in place to minimise client DNA / dropout rates and to support clients retained in treatment

There were 4 areas considered as weak in the service review and the PCT will pay particular attention to these areas to ensure standards are improved:

- Community prescribing services are commissioned in line with models of care and clinical guidelines

- Community prescribing services are delivered by competent practitioners who are appropriately trained and supervised and work in a supported and managed environment

- Service users and carers are integrated partners in the whole treatment planning process, and are fully informed about the range of treatment options, choices and access available

- Service users have rapid, equitable and flexible access to an appropriate range of drug treatment services

The Healthcare Commission rated Enfield as good in the national review of tobacco control.

The Commission considered PCT performance against six criteria, the following 3 were assessed as good:

- The primary care trust delivers an effective smoking cessation service

- The primary care trust promotes healthy lifestyles amongst the workforce and minimises risk in relation to smoking and exposure to second hand smoke

- The primary care trust works with partners to address the needs of the local population in relation to tobacco control

The remaining 3 areas were assessed as fair

- The primary care trust reduces the prevalence of smoking, particularly in groups within the local population who are most at risk from tobacco use and exposure

- The primary care trust develops public health capacity within its own workforce and that of independent

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contractors and their staff to reduce smoking prevalence

- The primary care trust champions the tobacco control agenda and promotes the benefits of a smoke free environment

Primary care achievement against the Quality and Outcomes Framework improved in 2006-07 with an average achievement of 902.71 out of 1000 compared with 899.8 out of 1050 in 2005-06. 29 practices achieved between 951-1000 points, 18 between 850-950 and 13> 845 and 2 practices did not participate.

For 2007-08 the PCT has identified the following local priorities for quality improvement alongside national priorities as indicated by the Quality Outcomes Framework and any public health targets that are relevant:

Primary Care: - Practice registers - GP and PCP access - Booking & Choice - Smoking Cessation - GUM access

Secondary Care - 18 weeks RTT - Infection control rates - Caesarean rates - Antibiotic prescribing - Smoking cessation (referrals prior to surgery) The PCT’s Commissioning & Performance Committee, which reports to the Board, will oversee and ensure quality assurance for all providers i.e. Acute Trusts, independent contractors and the PCT’s provider arm. The Enfield Commissioning Executive (formerly PEC) also monitors quality and health outcomes with a particular emphasis on GP services.

Further work is undertaken through the Local Area Agreement (LAA) where there is an emphasis on improving quality and health outcomes through partnership work. This includes 2 health targets with reward elements attached to them – reducing the CVD SMR from a baseline of 97.6 / 100,000 in 2004 and increasing the number of Turkish, Turkish Cypriot and Kurdish (TKC) people who stop smoking from a baseline of 66 in 2004/5 to 400 over the 3 year period from April 2006 to March 2009. Data is not yet available from the London Health Observatory (LHO) on the CVD target but at the end of year one of the LAA 143 quitters had been achieved against a target of 110.

Performance on reducing health inequalities commentary The PCT monitors several indicators of health and health inequalities. These include life expectancy, infant mortality, smoking, obesity, sexual health including teenage pregnancy, heart disease and stroke, cancers mental health and drug services. In addition data from QoF, PUMA, London-wide reports such as produced by the LHO and national data are also used to monitor performance on reducing inequalities in health. Many of these indicate that whilst overall Enfield compares favourably with many London or even national indicators such overall figures mask substantial inequalities within the borough. Generally, these are between the more affluent west of the borough and, particularly, the Southeast of the borough.

In order to tackle these inequalities the PCT has engaged strategically with various partners across the borough i.e. taking a strategic approach with partners particularly the Local Authority in developing the Enfield “Sustainable Communities strategy” and the Local Area Agreement (LAA) which reflects a number of joint health and social care targets. A number of targeted initiatives designed to improve health outcomes and reduce inequalities have evolved from the LAA. These include projects on smoking cessation for the Turkish/Kurdish population, Health Trainers project focusing on particular wards with high death rates from heart disease and stroke, Pharmacy life style screening project, Healthy Schools project (including reducing obesity), improving

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access to sexual health services and reducing teenage pregnancy, improving mental health and reducing suicide and increasing immunisation uptake including that for winter flu.

In addition the LAA centres on the reduction of child poverty with the creation of four children’s area boards in Enfield ensuring partnership working amongst key stakeholders in each area. The new LAA is currently being developed with partners assessing where local targets need to be set to achieve already identified needs. We are particularly keen to retain the ongoing focus on smoking and obesity prevention and tackling major killers such as heart disease and stroke but also include new local targets on mental health promotion, sexual health promotion and immunization uptake. The partnership is also keen to continue tackling worklessness in Enfield by focusing on specific targets that will have an impact on this issue. The PCT will be carrying out a joint strategic needs assessment on an aspect of health and social care with key partners in 2008/09. The PCT also intends to maximise opportunities available in the “Place Shaping” strategy in Enfield i.e. ensuring that adequate health and healthcare services are located near areas of new housing developments in Enfield.

Furthermore, the improvement of Primary Care and particularly GP services across the Borough through Practice Based commissioning including the Forest Primary Care Centre LIFT development and Edmonton Green Health centre will contribute to the reduction in health inequalities across Enfield. These services have focused on management of chronic disease in primary care, quality prescribing, cancer screening and provision of immunisation services. The PCT will be developing a primary care strategy in the next few months in response to “ Care closer to home” and the Barnet and Enfield and Haringey clinical strategy. This will also have a major impact in the reduction of health inequalities across Enfield.

Providing support to commissioning decisions through the provision of evidence and intelligence is also key to reducing health inequalities. This is ongoing and the next 5 years will see development of more evidenced based care pathways, guidelines and evaluation of existing interventions to ensure maximum value for the people of Enfield.

Summary of Key achievements in 2006/07 include:

- Standardised mortality rates for cardiovascular disease in Enfield falling to 94 per 100,000 compared to London rates 105 per 100,000.

- Deaths from all cancers for persons aged under 75 years has fallen in Enfield from SMR 99 in 1998-2002 to SMR 93 2001-2005

- Achieving 2094 four-week quitters in financial year 2006-7

- Winter flu vaccinations are above the national 70% target

- Enfield Southgate has the lowest rate of smoking related deaths in London

- The Teenage Pregnancy rate has fallen by 20% in the last 2 years of data available.

- Enfield has the highest percentage of healthy schools in London.

-Increase in cervical screening coverage to 75.2% from previous year coverage of 74.5.

-Decrease in TB notification rates in Enfield.

-Commissioning new tier 2 and 3 drug services in Enfield.

-Opening a new Health centre in Enfield – Edmonton Green Health centre.

Ongoing areas of challenge for reducing health inequalities include:

- Vaccination rates remain low – particularly that of MMR at 75.6% against the national target of 75.6%

- Teenage pregnancy remains high despite the falls in rates described above.

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- Achieving the chlamydia screening target and 48 hour access to GUM

-17.5% of pupils measured in the first obesity survey were obese and 14.4% were overweight. In Enfield 9.8% of those aged between 15 and 75 years old had a BMI of 30 or more against a London average of 7.9%.

-Improving cancer screening coverage for cervical and breast cancer screening.

-Reducing the infant mortality rates.

-Focusing on reducing deaths from major killers such as heart disease and stroke in the most deprived wards in Enfield.

Note: See Enfield PCT Public Health Report (2006/07) and Enfield’s Future – Sustainable Communities Strategy for Enfield 2007-2017 for comprehensive information on plans to continue improving health outcomes and reducing health inequalities in Enfield.

We continue to work on the public health priorities over and above the initiatives that we have chosen to detail later in section 5.

A summary of the achievements in these areas are given below:

Smoking cessation:

Smoking cessation is a priority target for the PCT and Enfield has over 100 Level 2 advisors across the Borough. The PCT exceeded its 2006/7 four weeks quitter target and has also negotiated an Local Area Agreement target with the Local Authority to target smoking cessation services towards the Turkish, Turkish-Cypriot and Kurdish Community which has an extremely high smoking prevalence. At the end of 2006/7 the PCT was 25% above trajectory to achieve this LAA target.

Smoking cessation Achievements 2006-2007:

 Supported 1392 smokers to stop smoking (by end of 3rd quarter).

 Supported 78 Turkish Cypriot smokers to stop smoking (by end of 3rd quarter).

 Between 2003 and 2006 Enfield Primary Care Trust supported 2,580 smokers to stop smoking.

 The Primary Care Trust has trained over 100 one-to-one stop smoking advisors in Enfield.

 A new stop-smoking clinic was established in the Forest Primary Care Centre.

 A new stop-smoking clinic was set up in the Local Authority.

 A drop-in stop smoking clinic was set up in Artzone in Edmonton.

 Enfield Southgate has the lowest percentage of smoking related deaths in London.

 The Primary Care Trust is working in partnership with the Local Authority to ensure the successful implementation of smoke-free legislation on July 1st 2007, including distributing over 6000 leaflets to local businesses.

 Staying smoke-free is a major theme of the National Healthy Schools Standard. Enfield has the highest percentage of schools accredited to the healthy schools standard in London.

 A Health Equity Audit of smoking was conducted in the Borough to ascertain if all ethnic groups use the Stop Smoking Service equitably.

 A ‘Stop before the Op’ referral scheme was established.

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We have been very successful in helping people to stop smoking with a year-on-year increase in the number of quitters since 2002 when the service was established.

Sexual Health:

Although teenage pregnancy rates in Enfield have dropped by 20% in the last 2 years they remain high at 46.2 / 1000 females aged 15-44. The PCT and Local Authority are working together to improve services and continue this downward trend. Young Peoples’ integrated sexual health clinics will continue to be provided by the PCT through RASH, with the aim of offering clinics in areas where deprivation and teenage pregnancy are high such as Edmonton and Ponders End. There will be a focus - shared with local authority - on identifying and targeting the most vulnerable young people in the borough. All contraceptive clinics will work towards achieving the ‘You’re Welcome’ criteria for being young people friendly and will continue to increase provision of LARC methods and training for primary care.

Enfield has a higher than average rate of repeat abortions in under-18s, which contributes to the teenage pregnancy rate. We will continue to explore and reduce this rate, by better follow up and integration of young women into contraceptive services.

The SHA has rated EPCT as red on the chlamydia screening target for quarter 1, but this is proving a difficult challenge for most London PCTs as a total of 15 PCTs were rated red. Out of the 10 PCTs rated green, 6 had set themselves a zero target for Q1. Enfield has developed plans to further increase uptake, and will continue to fund the chlamydia screening project.

Access to GU services is improving through reorganisation of care pathways and the use of new testing technology. This together with the planned service outlet in Edmonton and expansion of staff and clinics as permitted by funding levels will enable us to increase the number of appointments from about 5000 in 2006/7 to about 10,000 in 2009/10. Funding should increase with PbR in April 2008.

The sexual health service in Enfield will continue to work with NHS London, and work towards setting up a Sexual Health Network for North Central Sector. This will result in better audit and clinical protocols across the area, increase training opportunities, and will also better inform the commissioning of effective services.

Addressing Obesity: PCT Achievements 2006-2007

 Interventions include expanding the National Healthy School Status for Enfield schools (67% of Enfield schools are healthy schools). This is the highest percentage of accredited schools in London. Enfield was a finalist for the Beacon Award.

 The majority of schools (67%) developed a Food and Nutrition policy in conjunction with the London Borough of Enfield school meals service.

 Four Community Nutrition Assistants have been trained and are working across Enfield and Haringey to support healthy eating initiatives.

 A North Central London Obesity Care Pathway has been developed in collaboration with other Primary Care Trust’s within the sector.

 A range of physical activity sessions was provided in partnership with the London Borough of Enfield.

 A variety of Healthy Eating and Promoting Physical Activity events have successfully taken place.

 The childhood obesity survey was conducted in partnership with the London Borough of Enfield and local Schools. The survey will be repeated each year.

 A conference to promote Physical Activity and healthy eating was held in January 2007. Results of the childhood obesity survey were disseminated; evidence based interventions outlined and action to be

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undertaken to halt the rise of obesity in children was determined.

Immunisation uptake, especially MMR:

Achievements 2006-2007

 The percentage of children receiving the MMR vaccine has remained relatively stable over recent years at 67% in 2005-2006. EPCT carried out a MMR campaign among primary school children and the rate was increased to 75.6%. This is still below World Health Organisation recommendation of 95%.

 Uptake of the flu immunization has increased to an average of 72% during 2006-07 campaign.

Increasing screening uptake (cancer, antenatal, identifying high blood pressure, diabetes and high blood lipids via GP practice registers):

 Cervical screening coverage rate in Enfield increase to 75.2% from previous year’s rate of 74.5%. Enfield was one of the few PCTs to achieve an increase in coverage due to the extensive work carried out as part of the Edmonton Cervical Screening Access Project.

 A smear clinic was established in Edmonton to increase capacity, access and provide choice for women.

 NHS bowel screening programme began in April 2006 for a 3-year period. It will be offered to men and women aged between 60 and 69 years every two years. The NCL sector is participating in the first phase of the programme with implementation for EPCT being September 2007

Addressing alcohol and drug misuse:

 The opening in March 2006 of a new “tier 2” service, Rugby House in new, bespoke premises at the Forest Primary Care Centre in Hertford Road, Edmonton. Tier 2 services comprise drug-related information and advice, screening, assessment, referral to structured drug treatment, brief psychosocial interventions, harm reduction interventions and aftercare.

 The opening in February 2007 of a new specialist prescribing service delivered by Central North-West London Mental Health Trust in a partnership arrangement with Rugby House at the Forest Primary Care Centre in Hertford Road, Edmonton.

 The expansion of the Drug Interventions Programme that involves criminal justice and treatment agencies working together with other services to provide a tailored solution for adults who commit crime to fund their drug misuse. Enfield became an “intensive” Drug Interventions Programme borough in 2005-2006 and successfully introduced the Tough Choices programme (Testing on Arrest, Required Assessment and Restriction on Bail). Enfield’s Drug Interventions Programme has been widely cited as a national example of best practice.

 Establishment of a formal, stand alone GP shared care scheme to widen access to, and increase numbers entering treatment.

 Expansion of the community pharmacy needle exchange scheme to aid harm reduction.

 The setting up of “Break The Cycle”, a service user forum.

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 The appointment in November 2006 of a service user and carer development worker.

 The successful negotiation with government of Local Area Agreement drug targets demonstrating the continued high-level strategic commitment to tackling problems associated with drug misuse locally.

Alcohol Services Achievements and Future Plans

The multi-agency Alcohol Harm Reduction Board launched its strategy “Taking Responsible Measures” in early 2006. The strategy sets out an action plan for reducing alcohol related harm in Enfield by:

 Improving information and communication about alcohol.

 Improving identification and treatment of alcohol problems.

 Better coordination of enforcement activity to tackle alcohol-related crime.

 Encouraging the licensed trade to promote responsible drinking.

 Improving local data on alcohol-related harms.

 Training front-line staff in alcohol awareness.

 Partnership working on the strategy led to Enfield Town becoming safer at night – it is no longer a hotspot for crime and disorder.

 Audit conducted in A&E departments ascertaining level of need for alcohol interventions.

3.5. Other challenges within the local health economy

Other challenges within the local health economy commentary

The PCT and its health partners face a number of challenges in the short and longer term:

 Achieving financial stability. Currently both the PCT and B&CFHT are in deficit with agreed plans to rectify their positions. The PCT is using more resources than it can afford evidenced by the overspend in 2006/07 of £13 million and forecast overspend in 2007/08 of £10-12m. The PCT’s demand management targets detailed in the operating plan are challenging and may not be aligned with the financial assumptions underpinning B&CFHT’s recovery plan. Delivering the changes required to implement the White Paper ‘Our heath our care our say’.

 Maintaining clinical engagement on the part of primary and secondary care professionals in the change programs necessary to deliver financial stability and improved quality and outcomes for users, and in

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the case of the PCT to maintain the level of clinical engagement in practice based commissioning necessary to support PCT turnaround and the implementation of Barnet, Enfield and Haringey clinical strategy.

 Maintaining the partnership with the London Borough of Enfield, which has been challenged by the PCT’s review of its financial arrangements with the local authority in 2007-08. Discussions between the PCT and LA have reviewed the effect of the integration programme and it was agreed that this would be implemented over time.

 Improving user experience and involving users in their care through development of a self care strategy and the expert patient programme. In addition the PCT needs to extend its market intelligence gathering to ensure that services meet users expectations as well as needs. The PCT will instigate a process for the Equality Impact Assessments for all service changes to ensure that we continue to provide services that deliver equality of access and service levels to the whole population of Enfield.

 Workforce capacity and competency: Growing and developing a workforce that is fit for purpose to meet the challenges of delivering a more primary care focused model of care. This will require many changes in structure and the skills base of the existing staff and increased opportunities for staff in the acute sector to work across both primary and acute care.

3.6. Existing targets and national priorities

Existing targets and national priorities commentary Existing Targets and National Priorities

The following existing targets, identified as national priorities, were all met by Enfield PCT in 2006/07. The PCT will continue to monitor these closely to ensure this success is maintained throughout 2007/08.

 A&E waits in 4 hours  Cancer: 2 week referral to 1st appointment  Cancer: 1 month diagnosis to treatment  Cancer: 2 month GP urgent referral to treatment

The picture was more variable on the remaining existing targets.

The following targets were met in 2006/07:

 Outpatients maximum 13 week wait  Inpatients maximum 26 week wait  Category A ambulance calls – 75% response within 8 minutes  Category A ambulance calls – 95% response within 19 minutes  Delayed transfers of care  Revascularisation waits within 3 months  Thrombolysis 60 minute call to needle time – The number of patients receiving thrombolysis fell below the threshold for inclusion in annual health check, as more patients were treated through primary angioplasty

Three targets were underachieved:

 Access to a GP in 48 hrs and Primary Care Practitioner in 24 hrs – Whereas access had been 100% in 11 months of the year, a drop in performance in March led to the targets being narrowly missed: 99.17% for GP

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access and 99.27% for PCP access.  Improvements are now in place and in October 2007 the figures were 100% for both targets.  Category B ambulance calls – 95% response within 19 minutes  Practice-based registers – CHD & diabetes: 96.39% of planned performance achieved

Three targets were failed:

 Diabetic retinopathy screening - The PCT has made a further investment in the screening service. Enfield and Haringey PCTs have jointly developed a service specification for a fully comprehensive programme and are working with the provider to ensure that the new model of service will meet the 2007/08 target. Appendix A provides more details on the initiative to achieve this target.

 Choose & book - The PCT has examined the underlying reasons for the underperformance and taken many steps to ensure improved performance in 2007/08 including:

- Ensuring all routine referrals correctly routed through SCAS and onto choose and book. - Piloting booking service at larger practices - Encouraging the main provider to enable direct booking to services - Visiting high-performing PCTs to learn from good practice

 CAMHS and crisis resolution services – Although CAMHS targets were met in 2006/07, the overall target was failed because of failure to achieve adequate numbers receiving the crisis resolution services. The PCT is working with the MHT to identify the underlying causes for the underachievement and agree actions to ensure activity levels are met. The number of patients receiving assertive outreach services was also of concern in 2006/07 and again the PCT will work with the MHT to ensure the target is met in 2007/08.

The new national target set covers targets to be achieved, within these there are a number of priority areas highlighted in the SHA’s Commissioning Regime:

 18 week different stages of treatment milestones

- 85% of admitted patients in 18 weeks by March 2008 - 90% of non-admitted patients in 18 weeks by March 2008 - Outpatient waits maximum 5 weeks by March 2008 - Diagnostic waits maximum 6 weeks by March 2008 - Inpatients waits maximum 11 weeks by March 2008

 The 2006/07 Annual Health Check measured the Stage-of-Treatment targets for inpatients, outpatients and diagnostic waits. The target was underachieved: inpatient and outpatient targets were met but diagnostic waiting times were missed by 0.79%. The PCT has commissioned additional capacity from its acute trusts and has a programme of workstreams in hand with its local providers to ensure delivery of the targets.

 MRSA (hosted trust performance) – Whilst the PCT achieved its Healthcare Commission target for MRSA in 2006/07. The PCT was compliant with the core standards relating to infection control, but the Acute Trust did not meet it’s MRSA target last year. The PCT continues to monitor the Trust action plan, in response to the Healthcare Commission Improvement Notice, to ensure full compliance with recommendations and to work closely with the Trust to minimise risk of MRSA and other HCAIs. The acute trust was re-inspected by the Healthcare Commission and the final report is awaited.

 Smokers Quitters – The PCT achieved this target in 2006/07 and will strive to achieve the increased target in 2007/08, supported by local performance agreements with its provider trust on pre-op referrals to the cessation service and local area agreements to target Turkish & Kurdish communities

 GUM access – this was achieved in 2006/07 and currently on track to be met in 2007/08

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Other new targets achieved in 2006/07:

 Reducing cancer mortality – Both the cancer mortality rates indicator and the NICE Improving Outcomes Guidance (IOG) indicator were achieved on this target however, the breast cancer screening indicator was underachieved. Performance on breast screening in 2006/07 was measured against 2005/06 activity and was lower than expected. The PCT recognises that performance may dip still further in 2007/08 as the effects of the closure of the screening service impact on activity levels for 2006/07. Recovery to acceptable performance levels may be slow as the screening backlog takes place.

 Drug misusers: numbers in treatment and numbers sustained in treatment

 Reducing obesity - GP recording of BMI status

 Patient experience

 Reducing suicides - Care Programme Approach (CPA) 7-day follow up following discharge indicator was achieved however the indicator on early intervention services was excluded from the annual health check as no service was planned in 2006/07.The planned commissioning of a service in 2007/08, will be further deferred to reflect the current financial situation, and is likely to be commissioned in 2008-09.

The following new targets were under-achieved in 2006/07:

 Health Inequalities - Smoking during pregnancy was underachieved but on track to be met in 2007/08. Breastfeeding initiation rates were met and the PCT is working with local trusts to ensure that the target continues to be met in 2007/08.

 Sexual Health – Whereas the GUM access indicator was met, the other components of teenage pregnancy and access to contraception were underachieved. The PCT continues to work with the local authority to reduce the number of teenage conceptions but although the last reported year saw a reduction in numbers it was not sufficient to address the rise in previous years. Chlamydia screening will be included in the 2007/08 targets and the PCT has a programme of actions to facilitate screening in place to support this challenging target. The PCT also has plans in place to reduce the number of new gonorrhoea cases in 2007.

The PCT failed the following targets in 2006/07:

 Quality of life for older people – The PCT achieved the provision of community equipment target in 2006/07 but failed the indicator relating to older people’s mental health needs assessment. The Healthcare Commission has separated out these targets for 2007/08 and the PCT expects to meet both of these.

 Reducing heart disease, stroke and other diseases – The PCT achieved 2 out of 4 indicators, on blood pressure and CVD, within this target. The PCT will focus on practice-based registers in 2007/08 to ensure all aspects are met this year.

 Long-term conditions – Only the emergency bed day component was met in 2006/07. The PCT is now aware that it was under-reporting the total number of community matrons and case managers and, consequently, the number of high intensity users throughout 2006/07. It is now including other case managers and their caseloads in submitted data and on track to meet the 2007/08 target.

Improving Health Targets-

The national targets are:

- Reducing the rate of teenage pregnancy to 25.5 conceptions per 1000 females aged 15-17 by 2010 (currently 46.2)

- Helping 2307 smokers to stop smoking (2007-8)

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- Achieving 48 hour access to GU for 100% of patients - Achieving 70% winter flu uptake - Achieving 95% MMR vaccination rates - Stopping the year on year increase in childhood obesity - Offering diabetic retinopathy screening to all residents with diabetes - 15% of young people aged 16-25 taking up chlamydia screening - Reduce mortality rates from cancer by 40% from 1995 baseline by 2010 - Increase uptake of breast screening to 70% - Increase uptake rate of cervical screening to 80% for women 25-64 - Halt the year on year increase in childhood obesity

Local Targets

- Supporting 400 Turkish, Turkish Cypriot or Kurdish smokers to quit by March 2009

- Reducing the CVD SMR from to 80 / 100,000 by March 2009

Other PCT priorities:

Supporting people with Long Term Conditions

The PCT has implemented a robust model of care for the better management of people with Long term conditions. This is based on the implementation of generic case management as per the Unique care model with active case finding using Parr 2 and subsequent management. This is complimented by specialist care in specific areas:

. Diabetes . Heart failure (BHF funded support) . Lymphoedema . Respiratory care

Patient/User experience The patient-user experience will be improved by the increasing use of patient forums, expert patients, community engagement in the development of services and patient / user input into PCT National Framework Service (NSF) key disease groups. This will build on, for example, the PCT consultation on the development of sexual health services and diabetes treatment in primary care, feedback on the clinical strategy and be supported by the Enfield PCT ‘Getting Health and Healthcare Right for the Future- Commissioning Strategy Plan Development’ strategy.

Hospital acquired infection The sector has been very challenged in meeting the targets for HCAI reduction. The PCT has recorded compliance with Core standard 4a-e and has implemented admission screening for all patient entering in-patient units with the PCT. The “Essential Steps” programme is being put in place and any community-acquired bacteraemias reported by the acute providers are being followed up by root cause analysis. The PCT seeks to work as collaboratively as possible with acute providers to achieve the national reduction targets for MRSA. The designated Director of Infection Prevention & Control (DIPC) is working at national level on the role and the scope of the work of the DIPC, and particularly addressing the role from a commissioning perspective. Training and support of all clinical staff is in place and this is extending out through outreach to local nursing homes and to the local authority to ensure consistency of training and understanding across the Borough. The local acute providers have very specific issues relating to achievement of the targets. Significant reductions in the C.Diff. target has been achieved in the first quarter and BCFHT have managed to meet the 20% reduction as per the local target. This will continue to be monitored and supported by the PCT.

Older People

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Targets and national priorities for Older People draw in general from the White Paper Our Health Our Care Our Say, and in particular from A Recipe for Care, update report on the Older People’s NSF. Older People’s targets are also contained within the Local Area Agreement. Oversight of older people’s issues is maintained through the Older People’s Partnership Board and the Older People’s Thematic Action Group. This Older People’s Partnership Board and Thematic Action Group are reshaping into one body around an action plan that encompasses local and national strategies. Themes are currently being worked up (November 2007) and will encompass the following: - early intervention and assessment of old age conditions - long term conditions management in the community integrated with social care and specialist services - early supported discharge wherever possible delivering care closer to home - general acute hospital care whenever needed combined with quick access to new specialist centres - partnership built around the needs and wishes of older people and their families

Local priorities identified through the Partnership Board are: - strategic commissioning, structured around the outline plan in the local response to the White Paper entitled Care Closer to Home - mental health, including dementia, and needs assessment - rehabilitation strategy - full and active lives, focusing on prevention

Local Area Agreement targets in conjunction with the LA for older people are: - prevention of house fires and accidents leading to hospitalisation - admissions to residential/nursing care - households supported intensively at home - Direct Payments - Delivery of equipment and adaptations - Waiting times for care packages - Older people helped to live at home

3.7. Provider Landscape

Current key providers Provider/Number Amount/value Provider-specific commentary of providers of activity commissioned

Primary care - GPs, prison 62 GP practices £33.8m The PCT commissions Personal Medical healthcare, dentistry, and Services (PMS) from 34 practices and optometry General Medical Services (GMS) from 28 practices. Relatively large number of small practices in poor premises.

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49 dental £11.2m The PCT commissions Dental activity from 42 practices practices, orthodontic activity from 2 practices and commissions 1 dental access centre. Sufficient capacity to meet local needs but PCT need to review referrals for secondary care. Shortage of NHS orthodontic treatment.

Community and 160 Private Provision of continuing care intermediate services Nursing home placements/ independent providers

LBE Home support/OT/Aids and Adaptations PCT provider £30.638m total Provision of Adults and Older People’s units (not just EPCT) services/Children’s and Younger People’s services and Specialist services are managed by EPCT Provider Division. Mental health 1 MH NHS Trust £32.2m Provision of local MH services plus ED service. Trust has had several changes in leadership and need to improve its performance. 1 MH FT Provision of tertiary psychology Specialist Provision of specialist services plus forensic Commissioning consortium 9 Voluntary Provision of support/recovery in the organisations community Secondary care 22 Acute Trusts £147.9m Purchases services to value of £148m from plus NCAs 22 acute trusts of which 70% is from 2 local trusts, (6 are Foundation Trusts) Barnet and Chase £72.5M Trust based on two sites and has strategic Farm Hospitals importance to South Herts. Future proposals contained within the BEH clinical Strategy North Middlesex £43M Trust received much of its income (80%) from Hospitals emergency admissions.

Tertiary and specialist £23m Services to value of £23m managed via commissioning sector-wide team based at Haringey PCT. £7.5m Ambulance contracts amount to £7.5m via London Ambulance Service

Provider landscape commentary Strengths, Weaknesses and Constraints of local provision:

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 Variation of resource allocation due to historical positions  Good range of skills within GP practices

 Inconsistency of service quality and responsiveness

 Some poor GP premises

 Quality of practice nursing

 Equity of access (weakness)

 Lack of resources

 Ageing primary care workplace

Primary Care Services: There are 62 GP practices of which a high proportion are small practices working out of poor premises which restricts the ability to respond to access targets and develop new service out of hospital.

Over the last five year’s Enfield PCT has made some significant additional annual investment in primary and community services that have improved the provider landscape. The monies totalling £7.7m cover the following:

 £2.0m in GP services through Personal Medical Services (PMS) contracts with GPs for additional services over and above core services (phased implementation between 1999/2000 to 2003/04) A range of Services are commissioned including:

 Extended Access  Special services for non-English speaking  Nurse Triage  Enhanced diabetes  Care of the elderly > 75  Osteoporosis  Nursing homes

 £4.8m investment in general practice for improved clinical and organisation quality through Quality and Outcome Framework (QOF) payments (started 2004/05)

 £200,000 in Intermediate Care (from 2005/06)

 £1.3m in new premises – Forest and Evergreen Primary Care Centres (from 2006/07)

 £120,000 in community matrons who case manage people with complex long term conditions (from 2005/06)

 £140,000 in a consultant nurse for Intermediate Care and a consultant nurse for Diabetes(from 2005/06)

 £64,000 in GPs with a special interest (GPwSIs) in dermatology and minor surgery (from 2004/05)

 £209,000 in Specialist Clinical Assessment Service including musculoskeletal service (phased development from 2005/06)

 £150,000 in pharmacists providing anticoagulation treatment to stable patients (from 2007/08)

 £12,000 in pharmacies providing minor ailment treatment to selected practices (from 2006/07)

Dental Practices:

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In 2006/07 EPCT contracted with 47 dental practices to provide 413,367 units of dental activity (UDAs). The table below shows the position at the end of 2006/07

Total >104% 96% - 104% 90% - 96% < 90%

47 practices 6 21 7 13

Out of the 13 practices who performed < 90%, 3 of these performed < 70% of their contract. For 2007/08, 5 out of the 13 contracts that significantly under performed in 2006/07 have been reduced in 2007/08. Half yearly monitoring is taking place in November. Contract monitoring will increase where activity levels have not significantly improved. However, EPCT still has adequate access to NHS dentistry within all 3 boroughs and therefore complaints are minimal.

Pharmacists: Currently there are 57 pharmacies in Enfield and they provide medication reviews, in addition many provide enhanced services such as smoking cessation (34 pharmacies), treat minor ailments (4 pharmacies) and the provision of emergency contraception (35 pharmacies). Future plans include rolling out of minor ailment scheme to support the PCT’s demand management programme and provision of flu immunisation.

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Acute Services: Enfield PCT commissions around 70% of its non-specialist acute activity from its 2 local acute trusts, Barnet & Chase Farm and North Middlesex Hospitals that are both sited within Enfield. Both CFH and NMUHT are in turnaround and face significant challenges. B&CFH also face tough challenges to reach 18 -week referral to treatment targets, as reported performance to date has been poor, which in part is owing to implementation of a new PAS and temporary poor data quality. The Trust is expected to meet the target of 85% by March 2008, and is the North Middlesex.

Enfield PCT, together with other NHS colleagues is leading the development of the Barnet, Enfield and Haringey Clinical Strategy, which aims to achieve essential reconfiguration of health services locally. Public consultation is running until 19 October 2007 on the future configuration of acute services. The aim is to achieve safe sustainable services and long-term financial stability for the health community. Mental Health Services: Mainstream mental health services are commissioned from Barnet, Enfield and Haringey Mental Health Trust. Financial constraints have precluded significant investment in new MH services with the exception of crisis resolution, rehabilitation services and most recently Early Intervention services.

The development of Early Intervention in Psychosis Services is a central initiative of the Mental Health NSF and is also a required development for the SHA IN 2007/2008. Services are designed to improve the care of patients experiencing first onset psychosis. In particular the aim of the intervention is to reduce the length of what is termed the Duration of Untreated Psychosis (DUP). The evidence is that the length of time a patient is effectively undiagnosed has a direct impact on the quality of the recovery and the likelihood of relapse.

Enfield PCT in collaboration with Barnet and Haringey PCT’s has recently commissioned a “core” EIP service from the local services provider- Barnet, Enfield & Haringey Mental Health Trust- scheduled to commence in January 2008. Initial investment in this core team is £300k full year. It is planned to increase the capacity of the service once further investment is approved. Service provision complaint with the NSF policy implementation guidelines would require an investment of £800k full year. Prevalence in Enfield is estimated at 50 patients per year and with a service model that retains patients for three years that results in an ongoing case load of 150- approximately the capacity of a “policy implementation guidance complaint” team.

Major benefits of Early Intervention in Psychosis service are that a dedicated team can deliver a service that is more effective for both the patient and the family and thus minimise the impact that the onset of psychosis has on both. More attention can also be paid to “relapse indicators” and thus steps can be taken to manage the risk of subsequent relapse.

The PCT has also prioritised investment to address significant historic inequities in service between Edmonton and the rest of Enfield. Community Care Services The PCT’s provider arm provides the following services to its commissioners:

 sexual health including GUM  community and sub regional in patient assessment and treatment services for adults with learning disabilities  community hospital services including in patient rehabilitation and intermediate care and continuing care  community and specialist nursing and therapy services for adults and older people including intermediate care, community matrons, Specialist nurses who manage continence; lymphoedema; heart failure; sickle cell anaemia; respiratory conditions; pressure sores and ulcers and specialist palliative care  community nursing and therapy services for children including palliative care  primary care diabetes and heart failure services

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 specialist therapy services including input to the SCAS

3.8. Financial situation

Commentary on the PCT’s financial position The Current Financial Situation of the PCT

Enfield PCT ended 2006/07 with a year-end deficit of £13.07m. This resulted in the PCT receiving a qualified audit opinion for the year, and being declared weak on its use of resources in the Healthcare Commission Annual Health Check. The PCT is therefore in turn around during 2007/08: the senior management team has changed, as has the focus of the PCT on its finances.

Initial plans were produced by the PCT for 2007/08 to develop a turnaround plan intended to bring the position back to balance in year, and to pay off some of the brought forward deficit. These plans were not robust and the true in year deficit continued to grow. The extent of the recurrent deficit is such that at month 6 2007/08, a further in year deficit of £11.73m had been identified. A robust analysis underpins this assessment of the in year deficit, and the PCT is confident that it is now reasonable and realistic. The PCT had agreed to repay £4.61m of its brought forward debt in year, making the 2007/08 deficit £16.34m at month 6.

The month 6 figures already included a realistic assessment of the extent to which cost savings measures identified in the initial plans, would deliver a reduced cost in year. In addition, the PCT has identified a further set of in year savings measures totaling £6.39m. Again, while these are challenging, they are robustly analysed and costed, and the PCT is confident that they are reasonable and realistic.

The net projected in year deficit is therefore now £9.95m, which is a target total the PCT has signed off on with NHS London. This is consistent with the 07/08 deficit of £9.95M reflected in the Operating Plan. These two positions will be held in common through the financial monitoring arrangements in year and carried forward into future years in a consistent fashion.

The Forward Financial Strategy of the PCT

A financial strategy for future years has been developed. This strategy is consistent with the CSP and with other key plans such as the primary care strategy. The strategy is a 5 year financial plan starting with the forecast outturn for 2007/08 and taking the PCT to 2011/12. The current plan for 2008/09 is consistent with the latest planning guidance from the Department of Health, NHS London and the London Commissioning Group, which consists of the 31 PCTs in London. Some of this guidance is currently in draft form and is subject to future revision before sign off: this may impact on the future financial strategy. At this stage the financial strategy is therefore in draft form, and not yet signed off by the PCT or by key stakeholders such as NHS London.

The strategy is projecting to bring the PCT back to in year run rate balance in 2008/09, and to pay back the brought forward deficit over a 3 year timeframe. Final determination of the pay back period depends on a number of variables which are subject to the final sign off of the draft planning guidance, including the timetable for repayment of the money topsliced from the PCT in previous years, inflation and growth rates, and projections for future investment in primary care associated with delivery of the Barnet, Enfield and Haringey Clinical Strategy.

Other key assumptions within the current financial strategy are:

- Income growth of 5% in 2008/09 increasing to 6.3% in 2009/10 and 6.4% in 2010/11

- Expenditure inflation at a net average of under 2% in 2008/09 across all services, in particular incorporating a net 1.5% tariff uplift for acute services and a 1.7% uplift for activity in acute services

- £2m additional demand management savings in 2008/09, with a projection of a dampened net growth in

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demand in future years

- £10m gross additional investment in primary care services and the revenue costs of infrastructure towards the end of the 5 year period.

There are a number of significant risks associated with the financial projection. The PCT has undertaken a rigorous review process in order to identify, cost and manage these risks, which are partly due to the challenging nature of the recovery and turn around programme, and partly due to the need to rebuild financial systems and processes. The PCT has built coverage for these risks into the financial strategy, including setting in a contingency reserve equivalent to 1.5% of the total resource limit allocation of the PCT, consistent with identified best practice.

Financial performance summary Baseline Year 1 £’000 2006/07 2007/08 forecast* Trend (%) Income Recurrent revenue allocation 362,134 395,232 9% Non-recurrent revenue allocation 4418 361 -91% Anticipated allocations and deductions: 2007/08 topslice to be paid by PCT Repayment received in the year to PCT of previous year's top-slice MFF Adjustment (27,593) (28,749) 4% Purchaser parity adjustment 3,588 1,888 -47% RAB adjustment to be paid during the year Debt deferral/repayment to be paid during the year Other in-scope adjustments (e.g., difference between month 12 and end-year) Debt carried forward that is not to be repaid 8,463 during the year Remove repayment to PCT of top-slice not repaid during the year Non-recurrent revenue allocation - as adjusted Other income (excluding income from provider 5,990 7,442 24% activities) Total income 348,537 384,637 10% Expenses Commissioning activities: Primary and community (85,823) (87,482) 1.8% GPs (33,904) (33,865) -0.1% Prescribing (36,785) (38,938) 5.8%

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Dentistry (10,545) (11,213) 6% Optometry Community and intermediate services (4,589) (3,465) -24% Other Mental health and learning disabilities (54,007) (56,994) 5.5% commissioning, pooled arrangements or jointly funded commissioning (e.g., s28 or s31) Provided by mental health trusts (32,135) (32,247) 0.3% Other (21,872) (24,747) 13% Secondary and tertiary (136,370) (146,938) 7.7% Secondary and tertiary non-recurrent Secondary and tertiary recurrent (136,370) (146,938) 7.7% Elective day case (15,128) (16,856) 11% Elective ordinary (13,621) (15,106) 10.9% Non-elective (49,021) (50,674) 3.3% Outpatient (new) (12,820) (13,782) 7.5% Outpatient (follow up) (16,332) (17,464) 6.9% Regular attendee (1,364) (1,410) 3% Bed days (PICU, NICU, ITU, HDU Critical (7,064) (8,366) 18% Care) Mixed (HIV and Renal) (5,987) (6,684) 11% A&E Major (4,011) (4,318) 7.6% A&E Standard (1,760) (1,895) 7.6% A&E Minor (3,470) (3,736) 7.6% GP direct access attendance (5,788.8) (6,642.2) 14.7% Other Ambulance services (7109) (7,571) 6.4% Other (33,943) (37,878) 11.5% Total cost of commissioned services (317,253) (336,863) 6.1% Provider activities: Pay expenditure (20,608) (19,536) -5% Non-pay expenditure (10,748) (10,189) -5% Less - provider income 8,583 6,365 -25% Net provider costs (22,773) (23,361) -2.5% Other costs Other pay expenditure (14,152) (15,311) 8% Other non-pay expenditure (7,431) (5,978) -19% Depreciation and amortisation Exceptional items Total other costs (21,584) (21,290) -1%

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Total cost (361,610) (381,514) 5.5%

PCT surplus/deficit in year (13,073) 3,123 123%

PCT normalised position (excluding exceptional (13,073) 3,123 123% items)

Carried forward deficit 0 (13,073)

PCT normalised position including carried (13,073) (9,950) 23% forward deficit

*Based on latest actuals plus forecast for remainder of year

3.9. Activity Commissioned

Commentary on activity commissioned

The PCT commission’s activity on the basis of the previous year’s activity taking into consideration growth. This outline approach to the determination of SLA baselines was then adjusted for additional activity required to meet 18-week milestones and service redesign priorities including those necessary to accommodate additional 18-week activity and the revised 18-week referral pathways. The PCT is seeking to release £2million of resources per annum through demand management in the Acute setting. Out patients including follow ups and non GP initiated referrals: In 2006-07 the PCT extended the scope of its Specialist Clinical Assessment Service (SCAS) to clinically triage all non-urgent referrals. This initiative was implemented in December 2006 and was a part-year effect in 2006-07. This is expected to reduce the number of referrals into secondary care across all specialties by at least 10% (full year effect) in 2007-08. There will be significant variance across specialties, as a result of which the PCT’s activity proposals have been set at specialty level. From December 2007 this service is being extended to include dental referrals for oral surgery. Consultant to consultant outpatient referrals will be managed according to specialty specific clinical protocols, reflected in the pan-London guidance, which is expected to reduce such referrals in 2007-08. Outpatient follow-ups will also be monitored and performance managed in line with the 10 high impact changes and the PCT’s key trusts will be expected to meet the first to follow up ratios negotiated and contracted for in the 2007-08 financial year. The PCT expects to set targets for first to follow up ratios over the next three years that will take it to the national upper decile. Urgent care and emergency admissions: The employment of Community Matrons and direct access by GPs to intermediate care facilities will also help to reduce emergency admissions. The PCT intends to develop pathways for the management of conditions, which frequently result in short-stay admissions. The PCT’s primary care development plan incorporates proposals to build capacity in primary care in 2007- 08, concentrating on areas known to be under-doctored, and with sub standard premises, alongside which a target has been set for reducing A&E attendances over the next 5 years. Following audits of emergency admissions at Chase Farm Hospital, the PCT will work with the Trust and community service providers including the provider division to ensure services are in place which will reduce the levels of avoidable admissions. Audit work indicates issues include access to intermediate care and therapy and falls service

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access to be major issues in the health economy. The demand management plans include targets for reductions in emergency medical admissions of 5% arising from this work and the work of the community matrons and intermediate care service.

The wide fluctuations between A&E categories between 2006-07 and 2007-08 are part as a result of coding changes at the A&E department at Chase Farm. Activity previously in 2006/07 coded to minor has been coded to the other two categories in reflection of the actual clinical treatment.

Excess bed day reductions: The PCT will establish targets for reductions in excess bed days, matched by capacity reductions in the acute sector. The impact of this has been estimated at £0.5m in the full year.

18 week referral to treatment The PCT’s detailed plans for achievement of these milestones are set out in a separate plan, which includes detailed activity and financial modelling supporting delivery of the milestones, and risk assessment of the specialities and diagnostic challenges facing the PCT. NHS contracts include the level of additional activity assessed as necessary to meet the milestones.

Independent Sector The PCT will participate in the London North Electives programme for 2008-09. In addition the PCT currently uses the independent sector for certain specialities. It expects the use of these services to be cost neutral as opposed to using NHS providers. Other activity In regards to activity under other programmes, renal dialysis demand will continue to grow between 7-8%. The large rise in GP direct access is a result of Barnet & Chase Farm moving from counting requests in 2006/07 to counting tests in 2007/08.

Summary of non-acute activity commissioned Baseline Year 1 2006/07 2007/08 forecast* Trend (%) Primary Care: GP practice in-hours Consultations1 1550k 1581k 1% GP practice out-of-hours Consultations1 24k 31k 25% Prescriptions Number1 Budget - £36,785k Budget – Number of Items £37,273k 2006/07- 3,166,286 Number of Items 5% 2007/08 forecast - 3,380,236 Optometry Sight tests 46316 50469 7.4% Dentistry Attendances1 449 (UDA +UOA) 444 1% Community and intermediate: Community and social – Attendances1 24 beds at St 14 beds for bed based care Michael’s site admissions & 10 continuing care beds Community and social – Attendances1 I intermediate care I intermediate care community care team team

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Other Attendances1 Mental Health and Learning Disabilities: Community mental health Numbers under care1 6 CMHTs 6 CMHTs Access and crisis Attendances1 435 599 +38% services Clinical services Attendances1 2080 1600 -23% Ambulance: Ambulance services Cases seen1 Covered by London 25,680 contract with LAS Notes 1. Or alternative activity measure *Based on latest actuals plus forecast for remainder of year Clinical services – the accuracy of these figures cannot be guaranteed due to major data quality issues at present

Summary of acute activity commissioned ‘000 Baseline Year 1 Admission 2006/07 2007/08 forecast* Trend (%) Elective day case 22.9 23.9 4.3 Elective ordinary 6.6 7.0 6% Non-elective 31.1 31.4 0.6% Outpatient (new) 81.4 74.6 -8.3% Outpatient (follow up) 202.5 202.3 -0.01% Regular attendee 3.6 3.7 3% Bed days (PICU, NICU, ITU, HDU Critical Care) 9.9 11.4 15% Mixed (HIV and Renal) 1.2 - - A&E Major 24.9 40.7 63% A&E Standard 53.1 25.2 -52% A&E Minor 49.0 64.7 32% GP direct access attendance 1,855 1,919 3% Other *Based on latest actuals plus forecast for remainder of year

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3.10. Internal capabilities

PCT capability strengths commentary PCT Development Plan - Overview of approach being adopted

Prioritisation

Following the assessment and diagnostic phases of the Fitness for Purpose exercise, the PCT has reviewed the priority areas for action through a series of workshops

The overarching objective that Enfield PCT has set for itself is to improve capacity and capability in the key areas of the Fitness for Purpose diagnostic over an 18 month period, leading up to April 2008. Informally, there was a recognition that the PCT development plan was in four main phases, (1) immediate actions/ mitigation plans, (2) preparing for 2007/8 contracting round, (3) consolidating and reviewing, (4) preparing for the 2008/9 contracting round.

Since then the PCT has been in turnaround and now is starting an accelerated developmental process. The previous development plan has been reviewed and updated and the main areas being addressed are finance and commissioning capability and capacity. The PCT has implemented a new management team that has brought in external skills and capacity to support the development programme. The PCT is also aware that good relationship with the London Borough of Enfield has set back in some areas, particularly in relation some adult services and strengthening this relationship is a key objective for the CEO and the Deputy CEO.

The PCT is looking to accelerate commissioning skills to match the world class competencies as defined by the DH. The key commissioning roles are:

Assessing needs, reviewing provision & deciding priorities: assessing the needs of its population, gaining an excellent understanding of its’ expectations and wishes; mapping these against an evaluation of current service provision, including an assessment of the structure of supply and the ability of patients to choose; deciding its local priorities for developing and transforming services

Designing services: in partnership with practice-based commissioners, specifying the range, nature and quality of services to be provided along different patient pathways, in line with the White Paper Our Health, Our Care, Our Say; drawing on evidence of cost-effectiveness and best practice; enabling provider innovation; and reflecting expected capacity requirements to produce service specifications

Shaping the structure of supply through stimulating provider interest, deciding when to go to tender, and by placing contracts. The aims being (a) to promote patient choice and competition between providers - and where not that is not possible, to maximise contestability for supply; and (b) to ensure services are joined-up for patients along pathways, through providers working in partnership. In discharging this aspect of commissioning, the PCT works closely with relevant SHAs and other PCTs

Managing demand for services and living within its cash-limited allocation of resources, particularly through comprehensive system of practice-based commissioners

Contracting and financing – improving contract skills and process including PbR understanding, local pricing; capacity planning and scenario modelling; contract negotiation; contract documentation, monitoring and management; and improving the iterative interface between strategic and Practice Based Commissioning and procurement

Performance-managing providers through contracts to ensure that volume and wider relationships, to ensure contract requirements are met e.g. on national targets, quality and equity of access; and taking systematic account of patient and practice feedback. The PCT also regulates primary care performers.

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The following table shows the key areas of development chosen by the PCT through the prioritisation processes indicated in the Fitness for Purpose exercise.

PCT capability gaps commentary

Accelerated Development Plan

Area of  Objectives  Progress (as of Nov 2007) Development

Finance Capacity  Short-term strengthening of Finance  Full team in place using interim staff and Capability functions with interim staff  Substantive positions to be  Establishing a finance function with advertised in new year when PCT substantive posts future direction clear

 Individual objectives and PDPs will  PDPs complete be completed for all senior staff  Plan in place for phased  Implement all agreed Audit implementation of audit Recommendations recommendations

 Develop detailed Project Plan to  Project plan in draft form Improve ALE scores  SOs , SFIs and SoD to be signed off  Updated SOs, SFIs and the Scheme at the Audit Committee in December of Delegation  Board and SHA sign off in November  Operating plan agreed  Regular Board executive and non-  Develop and deliver financial training executive directors financial briefings and development programmes for in place: need a Board seminar on non-finance leaders financial expertise and expectations

 Review of Financial Reporting  Financial reporting review complete: requirements throughout the budget book to be devolved to and organisation to support decision signed off by budget holders making and delivery of objectives  Financial procedure review underway  Comprehensive review and re- and key processes in place: review instatement of financial processes to be completed by January 2008 and procedures to raise standards, ensure consistency of approach, and improve finance capabilities

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Contracting  Strengthen monitoring and data  Systems reviewed and data Capacity and collection process challenges more robust: data Capability challenges to be better focussed  Develop negotiating style including New structure in place: 0809 early setting of contracting principles commissioning round timetable and and objectives plan in place end November.

 Ensure that PBC is closely integrated  PCT contracts and budget fully to commissioning and negotiating aligned to PBC. Shared priorities for process and that it helps deliver service redesign being worked on clinical engagement with new responsibilities in the procurement team and a stronger  Access appropriate clinical advice focus on PBC Business Case across all professions outputs.

 Commissioning Executive has strong clinical leads in place. New PBC Clinical Leads created and being recruited to by Jan 08.

Strengthen PbC  Develop joint OD programme to  Finance and information requirement and clinical develop the clusters as semi met; new PBC clusters to be in place engagement autonomous commissioners with by January 2008. their own commissioning plans focused in a maximum of 3 areas in  Clinical leads being recruited; PBC each cluster. PBC incentive scheme incentive scheme uptake is high in place  All DH care pathway templates  To appoint 4 clinical directors to work reviewed for local adoption in primary with clusters and help them develop care and either implemented or in ideas, produce business plans and process of rolling out improve clinical engagement.  PBC business processes under  Service redesign/Care pathways review with the new Director of Primary Care and to be strengthen  To work with other clusters in areas within the 3 new clusters of common development priority and a clear process for planning and business case sign off.

Information  Assess information requirements and  New Information Analyst post funded provision in the light of PBC, PPI and in the Finance Directorate and contracting integrated into the procurement team. Finance Directorate  Develop an integrated information management of the LCSS facility that is able to provide detailed established and joint objectives being information on costs, activity and worked up for 200809. quality (by service area, conditions etc) as well as health needs  Non financial informatics on quality assessment, heath intelligence and and performance data being patient experience to support strengthen – AD Performance now commissioning reports to Deputy CEO; new system to ensure Director ownership of  Establish processes for the collection targets and remedial action in place

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and dissemination of data on quality by Jan 08 and patient experience and ensure that there is a strong corporate focus

 Review organisational skills and capacity to deliver these information requirements

Provider  Develop a rigorous performance for  New activity-driven local prices performance all providers including, in house; established and costs re-based management building clear incentives, penalties across Enfield and Haringey and removal of contracts provider-sides Summer 2007

 Acute Services: Model Contract  Provider-side diagnostic self implementation assessment return completed October 2007 and development plan  Develop own terms of business proposals due to be presented to CEO and FD early December 2007  Improve performance reports from trusts  Contract monitoring process with acute trust reviewed and cover all  Value-for-Money (VFM) Framework aspects of quality. Specific meeting re infection control n place.  18-Week RTT  18 week RTT monitoring has been reviewed by the IST who have deemed the PCT processes to be good.

Develop primary  Implement primary care capacity  The PCT produced a strategy to care plan address these issues ‘Care Closer to Home’ and this strategy will be  Improve quality reviewed an refreshed in Q4 20007/08.  Implement five year strategy for primary care

 Develop policy framework for market entry and contestability

Commissioning  Separation of PCT provision and  New Governance Structure in place, non acute services commissioning including a Provider Chief Officer and provider board.  Develop SLA with provider arm identifying clearly objectives and  SLA will be in place for 08/09. PCT targets, including long-term is participating in the London review conditions etc. of community prices.

 Develop options for long-term  Consideration of core business commissioning of in-house services underway. LD services to be and future of provider arm decommissioned in 08/09

 Review contracts for community  To be reviewed as part of contract services external to the PCT round for 08/09

Children services  Develop appropriate commissioning  Children’s commissioner post being

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and service provision arrangements reviewed and regarded. Discussions with Local Authority underway with LBE regarding joint appointment.  Secure adequate clinical advice and skills across all services

Programme Management

Named directors are responsible for key delivery areas; it is their responsibility to ensure that milestones are met, through co-ordination. Most development areas cut across several departments and all directorates will need to contribute to ensure that the plan is delivered. We have constructed a programme to deliver changes in line with our Goals and Initiatives that will also enhance the skills and performance of the organisation See page XXX).

Where we are developing core skills, such as contracting and finance, then we are using a process of planning and reflection on the task required to deliver signed contracts in line with the London Commissioning Regime timetable.

There will be regular meetings to review and progress on the development programme. Quarterly reports will be made to the PCT Board on progress being made on the Development Plan.

4. Goals

Goals commentary Following the PCT’s ‘Bright Future ‘ strategy, which involved consultation with Enfield stakeholders, the strategic priorities were further developed into our medium term plan’ Getting health and Healthcare right for the future’. We recognise the changing demographics and our current financial position have shaped the final priorities and goals in the CSP.

The PCT has made use of a commissioning priorities tool to support the prioritisation of initiatives as part of the Commissioning Intentions process for 2008/9. The scoring tool consists of criterion considered the most important to setting the Trust’s commissioning priorities. The criterion, weighting and scoring is summarised in the table below:

Criterion Weighting Scoring 1-10 Total Score

Clinical Cost Effectiveness 0.25

Finance – Value for Money 0.25

Equity 0.20

Nation Priorities 0.15

Local Priorities 0.15

Scores are totalled and ranked in priority order, which has been debated (challenged or agreed) at the Directors’ Group and ranked by the Executive. The ranking will guide the final decision making in relation to the commissioning intentions aligned to the Operating Plan.

The PCT has considered the setting of its goals carefully, taking into account our local needs and service gaps, our partnership commitment to the LAA, DAAT and Children’s Trust development; the BEH Clinical Strategy and the emerging Healthcare for London Strategy. The PCT also has to deliver financial recovery and make rapid progress towards world class commissioning. At this point in

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time, the identification of our goals is heavily influenced by the PCT’s financial position. We have therefore focussed on examining ourselves against national bench marks and best practice to identify where we can be more efficient.

The BEH clinical Strategy is the main clinical driver for change now that the consultation period has ended. The PCT will also take into account of the emerging framework for World Class Commissioning, and if our medium term financial plan is accepted, then the PCT can be more ambitious in its plans to transform local health care services and improve health.

We have identified six goals that we want to achieve over the next 5 years:

1. Planned (non urgent) care

2. Urgent care

3. Contracting and Procurement

4. Evidenced Based Commissioning (including Prescribing)

5. Community and Specialist Services (including our Provider Division)

6. Staying Healthy- working with our partners

In setting these Goals the PCT has benchmarked itself and identified a number of areas where its commissioning and provisions can be more clinically efficient and cost-effective.

Prescribing- Comparing ourselves with the PCTs in London using actual cost per Astrou-PU (Age, sex, temporary resident originated- Patient Unit) Enfield comes in at £30.23 per head of population compared with the London average of £28 per head and best performance PCT at £22.99 per head. For each £1 per head we reduce costs we will save approximately £1m.

Urgent Care-spending approximately £1million per annum more than best practice on unnecessary hospital admissions.

Surgery rates- undertaking surgical procedures where other treatment options could be offered. Adverse cost impact £0.5m pa

Outpatient referrals- spending some £3-5 million per annum more than best practice on the number of hospital referrals.

Excess bed days- spending between £1.5million and £2million per annum on patients exceeding the number of pre-determined bed days for their treatment (judged against national tariff expectations).

1. Planned (non urgent) Care: Patients will receive appropriate, safe and high quality services increasingly delivered within primary care in a more local setting improving access and convenience. This will result in a 25% shift of work currently taking place in secondary care transferring to a primary care setting.

Other indicators of success include:

 Planned referrals to secondary care where patients require more specialised opinion and treatment. Secondary care consultants detailing the care/treatment programme for GP’s to manage the ongoing care of the patient. This will enable the majority of follow up appointments to be held in the community with the primary care teams. This will avoid unnecessary patient journeys to hospital.

 Patients will be given appropriate information at all stages of their referral

 Patients will wait a maximum week of 18 weeks from referral to treatment

To achieve the goals we will implement the following actions:  Creating appropriate care pathways that allow best practice services to be delivered

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 Defining consistent referral practices across Enfield PCT in line with agreed clinical protocols

 Increase follow-up outpatient appointments in the community and reduce those in the acute sector

 Increasing hospital and GP choice for patients and developing closer links with the independent sector

 Encouraging the procurement of appropriate clinical services that meet the agreed care pathways, including locally based diagnostics

Goal 2. Urgent Care: Patients will receive appropriate and prompt treatment 24/7 for their urgent health needs from a range of health and care services. At least 25% of A&E attendances to be seen in co-located urgent care centres. A reduction in unnecessary hospital admissions of 5% in General Medicine, Elderly and Accident and Emergency.

Other indicators of success include: Patients with known conditions are managed within a personalised pathway that supports self care and avoids unnecessary unscheduled admission to hospital.

To achieve the goals we will implement the following actions:  Designing and introducing urgent care centres to assess patients and avoid unnecessary admissions through Accident and Emergency

 An urgent care centre at the front of each A&E department in Enfield. Access to A&E for walk in patients will be through the Urgent Care Centre, where patients will be seen to determine the appropriate course of treatment.

 Providing proactive care for people with complex needs and long term conditions

 Enhancing the Single Point of Access Service – (a signposting service that ensures that patients are treated in the right setting)

 Developing Rapid Response teams based in the community

 Developing local Community Clinical Assessment and Treatment Units

 Ensuring patients are hospitalised for only as long as is necessary by improving discharge planning.

Goal 3- Contracting and Procurement- To ensure that we manage our healthcare providers effectively to get the ‘best’ out of our contracts and ensure that we are only paying for the patient services that Enfield PCT requires.

Other indicators of success include:  Effective contract negotiation strategy for 2008/09 to deliver signed contract by February 2008

 To establish robust procedures whereby we can challenge as necessary the information that our providers give us

 Effective procurement process in place to support changes in clinical pathways

To achieve the goals we will implement the following actions:  Reviewing provider data for accuracy

 Ensuring that patients belong to a Enfield PCT GP

 Ensure data is coded accurately

 Encourage patients to register with a GP in the Borough where they live

 Review treatments to ensure correct diagnosis and to ensure they are delivered in the right setting, within agreed protocols and pathways

 Working jointly with providers to rectify invoice errors and to improve quality of the information

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 Local prices are validated

Goal 4. Evidence Based Commissioning (including Prescribing): To ensure that high quality, cost effective services are provided to Enfield patients. To reduce our Astro-PU* (Age, sex, temporary resident originated-Patient Unit) from £30.23 per head of population 07/08 by £1 per head to bring the PCT more in line with the London average of £28 per head.

Comparing ourselves with the PCT’s in London using actual cost per Astro- PU*(Age, sex, temporary resident originated-Patient Unit) Enfield comes in at £30.23 per head of population, compared with the London average of £28 per head and best performance PCT at £22.99 per head. For each £1 per head we reduce costs we will save approximately £1m. Astro - PU explain part of the differences in prescribing cost, but they are not accepted to be a perfect quality marker. Inclusion of deprivation factors, mobile population and ethnicity would be necessary when attempting to make comparison. To compare with London average is sensible, but the aspiration to be the lowest is not appropriate. Prescribing that is cheap may be due to failure to ascertain patient needs, and increasingly adherence to NSF and NICE guidelines is leading to increased expenditure.

In Enfield the current cost of an ASTRO PU shows a reduced rate of increase. This is a better situation than others whose costs are rising at such a rate that they may well outstrip expenditure.

To achieve the goals we will implement the following actions:  Work with clinicians encouraging their pursuit of local aims for prescribing

 Devolve to the Practice Based Clusters the responsibility for managing the prescribing budgets. They will work with their constituency practices to get best value

 Continue the incentive scheme approach, designed to improve prescribing practices

 Collaborative working with secondary care to develop care pathways and managed introduction of new drugs in primary care

 Provide funding for new developments identified by NICE working within PCT priorities

 Publish bulletins to GPs to update them on new information

 Continue to review the PCT drug formulary on an ongoing basis and seek to identify alternative supply mechanisms e.g. dressings and catheters

Gaol 5. Community and Specialist Services (including our Provider Division): To offer our patients a wider range of quality services by improving productivity and meeting the needs of the revised care pathways. Services will be delivered consistently across Enfield PCT e.g. in rolling out the Gold Standard Framework we would expect there to be 20% increase in deaths at home and in the case of pulmonary rehabilitation in the community a 50% reduction in admissions for moderate to severe COPD. Other indicators of success include:

 Efficient services that are customised to meet the patient needs

 Clearly defined clinic based and other services with available information on costs of the service

 Quality care for patients in our community hospital and intermediate care services with the aim of getting patients back to their home and community settings as soon as is appropriate.

 Supporting vulnerable patients in nursing and residential homes to avoid admission to hospital

 Increasing support for ‘home’ based palliative care services

To achieve these goals we will implement the following actions:  Community Based Services – including rehabilitation (stroke services; Pulmonary rehab); palliative care and community matrons

 Joint working with the local authority on adult services, particularly mental health and learning disabilities, and on integrating

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children’s’ services.

 Inpatient and intermediate care services – developing high quality inpatient care with the goal of getting patients back into their communities as soon as possible

 Support Services – The provision of high quality, flexible responsive services that deliver consistently for commissioners and represent best value for money.

 Create a multi skilled workforce who can undertake many clinical roles

Goal 6. Staying Healthy- We will maximise our resources with the Local Authority to ensure that we provide effective programmes that would enable people from Enfield to make healthy life style choices.

Other indicators of success include:

-Ensure that we are getting the very best value and best programmes for our population by supporting evidence based programmes

-Focus on providing services closer to home

-Focus on ensuring health issues are considered in the planning and development opportunities across Enfield.

To achieve these goals we will implement the following actions:

· Working closely with our partners in other health organisations and in Local Authorities to ensure that as much as is possible we keep services close to home and as accessible to patients as possible.

· Work with the Local Authority and partners to ensure a focus on health within the Local Area Agreement.

· To continue to develop and improve access to information and services such as smoking cessation, nutrition and physical activity, sexual health, alcohol and mental health promotion.

· To improve uptake in the range of cancer screening services and other screening programmes including immunization programmes.

See Appendix A for the Public Health Action Plans for 2007-2008.

BEH Clinical Strategy

On the 11 December the Barnet, Enfield and Haringey Boards to the decision to implement the BEH Clinical Strategy, which went out for extensive consultation. The BEH Clinical Strategy forms the main focus of service Development/Redesign over the life of this plan, along with the initiatives contained in Goal 5 and the LAA focus of Goal 6. The table below is an extract from the Programme Brief (shown in full as an appendix 4), it articulates the Vision and the Blueprint for future service provision.

Barnet PCT, Enfield PCT and Haringey TPCT have jointly developed a vision for a future model of health care in collaboration with providers and partners to service the needs of local residents.

The Vision of the BEH Clinical Strategy is:

Safer, Closer, Better Health Care Safer care through more consultants available 24/7 Close to home through more services based in the community or delivered in people’s homes Better through earlier help and support with long term health conditions

that are affordable and sustainable.

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The Blueprint is a forward look at what the local health provision will look like when the programme has been delivered. It essentially sets out the new capabilities that will have been delivered by the programme. The table below shows a summary of the services to be provided in the future model for local health services. Appendix D provides details of the BEH clinical Strategy.

Blueprint for future local health Barnet North Chase Farm Primary Care provision Middlesex

A & E with GP service, including Increased Increased Local A&E2 Increased Urgent Care Centre Capacity Capacity min.12 hrs per day Capacity

Emergency admission activity Increased Increased No N/A Capacity Capacity

Rapid Assessment - Elderly Continued Continued Continued N/A service service service

Intensive Therapy Unit Minor increase Minor increase No (Surgical N/A HDU)

Routine inpatient surgery3 Some Some Increased N/A reduction reduction Capacity

Full Maternity Services Increased Increased Potential N/A Capacity Capacity Midwife led Birthing Unit

Full Paediatric Services Increased Increased Assessment N/A Capacity Capacity unit

Day Surgery Continued Continued Increased Minor Surgery service service Capacity2

Outpatients Some Some Some Increased Reduction Reduction Reduction Capacity

Diagnostic Services Continued Continued Continued Increased service service service Capacity

Increasing in Reducing in Key to shading: scale scale

2 Integrated with GP Out of Hours services 3 Subject to further review

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Baseline Year 1 Year 2 Year 3 Year 4 Year 5 position

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Goal 1: Planned Care- Non urgent Measure New & Follow up 283.9 (6.6 ) (115.3) (28.8) (29.2) OP attendances (‘000) Measure Elective Daycase 22.9 (0.2) (0.2) (0.2) (0.2) spells (‘000) Goal 2: Urgent Care Measure Non-Elective 31.2 (0.4) (0.9) (1.3) (1.8) Spells (‘000) Measure A&E attendances 129.6 (6.3) (13) (20) (27.3) A&E front End Strengthen 5% reduction in case admissions for: managem Heart failure 239 admi 5% 5% 5% 5% 5% ent COPD 249 admi Reduction Reduction Reduction Reduction on Reduction on Parkinson’s 16admi4 on 06/07 on 07/08 on 08/09 09/10 outturn 10/11 outturn Disease outturn outturn outturn Increased 50% increase in 50 55 60 65 70 75 capacity in admissions ICT avoided Goal 3: Contracting and Procurement Measure Contracts Agreed 100% 100% 100% 100% 100% 100% Measure All acute patient 40% 50% 60% 70% 80% 90% activity validated Goal 4: Evidence Based Commissioning (including Prescribing) Measure Prescription Cost (36,785) -2.9% -3.2% -3.4% -3.6% (% reduction in£) Measure £Cost per Astro- 30 29.1 28.6 28.3 28.1 27.9 PU Goal 5: Community and Specialist services (including our Provider Division) Roll out 20% increase in 1339 1405 11471 1537 deaths 1603 deaths 1605 deaths GSF deaths at home deaths at deaths at deaths at at home at home at home (266 deaths at home home home home in total) Pulmonary 50% Reduced 656 574 492 410 350 328 Rehabilitati admissions for emergency emergency emergency emergency emergency emergency on in the moderate to admissions admissions admissions admissions admissions admissions community severe COPD Goal 6: Staying Healthy – working with our partners

4 Parkinson’s Disease is likely to be highly underreported as it is often not viewed as the primary reason for admissions but may be the underlying cause for admissions

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Reduce Baseline 94.5 90 81 75 74.5 74 heart and 96.8 per 100,000 stroke (CVD) mortality for persons under 75yr in line with LDP Reduce 28% 26% 25% 23% 22% 21.5% 21% smoking prevalenc e for the population as a whole by at least 8% Increase Baseline 110 285 400 the 66 number of Turkish Cypriots and Kurdish residents who are 4 weeks quitter by 2009 Halt the Baseline 17.5% 17% year on 17.5% year increase in obesity year 6 and reception classes

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5. Initiatives

Drivers for the development of service changes

The national drivers for the initiatives to be implemented include the strategic driver for NHS organisations’ roles and responsibilities as described in Commissioning a Patient-led NHS. The CSP acknowledges the changes needed within the NHS, to its culture and systems so that it becomes truly patient-led with a greater emphasis on health promotion and prevention as well as dealing with sickness and injury. It also supports building of new arrangements to improve quality, patient safety and leadership of networks to support integrated approaches for innovation, service development as well as new and different models for service provision.

In our local health community, the PCT’s view is that the best way to achieve the right balance between hospital and community services and improving health services for people in Enfield is to improve GP services and community services. The BEH Clinical Strategy, our strategic objectives contained within the CSP and partnership working with the LBE on the LAA, Adult and Children’s services.

The PCT’s commitment is to invest £10M in new primary care services over the next 5 years. The PCT is reviewing its investment strategy in line with the preferred option 1 of the BEH strategy and to ensure synergy with the emerging Health Care for London strategic direction. This primary care strategy will indicate the priorities fro investment to develop a Chase Farm co-located urgent care centre and the ‘hub and spoke’ model for extended primary care delivery in Enfield. Collaborative Commissioning Initiatives

Enfield PCT is committed to working with the other PCTs within the North Central London (NCL). The process of deciding the collaborative initiatives have been made by the North Central London Collaborative Commissioning Group (NCLCG) that comprises of Chief Executives and Directors of Commissioning from each of the 5 PCTs in the sector. It oversees a number of working groups and networks that have delivered a range of collaborative initiatives in the past.

The NCLCG’s vision for the residents of North Central London is that by 2012 they will have access to world- class healthcare wherever they live in the sector. The NCLCG has identified 4 main areas for collaborative initiatives to fulfil the 6 strategic objectives.

The PCT will work with North Central London Sector partners, through working groups and networks that are overseen by NCLCG to develop the four agreed initiatives in the phased approach to improving healthcare locally in the next 5 years:

 Cancer- the quality and disposition of services particularly in Urology, pancreatic and breast cancers and to include redesigned care pathways and more care, where appropriate, closer to home.

 End of Life care- to provide End of Life Care that is NICE complaint and fit for purpose. During the first year of the initiative the End of Life strategy will be broadened to include non-cancer patients such as those with cardiac disease. See Goal 5 Community & Specialist Services (including our Provider Division)

 Urgent Care – in particular to develop a stroke pathway model in the first year that will be delivered in future years including other aspects of urgent care. See Goal 2 Urgent Care

 Renal: to review and agree the future sector wide requirements for renal dialysis facilities and plan distribution/organisation of new developments.

We will also continue to work towards the 5 public health priorities for the sector that are:

 Smoking cessation  Addressing obesity

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 Immunisation uptake, especially MMR  Increasing screening uptake (cancer, antenatal, identifying high blood pressure, diabetes and high blood lipids via GP practice registers)  Addressing alcohol and drug misuse

More details about the sector’s 6 shared strategic objectives/goals, the initiatives and how they will be achieved are provided in the North Central London Collaborative Commissioning Initiatives 2007/8-2011/12. The initiatives outlines in the CCI are ‘work in progress’ and is a ‘live document that will be refined over time as the NCLCG’s vision becomes more focused through the various working groups.

The recent framework for health care in London will impact on the initiatives that will be implemented. Future versions of Commissioning Strategy Plan and the Collaborative Commissioning Initiatives will be informed by the result of the pan-London review work, Healthcare for London ‘A Framework for Action’, consultation, which will start on 30 November 2007 and be completed in February 2007. We will need to take into account the outcomes of the 5 areas identified by Healthcare for London i.e. stroke, major trauma, unscheduled care, polyclinics and local hospital feasibility. Stakeholder engagement

The PCT has developed a communication action plan that is linked to the PCT’s Communication strategy that will shortly be approved by the Trust Board see Appendix C.

Stakeholders are engaged with the PCT in a number of ways and have been over a period of time since 2004. From late 2004, Enfield PCT consulted with local residents, GPs, hospital consultants, patients, carers, other healthcare workers and the local authority. This joint work led to development of the 5 year Bright Future Strategy for Enfield. Further consultation occurred during 2006 that involved the health and social care community to take into account service reconfiguration across Enfield and the Government White Paper ‘Our health, our care, our say’. This led to the development of the projects in the Integrated Service Improvement Programme (ISIP).

The PCT (along with Barnet and Haringey PCTs) has just completed a very large public consultation on the BEH strategy, which is a major plank of the CSP.

The PCT has a Patient and Public Involvement officer employed to undertake patient and public involvement. A Patient Reference Group was also established to review and comment on the projects developed under ISIP.

There are regular press releases and the PCT is a key partner in the Community Engagement day led by the Local Authority as part of the Community Strategy, which includes a joint consultation on Care out of Hospital that reflects the PCT CSP.

The stakeholder engagement with the CSP so far has been:

1. Practice Based Commissioning Workshops on 18 July and 6 September 2007, the second workshop included representatives from acute trusts. The comments received from these have been worked into the CSP and form the basis of specific action plans at cluster and PCT level. Practices endorsed the PCT’s key goals and in addition resolved to take forward work on patient information and self care.

2. At the Patient Reference Group meeting on 5 September 2007, they considered an overview of this 5-year strategic plan. Users strongly supported the commitments to developing capacity and capability in primary care and specifically to commissioning diabetic retinopathy. At the Patient Reference Group meeting on 21 November 2007, members were updated on the changes to the Commissioning Strategy Plan and advised that they would be able to provide their views on the CSP following Board approval.

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Additionally, stakeholders will also be consulted on Healthcare for London A Framework for Action from November 2007 to February 2008 as part of the London wide consultations. The result of this will be taken into account in next year’s updated CSP.

More details are provided under each initiative in Appendix B

Initiative 1 (Details are provided in the Appendix B).

Please complete this section separately for each significant initiative.

5.1. Description and prioritisation against health outcomes, inequalities and strategic goals

Initiative description

Initiative impact and prioritisation against health outcomes, inequalities and strategic goals

5.2. Initiative capital requirements

Initiative capital requirements description

5.3. Impact of initiative on quality and outcomes

Description of impact of initiative on quality and outcomes

5.4. Impact of initiative on activity levels

Description of impact of initiative on activity levels

5.5. Impact of initiative on commissioning cost

Description of impact of initiative on commissioning cost

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5.6. Stakeholder engagement and risk

Stakeholder engagement commentary

Initiative risk Risk Severity Likelihood (%) Mitigating actions

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6. Overall Impact

6.1. Impact on quality, health outcomes, and inequalities

Overall impact on population health commentary Life expectancy in Enfield compares favourably with both London and England and is expected to continue to do so. In addition to the specific initiatives set out in this Plan, challenging local targets for both smoking and CVD have been set as part of the Local Area Agreement. The implementation of these initiatives will develop new models of care across the health economy with a focus on prevention, earlier treatment and treatment closer to home, and will prioritise primary and community developments in the areas of highest need in the PCT.

Impact on increasing quality and health outcomes Performance management with a focus on increasing quality and improvement of health outcomes will be a continued focus of the PCT. This will include regular monitoring of progress against the Local Development Plan, national targets and benchmarks and clinical governance systems. Where there are indications that population health is an outlier this will continue to be monitored and appropriate action taken. There will be a particular focus on monitoring core standards and ensuring that these are maintained.

Outcomes for patients will be:

 Patients will be treated on evidence based pathways

 Patients will be able to access a network of Urgent Care Centres in Enfield that will provide improved access. Each centre will operate with extended hours. Urgent Care Centres will be part of primary care services, staffed by GPs, hospital clinicians and nursing staff and integrated with acute services. Clinical staff will work in rotation across the urgent care centres and A&E’s to ensure clinical skills and developed and maintained.

 Improved prescribing to ensure that cost effective choices of appropriate medications will be provided to patients when their clinical condition requires. E.g. the prescribing of non-branded or ‘generic’ drugs where possible or the prescription of a lower cost drug to reduce cholesterol.

 Community Based Services – patients will be able to access standardised Community Based Services. The services will be provided through integrated teams comprising health and social care professionals. Home visits will be tailored to provide for those with appropriate needs and other services will take place at community hospitals or GP surgeries. Multi agency services will be provided across adult, children and family services using existing facilities.

 Inpatient/intermediate care Facilities – patients will be able to access high quality inpatient facilities where there is need. These services will be community based maximising the use of our community infrastructure. They will support the discharge of patients from the acute sector as well as provide appropriate rehabilitation prior to discharge to home or community settings.

 Multi skill our workforce creating flexibility and responsiveness to needs e.g. opportunistic screening and immunisations

 Support Services – improve clinical services to patients/clients through them being better supported by

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responsive, effective support functions.

 Integrated services able to respond to multiple patient needs e.g. housing, benefits advice etc.

Impact on reducing health inequalities

Enfield’s overall good health masks inequalities in health between the most and least affluent parts of the borough i.e. (often) between the northwest and the southeast. The initiatives in the CSP are intended to reduce these inequalities by moving resources to more deprived areas and by targeting resources more effectively towards vulnerable populations. As a result we expect our populations to

 Make more healthy life style choices contributing to improved life expectancy and quality of life.

 Make more healthy life style choices with a positive impact in managing long term conditions.

 Uptake of screening services leading to early detection and treatment of certain health conditions.

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6.2. Impact on activity

This section of the CSP will be completed once the PCT’s 2007-08 operating plan and financial recovery plan have been agreed with NHS London, which will enable financial and activity modelling for the next five years to be completed

Non-acute summary

Baseline Expected annual growth rates Projected Impact of initiatives on activity Projected position position Year 0 Incidence Population Overall Year 1 Year 2 Year 3 Year 4 Year 5 without with initiatives initiatives

2006/07 (%) (%) (%) 2011/12 2007/08 2008/09 2009/10 2010/11 2011/12 2011/12

Primary care:

GP practice Consultations 1444 0.85 2,171 2,171 in-hours (000)1

GP practice Consultations 9 0.85 14 14 out-of-hours (000)1

Prescriptions Number of 3,166 0.85 4,761 4,761 items (000)

Optometry Attendances 46 0.85 69 69 (000)

Dentistry Attendances 453 0.85 681 681 UDA’s (000)

WIC Attendances1 12 0.85 18 18 (000)

Community and intermediate:

Community Attendances1 130 0.85 141 195 and social – bed based care

Community Attendances1 141 0.85 212 212 and social – community care

Other Attendances1

Mental Health and Learning Disabilities:

Community Numbers 1.5 0.85 2.269 2.269 mental under care1 health

Access and Attendances1 0.62 0.85 0.93 0.93 crisis services

Asst. & Admissions 16 0.85 24 24 treatment LD beds

Clinical Attendances1 2.012 0.85 3.025 3.025 services

Ambulance:

Ambulance Cases seen1 25.906 0.85 38.596 38.596 services

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1. Dentistry- reduced number of UDA’s in 2007/08 due to contract reductions due to underperformance in 2006/07

2. WIC- only 1 months robust data in 2007/08 therefore this may be an inaccurate forecast. Quarter data for 2006/07 was not reliable.

Acute summary

‘000 Baseline Expected annual growth rates Projected Impact of initiatives on activity Projected Financial activity activity impact of Year 0 Incidence Population Overall Year 1 Year 2 Year 3 Year 4 Year 5 without with activity initiatives initiative change

Admission 2006/07 (%) (%) (%) 20011/12 2007/08 2008/09 2009/10 2010/11 2011/12 2011/12 (£’000)

Elective day 22.9 0.85 23.8 - (0.2) (0.2) (0.2) (0.2) 23.6 185.2 case

Elective 6.6 0.85 6.6 - - - - - 6.6 0 ordinary

Non-elective 31.2 0.85 32.5 - (0.4) (0.9) (1.3) (1.8) (30.7) 3,206.8

Outpatient 81.4 0.85 84.9 - (1.9) (2.6) (3.1) (3.5) 81.4 292.2306.3 (new)

Outpatient 202.5 0.85 211.2 - (4.7) (12.7) (25.7) (25.7) 185.6 2423.5 (follow up)

Regular 3.6 0.85 3.7 - - - - - 3.7 - attendee

Bed days 9.9 0.85 12.3 - - - - - 12.3 - (PICU, NICU, ITU, HDU Critical Care)

1.2 8% renal 0.85 1.9 - - - - - 1.9 - Mixed (HIV and Renal)

A&E Major 40.5 4.15 0.85 51.8 - - - - - 51.8 -

A&E 24.8 4.15 0.85 31.7 - (1.0) (2.1) (3.2) (4.4) 27.3 365.2 Standard

A&E Minor 64.3 4.15 0.85 82.2 - (5.3) (10.9) (16.8) (22.9) 59.2 1439.8

GP direct 1855.4 11% 0.85 3261.6 - - - - - 3,261.6 access attendance

6.3. Impact on provider landscape

Overall implications on provider landscape There will be 4 key influences on the development of the Provider landscape:

 Achievement of Financial stability

 Implementation of the preferred option of the Barnet, Enfield and Haringey Clinical Strategy

 Enfield primary Care Investment Strategy

 Healthcare for London consultation

The Primary Care Investment Plan is our 5 year local implementation plan which aims to provide people with more choice over the care they receive in the community and facilitate closer working together between health and social

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care. It encompasses the following;

Primary Care – fewer, larger practices, with a plurality of providers. Urgent care services will be delivered from primary care centres 7 days a week by a workforce with a broader range of skills than at present, particularly in terms of the role of urgent care nurses and other practitioners. We want to invest £10milion in primary and community services over the next five year’s so that we can deliver our vision for Care Closer to Home in Enfield and to address the remaining gaps. We are looking to develop 2 new primary care centres in Enfield by2010/11; new centres where GPs and hospital specialists working alongside one another on the Chase Farm and North Middlesex University Hospital sites with access to the full range of diagnostics (2011/12).

In line with ‘A Framework for Action’ to gain improved services, then large, high quality community facilities are required, providing a much wider range of services that is currently being provided by most GP practices. The proposal is to call these facilities polyclinics where most routine healthcare needs are met. GP practices will be based at polyclinics, but the range of services available will far exceed that of most existing GP practices. They will offer access to antenatal and post-natal care, healthy living information and services, community mental health services, community care, social care and specialist advice all in one place. They will provide the infrastructure (such as diagnostics and consulting rooms for outpatients) to allow a shift of services out of hospital settings. They will be where the majority of urgent care centres will be located. They will provide the integrated one-stop-shop care for people with long term conditions.

Community services – greater plurality of providers including third sector; services such as rehabilitation and stroke will be delivered by integrated health and social care teams

Acute services – out patient and diagnostic services will be delivered in primary care as well as hospital sites. The PCT will commission fewer hospital based services and more in the community. Community based services may be delivered by clinicians currently working in hospitals, or may be delivered by new providers. We expect that there will be specialist centres for stoke and cancer. We will be reviewing the provision of Diabetes services across Enfield.

Mental health services - in patient acute services will be delivered in borough for Enfield users and there will be a greater plurality of service provider for community and primary care mental health services, particularly psychological therapies. There is likely to be a rebalancing of services away from acute in patients and into community based specialist and primary care teams.

Other Developments- There are other developments that are not covered by the Primary Care Investment plan, but will be occurring, for example over the next few months the PCT (in partnership with Social Services where appropriate) will be developing five year service improvement plans for:  health improvement – helping people to choose healthier life styles and improving screening services

 mental health – community based services for all people and specialist services for children & young people and older people

 alcohol and drug services

 end of life services

6.4. Impact on finance

Summary of financial impact Baseline Projected Financial Projected position impact of position without initiatives including initiatives initiatives

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£’000 2006/07 2011/12 2011/12 Income Recurrent revenue allocation 362,134 469,378 469,378 Non-recurrent revenue allocation 4,418 9,275 9,275 Other income (excluding income from provider activities) 5,990 8,056 8,056 Total income 348,537 454,611 454,611 Expenses Commissioning activities: Primary and community (85,823) (116,525) 1,347 (115,301) GPs (33,904) (45,277) (45,277) Prescribing (36,785) (51,648) 1,347 (50,301) Dentistry (10,545) (15,670) (15,670) Optometry Other primary and community (4,589) (4,053) (4,053) Community and intermediate services Mental health and learning disabilities commissioning, (54,007) (65,855) (65,855) pooled arrangements or jointly funded commissioning (e.g., s28 or s31) Provided by Mental Health Trusts (32,135) (36,575) (36,575) Other (21,872) (29,280) (29,280) Secondary and tertiary (136,370) (176,703) 7,926.7 (168,777) Secondary and tertiary non-recurrent Secondary and tertiary recurrent (136,370) (176,703) 7,926.7 (167,777) Elective day case (15,128) (18,404) 185 (18,219) Elective ordinary (13,621) (15,649) - (15,649) Non-elective (49,021) (59,457) 3,206 (56,251) Outpatient (new) (12,820) (15,549) 306 (15,243) Outpatient (follow up) (16,332) (19,809) 2,423 (17,385) Regular attendee (1,364) (1,655) - (1,655) Bed days (PICU, NICU, ITU, HDU Critical Care) (7,064) (9,940) - (9,940) Mixed (HIV and Renal) (5,987) (10,669) - (10,669) A&E Major (4,011) (5,962) - (5,962) A&E Standard (1,760) (2,617) 365 (2,251) A&E Minor (3,470) (5,158) 1,439 (3,718) GP direct access attendance (5,788) (11,831) - (11,831) Other - - - - Ambulance services (7,109) (8,587) - (8,587) Other (33,943) (39,230) - (39,230) Total cost of commissioned services (317,253) (407,294) 9,273 (398,020) Provider activities:

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Pay expenditure (20,608) (21,208) (21,208) Non-pay expenditure (10,748) (11,061) (11,061) Less - provider income 8,583 5,807 5,807 Net provider costs (22,773) (26,462) (26,462) Other costs

Other pay expenditure (14,152) (17,015) (17,105) Other non-pay expenditure (7,431) (4,509) (4,509) Depreciation and amortisation Exceptional items Total other costs (21,584) (21,525) (21,525) Total cost (361,610) (455,821) 9,273 (446,007)

PCT surplus/deficit in year (13,073) (670) 9,274 8,604

PCT normalised position (excluding exceptional (13,073) (670) 9,274) 8,604 items)

Carried forward deficit (4,706) 4,706 -

PCT normalised position including carried forward (13,073) (5,376) 13,980 8,604 deficit

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7. Implementation and monitoring

Initiative implementation commentary NHS London has agreed with the PCT that the CSP will be complete with finances and activity information once the operating plan for 2007/08 and associated financial recovery plan are agreed. This is not expected before the end of October.

Our Fitness for Purpose review and the ongoing work being monitored by the Finance Committee (more details provided below) have indicated that the PCT needs dedicated project and programme management for the development of the PCT commissioning initiatives.

The initiatives will have a direct impact not only on the wider health community but also on our integrated programme with London Borough of Enfield. The implementation of the initiatives and hence the timing of their impact is dependent on the agreement made with NHS London. Once this is clear, a review of the initiatives will take place, including looking at the prioritisation and the best method in which to carry this out.

This work will also take into account the following:

 Outcome of the BEH Clinical Strategy and the implications of the preferred option on the shift of service provision from hospital to primary care. This is due to be completed on 19 October with the report due in December 2007

 The outcome of the Healthcare for London consultation that is due to take place from November 2007 to February 2008

 Outcome of EPCT consultation on CSP initiatives that are the PCT’s primary investment care plan

 The new LAA

Our CSP has to be flexible enough to incorporate the outcomes of the above as these will also effect the implementation of agreed initiatives.

Capabilities commentary As already stated in section 3.10, one of the areas requiring strengthening was financial management and it is our priority goal over the next two years. The Finance Committee was established as a committee of the Trust Board and its purpose includes: a. Keep under review the financial position of Enfield PCT.

b. Consider and review the Finance Report to be presented to the Board, incorporating financial performance against budget, risk analysis and forecasts.

c. Provide assurance to the Audit Committee and the Board that the systems for financial reporting to the Board, including those of budgetary control are subject to review as to completeness and accuracy of the information provided to the Board.

d. Consider and review progress against the Turnaround Plan incorporating performance against plan; key issues and risks and development of Plan B.

e. Annually, the Committee shall consider the Strategic and Operational Financial Plans and review the soundness of the underlying assumptions.

f. Receive exception reports issued to SHA London each month and the cumulative log of all reception reports made.

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g. Ensure that the Turnaround Report is consistent with the Finance Report.

Representation on this Board includes the Chairman of the PCT (Chair); Chair of the Audit Committee, Chief Executive, Director of Finance, Turnaround Programme Director and any other person as designated by the Committee. All Directors have a designated responsibility for projects under Turnaround and CSP initiatives.

The PCT commissioners will be monitoring the performance of Mental Health initiatives through its contracts.

Milestones commentary As previously mentioned it is difficult at this stage to confirm the phasing of all the initiatives, here is a proposed timetable: The implementation of the initiatives that require new investment may vary from that provided below once the contracting process has been completed by the end of March 2008. It is expected that the PCT’s Trust Board meeting in May 2008 will finalise the phasing of these.

Project Description 2008/9 2009/10

Q1 Q2 Q3 Q4 Q1 Q2 Ongoing

s 1. Planned Care e v i t

a 1.1a Urology Pilot i t i n I

1.1b Dentistry Pilot t n e 1.1c Ophthalmology Pilot m e g

a 1.1d Gynaecology Pilot n a M

1.1e Paediatric Pilot d n

a 1.1f Anticoagulant Monitoring m e

D 1.1g Phlebotomy services in the Community

1.2 Musculo-skeletal

2. Urgent Care

2.1 Primary Care Front End A&E

2.2 Admission avoidance (case mgt)

2.3 Increasing capacity in Intermediate Care Team

5.8 Continuing Care

3. Contracting & Procurement

3.1 Contracts data Validation - shared services

3.2 Out Patient Follow up Ratios

5.4 Development of PC Mental Health Scheme

5.5 Recommissioning LD

5.6 Integration of Children’s services with LBE

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4. Prescribing/Evidence Based Commissioning

4.1 Improve quality and effectiveness of prescribing

4.2 Ongoing development of care pathways

5. Community Services

5.1 Community Rehab - Stroke

5.2 Pulmonary Rehab

5.3 Palliative Care

5.7 Sexual Health/ GUM

6. Staying Healthy

6.1 Obesity n g

i 6.2 Community development- health trainers s e d

e 6.3 Pharmacy healthy lifestyle screening R / t

n 6.4 Stop Smoking initiative e m

p Sexual health -chlamydia screening o l 6.5 programme e v e

D 6.6 Diabetic Retinopathy screen

v BEH Clinical Strategy Implementation r e

S 1 Planned Care

Review of Needs

2 Urgent Care

Full Business Case

3 Children & Family

Full Business Case

4 Primary Care Strategy

London Polyclinic Pathfinder Bid

Project Initiation/Planning Project Implementation

Monitoring and progress management commentary

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National targets, including 18 weeks RTT, will be monitored through the Performance Management Group and reported regularly to the PCT Board.

The ability to collect robust data remains an issue in the NHS, but the ability to use Connecting for Health and IT technology to improve the delivery of initiatives and monitor impact will be significant.

The PCT has carried out the following to improve collection of robust data:

 Rolled out PUMA project

 Implement Rio across community services

 Implementation of CHOICE and the booking process through SCAS

The PCT has invested in additional capacity to establish a Programme office headed by a dedicated Programme Director. The programme office will become the ‘information hub’ for an accelerated development programme that will deliver the overall vision and the outcomes articulated in this Strategy commissioning plan.

Implementation Structure

The implementation of the programme will be monitored by the Performance Committee acting as the CSP Programme Board. Operationally the programme board will reside with the Directors Team. This board will be serviced by the programme office with advise from and a programme surety group (consisting clinical/finance/HR/performance specialists) providing project/programme quality assurance at specific points in the initiative life cycle. The PCT structure to support the implementation of the CSP is set out below:

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Enfield PCT Board

Performance Management Committee

Programme Surety Operational Programme Office Team Programme Board

(Directors Team)

Delivery Programmes

Planned Urgent Care Contracting Evidence Based Community & Staying (non urgent & Commissioning Specialist Healthy care) Procurement Services Director of Director of Corporate Chief Operating Director of Primary Nursing & Medical Director Director of Officer Public Health Care Governance Finance

Each of the CSP Goals have been defined as a delivery programme, each with a programme sponsor at Director level accountable and responsible for the delivery of their programme. Each delivery programme will have a Programme Manager at Assistant Director level or equivalent who will be responsible for the coordinated delivery of the initiatives nested within each goal/delivery programme.

Each initiative will be assigned a project/delivery manager to ensure effective delivery and benefit realisation. All programme/project staff will deliver within the corporate standards set by the Programme Director and Programme Office.

High level implementation time lines have been produced as part of the development of this plan, the production and agreement of detailed local plans, for each initiative is being developed inline with our new corporate standards and approval processes.

Initiative Monitoring

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The emphasis will be on integrating the initiatives into the existing performance framework of the PCT whilst ensuring a focus of effort and resources to enable the successful delivery of the initiatives and the efficiency gains that some will produce. The initiative delivery process from approval to benefit realisation will be driven through a series of gateways:

Gateway Propose Who is involved ?

Gateway 1 Is the project deliverable? CSP Programme Board

Business Case Are the benefits achievable? Delivery Programme Board

Evaluate Business Care Surety Team

Assessment of whether the PID & Benefit Delivery Programme Board Gateway 2 Realisation Plan are sound Project Executive Approval to Evaluate PID and Benefit realisation Plan Proceed with Project Manager Delivery Surety Team

Initiative Delivery

Can the project succeed to the next stage? Gateway 3 Project Board Managing Project Delivery Stages Projects will be managed through a number Project Executive of stages with a decision point at each end of stage Project Manager

Delivery Programme Board Gateway 4 Programme Manager Project closure Can the Project be closed? Project Executive

Project Manager

Change capability delivered – Benefits Realised

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The Operational Programme Board will meet bi-weekly to steer the programme. The Programme Director will report monthly to the Performance Committee and provide exception reports to the PCT Board to highlight progress delivering the initiatives and at key decision points.

Following the formal sign off of the CSP with NHS London we will operationalise the CSP into a formal strategic programme with six delivery programmes which will form part of our formal expenditure commitment when the draft Operating Plan is forwarded to NHS London on 15th January 2008.

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8. Declarations

8.1. Board statements

Commentary

This document is a ‘working document’ therefore this version should be considered to be fixed at this point in time. It will be updated annually to take into account the result of the London wide consultation Healthcare for London and A framework for action as well as the outcome of the Barnet, Enfield and Haringey Clinical strategy. Finance and activity figures will be revised as the PCT financial position improves and the document will be formally revised during 2008/09.

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9. Annex – Further details of planned initiatives

9.1. Impact of initiative on commissioning cost

Impact of initiative on baseline commissioning cost position Baseline position (including waiting list reduction but excluding Financial Financial Non demand impact of any impact of impact of Demand management/ initiatives) removed reprovided management reprovision £’000 2006/07 2011/12 activity activity cost impact Primary and community GPs (33,904) (45,277) - - - - Prescribing (36,785) (51,648) 1,347 - - - Dentistry (10,545) (15,670) - - - - Optometry ------Community and intermediate services (4,589) (4,053) - - - - Other ------Mental health and learning disabilities commissioning, pooled arrangements or jointly funded commissioning (e.g., s28 or 31) (54,007) (65,855) - - - - Provided by mental health trusts (32,135) (36,575) - - - - Other (21,872) (29,280) - - - - Actual secondary and tertiary care (136,370) (176,703) 8,446 (305) (553) 339 Secondary and tertiary non- recurrent ------Secondary and tertiary recurrent (136,370) (176,703) 8,446 (305) (553) 339 Elective day case (15,128) (18,404) 185.2 - - - Elective ordinary (13,621) (15,649) - - - - Non-elective (49,021) (59,457) 3,759.8 - (553) - Outpatient (new) (12,820) (15,549) 273 (293) - 326 Outpatient follow up (16,332) (19,809) 2,442 (12.2) - 13.5 Regular attendee (1,364) (1,655) - - - - Bed days (PICU, NICU, ITU, HDU Critical Care) (7,064) (9,940) - - - - Mixed (HIV and Renal) (5,987) (10,669) - - - - A&E Major (4,011) (5,962) - - - - A&E Standard (1,760) (2,617) 365.2 - - -

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A&E Minor (3,470) (5,158) 1,439.8 - - - GP direct access attendance (5,788) (11,831) - - - - Other ------Ambulance (7,109) (8,587) - - - - Other (33,948) (39,230) - - - - Total cost of commissioned services (317,253) (407,294) 9,792 340 (553) (305) Net impact of initiative on commissioning costs 9,274

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9.2. Initiative capital requirements

Initiative capital requirements Description - commentary

Intended year of build Cash - building costs New clinical build £'000 Refurbishment £'000 New non clinical build £'000 Other cash building costs £'000 Demolition costs £'000 Receipts of sale £'000 Source of valuation for existing assets – commentary

Other (please specify) £'000 Optimism bias and contingency % Cash - non-building costs Relocation £'000 Re-training £'000 Other (please specify) £'000 Non cash adjustments Land sale £'000 Building sale £'000 Equipment sale £'000 Reevaluate contingencies £'000 Other (please specify) £'000 Cost of capital %

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9.3. Impact of initiative on activity levels

Initiative non-acute impact ‘000 Baseline Projected position Impact of initiatives on activity Projected position without initiatives with initiatives Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 2006/07 2011/12 2007/08 2008/09 2009/10 2010/11 2011/12 2011/12 Primary care: GP practice in-hours Consultations1 1,444 2,171 2,171 GP practice out-of-hours Consultations1 9 14 14 Prescriptions Number1 3,166 4,761 4,761 Optometry Attendances1 46 69 69 Dentistry Attendances1 453 681 681 Other Attendances1 12 18 18 Community and intermediate: Community and social – bed based Attendances1 130 141 195 care Community and social – community Attendances1 141 212 212 care Other Attendances1 Mental health and learning disabilities: Community mental health Numbers under care1 1.5 2.269 2.269 Access and crisis services Attendances1 0.62 0.85 0.93 Clinical services Attendances1 16 24 24 Ambulance: Ambulance services Cases seen1 25.9 38.5 38.5 Notes 1. Or alternative activity measure

82 FINAL DRAFT

Initiative acute impact summary ‘000 Baseline Projected Impact of initiative on activity Projected Financial impact activity without activity with of activity Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 initiative initiative change Admission 2006/07 20011/12 2007/08 2008/09 2009/10 2010/11 2011/12 2011/12 (£’000) Elective day case 22.9 23.8 0 (0.2) (0.2) (0.2) (0.2) 23.6 185.2 Elective ordinary 6.6 6.6 - - - - - 6.6 - Non-elective 31.2 32.5 - (0.4) (0.9) (1.3) (1.8) 30.7 3,206.8 Outpatient (new) 81.4 84.9 - (1.0) (1.8) (2.3) (2.7) 82.2 292.2306.3 Outpatient (follow up) 202.5 211.2 - (4.7) (12.7) (25.7) (25.7) 185.6 2,423.5 Regular attendee 3.6 3.7 - - - - - 3.7 - Bed days (PICU, NICU, ITU, 9.9 12.3 - - - - - 12.3 - HDU Critical Care) Mixed (HIV and Renal) 1.2 1.9 - - - - - 1.9 - A&E Major 40.5 51.8 - - - - - 51.8 - A&E Standard 24.8 31.7 - (1.0) (2.1) (3.2) (4.4) 27.3 365.2 A&E Minor 64.3 82.2 - (5.3) (10.9) (16.8) (22.9) 59.2 1,439.8 GP direct access attendance 1,855.4 3,261.6 - - - - - 3,261.6 - Other ------