Joint Committee of Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

8 November 2018

11.30am – 12.30pm

Boardrooms, Becketts House, Ilford, IG1 2QX

Item Time Lead Attached, Director verbal or to follow 1.0 Welcome, introductions and apologies 11.30 Chair 1.1 Declaration of conflicts of interest Attached Types of interest - financial, non-financial professional, non-financial personal, indirect

2.0 Questions from the public 11.35

3.0 Community Urgent Care review 11.45 SM Attached

4.0 Date of next meeting – 29 November 2018 12.30

1 Joint Committee of Barking and Dagenham, Havering and Redbridge (BHR) CCGs Conflicts of Interest Register, which includes BHR CCGs Governing Body members and other decision makers Date - 9 October 2018 Conflics of interest will remain on the register for a minimum of 6 months following expiry Date of Interest Type of Interest Current position Declared Interest- Is the (s) held- i.e. (Name of the interest First Name Surname Governing Body, Nature of Interest Action taken to mitigate risk organisation and direct or From To Member practice,

nature of business) Non- Non- indirect? Employee or other Interests Interests Interests Personal Personal Financial Financial Financial Professional Professional Barking & Dagenham CCG Jagan John Governing Body King Edwards Medical X Direct GP partner and other GPs are Jun-10 current No immediate action required. Member - CCG Group family members Declarations made at the Chair beginning of meetings. Will not be involved in any decision making regarding the conflict. King Edwards Medical X Indirect Other GPs are family members Jun-10 current No immediate action required. Group Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Health 1000 X Direct Director. PMCF lead Dec-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Proactive Care, X Direct Clinical Lead Mar-17 current No immediate action required. Healthy London Declarations made at the Partnerships, NHS beginning of meetings. Will England not be involved in any decision making regarding the conflict. North East London X Direct GPwSI - Cardiology service, Aug-11 current No immediate action required. Foundation trust Barking & Dagenham Declarations made at the Community Cardiology Service beginning of meetings. Will not be involved in any decision making regarding the conflict. Together First X Direct Shareholder May-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Harley Fitzrovia Health X Direct Director and Shareholder Jan-18 current No immediate action required. Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Monifieth Limited X Direct Director and Shareholder Mar-18 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic - Barking, X Direct Member Oct-13 Mar-18 Historic Dagenham and Havering LMC

2 Gurkirit Kalkat Governing Body Thames View Health X Direct GP principal Apr-17 current No immediate action required. Member - Clinical Centre Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Primary Clinical X Direct Director/Shareholder Apr-17 current No immediate action required. Partnership Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Apex Healthcare Ltd X Direct Director/Shareholder Apr-17 current No immediate action required. (who own Declarations made at the Knightswood beginning of meetings. Will Residential Care not be involved in any Home) decision making regarding the conflict. Queen Mary Medical X Direct Honorary Lecturer Apr-17 current No immediate action required. School-London Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Together First X Direct Shareholder May-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. BHR CCGs Area X Direct Chair Mar-15 current No immediate action required. Prescribing Committee Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Ramneek Hara Governing Body Urswick Medical X Direct GP Principal Apr-17 current No immediate action required. Member - Clinical Centre Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Together First Ltd X Direct Shareholder May-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. London Deanery X Direct GP registrar and GP appraiser Apr-17 current No immediate action required. mainly in Havering Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Barts Hospital & X Direct Under-graduate tutor Oct-16 current No immediate action required. Queen Mary's Declarations made at the university beginning of meetings. Will not be involved in any decision making regarding the conflict. Medimmune X Indirect Spouse is medical director Apr-11 current No immediate action required. (Astrazeneca) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

3 Anju Gupta Governing Body Abbey Medical Centre X Direct GP Principal. Apr-16 current No immediate action required. Member - Clinical Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. BHR CCGs X Direct Diabetes lead Sep-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Together First Ltd X Direct Shareholder Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NELFT X Direct GPwSI -Diabetes Mar-10 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NHSE X Direct GP Appriaser Sep-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. London Deanery X Direct GP Trainer Nov-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Wilson Mason X Indirect Spouse is a consultant 2015 current No immediate action required. PLC(Architects) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Kanika Rai Governing Body White House surgery, X Direct GP principal Sep-06 current No immediate action required. Member - Clinical Barking Declarations made at the Director beginning of meetings. Will X Indirect Sister is a GP partner and not be involved in any GPwSI-dermatology decision making regarding the conflict. X Indirect Brother is also a GP partner Castleton Road Health X Direct GP principal April 2018 current No immediate action required. Centre, Redbridge Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. B&D CCG X Indirect Brother-in-law is a B&D Clinical April 2018 current No immediate action required. director. Declarations made at the beginning of meetings. Will X Indirect Husband is a B&D GP not be involved in any decision making regarding the conflict. Together First Ltd X Direct Shareholder. Brother is also a May-14 current No immediate action required. director Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

4 Kanika Rai Governing Body Member - Clinical Director

MacMillan X Direct GP for Barking and Dagenham Jun-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NEL Cancer X Direct Cancer Lead Dec-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. London Deanery X Direct FY2 Superviser and GP trainer 2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Queen Mary X Direct Under-graduate tutor 2007 current No immediate action required. University & Imperial Declarations made at the College beginning of meetings. Will not be involved in any decision making regarding the conflict. Amit Sharma Governing Body Tulasi Medical X Direct Salaried GP and medical director Jul-13 current No immediate action required. Member- Practice Declarations made at the Clinical Director beginning of meetings. Will not be involved in any decision making regarding the conflict. St Albans Surgery X Direct Salaried GP - one session May-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. B&D CCG X Direct Macmillan GP Apr-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. X Indirect Sister-in-law is a B&D Clinical Nov-11 current No immediate action required. Director Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. X Indirect Wife is a B&D GP Aug-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Barking, Dagenham & X Direct Member Sep-14 current No immediate action required. Havering LMC Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Care Quality X Direct GP specialist adviser Nov-14 current No immediate action required. Commission Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

5 Amit Sharma Governing Body Member- Clinical Director

Veda Solutions X Direct Director Aug-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Uzma Haque Governing Body Gables Surgery - X Direct GP partner Oct-15 current No immediate action required. Member - Dagenham Declarations made at the Clinical Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Together First X Direct Shareholder Oct-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. BHR CCGs X Direct Registered at a GP practice in Jan-08 current No immediate action required. Redbridge. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. BHRUT X Indirect Husband is head of department Jul-05 current No immediate action required. for care of the elderly Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Babylon GP on-line X Indirect GP partner is a Babylon Oct-15 current No immediate action required. system governance lead Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic - B&D and X Direct Ex LMC Chair May-17 Oct-18 Historic. Havering LMC Historic - Astra X Direct Chaired a meeting. Details of Apr-18 N/A as one Historic. Zeneca remuneration declared on off. declaration form. Sahdia Warraich Governing Body Tower Hamlets GP X Direct Social Prescription Manager 18/06/2018 current No immediate action required. member - Lay Care Group CIC Declarations made at the member, PPI beginning of meetings. Will not be involved in any decision making regarding the conflict. Newham Deanery CIO X Direct Trustee 01/06/2016 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Redbridge X Direct Member 01/04/2013 current No immediate action required. Healthwatch Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic - London X Indirect Husband is a Councillor 01/05/2014 29/05/2018 Historic. Borough of Redbridge Historic - Forum for X Direct Director (paid employee) 01/12/1994 01/04/2018 Historic. Health & Wellbeing

6 Havering CCG Atul Aggarwal Governing Body Maylands Healthcare X Direct GP Partner Apr-13 current No immediate action required. Member - CCG Declarations made at the Chair beginning of meetings. Will not be involved in any decision making regarding the conflict. Maylands Healthcare X Direct Director and shareholder in on- Apr-13 current No immediate action required. Ltd site pharamcy Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Parkview Dental X Indirect Sister is NHS dentist within 1996 current No immediate action required. Practice Havering Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Essex Medicare LLP X Direct Part owner which owns 2014 current No immediate action required. Westland Clinic, Hornchurch. Declarations made at the Space rented out to Inhealth beginning of meetings. Will (Diagnostic),Nuffield Health not be involved in any (Brentwood), Communitas decision making regarding the Clinics (Dermatology & conflict. Gynaecology) Havering Health Ltd X Direct Shareholder. GP partner (Dr Sep-14 current No immediate action required. Kendall) is a director Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Barking, Dagenham X Direct Co-opted member 2013 current No immediate action required. and Havering LMC Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Westlands Clinic Indirect Spouse is a dentist who has an May-18 current No immediate action required. (Langton Dental) outsourced contract with BHRUT Declarations made at the for oral surgery. beginning of meetings. Will not be involved in any decision making regarding the conflict. Alex Tran Governing Body Hornchurch X Direct GP principal 2007 current No immediate action required. Member - Clinical Healthcare Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering Health Ltd X Direct Shareholder 2016 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Hornchchurch X Direct Director Jul-05 current No immediate action required. Healthcare Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Maurice Sanomi Governing Body Rush Green Medical X Direct Senior GP partner 2000 current No immediate action required. Member - Clinical Centre Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict.

7 Maurice Sanomi Governing Body Member - Clinical Director

Practice Based X Direct Director/Shareholder abd GPwSI 2007 current No immediate action required. Clinical Service Ltd Declarations made at the (ENT service) beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering CCG X Direct GP Tutor & education lead 2000 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering Health Ltd X Direct Shareholder 2014 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Inspire Health Ltd (not X Direct Director/Shareholder 2013 current No immediate action required. trading) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Ann Baldwin Governing Body Central Park surgery, X Direct GP partner 2009 current No immediate action required. Member-Clinical Harold Hill Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering Health Ltd X Direct Shareholder Aug-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Barking, Dagenham X Direct Joint vice chair Jun-17 May-19 No immediate action required. and Havering LMC Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Royal College of GPs X Direct Member 2012 current No immediate action required. and British Society of Declarations made at the Rheumotology beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering CCG X Direct GP Appraiser 2012 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Richard Coleman Governing Body Richard Coleman X Direct Director/Co-owner. Spouse is 01/04/2013 current No immediate action required. member - Lay Associates also Director/Co-owner Declarations made at the member, PPI beginning of meetings. Will not be involved in any decision making regarding the conflict. BHR CCGs X Indirect Brother-in-law is Independent 01/10/2017 current No immediate action required. GP on the Primary Care Declarations made at the Commissioning Committee beginning of meetings. Will not be involved in any decision making regarding the conflict.

8 Richard Coleman Governing Body member - Lay member, PPI

1-2-1 Social X Direct Associate 01/10/2014 current No immediate action required. Enterprise Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. PriceWaterhouse X Indirect Nephew is a partner 01/08/2013 current No immediate action required. Cooper Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Redbridge CCG Anil Mehta Governing Body Fullwell Cross Medical X Direct GP partner Apr-13 current No immediate action required. member - CCG Centre Declarations made at the Chair beginning of meetings. Will not be involved in any decision making regarding the conflict. Metropolitan Police X Direct Forensic examiner Nov-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. The Cleaning X Indirect Sister-in-law is the owner 2013 current No immediate action required. Company Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NHSE X Direct GP appraiser Feb-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder Sep-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Fouress enterprises X Direct Director 2015 current No immediate action required. Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Prescon X Direct Ad-hoc screening work Jan-18 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Sarah Heyes Governing Body The Shrubberies X Direct GP partner Oct-05 current No immediate action required. member - Clinical Medical Centre Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder Sep-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

9 Jyoti Sood Governing Body Newbury Group X Direct GP partner Jun-05 current No immediate action required. Member - Clinical Practice Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Communitas Clinics X Direct GPwSI - Dermatology 2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. DMC Healthcare X Direct GPwSI - Dermatology & minor Jul-17 current No immediate action required. surgery Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. ESS Wanstead X Direct GPwSI - Dermatology 2011 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Ealing Hospital Trust X Direct GPwSI - Dermatology 2010 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NELFT X Direct GPwSI - Diabetes 2007 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Soods Ltd X Direct Director and husband is a 2005 current No immediate action required. partner. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NHSE X Direct GP appraiser Jun-05 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Health Education X Direct GP trainer 2004 current No immediate action required. England Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Imperial College X Direct GP trainer 2011 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Redbridge LMC X Direct Member Sep-16 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

10 Jyoti Sood Governing Body Member - Clinical Director

Care Quality X Direct Special adviser Jul-16 current No immediate action required. Commission Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Metrolaw Solicitors X Indirect Husband's firm 2002 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Royal College of GPs X Direct GPWSi assessor 28/02/2018 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Shujah Hameed Governing Body Castleton Road Health X Direct GP Partner Apr-17 current No immediate action required. member - Clinical Centre Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder and locum doctor at Apr-16 current No immediate action required. urgent care centre Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. PELC X Direct Locum doctor Apr-16 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Partners in Healthcare X Direct Director Apr-16 current No immediate action required. Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. BHR GP Solutions X Direct Locum GP Jul-16 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Syed Raza Governing Body Seven Kings surgery X Direct GP partner Oct-17 current No immediate action required. member - Clinical Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Raza Syed Medical X Direct Director Jun-14 current No immediate action required. Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

11 Syed Raza Governing Body member - Clinical Director

Healthbridge Direct X Direct Shareholder and employed as a Sep-14 current No immediate action required. locum at the hub Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. PELC X Direct Locum GP current current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. London Deanery X Direct GP Trainer 2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Shabana Ali Governing Body Southdene Surgery X Direct GP partner/principal 2008 current No immediate action required. member - Clinical Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder 2015 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NELFT X Direct GPwSI - cardiology 2008 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Avicenna Ltd X Direct Director 2012 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Avicenna Ltd X Indirect Husband is a director 2012 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. BMA X Direct member 2004 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. PCGP X Direct member 2006 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NHSE X Direct GP appraiser (B&D and 2016 current No immediate action required. Havering) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic Healthbridge X Indirect Daughter works in 2015 Jul-18 Historic Direct reception/admin

12 Muhammad Tahir Govering Body Forest Edge practice, X Direct GP partner Oct-93 current No immediate action required. member - Clinical Hainault Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Dagenham & X Direct Medical doctor 1999 current No immediate action required. Redbridge Football Declarations made at the Club beginning of meetings. Will not be involved in any decision making regarding the conflict. Redbridge Local X Direct Member current 2019 No immediate action required. Medical Committee Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder 2015 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Mehul Mathukia Governing Body Mathukia Surgery X Direct GP principal. Brother is also GP 2010 current No immediate action required. member - Clinical principal Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder Sep-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Valia Consultancy X Direct Director & Shareholder 2014 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NOCLOR & NIHR X Direct GP research champion 2015 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. PELC X Direct GP Locum 2010 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Anita Bhatia Governing Body Southdene Surgery X Direct GP partner current current No immediate action required. member - Clinical Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder Sep-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

13 Anita Bhatia Governing Body member - Clinical Director

MyChem Ltd X Indirect Husband is owner/director of current current No immediate action required. pharmacy Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Phoenix Medics Ltd X Indirect Brother is a director current current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Essex Local X Indirect Husband does ad-hoc work current current No immediate action required. prescribing Committee Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Khalil Ali Governing Body Dr Joseph GP X Indirect Famiy doctor 01/04/2017 31/03/2018 No immediate action required. member - Lay practice, Collier Row Declarations made at the member, PPI beginning of meetings. Will not be involved in any decision making regarding the conflict. St Francis Hospice X Indirect Spouse is a regular donor 01/04/2017 31/03/2018 No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Cancer Research UK X Indirect Spouse is a regular donor 01/04/2017 31/03/2018 No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Ah-fee Chan Governing Body North Middlesex X Direct Consultant Anaesthetist May-96 current No immediate action required. member - University Hospital Declarations made at the Secondary Care Trust beginning of meetings. Will Consultant not be involved in any decision making regarding the conflict. Nadia Medical X Direct Director (provides anaesthetic Mar-15 current No immediate action required. Secrives Ltd services) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Members representing BHR CCGs Jane Milligan Employee - NEL Commissioning X Indirect Partner is employed 2014 current No immediate action required. Governing Body Support Unit substantively Declarations made at the Executive Member - beginning of meetings. Will Accountable Officer, not be involved in any NEL CCGs decision making regarding the conflict. NHSE X Indirect Partner on secondment to Jan-18 current No immediate action required. London Regional Director for Declarations made at the primary care beginning of meetings. Will not be involved in any decision making regarding the conflict. Action for stammering X Indirect partner is a Trustee Oct-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

14 Jane Milligan Employee - Governing Body Executive Member - Accountable Officer, NEL CCGs

Family Mosaic X Direct Non-executive director May-14 current No immediate action required. Housing Association Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Stonewall X Direct Ambassador Oct-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Peabody Housing X Direct Non-executive director Jan-17 current No immediate action required. Association Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Chartered X Direct Member (non-practising) Sep-87 current No immediate action required. Physiotherapists Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Ceri Jacob Employee - Ruislip Primary School X Direct Chair of Governors Feb-18 Current No immediate action required. Managing Director Declarations made at the BHR CCGs beginning of meetings. Will not be involved in any decision making regarding the conflict. Tom Travers Employee - Royal Free X Indirect Wife employed in the Finance Jul-14 current No immediate action required. Governing Body Foundation Trust Department Declarations made at the Excecutive Member - beginning of meetings. Will Chief Finance not be involved in any Officer decision making regarding the conflict. Jacqui Himbury Employee - None Governing Body Executive Member - Nurse director Kash Pandya Governing Body NHS Barking and X Direct Lay member, Governance and 2013 2019 No immediate action required. Member - Lay Dagenham CCG Audit Chair Declarations made at the member, beginning of meetings. Will Governance not be involved in any decision making regarding the conflict. NHS Havering CCG X Direct Lay member, Governance and 2013 2019 No immediate action required. Audit Chair Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NHS Redbridge CCG X Direct Lay member, Governance and 2013 2019 No immediate action required. Audit Chair Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. University of Essex X Direct Independent Audit Committee 2013 2019 No immediate action required. member Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

15 Kash Pandya Governing Body Member - Lay member, Governance

Southend-on-Sea X Direct Independent Audit Committee 2016 2018 No immediate action required. Borough Council member Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Brentwood Citizen's X Direct General Advisor 2009 current No immediate action required. Advice Bureau Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Essex Ministry of X Direct Lay member, Governance and 2010 2018 No immediate action required. Justice Advisor Audit Chair Declarations made at the Committee beginning of meetings. Will not be involved in any decision making regarding the conflict. PriceWaterhouse X Indirect Son is employeed as a 2013 current No immediate action required. Cooper management accountant Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Accenture X Indirect Son is employeed as Legal 2015 current No immediate action required. Counsel Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Stephen Rubery Employee - BHR CCGs X Indirect Co-habiting partner is Acting Aug-18 current No immediate action required. Governing Body Director of Transformation & Declarations made at the Executive Member - Delivery within BHR CCGs (and beginning of meetings. Will Director of appointed to the substantive role not be involved in any Commissioning & w.e.f 28/10/2018) decision making regarding the Performance BHR conflict. CCGs Other decision makers Adedayo Adedeji Barking & Halbutt Street Surgery X Direct GP 2017 current No immediate action required. Dagenham CCG GP Declarations made at the and member of BHR beginning of meetings. Will CCGs Primary Care not be involved in any Commissioning decision making regarding the Committee conflict. PELC X Direct Council Member Dec-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Together First Ltd X Direct Board Member & shareholder Apr-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Primary Care Clinical X Direct Shareholder 2017 current No immediate action required. partnership Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Shabnam Ali Redbridge CCG GP Cranbrook & Loxford X Direct Network Lead Mar-11 current No immediate action required. and member of BHR Locality Declarations made at the CCGS Primary Care beginning of meetings. Will Commissioning not be involved in any Committee decision making regarding the conflict.

16 Charles Beaumont Independent Lay None Member of BHR CCGs Audit & Governance Committee Lucy Botting Employee - Deputy Care UK (surrey wide) X Direct Nurse Practitioner, Clinical Lead - 2007 current No immediate action required. Director, Primary bank work Declarations made at the Care beginning of meetings. Will Transformation BHR not be involved in any CCGs decision making regarding the conflict. Greenbrook X Direct Nurse Practitioner, Clinical Lead - 2016 current No immediate action required. Healthcare (Londond bank work Declarations made at the wide) beginning of meetings. Will not be involved in any decision making regarding the conflict. Mole Valley District X Direct Local district councillor 2014 current No immediate action required. Council Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Richard Burack Havering CCG GP, North Street Medical X Direct GP senior partner No immediate action required. Named GP lead in Care Declarations made at the Safeguarding for beginning of meetings. Will B&D and Havering not be involved in any CCGs decision making regarding the conflict. RCGP Adolescent X Direct Member 2017 current No immediate action required. Working Party Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Primary Care Child X Direct Chair Sep-17 current No immediate action required. Safeguarding Forum Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering Health Ltd X Direct Clinical Director 2016 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Oge Chesa Employee - Deputy NICE X Direct Medicines & Prescribing On-going On-going No immediate action required. Chief Pharmacist; associate. Also Adoption & Declarations made at the APC Member Impact Programme Reference beginning of meetings. Will Panel member not be involved in any decision making regarding the conflict. David Derby Havering CCG GP Rosewood Medical X Direct GP Partner 2011 current No immediate action required. and member of BHR Centre Declarations made at the CCGs Primary Care beginning of meetings. Will Commissioning not be involved in any Committee decision making regarding the conflict. Havering Health Ltd X Direct Shareholder/Director and 2014 current No immediate action required. company secretary Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

17 David Derby Havering CCG GP and member of BHR CCGs Primary Care Commissioning Committee

PELC X Direct Council member 2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Barking, Dagenham X Direct member 2013 current No immediate action required. and Havering LMC Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. BHRUT X Indirect Wife is a nurse 2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Mark Eaton Consultant - Amnis Ltd X Direct Shareholder. Apr-18 current Amnis Ltd will not provide any Director of services within NEL. Recovery Arnold Furtig Independent GP BHR CCGs X Indirect Lay member PPI (Havering 01/10/2017 Current No immediate action required. member of BHR CCG) PPI is brother in law Declarations made at the CCGs Primary Care beginning of meetings. Will Commissioning not be involved in any Committee decision making regarding the conflict. Arthur Rank Hospice X Direct Trustee 01/05/2017 current No immediate action required. Charity - Cambridge Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. PriceWaterhouse X Indirect Son is a partner (south Korea) 2015 current No immediate action required. Cooper Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Mayor of London X Indirect Son is a speech writer 2016 current No immediate action required. (Sadiq khan) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. University Hospital, X Indirect Son is an employee in middle 2015 current No immediate action required. Birmingham management Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Jane Gateley Employee - Director, PHP (Hurley Group) X Indirect Spouse is Prgramme Director On-going on-going No immediate action required. Strategy & Declarations made at the Integration BHR beginning of meetings. Will CCGs not be involved in any decision making regarding the conflict. Uzma Haque Barking and Gables Surgery X Direct GP partner 2015 current No immediate action required. Dagenham CCG Declarations made at the Gp; Area beginning of meetings. Will Prescribing not be involved in any Committee Member decision making regarding the conflict.

18 Uzma Haque Barking and Dagenham CCG Gp; Area Prescribing Committee Member

Barking, Dagenham X Direct Director 2013 current No immediate action required. and Havering LMC Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Barking & Dagenham, X Indirect Spouse is Head of Elderly Care 2016 current No immediate action required. Havering and Declarations made at the Redbridge University beginning of meetings. Will Trust not be involved in any decision making regarding the conflict. Astra Zeneca X Direct Chaired Meeting 26/04/2018 26/04/2018 No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Palms Medical Centre X Direct Patient at the Practice 2008 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Mohammed Kanji Employee - Crescent X Direct Paid work - pharmacist. Full Sep-93 current No immediate action required. Prescribing Adviser; Pharamcy,Romford details including remuneration - Declarations made at the APC Member provided on declaration form beginning of meetings. Will not be involved in any decision making regarding the conflict. Beta Pharmaceuticals X Direct Director Dec-04 current No immediate action required. Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Eaglebond Ltd X Direct Superintendant Pharamcist and Mar-10 current No immediate action required. director Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Beta Charitable Trust X Direct Trustee 2007 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Imran Khan Employee - Ilford Medical Centre X Direct Paid work providing locum Aug-16 current No immediate action required. Pharmaceutical community pharmacist cover. Declarations made at the Advisor/QIPP Full details including beginning of meetings. Will Pharmacist; APC remuneration - provided on not be involved in any Member declaration form decision making regarding the conflict. Diabetes UK X Direct Member 2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Belinda Krishek Employee - Chief North East London X Indirect Husband is an employee Apr-17 current No immediate action required. Pharmacist; APC Local Pharmaceutical Declarations made at the Member Committee (NEL LPC) beginning of meetings. Will not be involved in any decision making regarding the conflict.

19 Belinda Krishek Employee - Chief Pharmacist; APC Member

Fontus Health X Indirect Daughter undertakes work with Apr-17 current No immediate action required. them. Son awarded an Declarations made at the engineering project grant with beginning of meetings. Will them. not be involved in any decision making regarding the conflict. Raj Kumar Havering CCG GP, Berwick Surgery, X Direct GP Principal Apr-17 current No immediate action required. GP clinical lead for Rainham Declarations made at the BHR CCGs - Mental beginning of meetings. Will Health not be involved in any decision making regarding the conflict. Pharmacetical X Direct Paid work.Chaired 2 meetings. No immediate action required. Company Remuneration included on DOI Declarations made at the form beginning of meetings. Will not be involved in any decision making regarding the conflict. Vaibhav Mathukia Redbridge CCG GP, Mathukia Surgery X Direct GP. Brother is also a GP at the GP Clincal Lead - practice and a clinical director for Macmillan GP Redbridge CCG

Robert Meaker Employee - Vertergi Limited X Direct Holder of 100% of the company Sep-14 current No immediate action required. Innovation & shares Declarations made at the Information beginning of meetings. Will Technology Senior not be involved in any Responsible Officer decision making regarding the BHR CCGs conflict. MCB Software X Direct Holder of 100% of the company 01/06/2016 Current No immediate action required. shares Declarations made at the beginning of meetings. Will The software produced has been Amendment not be involved in any purchased by BHR CCGs and is August-18 decision making regarding the currently in use by the conflict. Continuing Healthcare Team The Network Group X Direct Vertergi Ltd is a member of the Aug-18 on-going No immediate action required. Network Group and I am a Declarations made at the named member of the leadership beginning of meetings. Will not be involved in any MCB Software Services is an decision making regarding the associate member of the conflict. Network Group

The Network Group was formed to enable small organisations to compete for larger consulting assignments. No work has been secured, but has secured a place on a framework agreement

Louise Mitchell Employee - Director None of Transformation & Delivery (Planned Care) Sharon Morrow Employee - Director None of Transformation & Delivery (Unplanned Care & Mental Health) Saiqa Mughal Employee - None Prescribing Advisor; APC Member

20 Sanjay Patel Employee - QIPP DSP Health Solutions X Direct Director Jun-15 current No immediate action required. Programme (DSPHS) Ltd Financial Declarations made at the Pharmacist; APC (Consultancy/ beginning of meetings. Will Member Training). not be involved in any decision making regarding the conflict. DSP Health Solutions X Indirect Wife is a shareholder in the Jun-15 Current No immediate action required. (DSPHS) Ltd Financial company Declarations made at the (Consultancy/ beginning of meetings. Will Training). not be involved in any decision making regarding the conflict. GlaxoSmithKline X Direct Shareholder (less than 1% of Oct-08 current No immediate action required. (GSK) stockholding) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Sterling Anglian X Shareholder (less than 1% of Dec-15 current No immediate action required. Pharamceuticals stockholding) Declarations made at the (SAP) beginning of meetings. Will not be involved in any decision making regarding the conflict. Various local X Direct Paid work providing locum Jul-17 current No immediate action required. pharmacies community pharmacist cover. Declarations made at the Full details including beginning of meetings. Will remuneration - provided on not be involved in any declaration form decision making regarding the conflict. Marie Price Employee - Greater London X Indirect Husband is area regeneration 2017 on-going No immediate action required. Corporate Services Authority (GLA) manager for North East London Declarations made at the Director BHR CCGs beginning of meetings. Will not be involved in any decision making regarding the conflict. Lower Clapton GP X Direct Registered as a patient where 2008 current No immediate action required. practice City & Hackney CCG Chair is Declarations made at the based. beginning of meetings. Will not be involved in any decision making regarding the conflict. Sarah See Employee - Primary NELFT X Indirect Partner is an employee working Mar-14 on-going No immediate action required. Care within Redbridge CAMHS Declarations made at the Transformation beginning of meetings. Will Director BHR CCGs not be involved in any decision making regarding the conflict. Alan Steward Employee - System Steward and Steward X Direct Director. Partner is also a 2012 current No immediate action required. OD and Transition Ltd director. Declarations made at the SRO (currently on beginning of meetings. Will secondment) not be involved in any decision making regarding the conflict. Julia Taylor Employee - Springfield Hospital, X Direct Paid bank work - Pharmacist. 01/04/2018 current Declared in line with CPOI Prescribing Advisor; Chelmsford Remuneration declared on DOI policy. Will be excluded from APC Member form. any related comissioning or decision making. Tina Teotia Barking and Green Lane Surgery X Direct GP Partner 2012 current No immediate action required. Dagenham CCG GP Declarations made at the and member of the beginning of meetings. Will Area Prescribing not be involved in any Committee decision making regarding the conflict.

21 Tina Teotia Barking and Dagenham CCG GP and member of the Area Prescribing Committee

Together First Ltd X Direct Director 01/04/2018 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Barking, Dagenham X Direct Member 17/05/2013 current No immediate action required. and Havering LMC Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Salma Wilson Employee - None Prescribing Adviser; APC Member

To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Sharon Morrow, Director of Transformation and Delivery -Unplanned Care and Mental Health

Date: 8 November 2018

Subject: Community Urgent Care Review

Executive summary The Barking and Dagenham, Havering and Redbridge Governing Bodies supported a Community Urgent Care Case for Change at their July 2017 meetings. This reviewed the urgent care services currently delivered outside of hospital - walk in centres, GP hubs and GP out of hours (face to face). The case for change considered the Five Year Forward View requirements for an integrated urgent care service, stakeholder, patient and public feedback on local services and the potential efficiency savings that could be achieved by removing duplication of services. The Governing Bodies (GBs) agreed to support an engagement process on the case for change and the development of a pre- consultation business case and commissioning timeline. A Project Initiation Document (PID) for a community urgent care review was approved by the Financial Recovery Programme Board (FRPB) on 16 November 2017, following assurance from the Financial Recovery Programme Delivery Meeting (FRPDM). The PID set out two commissioning options recommended by the Community Urgent Care Programme Board, based on the pre-consultation business case, and the financial impact if implemented. These were taken forward in a14-week public engagement exercise ‘Right care, right place, first time’. This report presents the findings of the community urgent care decision making business case and asks the committee to support the recommendation made by the Programme Board. Recommendations The committee is asked to: 1. Agree Option 1 as the future urgent care pathway:  To help people access the right care, right place, first time and to simplify the urgent care pathway, urgent care will have just two points of access and a consistent name for services: − Bookable services accessed through NHS 111 − Urgent Treatment Centres (UTCs)  This will be delivered from 12 sites in total including four UTCs (two on hospital sites and two in the community - accessed via both walk in and bookable via NHS 111) and bookable appointments accessed via NHS 111 at eight locations

2. Agree the Community Urgent Care Programme Board will progress to the procurement stage which will be overseen by the Procurement Oversight Group.

3. Subject to agreement of the above it is recommended that:  A comprehensive communications and engagement plan to support these changes is developed including the continued involvement of all three Healthwatch organisations  A plan to enhance the utilisation of the Loxford polyclinic site is developed

1.0 Purpose of the Report 1.1 The purpose of this report is to consider the community urgent care decision making business case (attached at appendix 2), taking into account the wider (including financial) risks associated with the proposals.

2.0 Background and context 2.1 The Barking and Dagenham, Havering and Redbridge Governing Bodies approved a Community Urgent Care Case for Change at their July 2017 meetings. This reviewed urgent care services currently delivered outside of hospital – walk in centres, GP hubs and GP out of hours (face to face). The case for change considered the Five Year Forward View requirements for an integrated urgent care service, stakeholder, patient and public feedback on local services and the potential efficiency savings that could be achieved by removing duplication of services. The Governing Body agreed to support an engagement process on the case for change, and the development of a pre-consultation business case and commissioning timeline.

2.2 A Project Initiation Document (PID) for a community urgent care review was approved by the FRPB on 16 November 2017, following assurance from the FRPDM. The PID set out two commissioning options that the Community Urgent Care Programme Board had recommended based on the pre-consultation business case, and the financial impact if implemented. A project timeline was set out which included the launch of a public consultation on these options, commencing 29 May 2018.

2.3 Following support for the Case for Change at the July GB meetings a Community Urgent Care Programme Board was established to oversee the programme development. The Board has membership from a Lay Member, Public Health, Primary care, Finance and Estates. Legal advice was sought on local GP involvement and it was determined that our local GPs could not be part of the board due to the conflict of interest arising from being possible future providers. We have therefore engaged support from an Independent GP.

2.4 Clinical workshops were held in August 2017, February and May 2018; with engagement from clinicians across the system. These sessions have been used to share the options that had been developed and discussed the priorities for clinicians across the system.

3.0 Pre-consultation business case 3.1 Thirteen scenarios were developed and scored by a dedicated Panel on a range of factors: Patient Experience, Affordability, Clinical Quality, Deliverability and Efficiency. The Panel consisted of the Programme Board members, along with another Lay Member (Governance) and a Quality Manager. This process identified the four highest scoring scenarios, which met the minimum scores set by the Programme Board, and these were reduced to two following review at the FRPDM as two of the options did not deliver any patient benefits or additional savings.

4.0 Summary of the proposed options 4.1 Both proposed options focus on a move to bookable services in community hubs and Urgent Treatment Centres (UTCs), booked through NHS111 in line with the National Five Year Forward View. UTCs will be commissioned in line with the national specification. The main differences between an Urgent Care Centre (UCC) and an Urgent Treatment Centre (UTC) is that a UTC has diagnostic access and appointments that are bookable through 111.

The two options differ as to the number of hubs and UTCs and are as follows:

Option 1 would see 12 sites in total, with four Urgent Treatment Centres open within Barking and Dagenham, Havering and Redbridge (2 on hospital sites, and two in the community) and as now

local people may still use those in our neighbouring boroughs (Newham and Whipps Cross), plus eight locations for booked community urgent care services.

Option 2 would see 12 sites in total, with two UTCs within our area on our hospital sites, and as now local people may still use those in our neighbouring boroughs (at Newham and Whipps Cross hospitals). Plus there will be 10 places to be booked when a patient’s GP practice is closed and they have an urgent health need.

5.0 Public consultation process 5.1 The 14-week public engagement exercise ‘Right care, right place, first time’ ran from Tuesday 29 May and closed at 5pm on Tuesday 4 September 2018 and sought local people’s views on proposals for changes to the community urgent care pathway (GP out of hours services, GP access hubs and walk in services). The consultation was originally planned for twelve weeks in line with local Compacts and best practice guidance, but was extended by a fortnight following representations from local scrutiny committees.

5.2 During the 14-week consultation, the CCGs’ independent GP clinical lead, Redbridge CCG’s Lay Member for Patient and Public Participation and CCG staff presented to community groups, health scrutiny committees and healthcare professionals; held drop-in sessions in public places; and carried out traditional media and social media activity, in order to reach as many people as possible across the three boroughs. Over 3000 people were reached during the face to face sessions.

5.3 In addition to the proactive outreach and in line with the successful approach taken for previous consultations (and those of a number of our local stakeholders), an online consultation document and questionnaire were developed (printed copied available as required). The public and stakeholders were encouraged to view the consultation document online and complete the online questionnaire. This online approach was proven to be an effective strategy, with the community

urgent care consultation generating our largest consultation response ever, with 1,062 people sharing their feedback through the online survey.

6.0 Feedback from the public consultation 6.1 In response to the two options presented, the majority of consultation respondents (67%) favour Option 1, which comprises four UTCs and eight bookable-only community urgent care services. The majority of residents in all three areas prefer option 1 (60% Barking and Dagenham, 78% Havering, and 50% Redbridge).

6.2 One in five 19% favour Option 2 (two UTCs and ten bookable-only community urgent care services). The remaining 14% have no preference. In Redbridge there was increased support for Option 2 (29%) as well as more residents expressing no preference (21%).

6.3 69% of respondents agree that BHR’s proposals will make it easier to know where to go if they need urgent care. This rises to 75% of those who are disabled and to 76% among those who are NHS staff. One in five (19%) residents disagree that the proposals will make it easier to know where to go for urgent care.

6.4 In regards to bookable appointments, 74% of respondents say more bookable appointments will make it easier to get urgent care when they need it. This agreement peaks at 82% for respondents aged 75+ and 80% for disabled respondents. Furthermore, almost nine in ten respondents (87%) think weekend appointments would be useful to them.

6.5 Of the key stakeholders who wrote in to share their views, the majority expressed a preference for Option 1.

6.6 The most common themes at engagement events, by stakeholders and from those who completed the survey were on: the accessibility of locations which includes comments on existing issues with accessibility; quality of our existing GP and primary care services, including lack of same-day appointments with GPs and long waits for even routine appointments; and the need for a comprehensive communications and engagement with the public on how to access urgent care under the new model.

6.7 In Havering, members of the public and stakeholders initially raised concerns over whether the proposals would mean removal of the urgent care service at Harold Wood Polyclinic. The CCGs were able to provide reassurance that both options demonstrated a commitment to maintaining urgent care services at the polyclinic site through engagement activity, briefings and meetings with councillors from the London Borough of Havering.

6.8 Stakeholders in Redbridge raised concerns over proposals to change the urgent care service at Loxford Polyclinic from a walk-in service to a bookable service. This was based on concerns regarding a perceived impact on health inequalities for a diverse and deprived part of the borough (south Ilford); concerns about existing poor quality and accessibility of primary care services in south Ilford, and issues with using NHS 111 for people who spoke little or no English. On 12 October, the CCGs received a letter from the London Borough of Redbridge (LBR) explaining that the Council had received a petition signed by 3,889 people which sets out the petition signatories’ opposition to ‘closure of the walk-in services at Loxford Polyclinic’. The Council requested that the CCGs reconsidered the proposals to change the walk-in service at Loxford Polyclinic for the reasons stated in the petition. The petition was not shared with the CCGs but it is noted in the consultation report.

6.9 The community urgent care programme board have carefully considered the request to retain a walk in service at Loxford Polyclinic and the concerns raised within LBR’s letter, and has

determined that the CCGs cannot retain a walk in service at this site. Improvements to the urgent care pathway options will be put into place to mitigate the concerns raised and these include: maintain existing commissioned activity levels for the new Loxford urgent care service of 14,000 appointments; ensure there is telephone access to NHS 111 in Loxford Polyclinic; a commitment to improve the use of the Loxford Polyclinic site, e.g. the CCGs agreed in October a change to how GPs property costs are funded in order to make Loxford Polyclinic a more appealing site for practices. The full reasoning for the determination to not retain a walk in service at Loxford Polyclinic is set out within the decision making business case.

7.0 Resources/investment 7.1 The activity and finance modelling has been refreshed in line with the most recent activity data available, using the same assumptions as published in the pre-consultation business case. The new baselines are based on July 2017 to June 2018 activity data:

Activity Cost Saving

Do nothing 447,459 £38,237,794

Option 1 403,941 £37,638,941 £598,852 per year Option 2 351,571 £37,371,893 £865,901 per year

7.2 In the pre-consultation business case the modelling, using the 17/18 baseline activity for Option 1, suggested savings of c£1.07m, and for Option 2 c£1.19m. There are a number of intricacies which have not been modelled and which will provide a positive financial benefit, compounded with a strong prudent approach to modelling, the bridge of the gap between the current and original estimated savings should be eliminated. These include the use of conservative unit costs, redirection at the front door of A&E and UTCs and duplication of attendance activity.

7.3 The Community Urgent Care Programme Board considered the greater savings forecast for Option 2 of £267k, but determined that Option 1 is more economically advantageous with more quality benefits for patients whilst contributing to our ability to live within our financial means. As the evidence presented in this business case sets out Option 1 has greater support from: the consultation responses, stakeholders, within the EIA and was scored higher by the CCGs scenario scoring panel.

7.4 An independent Clinical Lead was appointed to support the programme and the costs covered within the programme budget, supported through the FRPB.

8.0 Equalities 8.1 An initial Equality Impact Analysis (EIA) was carried out and made available at the beginning of the consultation. A full EIA was completed once the consultation concluded. It is attached to the DMBC. The EIA was carried out by a separate organisation to ensure that the CCGs received independent advice on any potential impacts of the options proposed.

9.0 Risk 9.1 Patient behaviour does not follow the modelling assumptions and savings are not realised - i.e. where WICs become bookable services (Loxford and South Hornchurch) that 70% of patients will book appointments.

7.0 Managing conflicts of interest

7.1 The CCGs’ Clinical Directors are not involved in the decision making for this proposal given they are members of organisations that may have an interest in providing community urgent care services in future.

Attachments: 1. Pre-consultation business case 2. Decision making business case 3. Consultation report 4. Equality impact analysis 5. Review of the four tests of service change Electronic copies will be made available to committee members and a hard copy will be available at the meeting

Author: Carla Morgan Date: 02 November 2018

Making changes to community urgent care services

Pre-consultation business case

Barking and Dagenham, Havering and Redbridge (BHR) clinical commissioning groups (CCG) May 2018

Right care, right place, first time

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Contents 1.0 Executive summary 3 2.0 Context 4 Community urgent care review 4 Aims and objectives 4 Scope of this review 4 Current urgent care service offer 5 Service location map 5 Urgent and emergency care service usage 5 Primary care 6 Wound care 8 National context 8 Financial context 10 2.0 Case for change 12 What is urgent care? 12 BHR vision for urgent and emergency care 12 Variation in existing community urgent care services 12 Duplicate attendances 12 3.0 Engagement to date - urgent care co-design and research 16 Learning from our engagement 17 4.0 Options development and selection 18 5.0 Context for our options 20 Click or call before you come in - bookability 20 Consistent elements which will exist regardless of this proposed service change 20 Options for public consultation 22 What the future will look like 25 6.0 Proposed consultation process 27 Engagement plan for the next stage 27 Consultation process 27 Summary of the key stages of the consultation process and indicative timeline 28 7.0 Annex 1 - Case for change 29 8.0 Annex 2 - Variation in existing community urgent care services 29 9.0 Annex 3 - Current urgent and emergency care services 33 10.0 Annex 4 - Options appraisal 36 11.0 Annex 5 - Selected option description, activity shifts and savings profiles 43 12.0 Annex 6 - Consultation requirements 45 13.0 Glossary 47

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1.0 Executive summary This draft pre consultation business case sets out the vision and options for future delivery of community urgent care across Barking and Dagenham, Havering and Redbridge (BHR).

The document sets out the case for change, which was agreed through Governing Bodies in July 2017 and based on what we have learnt from the system and our people.

The case concerns the provision of walk-in centres, GP out of hours and GP access hubs with a move to bookable activity through NHS 111 and provision of urgent treatment centres (UTC) which will provide for walk-in and bookable services.

The clinical commissioning groups (CCGs) cannot leave the system as it is currently. Doing nothing is not an option for the following reasons:  Local people have told us it’s too complicated and we want to provide services that are easier to access and use  To do nothing is unaffordable. All urgent and emergency care service models illustrate that doing nothing would cost us £2.57m per year above our current spend of £35.77m  If we do nothing then the profile of increasing demand and high levels of duplication seen at all of our urgent care service and in our A&E departments will continue.

Ultimately, doing nothing will not help us resolve the challenges in our urgent and emergency care system and will not ease the pressure on our emergency department, leading to an unsustainable model of care for our population. We need to deliver a simpler, cost-effective system that meets our future needs.

Two options have been developed for the future model (detailed in section 5.0) and the proposal is that we share these with our public in a formal consultation to determine the best fit for the future.

Both options also include a move towards booked appointments for urgent care needs, building on call or click before you come in. They will utilise NHS 111 as a way for us to help people get the right care, right place, first time.

Audits have demonstrated that people are attending, and being seen in, A&E for conditions that can be managed in an urgent treatment centre or in the community. We are currently working with providers in the system to strengthen the streaming in the Urgent treatment Centres and ensure that we maximise the attendances that can appropriately be seen in this setting. This will reduce the number of patients seen in A&E and ensure that our performance is improved. This activity shift is closely linked to the community urgent care review but not formally part of the scope of this work.

Option 1 would see 12 sites in total, with four Urgent Treatment Centres open within Barking and Dagenham, Havering and Redbridge (2 on hospital sites, and 2 in the community), plus eight locations for booked community urgent care services. This option would save £1.07 million a year and was our highest scoring option.

Option 2 would see 12 sites in total, with two UTCs within our area on our hospital sites, although local people may still use those in our neighbouring boroughs (Newham and Whipps Cross). Plus there will be 10 places to be booked when your own GP practice is closed and you have an urgent health need. This option would save £1.19 million a year - £117,589 a year more than Option 1, but despite this scored less overall than option 1.

During our engagement work we have consistently been given a clear message that urgent and emergency care services are confusing. We feel both options will help us to address this critical issue - and future-proof urgent care.

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2.0 Context Urgent and emergency care (UEC) has been a key challenge for our health economy for many years with a background that includes:  A complex urgent and emergency care system with duplication and fragmentation across services.  A challenged health economy that is struggling to manage increasing demand, partially driven through population and health profile changes.  Key performance targets, particularly in accident and emergency, not being met.

In Barking and Dagenham, Havering and Redbridge (BHR), as with other parts of England, increasing numbers of people are using NHS services every year. The current urgent and emergency care system does not provide a good experience for patients as it can lead to a long wait to see a GP or in accident and emergency (A&E), and also puts increasing pressure on our hard-working frontline staff and clinicians.

Community urgent care review Aims and objectives The aims of the community urgent care review are to:  Improve patient experience including provision of a clear and defined service offer so that patients can be confident about where to go for treatment, e.g. illness, injury, urgent or emergency.  Improve quality including safety, consistency and right care, right place, first time – for example this will this will support management of patients within the community.  Ensure services are designed to support the changing profile of population growth.  Support delivery of the urgent and emergency care performance targets.  Support system and financial sustainability.  Achieve an integrated service that works more effectively with 111, primary, community and acute care services (in line with national requirements)

The objectives for the BHR proposals for community urgent care services were set out in the case for change and summarised below:  Simplify the system for patients - provide a clear and defined service structure so that patients can be confident about where to go for treatment, e.g. illness/ injury, urgent or emergency need, and to reduce duplication and inappropriate attendances.  Move towards bookable appointments - the national requirement is bookable from 8am-8pm daily.  Consistent assessment -  Consistent assessment and re-direction when booking and at the front door of services where people walk in, such as A&E.  Appointments bookable through centralised systems (phone and online) to increase self-care and remove inappropriate appointments.  Plan for the changing profile of population growth.  Provide more local services, this being an opportunity to review the location of where and how services are delivered.  Improved provision for children (newborn - 18 years) as they represent the greatest proportion of attendance growth.

Scope of this review The focus of this review is on the community based urgent care services:  GP out of hours service (GP OOH)  Primary care access hubs (or GP access hubs)  Walk-in centres (WICs).

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In 2017/18 these services alone delivered over 171,467 appointments which is 40% of the total urgent and emergency care activity of 421,627.

Whilst the Urgent Care Centres (UCCs) at King George Hospital and at Queen’s Hospital do offer a GP led/delivered service, the purpose of these co-located services is to manage patients who present at A&E and are not suitable for an A&E attendance. There are separate plans in place to bring these services up to the UTC specification.

This consultation is not about emergency care services or changes to A&E services at Queen’s, King George, Whipps Cross or Newham hospitals - all of which serve our residents.

Current urgent care service offer People in Barking and Dagenham, Havering and Redbridge are able to use a range of different services when they feel they need medical advice urgently, but when it is not an emergency. These include:  Pharmacists  General practice  NHS 111  Primary care access hubs (or GP access hubs)  GP out of hours service (GP OOH)  Urgent Care Centres (UCCs). Descriptions of these services can be found in annex 3.

Service location map The map below shows the locations of our urgent and emergency care services.

Urgent and emergency care service usage Over the last few years A&E activity has consistently increased. Our latest analysis shows this is generally in line with population growth. However, most of the increase in A&E activity has occurred during the 'in hours’ period (8am and 6pm), which creates a bottle neck and pressure points, resulting in poor A&E performance and an emergency team which is unable to cope with so many people turning up over a short timeframe.

33 5 it is seen as a reliable 24/7 service where their issue will be resolved, even if they have to wait for hours, and that the rest of the community urgent care being offered is too confusing.

Over the next 15 years, the population of Barking and Dagenham, Havering and Redbridge is expected to grow by 143,000 extra people, with population growth expected to follow the large- scale housing developments planned in Ilford, Barking town centres, Romford, Rainham, Beam Park and Barking Riverside. That’s a 19% increase, and equivalent to the size of Basildon.

If the trends described above continue in line with this enhanced level of population growth and within the context of our financial position, this would create a completely unsustainable model of care unless we change the service offered in order to manage this.

Doing nothing would not support our A&E departments, and inevitably lead to an unsustainable model of care for our population.

A&E activity has grown by 2.54% since April 2016 as seen in the figure below. This is above population growth for the same period by 1.15%. It should be noted that, from September 2017, A&E activity has been in line with plan.

Primary care Across BHR there are 124 General Practices:  44 practices in Redbridge  44 practices in Havering  36 Practices in Barking and Dagenham

Practices should be open for bookable appointments between 8am - 6.30pm Monday to Friday; although across BHR there is still is some variation in practice e.g. a small number of practices don’t open until 8.30am and some practices still operate with half day closures once a week.

Significant progress has been made in improving access to General Practice over the last few years. However in our 2016 research survey, 33% of those surveyed in A&E said they had been unable to get a timely appointment with their GP. Local GPs and stakeholders tell us that the current model in primary care is unsustainable. The primary care workload is increasing, and will do further with the ageing population, meaning practices can find it difficult to deliver the quality of care their patients need.

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Our workforce is stretched, with recruitment and retention of staff challenging. To put this in context BHR has some of the lowest rates of GPs per 1,000 population in London, with 0.44-0.47 GPs for every 1,000 registered patients compared to a London average of 0.55. The Practice Nursing picture is slightly better with 0.14-0.22 Nurses per 1,000 population compared to a London average of 0.2. Traditionally, outer London has found it harder to attract newly qualified GPs than inner London. It is difficult both to recruit and retain salaried GPs and to attract GP partners in BHR, as well as other members of the primary care workforce.

Patient behaviour also contributes to the increasing GP workload. Some patients still feel they need to see their GP for minor illnesses such as coughs and colds when another professional such as a community pharmacist could provide that care. Other people seek an appointment with their own GP, as well as seeking contact with professionals in urgent care - in our engagement survey 37% of people reported they had seen their GP with the same issue before attending A&E. Sometimes this is because their symptoms worsen, but it can also be due to initially attending an urgent care setting which could not meet their needs, to ‘check’ their treatment is correct, for further reassurance, or to seek a prescription to ‘cure’ the illness e.g. antibiotics or paracetamol. As we reported in our case for change, a Barking and Dagenham (B&D) GP practice audited attendances outside of the practice for 1 week. The greatest number of patients attending different services on the same day had a final outcome of having been prescribed antibiotics. GPs anecdotally report patients seeking antibiotics outside of the practice as a clinical concern and a driver of duplication.

In March 2018 BHR CCGs carried out a survey of GP practices to better understand the primary care role in the wider current urgent care patient pathway. Practices were asked to complete a short questionnaire to provide some of the primary care context. 46 practices responded to the survey - a 38% response rate. The results of this survey demonstrate the key role that primary care play in the delivery of urgent care.

Highlights from responding practices include:  100% of practices provide access to same day appointments  45% practices triage their same day appointments and this may be undertaken by anyone in the practice from a GP 48% to receptionists 43%  70% of practices undertake injury management - examples of this were:

Road Road traffic accidenttraffic accident  83% reported in the survey that their voicemail refers patients via NHS 111 to the GP out of hours service when the practice is closed for the day, 17% did not respond to this question  85% practices advertise the access hubs - using a range of methods such as text messaging, posters/leaflets, Jayex boards/TV screens, standard letters and on the practice website

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Wound care The CCGs are in the process of reviewing wound care – the review scope includes Lymphedema, complex wound care and simple wound care. It is likely that these three service will be improved through three separate projects. The simple wound care service is currently delivered by a range of providers across BHR including individual GP practices via a local incentive scheme to a borough wide contract in Havering with the Hurley group, who also provide the walk in centres (WIC) for the borough. During spring/summer 2018 the CCGs will undertake patient engagement on the simple wound care and the feedback will be used to inform future provision. Given this review is in place, the modelling for the community urgent care review has removed all wound care activity from the baselines as it will be re-provided as part of this project.

National context NHS England’s Next Steps on the NHS Five Year Forward View (5YFV) explains how the 5YFV’s goals will be implemented over the next two years. Urgent and Emergency Care (UEC) is one of the NHS’s main national service improvement priorities, focussing on improving national A&E performance whilst making access to services clearer for patients.

As part of the NHS Five Year Forward View and subsequent updates, including the Urgent and Emergency Care Review, NHS England (NHSE) have introduced a new set of key deliverables for urgent and emergency care in 2017/18 and 2018/19 which includes:  Achievement of the ‘4 hour target’  Comprehensive front-door clinical streaming  Specialist mental health care in accident and emergency departments (A&E)  Integrated urgent care (IUC) - an enhanced NHS 111 service which means more people will speak to a clinician and receive a booked appointment where appropriate  An enhanced primary care offer which will deliver a bookable general practice service from 8am - 8pm seven days a week  Standardise non-acute services - including urgent care centres (UCCs), minor injury units (MIU) and urgent treatment centres (UTCs).

This business case sets out the CCGs proposals for standardising non-acute services, including upgrading UCCs and walk in centres to Urgent Treatment Centres or a bookable service.

Developing an Integrated Urgent Care (IUC) system The review of community urgent care services is one of the programmes that is being taken forward to develop an integrated urgent care system.

Integrated Urgent Care (IUC) - A better NHS 111 - providing clinical advice, triage and booking.

NHS England see NHS 111 as a key part of providing patients with integrated urgent care, which is how they describe the way different services will link up to help people in need of urgent same- day care and advice.

There are some aspects to the current NHS 111 service which would be promoted as part of the model as they underpin the proposed changes:  Clinical advice service (or CAS) - allows NHS 111 health advisors to fast-track transfer children aged under 1 and people aged 65 and older to a GP or other health professional for advice and assessment.  Bookability - for those who do need to come into one of our services, our local NHS 111 service can already book appointments at some of our existing community urgent care services, and we plan to add more, meaning just one call to NHS 111 would be the only action required to access urgent care.  Interpretation services - NHS 111 is supported by two interpretation services:

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. Languages - there is a confidential interpreter service available in many languages. The caller needs to simply mention the language they wish to use when the NHS 111 operator answers the call line. NHS 111 patient information leaflets are available at NHS choices in several languages. . British sign language (BSL) - NHS 111 offers a video relay service that enables a video call to a British Sign Language (BSL) interpreter. The BSL interpreter will call NHS 111 to enable a real-time conversation with the NHS 111 adviser via the interpreter. This requires a webcam, a modern computer and a good broadband connection to use this service. Visit NHS 111 BSL interpreter service for more details, including an online user guide. http://interpreternow.co.uk/nhs111  Out of hours - available 6.30pm - 8am weekdays and all weekend when most core services are closed: Dental (Smile service) - NHS 111 can be used to access the dental service who can: . Assess the dental issue or problem . Make referrals to an Out of Hours Dental service . Look up urgent care services that provide dental treatment . Offer self-care advice. Prescriptions out of hours (PURM) - if a repeat prescription is required, for items that have previously been prescribed via an NHS prescription, NHS 111 can be used to access a pharmacy service who can: . Assess symptoms and provide clinical advice . Refer to a pharmacy that provides access to urgent medicines for assessment and potentially the supply of medicines.

The CCGs are already making improvements to our local NHS 111 service so it provides more than just advice and signposting to services now and in the future. We have introduced a Clinical Advice Service (or CAS) which allows NHS 111 health advisors to fast-track transfer children aged under 1 and people aged 65 and older to a GP or other health professional for advice and assessment. As a result of this pilot, currently over 50% of people now speak to a clinician on the phone after calling NHS 111.

In future, people may also be booked into an appointment with their own GP, and this is being tested in other parts of the country now. An online version of NHS 111 and a digital app are also being tested in other parts of London.

Urgent treatment centres (UTCs) The case for change for community urgent care services, which was agreed at July 2017 Governing Bodies meeting, reflects feedback from the public, both at a local and national level, that there is a confusing mix of urgent care services that they find difficulty in navigating:

From the outset of our review of urgent treatment services in the NHS, our patients and the public told us of the confusing mix of walk-in centres, minor injuries units and urgent care centres, in addition to numerous GP health centres and surgeries offering varied levels of core and extended service. Within and between these services, there is a confusing variation in opening times, in the types of staff present and what diagnostics may be available. Source: core principles and standards for UTCs https://www.england.nhs.uk/wp-content/uploads/2017/07/urgent- treatment-centres%E2%80%93principles-standards.pdf

NHSE have published a core set of standards and principles for urgent treatment centres (UTC) to establish as much commonality as possible across services, and offer a consistent route to access urgent appointments offered within 4 hours and those booked through NHS 111, ambulance services and general practice. NHS England expects us to have UTCs in place by December 2019, if not sooner.

The core principles for UTCs include: 37 9

a) Having access to urgent treatment centres that are open at least 12 hours a day, GP- led, staffed by GPs, nurses and other clinicians, with access to simple diagnostics, e.g. urinalysis, echocardiogram (ECG) and in some cases simple x-rays. b) Have a consistent route to access urgent appointments offered within 4 hours and booked through NHS 111, ambulance services and general practice. A walk-in access option will also be retained. c) Increasingly be able to access routine and same-day appointments and out-of-hours general practice for both urgent and routine appointments, at the same facility and where geographically appropriate. d) Know that the urgent treatment centre is part of locally integrated urgent and emergency care services working in conjunction with the ambulance service, NHS 111, local GPs, hospital A&E services and other local providers.

NHS England expect commissioners to have UTCs in place by December 2019 or sooner.

We have looked at our existing walk in services and compared them to the UTC national standard:  South Hornchurch Walk-in service is only open for 6 hours a day and significant investment would be required to open this site for 12 hours a day, every day of the year and make the other improvements needed to meet the standard.  Most people who use Loxford Polyclinic already book appointments rather than walk in. Fewer people use Loxford compared to the numbers seen at the other walk-in services in our area, and significant investment would be required to meet the UTC standard.  Based on the existing provision of diagnostics, it may be possible for Harold Wood Polyclinic and Barking Community Hospital to become UTCs, and this is included within one of the options.

UTCs will help reduce the pressure on our busy A&E departments, releasing capacity to treat those people requiring immediate emergency care when life or long term health is at risk.

Audits have demonstrated that people are attending, and being seen in, A&E for conditions that can be managed in an urgent treatment centre or in the community. We are currently working with providers in the system to strengthen the streaming in the urgent treatment centres and ensure that we maximise the attendances that can appropriately be seen in this setting. This will reduce the number of patients seen in A&E and ensure that our performance is improved. This activity shift is closely linked to the community urgent care review but not formally part of the scope of this work.

Financial context Nationally, the NHS is facing a challenging time as demand for services is growing - an increasing and ageing population coupled with more people living with long term health conditions, such as diabetes - placing further pressure on already stretched services and finances. The CCGs faced specific challenges to our budgets for 2017/18, and we reached a point where we did not have enough money to continue buying all the services in the way we had done previously. To achieve financial balance during the year we needed to address a financial shortfall of £55m, which is just over 5% of our total annual joint budget of just over £1 billion. The CCGs delivered £32.2 million in savings in 2017/18 (against a £55 million savings target). 2018/19 will be just as tough as we’re currently aiming to deliver £45 million savings to achieve financial balance. To achieve financial balance this year we have, therefore, had to maintain very close focus on where we are using our funds, reducing spending in some areas of our health budget to ensure we are making the most effective use of every penny that goes into our local NHS, all while making sure local people can access the healthcare which is most needed and that people with equal need have equal opportunity to access treatments.

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The CCGs have set up specific groups of key clinical and senior staff to ensure that our focus is maintained on making the most effective and efficient use of the CCGs’ resources and securing the required budgetary savings. We are not alone in needing to carry out major reviews of where money is spent. CCGs all over the country are now looking at how they can use limited resources responsibly to make sure the NHS in their areas is able to focus on those most in need, whilst remaining in financial balance. The CCGs remain totally committed to ensuring that we are commissioning the best health services we can for local patients and residents within the money we are allocated, and will continue to work with patients and stakeholders on the difficult decisions we need to take to achieve this. We spent £14.3 million on community urgent care in 2017/18. Too many of our existing urgent care services provide similar care at the same time. It’s confusing for patients, and not the best use of our limited NHS resources.

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2.0 Case for change

What is urgent care? The CCGs worked with Healthwatch in 2016 to create local definitions to help explain the difference between urgent and emergency care:

Urgent care is care needed the same day. This could include anything from cuts, minor injuries, wound infections or tonsillitis, urinary infections, mild fevers, etc.

Urgent care is not emergency care which is provided in a medical emergency when life or long term health is at risk. For example, this could include serious injuries or blood loss, chest pains, choking or blacking out.

BHR vision for urgent and emergency care The BHR vision for urgent and emergency care is: Health and social care partners across BHR want local people to receive the right care, in the right place, first time. If they do need to be admitted to hospital, we will get them home safely and quickly, with the right support to help them to recover their independence. No time will be wasted.

Our ambition is to radically transform local urgent and emergency care services, removing barriers between health and social care, and between organisations.

Variation in existing community urgent care services • There are a number of variations across our community urgent care services, including inconsistencies in: . access routes . service names / branding . opening times . diagnostic provision . skill mix . digital integration

• This complexity and variation within the system leads to: . duplicate attendances for the same health need . poor patient experience . multiple transfers of care . wasted time and resources for both patients and staff . poor value for money . all of the above ultimately leading to a likelihood of poorer clinical outcomes

Some of the evidence for duplicate attendances and patients not being seen in the most appropriate place first time is given below. The forms of variation across urgent and emergency care services are described in more detail in the case for change (annex 1) with more detail within annex 2.

Duplicate attendances We know that some NHS capacity is wasted due to duplicate or repeat attendances for the same health need.

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However some of this is also driven by patient behaviour and the perceived need to seek a second opinion.

Our IT systems are unconnected which means we cannot quantify the full extent of duplication that exists. However, where we can compare datasets (approx. 50% of urgent care attendances), the level of duplicate attendances was just over 5%, with most of these within 24 hours of the first attendance at 3.3%.

The highest number of attendances was one person attending 6 services within 72 hours.

Clinical audits have demonstrated a higher rate of duplication. In a clinical audit of 300 WIC attendance records, the following examples of duplication were observed: • 23% of cases would have been better seen by their own GP as the WIC could not manage their need. • 17% could have been managed by a pharmacist (conjunctivitis/ simple pains / gastroenteritis / ear nose and throat (ENT) symptoms such as ear pain). • 7% of cases were for a second opinion. This was a combination of patients with chronic conditions seeking second opinion or those seeking help after trying a new medication only for a few days. • 10% of cases were referred onto the emergency department (ED) (deep vein thrombosis (DVT) / some fractures / chest pains). • 44% of cases were appropriate and fully managed at the WIC.

This means 40% of these cases were potentially duplicated appointments where ED, primary care or other urgent care services and a further 17% could have been managed by pharmacy.

In our engagement work people reported attending multiple times for the same need.

Of those attending A&E: • 39% sought no advice before attending A&E. • 37% had seen their GP with the same issue. • 26% had been to A&E before with same issue.

Parents reported a slightly different profile: • 37% of parents who attended A&E had seen a GP previously for the same issue. • 25% had previously been to A&E with the same issue.

The following diagram shows excerpts from the BMG telephone survey:

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The following picture shows 45% of people sought advice before going to A&E from various sources including NHS 111, a GP or a pharmacist. This indicates multiple attendances for the same need. Although the survey was not able to analyse whether they were correctly advised to go to A&E, 87% said that the advice they were given was to go to Accident & Emergency. It is possible to infer from this that the other 13% went to A&E despite the advice suggesting an alternative course of action.

A much lower percentage of people sought advice before going to a hub or WIC (31% for a hub, 34% for a WIC) compared with A&E and UCCs (60%). This could be down to the confidence in or awareness of these services by those giving advice.

The re-direction trial at Queen’s hospital demonstrated up to 30% of A&E presentations do not require a same day urgent care service.

Do nothing The CCGs cannot leave the system as it is currently. Doing nothing is not an option for the following reasons:  Local people have told us it’s too complicated and we want to provide services that are easier to access and use.  To do nothing is unaffordable. All urgent and emergency care service models illustrate that doing nothing would cost us £2.57m per year above our current spend of £35.77m.  If we do nothing then the profile of increasing demand and high levels of duplication seen at all of our urgent care service and in our A&E departments will continue.

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Drive time analysis for ‘do nothing’:

The CCGs believe that the case for change is strong based on the results of our engagement exercise, financial and activity analysis, the need to strengthen urgent care services to reduce pressure on our hospital sites and the need to develop a sustainable integrated urgent care service going forward that builds on national and local developments.

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3.0 Engagement to date - urgent care co-design and research Over the last two years we have undertaken several engagement exercises with stakeholders and patient representatives to gather views on how we can transform urgent care services.

This includes the Barking and Dagenham, Havering and Redbridge (BHR) urgent care conference held on 1 July 2015 and engagement with the CCG patient engagement forums, a comprehensive UEC co-design research survey which included many patient events.

We have talked extensively to local residents to find out their views on local community urgent care services. Our research study involved more than 4,000 people and included a telephone survey, 10 focus groups and 2 workshops.

Residents told us that the wide range of services available is confusing and means they don’t know which service to choose. Even finding the right service is complicated, with different numbers, different opening hours and a mix of walk-in services or pre-bookable appointments to choose from. People said they can’t always get a same-day appointment with their own GP, so some will head to A&E instead of using an alternative, more appropriate service. Some people say the long waits do not deter them as they think of A&E as reliable service.

The info graphic below outlines the key messages from the 2016 urgent care research:

The clear message from all of this engagement is that all stakeholder groups view urgent care as complex and confusing and endorse the need to look at simplifying the pathway.

This year, the Healthwatch organisations in all three of our boroughs worked with us to talk with local people about some of our emerging ideas. They spoke with more than 500 people - a mix of parents, young adults (15-24) and older people aged 65 and over as these groups are our biggest users of urgent care services.

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A report on the findings is available on our websites alongside the other documents supporting this consultation.

While most people can confidently describe the difference between ‘urgent care’ and ‘emergency care’, it’s clear more needs to be done to help people feel confident to make the right choices for their urgent health needs. Simplifying the system and providing better support and advice through NHS 111, as well from your local pharmacist, will help patients.

While patients would prefer to see their own GP, there is support for more appointments within the local community (at a GP hub or bookable service) when your own GP is not available. There’s also good recognition of the role of pharmacies in providing expert advice for minor illnesses.

People welcomed news of the improvements to NHS 111 and felt this would make it easier to get health advice quickly, to book an urgent appointment and would reduce the number of people who go to A&E when they have a minor illness or minor injury. But people told us we need to do more to raise awareness what NHS 111 can now help with.

Learning from our engagement Services are confusing and vary across our three boroughs. People have told us they want it to be simpler to get the urgent care or advice they need quickly and in a timely way.

We know that the mix of services is confusing, both for patients and many professionals too. This can mean people aren’t seen in the most appropriate place first time. That can be frustrating as it means extra travel, longer waits and delays in getting the help required.

Also, services are not consistent across different A&E departments. Some patients might have a telephone assessment before they see or speak to a doctor or nurse; others are booked in for a detailed assessment; and then some people can just walk into others, regardless of the level of urgent care need.

This isn’t fair, and so we want to make sure that all services prioritise those in most need in a consistent way.

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4.0 Options development and selection

The options appraisal process was completed in 3 stages and overseen by a programme board, with membership including a lay member, an independent clinical lead, public health, primary care, finance, communications and engagement and estates.

1. Scenario generation - to generate our scenarios we looked at all the information that was available to us including: . Patient feedback including our huge research study and engagement programme . National requirements and regional studies and examples, including guidance on making it easier for local people to get help in the right place, first time . Data and analysis on our services and how they are used . Population growth estimates for the next 3 years.

Using this information, we modelled different scenarios and tested them against our priority themes.

2. Scenario appraisal - the scenarios were appraised in two stages: a) The ‘affordability test’ - the CCG finance team completed a financial evaluation of the modelling of each scenario. Only scenarios that are estimated within the ‘do nothing’ forecast value are scored against the non-financial criteria.

b) Non-financial criteria scoring process where a scenario scoring panel, consisting of Programme Board members and joined by an additional Lay Member (Audit Chair), the Quality Manager and Contract Manager from the Commissioning Support Unit, was formed to score the scenarios which passed the affordability test.

The scenario scoring panel evaluated each scenario against the following criteria:  Patient experience  Clinical quality  Deliverability  Efficiency.

3. Option selection - When setting the scenario shortlisting process, the programme board agreed that the top 4 scoring scenarios with a minimum score of five would be recommended for consultation. However, when reviewing the final scores, the programme board and financial recovery programme delivery meeting (FRPDM) agreed to recommend to financial recovery programme board (FRPB) and Governing Bodies (GB) that only the top two highest scoring scenarios would be recommended as options for consultation on the basis that no

46 18 additional benefits to either the public or CCGs could be identified for the scenarios which scored in third, fourth or fifth place. ‘Do nothing’ scored 3.30 and was excluded on this basis.

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5.0 Context for our options

Both of our options enhance current services in line with the standards set out in the government’s NHS Five Year Forward View plan which we are required to implement.

In response to the need to simplify the pathway, our options have just two points of access and a common name for services:  Bookable services accessed through NHS 111  Urgent Treatment Centres (UTCs).

Click or call before you come in - bookability When developing the scenarios we have considered how we could help to address the critical issue of confusion, and how we can help people access the right care, right place, first time. Call or click before you come in was an idea first developed in 2015 during our time as a vanguard site. As this model was supported by stakeholders and local people and is used nationally, we have continued to build on this when developing our models.

Both options also include a move towards booked appointments for urgent care needs, building on click or call before you come in. Both of our options will utilise NHS 111 as a way for us to help people get the right care, right place, first time. The message to our population would be to click or call before you come in, resulting in shorter times spent in our waiting rooms and fewer handoffs. People who come in for a booked appointment following click or call would be seen at their appointment time, rather than the current commitment to see people within 4 hours of arrival at our urgent and emergency services.

‘Click’ or ‘Call’ before you ‘Come in’  ‘Click’ - NHS111 online to provide support and information. This will help people to self- care and book urgent appointments when needed. NHS 111 on-line is being tested elsewhere now, and there are other systems being tested across the country.  ‘Call’ - NHS 111 telephone line for those who need more advice and reassurance or to book an appointment to come in if this is required.  ‘Come in’ - Urgent Treatment Centres (UTCs) where patients who need to come in can access urgent care.

Consistent elements which will exist regardless of this proposed service change Integrated Urgent Care - ‘the smart call to make’, providing clinical advice, triage and booking. There are some key aspects to the current NHS 111 service which would be promoted as part of the model:  Clinical advice service (or CAS) - for those who will benefit from telephone advice  Bookability - for those who do need to come into one of our services, NHS 111 will book an appointment at one of our community urgent care services  Interpretation services  Out-of-hours dental and prescription services (6.30pm - 8am).

Urgent Treatment Centres (UTCs) Both urgent care centres at King George and Queens Hospitals will be upgraded to the new national UTC specification. The main difference between our current UCCs and the UTC specification is that the centres would have:  access to simple diagnostics  bookable services via NHS 111 These enhancements are being addressed as part of this year’s winter plan.

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UTCs will have access to simple diagnostics, such as blood tests and simple x-rays, as well as treatment for ailments like wound closure and management of minor head and eye injuries. Staff will also be able to issue e-prescriptions and repeat prescriptions.

The CCGs are proposing two options for public consultation. We know that both options will mean we need to plan how we tell people about the changes and about how they can get help and care in the future so that they understand and feel confident when we are ready to make the changes. We believe each option would mean we could deliver improved care for local people in the future and meet our ambitions for the community urgent care.

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Options for public consultation

Option 1 - would see 12 sites in total – with four Urgent Treatment Centres open within Barking and Dagenham, Havering and Redbridge (2 on hospital sites, and 2 in the community), plus eight locations for booked community urgent care services.

Our existing Urgent Care Centres at King George and Queen’s Hospitals will be upgraded and become Urgent Treatment Centres in line with national policy. These will see patients who walk in or who are booked into a timed appointment by NHS 111.

As well as the two existing Urgent Care Centres, people could also continue to walk into Barking Community Hospital and Harold Wood Polyclinic, and facilities at these locations would be upgraded to become community Urgent Treatment Centres.

This would mean there would be four locations (including the hospital UTCs) in Barking and Dagenham, Havering and Redbridge where you can walk in and be seen as well as book an appointment by calling NHS 111.

There will also be eight community urgent care services across the area where you can be booked in following a call to NHS 111. You will be seen within a maximum of 30 minutes of your appointment time.

All sites (including UTCs) would have bookable appointments through NHS 111.

Financial modelling results conclude that this option would save £1.07 million a year.

Option 1 - map of services and drive time analysis for services within the BHR geography:

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Option 2 would mean 12 sites in total – with two UTCs within our area on the hospital sites (although local people may still use those in our neighbouring boroughs Newham and Whipps Cross). Plus there will be 10 more places to be booked when your own GP practice is closed and you have an urgent health need.

Under option 2, the Urgent Treatment Centres at King George and Queen’s Hospitals would be the only places you could walk in without making a call first or getting an appointment.

By calling NHS 111, you would be booked a timed appointment at 10 community urgent care service locations across Barking and Dagenham, Havering and Redbridge. These would include Harold Wood Polyclinic, South Hornchurch Health Centre, Loxford Polyclinic and Barking Community Hospital.

All sites would have bookable appointments through NHS 111.

Financial modelling results suggests that this option would save £1.19 million a year - £117,589 a year more than Option 1.

Option 2 - map of services and drive time analysis for services within the BHR geography:

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Option 1 Option 2 Service provision Twelve sites in total: Twelve sites in total: . Four UTCs (walk in and bookable access) . Two UTCS (walk in and bookable access) . Bookable appointments via NHS 111 at 8 locations . Bookable appointments via NHS 111 at 10 community urgent care for booked community urgent care services service locations across Barking and Dagenham, Havering and . Redbridge. These would include Harold Wood Polyclinic, South Hornchurch Health Centre, Loxford Polyclinic and Barking Community Hospital. . Scenario scoring panel Quality score Quality score

scores

£ score £ score Patient Patient Total score Total score Clinical Clinical Efficiency Efficiency experience experience Deliverabili Deliverability

1.80 1.50 1.32 1.40 1.34 7.36 2.00 1.18 1.30 1.14 1.38 7.00

Benefits Managing the 4 hour A&E wait - greater capacity for Greater savings - the modelling estimates that this scenario saves diagnostics to support minor injury management away £117,589 more than option 1. from the main hospital sites and closer to home. 70% bookable capacity – this both allows for the management of injuries as walk-in whilst reflecting a sensitivity analysis of people’s compliance with the click/ call/ come in message. Risks Patient behaviour does not follow the modelling Patient behaviour does not follow the modelling assumptions - i.e. where assumptions - i.e. where WICs become bookable services WICs become bookable services (Harold Wood Polyclinic, South (Loxford and South Hornchurch) that 70% of patients will Hornchurch Health Centre, Loxford Polyclinic and Barking Community book appointments Hospital) that 100% of patients will book appointments. There is no UTC facility in B&D.

52 What the future will look like We want to make it easier for local people to access help for urgent health needs. We want people to click or call before they come in, and to trust the advice they receive about what to do or where to go when they have an injury or illness.

We know that both options will mean we need to plan how we tell people about the changes so that they understand and feel confident about where to go for help when we are ready to make the changes.

In general we will not be closing existing services, but will be changing the way services are accessed from the existing locations. The only exception is Grays Court in Dagenham as the Council own this building and have alternative plans for its use in the future (subject to confirmation from London borough of Barking & Dagenham).

We will enhance our existing Urgent Care Centres to meet the new national Urgent Treatment Centres specification, and offer more pre-booked appointments with GPs and nurses in community locations away from hospital sites.

Both of these changes will help to reduce the pressure on our busy A&E departments, and will reduce waiting times for patients.

Local services will be designed to meet the growing and changing population of our three boroughs, but we will make sure we get better value for money from local NHS services by removing duplication and helping residents receive the right care in the right place, first time.

In the future, people will receive a more consistent quality assessment of their health needs before they see a clinician, whether it’s by NHS 111 or as they walk into any of our UTCs. This will help to address the issues of perceived vs urgent care need and help people get the right care in the right place, first time, with those with the most serious needs seen as a priority - not on the basis of who called or turned up first.

We’ll continue to build on improvements to NHS 111 and to the way that different services and organisations link up to share information including electronic health records. This will improve the quality of the care patients receive and tackle the challenge of those who visit several services for the same issue. National tools such as the summary care record will be used.

A digital future for healthcare Advances in digital technology are already making it easier to get health advice and services online. Across London, doctors and patients are talking via Skype and we’ve seen the launch of the ‘GP at Hand’ virtual NHS service. In our own area, GPs from NHS 111 are using video consultations with care homes when a resident is unwell so staff can care for them safely in the home and avoid an often unnecessary journey by ambulance to A&E.

Both of our options will allow patients to access urgent care on-line, which will include access to clinical advice and the ability to book an appointment at the right place for their needs for those who need it.

In future, it will be easier and quicker to get help from a health professional without needing to go into a busy health centre and see someone. Many people won’t even need to leave their home, as they’ll get advice through their phone, smartphone, tablet or PC.

People won’t waste time sitting in a waiting room, and if they do need to see someone they will be booked an appointment at the right place for their needs. Appointments will fit around an

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individual’s life and responsibilities, such as work, collecting children from school or other caring responsibilities.

We will make sure services and organisations link up to share information including electronic health records. This will improve the quality of care patients receive.

We think moving away from walk-in services will make it easier for local people to get help with urgent health needs. We will make it easier to call (and, in future, click), get clinical advice from home and be guided to the right place for the care needed.

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6.0 Proposed consultation process Engagement plan for the next stage The CCGs will be seeking views through online surveys or at events that we attend, and we will ensure personal information is kept secure and confidential and will only be used to help us analyse the feedback we receive.

When the consultation closes, we will read and consider all the responses we receive.

We will use feedback to write a report for the three CCGs’ decision-making Governing Bodies to consider, alongside any other evidence and/or information available. This includes the equality impact assessment (EQIA). The Governing Bodies will make a decision about what to do.

Responses on behalf of an organisation or for those who represent the public (as an MP, Councillor or similar) may be made available for the public to look at. Where an individual responds in a personal capacity, we will not publish the name or response in full but may instead use some of what is said to show particular points of view.

For responders who request to be kept up to date and provide contact details when completing the questionnaire, we will email updates to keep them informed.

Any comments on our proposals must be received by 5pm on 21 August 2018.

Consultation process We propose the following:  A 12 week, three-borough consultation, running from 29 May to 21 August 2018.  Online consultation in line with previous successful Spending Money Wisely consultations  Consultation to be promoted through social media and other established channels, through media releases, posters, and advertisements, and via newsletters, stakeholders and existing forums.  Printed copies of a flyer (written in plain English) promoting the consultation to be widely circulated throughout the three boroughs  Present at the BHR patient engagement forums (PEF).  Actively engage with Healthwatch and other local stakeholders.  Attend meetings with local stakeholders as requested.  Proactively engage the voluntary and community sector  Key stakeholders identified, with a targeted focus on hard to reach groups, parents of young children and young adults as high or frequent users of UEC services

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Summary of the key stages of the consultation process and indicative timeline

The timeline for the following stages (e.g. route to contract, market testing, procurement and mobilisation of the new service) will be developed and released following the consultation decision making stage.

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7.0 Annex 1 - Case for change

Community urgent care case for change_July 2017.pdf

8.0 Annex 2 - Variation in existing community urgent care services Access routes - people can access services by calling NHS 111, various call centres or at some services it is possible to simply walk in.

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Variation in service names / branding – there are many descriptions for our community urgent care services, despite common services being offered, e.g. treatment of minor ailments or minor injuries:

Variation and duplication of opening hours Across all urgent and emergency care services, there is plenty of access available covering 24 hours a day seven days a week. Variation does exist even within services of the same type, e.g. for walk in centres:  Loxford: 8am - 8pm  Harold Wood: 8am - 8pm  South Hornchurch: Monday to Fridays 10:00 - 14:00 and 15:00 - 19:00; Saturday and Sundays 10:00 - 14:00  Barking community hospital: Monday to Fridays 7am-10pm; Saturday and Sundays 8am - 8pm

UEC services week day opening hours:

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UEC services week opening hours:

 Variation in diagnostics – and, again, this even occurs in services with the same name: . Walk-in centre Loxford: urinalysis . Walk-in centre South Hornchurch: urinalysis, blood glucose . Walk-in centre Harold Wood: urinalysis, blood glucose, phlebotomy, simple x-ray . Walk-in centre Barking community hospital: urinalysis, phlebotomy, simple x-ray, ECGs.

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 Skill mix - there is no consistent staffing model in place with a mix of nursing and medical workforce delivering the service. This can be an issue if people attend a service and the skill required to deliver their needs are not available there. The diagram below shows this variation:

 D i g

 Digital integration - we have lots of community urgent care services, but few are digitally connected. This means medical records or care plans are not always available. This has a direct impact on patient care as clinical decision-making is improved where clinical history is available.

Even where the same system is used by multiple services (Adastra) it is not connected across the system.

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9.0 Annex 3 - Current urgent and emergency care services People in Barking and Dagenham, Havering and Redbridge are able to use a range of different services when they feel they need medical advice urgently, but when it is not an emergency.

Service location map The map below shows the locations of our urgent and emergency care services:

Descriptions of current services Pharmacists Daily, about 1.6 million people visit a pharmacy in England. There are around 140 community pharmacies across Barking and Dagenham, Havering and Redbridge, located in high streets, supermarkets and local shopping centres.

Community pharmacists (or chemists) dispense and check prescriptions and provide advice to patients on medicines that have been prescribed for them. They can also provide advice on minor illnesses and staying healthy. You can find out more on the NHS Choices website or by talking to your local community pharmacist.

General practice GP practices offer same-day urgent appointments and will continue to do so. These are the best place for you to be seen, especially if you have an ongoing medical condition or health need.

NHS 111 NHS 111 is the NHS non-emergency telephone number where you can speak to a highly trained adviser, supported by healthcare professionals. It is available 24 hours a day, 365 days a year. Calls are free from landlines and mobile phones. There is also a free text-phone service and a confidential translator service which is available in many languages.

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GP out of hours service (GP OOH) If your GP practice is closed, you can call NHS 111 and get advice from the GP out-of-hours (OOH) service. This service is staffed by GPs who can offer you medical advice by telephone. If you need to see someone, you may be given an appointment at one of three GP out-of-hours service centres: Grays Court in Dagenham, Queen’s Hospital in Romford and King George Hospital in Ilford. In some circumstances, such as housebound patients, a GP will visit you at home. The GP OOH service is available from 6.30pm to 8am on weekdays and 24 hours at weekends and on public holidays.

Primary care access hubs (or GP access hubs) These hubs provide bookable appointments with GPs for people who feel they need to be seen on the same day. There are seven primary care access hubs in Barking and Dagenham, Havering and Redbridge. Primary care access hubs can only be used by people registered with a GP in one of our 3 boroughs. Appointments are available every weekday evening between 6.30pm and 10pm and 8am to 8pm on weekends. You can book an appointment in advance by calling the service directly on 020 3770 1888 between 2pm and 9pm on weekdays and between 9am and 6pm on Saturdays and Sundays all year round. NHS 111 can also book you into a GP hub if you need an urgent appointment. You can’t walk in or turn up without an appointment.

Hubs are located at:  Barking and Dagenham: Broad Street Medical Centre in Dagenham and Barking Community Hospital in Upney Lane, Barking.  Havering: North Street Medical Care in Romford and Rosewood Medical Centre in Hornchurch.  Redbridge: Southdene Surgery in South Woodford, Newbury Group Practice in Newbury Park and Fulwell Cross Medical Centre in Barkingside. Over 60,000 appointments were made available at our seven hubs last year. The hubs provide a useful service for people who are not able to see their own GP during normal opening hours. They also mean local people benefit from access to a GP seven days a week, from 8am to 8pm.

Walk-in Centres (WICs) Barking Community Hospital (BCH) Walk-in Centre is located in Upney Lane, Barking. It is open from 7am to 10pm, Monday to Friday, and 9am to 10pm on Saturdays, Sundays and bank holidays, all year except 25 December. This is an urgent primary care service staffed by nurses for people with minor injuries and illnesses. It has simple x-ray facilities and can deal with simple fractures. You can also have urine tests, blood tests and electrocardiograms (ECGs) to test your heart. The nurses can prescribe certain medication if needed. You can walk in or other services (including NHS 111) can refer you. The service prioritises patients according to need. Harold Wood Polyclinic is located in St Clements Avenue in the Kings Park Development in Harold Wood. It is open 8am to 8pm seven days a week, every day of the year (including weekends and all public holidays). It is staffed by GPs and nurses who can provide help with minor illnesses and injuries and prescribe medication if needed. Services also include simple x- rays, wound care, urine testing and blood tests. South Hornchurch Walk-in service is located in South End Road, Rainham. It is open 10am to 2pm and 3pm to 7pm Monday to Friday, and 10am to 2pm on Saturdays and Sundays. This site is closed on Bank Holidays. It is staffed by highly skilled senior nurses (Advanced Nurse Practitioners) during the week. Treatment includes help with minor illnesses. Urine testing, blood glucose tests and wound care (changing of dressings) are also provided from this site. Loxford Polyclinic is located in Ilford Lane, Ilford. It is open 8am to 8pm, 7 days a week. It is a GP service providing help with minor ailments and illnesses that you would normally see your own GP with. It does not have x-ray or offer blood tests, but can offer urine tests. You can walk in and be allocated an appointment within four hours. You can also pre-book an appointment.

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Urgent Care Centres (UCCs) There are two Urgent Care Centres in our area. They work alongside the A&E departments at King George Hospital in Ilford and at Queen’s Hospital in Romford and are located next door to each other. Led by GPs with support from nurses and other health professionals, they can treat minor injuries and illnesses for patients who do not require an A&E attendance. UCCs do not provide emergency care or care for those with life-threatening conditions. The King George UCC is open 24 hours a day, with the UCC service at Queen’s currently open from 8am to 11pm.

Emergency departments (A&E) There are two emergency departments in our area: King George Hospital and Queen’s Hospital. Emergency departments provide care for those with life-threatening conditions or when long-term health is at risk. Given the close geographic proximity to services outside the BHR area, our residents often use the services at both Newham General and Whipps Cross hospital (which are part of Barts health). The emergency departments are open 24/7.

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10.0 Annex 4 - Options appraisal

Process The options appraisal process was completed in 3 stages and overseen by a programme board with membership including a lay member, an independent clinical lead, public health, primary care, finance, communications and engagement and estates.

Scenario generation Generation of scenarios was based on a comprehensive information set which included: . Information on who currently uses urgent care services such as: . Where people live or are registered with a GP . What symptoms or issues they wanted help with . What advice or treatment they received . Did they use more than one service for the same issue, e.g. NHS 111, GP hub, A&E . Cost of each service . Population growth estimates for the next 3 years . Location of proposed large-scale housing developments . Transport links for current services, which were then compared with the scenarios . Patient feedback including our in depth research study and significant engagement programme . National and regional studies and examples . National policy for urgent and emergency care including guidance on making it easier for local people to get help in the right place, first time.

Using this information, we modelled different scenarios and tested them against our priority themes.

Scenario modelling Scenarios were then modelled using the following methodology: 1. The baseline activity used to model all scenarios was the M10 freeze data for 2017/18. This was 174,542. 2. The baseline was adjusted to 157,707, to exclude the activity for wound care and phlebotomy as this is part of another review process and will be commissioned separately. 3. The average growth in activity across all urgent care settings between 2014/15 to 2016/17 financial years equated to a growth of 7.6% which has been applied and used as part of the ‘do nothing’ base costing. This was 187,807 4. All scenarios were compared with financial modelling for the ‘do nothing’ option on a relevant costing basis. Where appropriate a further adjustment has been made to take account of wound care and phlebotomy that will be commissioned through different pathways. 64 36

5. Based on a Nuffield trust research paper found here: https://www.nuffieldtrust.org.uk/files/2017-01/meeting-need-or-fuelling-demand-web-final.pdf Any closure to a walk in service results in a 15.9% dissipation of activity as patients choose to self-care rather than present at another service. We applied this assumption to the baseline activity prior to modelling any activity shifts. 6. Wherever possible current patient behaviour was used to inform the model utilising two methods: a. Activity - the current usage of services at the network (geographical) level was used to inform activity shifts, i.e. where patients will go if the model is changed. For example patients based in the B&D west network will present at Newham 20.4%, Whipps Cross Hospital 2%, King George Hospital 42.3% and Queens Hospital 35.3%. The modelling therefore assumes that if the WIC service at Barking Community Hospital (BCH) were to be altered, the patients of that network would present at the various urgent care sites in the proportionate manner outlined above. b. NHS 111 and Clinical Assessment Service (CAS) logic - we have extensive data on the NHS 111 service which has been operational for over 3 years. This data details the outcomes achieved where a patient calls the NHS 111 service. We have utilised these outcomes in the modelling where the option assumes patients will be using NHS 111 to access bookable services. The tables below show the proportion of calls which we anticipate will go through the NHS 111 service dependent on the option being modelled.

Options where 100% of activity goes through NHS 111

CAS LOGIC OUTPUTS BY SERVICE SERVICE NAME Harold Wood South Hornchurch Upney Lane Loxford GP HUBS GP BOOKABLE 8648 2257 8143 3017 17486 A&E DEMAND 254 66 239 89 515 UCC DEMAND 2778 725 2616 969 5617 NHS 111 A&E 1358 355 1518 563 3262

Options where 70% of activity goes through NHS 111

CAS LOGIC OUTPUTS 30% Activity of NHS 111 ACTIVITY - SERVICE NAME Baseline 70% GP BOOKABLE A&E DEMAND UCC DEMAND NHS 111 A&E TOTAL A&E Harold Wood 7272 16969 5941 175 1909 933 1108 South Hornchurch 1934 4513 1580 47 508 248 295 Upney Lane 6978 16282 5701 168 1832 896 1064 Loxford 2585 6032 2112 62 679 332 394 GP HUBS 49944 17487 515 5618 2747 3262

Financial modelling The following principles were applied to the financial modelling: 1. An average unit cost for the WICs was used. For Harold Wood /South Hornchurch the average cost between the injury and illness tariff was used. 2. An average unit cost has been used for the commissioning cost of any future bookable services. 3. A unit cost per call has been applied to any additional activity going through NHS 111. 4. Baseline costs for A&E was modelled on the 2017/18 actual average cost for the specific site across all HRGs, whereas any activity shift is costed at the average of the lowest three HRGs which are most appropriate due to the acuity of patients seen within community urgent care compared to the full range of A&E attendances. 5. Any adjustment for recharges for out of area has been costed at the value currently being invoiced to the commissioner. 6. An adjustment for wound care and phlebotomy has been modelled into the relevant options to take into account that it will be commissioned through a different pathway. 65 37

7. Where applicable the current x-ray lease and maintenance charges were included.

Where additional modelling assumptions have been applied to a specific scenario, these are detailed within the table at Annex 5

Scenario appraisal Scenarios were reviewed in two stages: c) Affordability test The modelling for each scenario included both expected activity shifts and an indicative cost for the new service.

Finance completed a financial evaluation of each scenario and only scenarios that are estimated within the ‘do nothing’ forecast value are scored.

Financial criteria Financial Underlying Descriptions 0 10 criteria factors

The options delivering smaller A score of BHR CCGs can ► Indicative levels of savings 10 is given Commissioner afford the option modelling of are scored to the proposed within its the options proportionally option that sustainability projected financial v. allocation against the provides envelope projections largest saving – the largest the score is set at saving the % difference

Only scenarios which pass the ‘affordability test’ were fully assessed and scored by the scenario scoring panel (consisting of Programme Board members and joined by an additional Lay Member (Audit Chair), the Quality Manager and Contract Manager from the Commissioning Support Unit). This means all scenarios within scope comply with the ‘affordability test’. Only scenarios that are estimated within the ‘do nothing’ forecast value will go forward for non-financial criteria scoring.

The results of this pass/fail assessment and financial scores were presented to the scenario scoring panel. d) Non-financial criteria scoring process As described above, the scenario scoring panel scored the scenarios which passed the affordability test.

The scenario scoring panel were presented with a consistent set of information on each scenario, which included the following: − a pictorial view of each scenario showing . current and future service components . scenario modelling activity and cost profiles . description . benefits . issues

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− drive time map

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Members of the scenario scoring panel then discussed each scenario and scored against the following criteria:

Non-financial criteria 1 10 Patient experience - Score 0: complex model Score 10: simple and easy covering: which is hard to to understand how to • A simple access model understand how to access. access. Reduced health which is easy to Increases health and and access inequalities. understand access inequalities. Service meets demand. Service does not meet • Flexible and convenient demand. appointments to meet the needs of all patients • Services delivered close to home informed by travel analysis • Equitable access for all patients, e.g. consistency in services. Clinical quality - covering: Score 0: Most affected Score 10: Improved • Improved outcomes for patients are likely to outcomes. The service patients experience significantly delivers tailored care poorer health (including through access to shared • Tailored care for patients mental health). records. No impact on the • Sharing of patients’ health of most patients. records. Deliverability - covering: Score 0: will not be able to Score 10: will be able to • Sufficient space cope with expected cope with expected • Sufficient skilled demand increases and demand increases and workforce does not effectively use effectively uses workforce workforce and estate. and estate. • Able to cope with the expected demand increases including, for example, the growth in parents and children. Efficiency - covering: Score 0: hard to Score 10: is easy to • The ability to ensure understand, will not understand, leading to patients get the right care, support right care first time reduced duplication and right place, first time and result in duplication redirections. Likely to have • Avoiding duplication of and redirections. Is likely to no noticeable effect on services have a negative effect on demand for other services. demand for services, e.g. • Prompt response times. ED/ primary care.

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The individual scores were recorded and an average score calculated.

The average score was then weighted to calculate the total score: Average Weighted Weighting score score Patient experience 20% 7 1.4 Clinical quality 20% 5 1

Efficiency 20% 6 1.2

Deliverability 20% 5 1

Affordability 20% 3 0.6

Total score 100% 5 5.2

Anticipated saving £300,000 Example

The final score will cover all criteria (including affordability).

Option selection When setting the scenario shortlisting process, the programme board agreed that the top 4 scoring scenarios with a minimum score of 5 would be recommended for consultation.

However, when reviewing the final scores, the programme board and FRPDM agreed to recommend to FRPB and Governing Bodies that only the top 2 highest scoring scenarios would be recommended as options for consultation on the basis that no additional benefits to either the public or CCGs could be identified for the scenarios which scored in 3rd, 4th or 5th place.

Scenarios ruled out during appraisal The following scenarios were ruled out at the ‘affordability test’ stage:

SCENARIO No. SCENARIO SCENARIO TOTAL COST Cost pressure Scenarios which do not pass the affordability test 2 De-Commission HAROLDWOOD 40,168,614 £1,812,399 3 DE-COMMISSION SOUTH HORNCHURCH 39,002,696 £646,482 4 DE-COMMISSION LOXFORD 38,700,501 £344,287 5 DE-COMMISSION UPNEY LANE 39,579,672 £1,223,457 DE-COMMISION ALL WALK-INS-SHIFT 100% 6 42,364,068 £4,007,853 to A&E and UCC DE-COMMISION ALL WALK-IN- Activity 7 39,680,755 £1,324,541 Shift 100% to UCC DE-COMMISION ALL WALK-IN- 10% to GP 8 41,901,760 £3,545,546 and 90% proportionately to A&E and UCC

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The following scenarios were ruled out at the ‘options selection’ stage:

Patient Indicative Affordability experience Deliverability Efficiency SCENARIO No. SCENARIO SCENARIO TOTAL COST saving / cost score score Clinical score score score Total score Scenarios which did not obtain the minimum score

38,356,215 £0 0.00 0.52 1.16 3.30 0.98 3.30

The programme board agreed that any scenario scoring less than 5 would automatically not be selected. Do nothing is not an option: local people have told us that the current service provision is too complicated, and we 1 DO NOTHING want to provide services that are easier to access and use in response to this. ‘Do nothing’ will not help us resolve the challenges in our urgent and emergency care system, and will instead see continued and increasing pressure on our emergency department leading to an un sustainable model of care. We need to deliver a simpler and cost- effective system that will meet our future needs. DE-COMMISION ALL 38,274,704 -£81,510 0.14 1.18 1.24 1.12 1.2 4.88 WALK-Ins, OOH F2F, GP HUBs-Activity Shift 70% The programme board did not select this option for public consultation as it was considered to be the same model 11 Bookable through NHS as Option 2, with a risk adjustment applied to the % of the population who would utilise NHS 111 as the access 111 and 30% flow to point. other sites. DE-COMMISION ALL 38,296,386 -£59,829 0.10 1.48 1.3 1.44 1.34 5.66 WALK-INS (Except Upney Lane), OOH F2F, The programme board did not select this option for public consultation as it considered that it had no additional 12 GP HUBS -Activity Shift benefits to Option 1 alongside the following negatives: 70% Bookable through • significantly lower level of savings NHS 111 and 30% flow • fewer UTCs available to the population to other sites.

DE-COMMISION ALL 37,164,567 -£1,191,648 2 1.04 1.28 1.08 1.34 6.74 WALK-Ins, OOHF2F, GP The programme board did not select this option for public consultation as it considered that reducing the number HUBS- Activity Shift 10 of sites to just 3 would result in more activity moving towards the hospital sites, with a subsequent impact on the 100% BOOKABLE hospital and a significant impact to the population in terms of travel times. The indicative modelled savings did THROUGH NHS 111 - 3 X not justify this level of change compared to option 2 UTCs

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11.0 Annex 5 - Selected option description, activity shifts and savings profiles

score score score

Patient Activity shifts and savings profile

Indicative Efficiency experience experience Affordability Affordability Clinical score Clinical Deliverability Deliverability Total score Total SCENARIO No. SCENARIO SCENARIO TOTAL COST saving / cost Shortlisted scenarios Compared to Option 2 (scenario 9) this scenario assumes that Upney Lane and Option 1 - Our existing Urgent Care Centres at Harold wood (HW) remain open. King George and Queen’s Hospitals will be When modelled this increases the cost of upgraded and become Urgent Treatment activity by £1.3m as result of: Centres in line with national policy. These will - the loss of the 15% reductions in the see patients who walk in or who are booked baselines of these centres into a timed appointment by NHS 111. - a further 50% reduction as a result of being

modelled through the NHS 111 CAS logic plus As well as the two existing Urgent Care a 30% reduction in the baseline activity that Centres, people could also continue to walk is modelled through NHS 111. into Barking Community Hospital and Harold £1.3m Activity increase Wood Polyclinic, and facilities at these £35k x-ray costs at Upney Lane locations would be upgraded to become (£537k) Out of area recharges (OATs) at 13 community Urgent Treatment Centres. £37,282,156 -£1,074,059 1.80 1.50 1.32 1.40 1.34 7.36 Harold Wood

(£260k) reduced 111 call costs This would mean there would be four locations (£170k) blood/wound care in baseline for (including the hospital UTCs) in Barking and HW Dagenham, Havering and Redbridge where you (£129k) Assumed adjustment for activity shift can walk in and be seen as well as book an to HW and Upney Lane appointment by calling NHS 111. All this equates to an additional cost of

c£120k for this scenario. There will also be eight community urgent care services across the area where you can be booked in following a call to NHS 111. You will be seen within a maximum of 30 minutes of your appointment time.

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The original baseline activity is 157,707. A 7.6% growth has already been applied to this baseline based on a 3 year average of urgent care activity increase across the sector. Based upon a Nuffield research paper any closure to an urgent care based service results in a 15% reduction to activity as Option 2 - the Urgent Treatment Centres at patients choose to self-care. King George and Queen’s Hospitals would be Therefore activity within this option equates the only places you could walk in without to 133k. making a call first or getting an appointment. The 133k of activity has been modelled through the NHS 111 (CAS Logic) and is By calling NHS 111, you would be booked a further reduced by 40% to 79k which 9 timed appointment at 10 community urgent 37,164,567 -£1,191,648 2 1.18 1.30 1.14 1.38 7.00 represents 50% of original baseline. care service locations across Barking and The original cost of the baseline activity is Dagenham, Havering and Redbridge. 8.8m and the cost of the activity shifts is 6.01m therefore a 2.79m saving on activity These would include Harold Wood Polyclinic, shifts. South Hornchurch Health Centre, Loxford The cost of the additional NHS 111 calls is Polyclinic and Barking Community Hospital. £1.6m. In addition there is a cost for bloods/wound care that was excluded from the baseline as this will be provisioned through a different service model (£207k). The total savings of 1.19m encapsulates an assumed activity reduction c50% taking into account variations in unit prices across the different settings.

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12.0 Annex 6 - Consultation requirements

Legislation / mandatory requirements As set out in section 14Z2 of the NHS Act 2006, NHS organisations should continually involve and engage patients and the public in service planning and operation and in the development of proposals for change.

There is significant benefit of engaging and involving service users and local stakeholders, including: - Increased public confidence in local NHS services and decision-making - Better decisions when designing safe, high quality services - Improved patient experience and outcomes - Building stronger relationships with key stakeholders, including staff - Mitigate risks and issues.

CCGs must also take into account the NHS Constitution which brings together a number of rights, pledges and responsibilities for staff and patients alike. It includes the ‘right to be involved, directly or through representatives in the planning of healthcare services, the development and consideration of proposals for changes in the way those services are provided and in decisions to be made affecting the operating of those services’. It also includes the ‘right to be provided with the information to influence and scrutinise the planning and delivery of NHS services’.

Application of the ‘4 tests’ In 2010, the Government introduced the ‘four tests’ for service change. As set out in the 2014/15 mandate from the government to NHS England, any NHS organisations considering a change to services should be able to demonstrate evidence of: - Strong public and patient engagement - Consistency with current and prospective need for patient choice - A clear clinical evidence base - Support for proposals from clinical commissioners (NHS England, 2013: 23).

Any NHS organisations considering a change to services must show that they have met the ‘four tests’ before any consultation goes ahead. While this normally applies to major service change, it was felt in this case that an assessment against the four tests would be helpful as they are designed to build confidence within the service and with patients and communities.

The NHS England 2013 guidance ‘Planning and delivering service changes for patients’ details that it is good practice for an initial assessment against the tests to take place at the early planning cycle and then be repeated at intervals during the life cycle of the scheme to refresh any findings from stakeholder and public engagement, therefore ensuring that any new evidence that is developed continues to support the case for change (NHS England, 2013:23).

This draft pre consultation business case covers each of the four tests. This will be refreshed in the decision-making business case following the consultation process should this be agreed by CCG Governing Bodies.

The Gunning principles The Gunning principles say consultations must have the following principles applied:

. When proposals are still at a formative stage . Sufficient information to give ‘intelligent consideration’ . Adequate time for consideration & response . Must be ‘conscientiously’ taken into account.

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Clinical engagement and conflicts of interest management The vast majority of local clinicians are involved in running or delivering existing services within the scope of this review, and this creates a potential conflict of interests. Legal advice has been obtained from Hempsons who have advised that the CCG clinical directors and local GP’s cannot act as clinical leads for the urgent care review. This is due to their conflict of interest as members of the local GP federations who are potential providers of proposed new service models. The CCG have therefore appointed an independent clinical lead to join the programme board for this review to provide expert clinical advice. The independent GP also provides support to the procurement oversight group and the primary care commissioning committee has been appointed as the independent clinical lead. This is in addition to CCG clinicians such as nursing and quality directorate nurses and public health. Lay members have provided valuable insight on patient experience.

Equality Impact Assessment (EIA) An EIA is a process to make sure that a policy, project or proposal does not discriminate or disadvantage against any of the following characteristics:  age  disability  gender reassignment  marriage and civil partnership  pregnancy and maternity  race  religion or belief  sex  sexual orientation

As part of this work, we will carry out an initial EIA and publish a draft on our websites. We will take into account people’s responses to our proposals, and this will inform a more detailed final EIA which will be considered before any decision is made about these proposals.

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13.0 Glossary

Accident and A 24 hour service provided by an acute hospital for conditions that need immediate medical Emergency (A&E) attention for emergency or life-threatening health conditions, e.g. a serious accidental injury, a heart attack, difficulty in breathing. Also known as an Emergency Department (ED)

CAS The clinical assessment service provided by NHS 111

CCG Clinical Commissioning Group

Clinical Observation, assessment and treatment of disease and other illness in a patient

Diagnostics Procedures to identify a condition or disease, e.g. X-ray, blood tests, ECG (A simple test that can be used to check your heart's rhythm and electrical activity. Used alongside other tests to help diagnose and monitor conditions affecting the heart)

Emergency care Emergency care is provided in a medical emergency when life or long term health is at risk. This could include serious injuries or blood loss, chest pains, choking or blacking out

GP General Practitioner. Your family doctor

Minor illnesses or Common health problems like aches and pains, skin conditions and stomach upsets ailments

Minor injuries These could include:

 Bites, human and animal  Cuts and lacerations  Foreign bodies in the eyes, nose and ears  Fractures that require plaster only  Minor burns and scalds  Minor head injuries (with no loss of consciousness)  Soft tissue injuries, for example sprains and bruises  Wound infections NHS 111 A free 24/7 telephone advice service for people who require urgent healthcare treatment and advice but who don’t know where to go.

GP access hub Urgent, same day GP appointments that can be pre-booked by telephone. Primarily for urgent care.

GP out of hours Medical care provided outside the normal working hours of GP practices. Available via NHS 111 service from 6.30pm to 8am on weekdays and throughout weekends and bank holidays

Phlebotomy Blood testing services

Primary care Services which are the main or first point of contact for the patient, usually GPs, practice nurses and pharmacies

Urgent care Urgent care is care needed the same day. This could include anything from cuts, minor injuries, wound infections, tonsillitis, urinary infections, or mild fevers etc.

Urgent Care Centre These are centres, usually located on a hospital site next to an A&E, which offer urgent care. or UCC Led by GPs supported by nurses.

Urgent Treatment Open at least 12 hours a day, 365 days a year, these centres will provide urgent care. Led by Centre or UTC GPs supported by nurses and other health professionals. Access to simple diagnostics and able to deal with a wide range of minor injuries and illnesses, including minor head injuries.

Walk-in centre or WIC This service offers urgent care to people who walk in, without pre-booking an appointment. See Annex 2 for the local variations.

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Making changes to community urgent care services

Decision making business case

Barking and Dagenham, Havering and Redbridge (BHR) clinical commissioning groups (CCG)

November 2018

Right care, right place, first time

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Contents 1.0 Executive summary 3 2.0 Context 5 3.0 Community urgent care review aims and objectives 5 4.0 Scope of this review 5 5.0 Current urgent care service offer 6 5.1 Urgent and emergency care service usage 6 5.2 Primary care 7 5.3 Wound care 9 5.4 Phlebotomy 9 6.0 National context 10 6.1 Developing an Integrated Urgent Care system 10 6.2 Urgent treatment centres (UTCs) 11 7.0 Financial context 12 8.0 Case for change 14 8.1 What is urgent care? 14 8.2 BHR vision for urgent and emergency care 14 8.3 Variation in existing community urgent care services 14 8.4 Duplicate attendances 14 8.5 Do nothing 16 9.0 Pre-consultation Business case 18 10.0 Consultation and engagement 19 10.1 Engagement 19 10.2 Community urgent care consultation 19 11.0 Equality impact assessment (EIA) 23 12.0 Financial impact 24 13.0 Consultation theme analysis 25 14.0 Description of the new urgent care pathway 33 14.1 Description of the urgent care pathway under Option 1 36 14.2 Description of the urgent care pathway under Option 2 37 15.0 Recommendation for decision making 40 16.0 Annex 1 - Case for change 41 17.0 Annex 2 - Pre-consultation business case 41 18.0 Annex 3 - Consultation documents 41 19.0 Annex 4 - Consultation report 41 20.0 Annex 5 - Equality Impact Assessment 41 21.0 Glossary 42

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1.0 Executive summary

This draft decision making business case (DMBC) sets out the vision and options for the future delivery of community urgent care across Barking and Dagenham, Havering and Redbridge (BHR).

The document sets out the case for change, which was agreed through CCG Governing Bodies in July 2017, and reflects what we have learnt from the system and our population.

This business case concerns the provision of walk-in centres, GP out of hours and GP access hubs, and sets out a move to bookable activity through NHS 111 and provision of urgent treatment centres (UTC) which will provide for walk-in and bookable services.

The clinical commissioning groups (CCGs) cannot leave the system as it is currently. Doing nothing is not an option for the following reasons:  Local people have told us it’s too complicated and we want to provide services that are easier to access and use  To do nothing is unaffordable. All urgent and emergency care service models illustrate that doing nothing would cost us £2.44m per year above current spend of £35.79m  If we do nothing then the profile of increasing demand and high levels of duplication, seen at urgent care services and in A&E departments, will continue.

Doing nothing will not help us resolve the challenges in the urgent and emergency care system and will not ease the pressure on our emergency department, leading to an unsustainable model of care for our population. We need to deliver a simpler, cost-effective system that meets future needs.

Two options were developed for the future model (detailed in section 8) and were shared with local people and stakeholders in a formal 14 week public consultation to determine the best fit for the future. The feedback has been used help inform the decision on the future model.

Both options include a move towards booked appointments for urgent care needs, building on call or click before you come in. They utilise NHS 111 as a way for us to help people get the right care, right place, first time, while those who need to be seen can access Urgent Treatment Centres, providing care for both minor illness and injury with access to diagnostics such as simple x-rays, by calling NHS 111 or by walking in.

Option 1 would see services operating from 12 sites in total, with 4 urgent treatment centres open within Barking and Dagenham, Havering and Redbridge (2 on hospital sites, and 2 in the community), plus 8 locations available for booked community urgent care services.

Option 2 would see services operating from 12 sites in total, with 2 UTCs within our area on hospital sites, although local people may still use those in neighbouring boroughs (Newham and Whipps Cross). Plus there will be 10 places available to be booked when your own GP practice is closed and you have an urgent health need.

Audits have demonstrated that people are attending, and being seen in, A&E for conditions that can be managed in an urgent treatment centre or in the community. BHR CCGs are currently working with providers in the system to strengthen the streaming in UTCs and ensure that we maximise the attendances that can appropriately be seen in this setting. This will reduce the number of patients seen in A&E and help to ensure that performance is improved. This activity shift is closely linked to the community urgent care review but not formally part of the scope of this work.

This decision-making business case sets out the robust process undertaken to reach the recommendations regarding the future community urgent care pathway. It details the case for change, alongside the consultation and engagement process and the findings of the analysis of 78 3 the consultation responses. The document reflect the recommendations from the community urgent care programme board, which involved much debate and discussion.

The Community Urgent Care Programme Board and the Financial Recovery Programme Board have reviewed the case for change, along with the evidence presented in this business case, and recommend that the CCGs joint committee endorse Option 1 to be commissioned as the future community urgent care pathway.

The CCGs joint committee is asked to: 1. Agree Option 1 as the future urgent care pathway:  To help people access the right care, right place, first time and to simplify the urgent care pathway so urgent care has just two points of access and a consistent name for services: − Bookable services accessed through NHS 111 − Urgent Treatment Centres (UTCs)  This will be delivered from 12 sites in total including 4 UTCs (2 on hospital sites and 2 in the community - accessed via both walk in and bookable via NHS 111) and bookable appointments accessed via NHS 111 at 8 locations.

2. Agree the Community Urgent Care Programme Board will progress to the procurement stage which will be overseen by the Procurement Oversight Group.

3. Subject to agreement of the above, it is recommended that:  A comprehensive communications and engagement plan to support these changes is developed including the continued involvement of all three Healthwatch organisations A plan to enhance the utilisation of the Loxford Polyclinic site is developed.

Modelling shows option 1 would deliver savings of £598,852 per year.

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2.0 Context Urgent and emergency care (UEC) has been a key challenge for our health economy for many years with a background that includes:  A complex urgent and emergency care system with duplication and fragmentation across services;  A challenged health economy that is struggling to manage increasing demand, partially driven through population and health profile changes;  Key performance targets, particularly in accident and emergency, not being met.

In Barking and Dagenham, Havering and Redbridge (BHR), as with other parts of England, increasing numbers of people are using NHS services every year. The current urgent and emergency care system does not provide a good experience for patients as it can lead to a long wait to see a GP or someone in accident and emergency (A&E), and also puts increasing pressure on our hard-working frontline staff and clinicians.

3.0 Community urgent care review aims and objectives The aims of the community urgent care review are to:  Improve patient experience including provision of a clear and defined service offer so that patients can be confident about where to go for treatment, e.g. illness, injury, urgent or emergency.  Improve quality including safety, consistency and right care, right place, first time which will help to support management of patients within the community.  Ensure services are designed to support the changing profile of population growth.  Support delivery of the urgent and emergency care performance targets.  Support system and financial sustainability.  Achieve an integrated service that works more effectively with 111, primary, community and acute care services (in line with national requirements as set out in the five year forward view (FYFV).

The objectives for the BHR proposals for community urgent care services were set out in the case for change and are summarised below:  Simplify the system for patients - provide a clear and defined service structure so that patients can be confident about where to go for treatment, e.g. illness/ injury, urgent or emergency need and to reduce duplication and inappropriate attendances.  Move towards bookable appointments - the national requirement is bookable from 8am-8pm daily.  Consistent assessment  Consistent assessment and re-direction when booking and at the front door of services where people walk in, such as A&E.  Appointments bookable through centralised systems (phone and online) to increase self-care and remove inappropriate appointments.  Plan for the changing profile of population growth.  Provide more local services, this being an opportunity to review the location of where and how services are delivered.  Improved provision for children (newborn - 18 years) as they represent the greatest proportion of attendance growth.

4.0 Scope of this review The focus of this review is on the community based urgent care services:  GP out of hours service (GP OOH)  Primary care access hubs (or GP access hubs)  Walk-in centres (WICs).

In 2017/18 these services alone delivered over 171,467 appointments which is 40% of the total urgent and emergency care activity of 421,627.

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This consultation is not about emergency care services or changes to A&E services at Queen’s, King George, Whipps Cross or Newham hospitals, all of which serve our residents.

5.0 Current urgent care service offer People in Barking and Dagenham, Havering and Redbridge are able to use a range of different services when they feel they need medical advice urgently, but when it is not an emergency. These include:  Pharmacists  General Practice (GPs)  NHS 111  Primary care access hubs (or GP access hubs)  Walk in centres (WICs)  GP out of hours service (GP OOH)  Urgent Care Centres (UCCs). Descriptions of these services can be found in the pre consultation business case (Annex 3).

Service location map The map below shows the locations of our urgent and emergency care services.

5.1 Urgent and emergency care service usage Over the last few years A&E activity has consistently increased in BHR, as it has across England. Our latest analysis shows this is generally in line with population growth. However, most of the increase in A&E activity in our area has occurred during the 'in hours’ period (8am and 6pm). This then creates a bottle neck and pressure, resulting in poor A&E performance and an emergency team which is unable to cope with so many people turning up over a short timeframe.

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In the same piece of analysis, activity ‘in hours’ at community urgent care services has not increased, which, when compared to population growth and the increase seen at the A&E and UCC, means the community urgent care services are being used relatively less. This is in line with messages from the public during our engagement work: that people tend to use A&E because it is seen as a reliable 24/7 service where their clinical issue will be resolved, even if they have to wait for hours, and that the rest of the community urgent care being offered is too confusing.

Over the next 15 years, the population of Barking and Dagenham, Havering and Redbridge is expected to grow by 143,000 extra people, with population growth expected to follow the large- scale housing developments planned in Ilford, Barking town centre, Romford, Rainham, Beam Park and Barking Riverside. That’s a 19% increase, and equivalent to the size of Basildon.

If the trends described above continue in line with this enhanced level of population growth, and within the context of our financial position, this would create a completely unsustainable model of care unless we change the service offered in order to manage this.

Doing nothing would not support our A&E departments, and inevitably lead to an unsustainable model of care for our population.

5.2 Primary care Across BHR there are 122 General Practices:  42 practices in Redbridge  44 practices in Havering  36 Practices in Barking and Dagenham

The breakdown of General Practitioners (GPs) and General Practices Nurses (GPNs) is as follows: CCG GP Headcount GP WTE GPN Headcount GPN WTE Havering 160 142.5 87 53.6 B&D 138 97.6 70 40.7 Redbridge 184 135.7 71 39.8 Totals: 482 375.8 228 134.1

General Practice organisation Practices are organised in networks, i.e. groups of practices across BHR who work together to support the needs of their local populations. There are 10 networks across BHR. Federations, one in each borough and chaired by a lead GP, support these networks on the delivery of service improvements.

Practices are open for bookable appointments between 8.00am - 6.30pm Monday to Friday, although it is acknowledged that there are a very small number of practices across BHR who still operate with half day closures. This is being addressed with those practices.

Significant progress has been made in improving access to General Practice over the last few years, and while we acknowledge from the consultation that there are concerns around capacity and demand (appointments and workforce) with BHR having some of the lowest GP ratios in London (0.44-0.47 GPs for every 1,000 registered patients compared to a London average of 0.55), BHR CCGs have made some good progress in improving recruitment. This includes:

The GP Spin Programme This programme enables new GPs to have a permanent job in a local BHR GP practice as well as having a role within a specialist area, i.e. accident and emergency or mental health.

As of October 2018 seven new GPs have accepted offers from surgeries in Barking and Dagenham, Havering and Redbridge (BHR) where they are all working between four and eight sessions a week.

International GP Recruitment 82 7

NHS England (NHSE) is in the process of recruiting International GPs from the European Economic Area (EEA). North east London (NEL) have so far secured two GPs who have passed their initial interviews and language tests, and will be based in Waltham Forest. This process will continue with further phases of recruitment which will provide GPs for BHR in the near future.

GP Retention The three GP Federations, with General Practices across BHR, have come together to explore how they can jointly attract and retain GPs. This will include supporting practices at local level and through networks, i.e. Loxford and Cranbrook in Redbridge, to improve population health and support access and capacity issues.

General Practice Nursing (GPNs) The CCGs are in the process of putting in place a structured nurse leadership programme across BHR as a way of supporting GPNs in general practice. It is anticipated that this will support the establishment and delivery of the following:  Identification of a professional lead for GPNs who will work with education partners to standardise training and career pathways for GPN and health care assistants (HCA).  Standardisation of GPN roles and requirements from Practice Nurse to Advanced Practitioner.  Development and delivery of training programmes and support of GPN mentors and trainers.

BHR CCGs have also started to work with our Federations, networks and practices on services to support some of the local population needs. This includes a new GP frail older persons service across Redbridge (Redbridge has a high number of older people with frailty) and developments across the disease spectrum of long term conditions, such as diabetes, atrial fibrillation and heart health, within BHR.

Highlights from responding practices include:  100% of practices provide access to same day appointments  45% of practices triage their same day appointments and this may be undertaken by anyone in the practice from a GP, 48%, to receptionists, 43%  70% of practices undertake injury management. Examples of this were:

Road traffic accident  83% reported in the survey that their voicemail refers patients via NHS 111 to the GP out of hours service when the practice is closed for the day, 17% did not respond to this question

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 85% of practices advertise the access hubs using a range of methods such as text messaging, posters/leaflets, Jayex boards/TV screens, standard letters and the practice website.

Primary care is a key service for our population and it should be the first place for urgent health needs as the GP practice provides care closest to home with the best continuity of care. This is beneficial especially for those with complex or long term conditions, as a patient’s GP practice takes a more holistic view of care including preventative healthcare (such as immunisations and health checks) as well as referral onward to specialists where required e.g. specialist diagnostics or surgery.

5.3 Wound care The simple wound care service is currently delivered by a range of providers across BHR, which includes in Havering and Barking and Dagenham two borough wide contracts currently delivered alongside the walk in centres (WIC) and by individual GP practices via a local incentive scheme in Redbridge. This is outside of the scope of this business case.

During June 2018 the CCGs undertook a patient engagement exercise on the simple wound care pathway. This highlighted that 42.1% of patients are presenting at A&E for simple wound care of which dressing change after an operation accounted for 34.7% and stitch or clip removal accounted for 23.2%. These attendances could potentially be avoided if adequate service provision was made available within a community service that included extended hours and weekend provision. This would improve patient experience and reduce A&E and urgent care costs for BHR CCGs.

Feedback from patient engagement highlighted that patients wanted to be seen closer to home within a local care/community setting rather than having to attend A&E and other urgent care services. Furthermore 32.5% of patients rated the provision of wound care service across BHR CCGs as average/poor. This would suggest that further improvements to the current service is required to improve patient experience.

Following on from these engagement results, the CCGs are currently in the process of procuring a simple wound care service to standardise the service across BHR CCGs. The simple wound care service will provide treatment for:  Post-surgical sutures and clips removal  Acute wounds  Superficial skin ulcer management  First degree superficial burns.

Any patients experiencing accidental wounds may access an UTC for urgent treatment. However any follow-up wound dressing changes required would be undertaken by the simple wound care service.

The simple wound care service will provide skilled, planned care in a clinical environment. The aim is to ensure that patients have access to services within a local care/community setting, enabling continuity of care and consistent review. The service should ensure that only appropriate patients are attending UTCs to have their wounds managed.

The proposed service commencement date for the new simple wound care service is 1 April 2019, therefore wound care covered by this service is excluded from consideration within this business case.

5.4 Phlebotomy The CCGs commission a wide range of phlebotomy services including services currently delivered alongside the walk in centres, hospital based, community clinics, via GP surgeries and a home visiting service. This is outside of the scope of this business case. 84 9

The CCGs will undertake a high level review during October and November 2018 to map the full range of services, sites and spend and to look at what is working well and what could be better (including best practice). From this, key themes will be identified and determine how phlebotomy will be commissioned going forward.

6.0 National context NHS England’s Next Steps on the NHS Five Year Forward View (5YFV) explains how the 5YFV’s goals will be implemented over the next two years. Urgent and emergency care is one of the NHS’s main national service improvement priorities, focussing on improving national A&E performance whilst making access to services clearer for patients.

As part of the NHS Five Year Forward View and subsequent updates, including the Urgent and Emergency Care Review, NHS England have introduced a new set of key deliverables for urgent and emergency care in 2017/18 and 2018/19 which includes:  Achievement of the ‘4 hour target’  Comprehensive front-door clinical streaming  Specialist mental health care in accident and emergency departments (A&E)  Integrated urgent care (IUC) - an enhanced NHS 111 service which means more people will speak to a clinician and receive a booked appointment where appropriate  An enhanced primary care offer which will deliver a bookable general practice service from 8am - 8pm seven days a week  Standardise non-acute services - including urgent care centres (UCCs), minor injury units (MIU) and urgent treatment centres (UTCs).

This business case sets out the CCGs proposals for standardising non-acute urgent care services as part of the Integrated Urgent Care (IUC) system; including upgrading UCCs and walk in centres to either urgent treatment centres or to a bookable service.

6.1 Developing an Integrated Urgent Care system The review of community urgent care services is one of the programmes that is being taken forward to develop an integrated urgent care system.

Integrated Urgent Care (IUC) - a better NHS 111 - providing clinical advice, triage and booking. NHS England see NHS 111 as a key part of providing patients with integrated urgent care, which is how they describe the way different services will link up to help people in need of urgent same- day care and advice.

There are a number of key aspects to the current NHS 111 service which would be promoted as part of the model as they underpin the proposed changes:  Clinical advice service (or CAS) - allows NHS 111 health advisors to fast-track transfer children aged under 1 and people aged 65 and older to a GP or other health professional for advice and assessment.  Bookability - for those who do need to come into an urgent care service, the local NHS 111 service can already book appointments at some of our existing community urgent care services, and we plan to add more, meaning just one call to NHS 111 would be the only action required to access urgent care.  Interpretation services - NHS 111 is supported by two interpretation services: . Languages - a confidential interpreter service available in many languages. The caller needs to simply mention the language they wish to use when the NHS 111 operator answers the call line. NHS 111 patient information leaflets are available at NHS choices in several languages. . British sign language (BSL) - NHS 111 offers a video relay service that enables a video call to a British Sign Language (BSL) interpreter. The BSL interpreter will call NHS 111 to enable a real-time conversation with the NHS 111 adviser via the interpreter. This requires a webcam, a modern computer and a good broadband 85 10

connection to use this service. Visit NHS 111 BSL interpreter service for more details, including an online user guide. http://interpreternow.co.uk/nhs111 . Typetalk or text phone - those with difficulties communicating or hearing can also use the NHS 111 service through the TextDirect system.  Out of hours - available 6.30pm - 8am weekdays and all weekend when most core services are closed: Dental (Smile service) - NHS 111 can be used to access the dental service who can: . Assess the dental issue or problem . Make referrals to an Out of Hours Dental service . Look up urgent care services that provide dental treatment . Offer self-care advice. Prescriptions out of hours (PURM) - if a repeat prescription is required, for items that have previously been prescribed via an NHS prescription, NHS 111 can be used to access a pharmacy service who can: . Assess symptoms and provide clinical advice . Refer to a pharmacy that provides access to urgent medicines for assessment and potentially the supply of medicines.

As part of a north east London-wide service that launched August 2018, the CCGs are already making improvements to the local NHS 111 service so it provides more than just advice and signposting to services now and in the future. A Clinical Advice Service (or CAS) has been introduced which allows NHS 111 health advisors to fast-track transfer children aged under 1 and people aged 65 and older to a GP or other health professional for advice and assessment. As part of this new service over 50% of people speak to a clinician on the phone after calling NHS 111.

In the future people may also be booked into an appointment with their own GP, and this is being tested in other parts of the country now. There is an STP level project to trial this in north east London. An online version of NHS 111 and a digital app are also being tested in other parts of London.

6.2 Urgent treatment centres (UTCs) The case for change for community urgent care services, which was agreed in July 2017 at a joint Governing Bodies meeting, reflects feedback from the public, both at a local and national level, that there is a confusing mix of urgent care services that they find difficulty in navigating:

NHSE have published a core set of standards and principles for urgent treatment centres to establish as much commonality as possible across services, and offer a consistent route to access urgent appointments offered within 4 hours and those booked through NHS 111, ambulance services and general practice.

The core principles for UTCs include: a) Having access to urgent treatment centres that are open at least 12 hours a day, GP- led, staffed by GPs, nurses and other clinicians and with access to simple diagnostics, e.g. urinalysis, echocardiogram (ECG), as well as simple x-rays in some cases.

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b) Have a consistent route to access urgent appointments offered within 4 hours and booked through NHS 111, ambulance services and general practice. A walk-in access option will also be retained. c) Increasingly be able to access routine and same-day appointments and out-of-hours general practice for both urgent and routine appointments, at the same facility and where geographically appropriate. d) Know that the urgent treatment centre is part of locally integrated urgent and emergency care services working in conjunction with the ambulance service, NHS 111, local GPs, hospital A&E services and other local providers.

NHS England expect commissioners to have UTCs in place by December 2019 or sooner.

BHR CCGs have looked at our existing walk-in services and compared them to the UTC national standard:  South Hornchurch Walk-in service is only open for 6 hours a day and so significant investment and staffing would be required to open this site for 12 hours a day, every day of the year and make the other improvements needed to meet the standard.  Fewer people use Loxford compared to the numbers seen at the other walk-in services in our area, and significant investment and staffing would be required to meet the UTC standard.  Based on the existing provision of diagnostics, it may be possible for Harold Wood Polyclinic and Barking Community Hospital to become UTCs, and this is included within one of the options.

UTCs will help reduce the pressure on our busy A&E departments, releasing capacity to treat those people requiring immediate emergency care when life or long term health is at risk.

Audits have demonstrated that people are attending, and being seen in, A&E for conditions that can be managed in an urgent treatment centre or in the community. We are currently working with providers in the system to strengthen the streaming into the urgent treatment centres and ensure that we maximise the attendances that can appropriately be seen in this setting. This will reduce the number of patients seen in A&E and ensure that our performance is improved. This activity shift is closely linked to the community urgent care review but not formally part of the scope of this work.

Since July 2018 the CCGs have been working to upgrade the urgent care centre at Queen’s hospital to meet the urgent treatment centre requirements. The first phases are complete and a more consistent streaming and re-direction pathway and management of minor injury is in place. During September 2018 15% of people who walked into the service at Queen’s hospital were re-directed into more appropriate services including the GP access hubs. This rollout plan is being extended to the King George Hospital service.

7.0 Financial context As part of our community urgent care review we are seeking a solution that maximises the benefit to patients whilst ensuring we are able to live within our financial means. Currently BHR CCGs spend over £90m each year more than our peers in north central and east London for hospital based care, despite our population having many of the same challenges and issues seen by our peers.

BHR CCGs want to ensure that the people we serve continue to receive high quality care and the support they need to remain well, but currently we are seeing a lot of people attending A&E who could have been treated closer to home and also a lot of people attending A&E and going on to be admitted who could be better supported to remain well and ultimately avoid an attendance and admission.

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Over the next 3 years BHR CCGs need to save £250m whilst concurrently ensuring we provide high quality, accessible care that improves the quality of life for the people we serve. To do this we will be investing in primary care (GPs) to help them improve the quality of care for people living with long term conditions such as diabetes, COPD and asthma - therefore helping them to reduce the need to attend A&E. We will also be looking to improve the care we provide out of hospital for older people to ensure they remain in their normal places of care for longer and also when the time comes are able to die in the place of their choosing. We will also be looking at improving access to Primary Care and where, when and how our population with urgent care needs can be supported including by their practice.

Through this work not only will we be improving the lives of many people within BHR, but also help us to deliver our financial plans.

This is not a unique challenge and the NHS all over the country is looking at how it can deliver all of the many things we have to do, from supporting people with mental health needs and those requiring planned operations to the needs of urgent and emergency care and ensuring we can continue to do so for many, many years to come. BHR CCGs spent £14.3 million on community urgent care in 2017/18. Too many of our existing urgent care services provide similar care at the same time. It’s confusing for patients, and not the best use of our limited NHS resources.

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8.0 Case for change

8.1 What is urgent care? The CCGs worked with Healthwatch in 2016 to create local definitions to help explain the difference between urgent and emergency care:

Urgent care is care needed the same day. This could include anything from cuts, minor injuries, wound infections or tonsillitis, urinary infections, mild fevers, etc.

8.2 BHR vision for urgent and emergency care The BHR vision for urgent and emergency care is: Health and social care partners across BHR want local people to receive the right care, in the right place, first time. If they do need to be admitted to hospital, we will get them home safely and quickly, with the right support to help them to recover their independence. No time will be wasted.

Our ambition is to radically transform local urgent and emergency care services, removing barriers between health and social care, and between organisations.

8.3 Variation in existing community urgent care services • There are a number of variations across our community urgent care services, including inconsistencies in: . access routes . service names / branding . opening times . diagnostic provision . skill mix . digital integration.

8.4 Duplicate attendances We know that some NHS capacity is wasted due to duplicate or repeat attendances for the same health need.

Some of this is caused by the variation in services, which can mean people’s first choice service cannot meet their health needs due to the different staff types, diagnostics or technology in place. However some of this is also driven by patient behaviour and the perceived need to seek a second opinion.

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The highest number of attendances in this data sample was one person attending 6 services within 72 hours.

This means 40% of these cases were potentially duplicated appointments where ED, primary care or other urgent care services and a further 17% could have been managed by pharmacy.

In our engagement work people reported attending multiple times for the same need.

Of those attending A&E: • 39% sought no advice before attending A&E • 37% had seen their GP with the same issue • 26% had been to A&E before with the same issue.

Parents reported a slightly different profile: • 37% of parents who attended A&E had seen a GP previously for the same issue • 25% had previously been to A&E with the same issue.

The following diagram shows excerpts from the BMG telephone survey:

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The following picture shows 45% of people sought advice before going to A&E from various sources, including NHS 111, a GP or a pharmacist. This indicates multiple attendances for the same need. Although the survey was not able to analyse whether they were correctly advised to go to A&E, 87% said that the advice they were given was to go to Accident & Emergency. It is possible to infer from this that the other 13% went to A&E despite the advice suggesting an alternative course of action.

The re-direction trial at Queen’s hospital in 2016 demonstrated up to 30% of A&E presentations do not require a same day urgent care service.

8.5 Do nothing The CCGs cannot leave the system as it is currently. Doing nothing is not an option for the following reasons:  Local people have told us it’s too complicated and we want to provide services that are easier to access and use.  To do nothing is unaffordable. Our urgent and emergency care service models illustrate that doing nothing would cost us £2.44m per year above our current spend of £35.79m.  If we do nothing then the profile of increasing demand and high levels of duplication seen at all of our urgent care service and in our A&E departments will continue.

Ultimately, doing nothing will not help us resolve the challenges in our urgent and emergency care system and will not ease the pressure on our emergency department, leading to an unsustainable model of care for our population. We need to deliver a simpler, cost-effective system that meets our future needs.

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Drive time analysis for ‘do nothing’:

The case for change can be found at Annex 1. 92 17

9.0 Pre-consultation Business case The pre consultation business case (PCBC) was developed by the Community Urgent Care Programme Board and approved at the May 2018 meeting.

The pre consultation business case restated the vision and objectives for future delivery of community urgent care across BHR and the case for change. The scope was confirmed as the provision of walk-in centres, GP out of hours and GP access hubs with a move to bookable activity through NHS 111 and provision of urgent treatment centres (UTCs) which will provide for walk-in and bookable services.

The PCBC set out two options developed for the future model, and proposed to share these with the public in a formal consultation to determine the best fit for the future.

Option 1 would see 12 sites in total, with 4 Urgent Treatment Centres open within Barking and Dagenham, Havering and Redbridge (2 on hospital sites, and 2 in the community) and as now local people may still use those in our neighbouring boroughs (Newham and Whipps Cross), plus 8 locations for booked community urgent care services.

Option 2 would see 12 sites in total, with 2 UTCs within our area on our hospital sites, and as now local people may still use those in our neighbouring boroughs (Newham and Whipps Cross). Plus there will be 10 places to be booked when your own GP practice is closed and you have an urgent health need.

The full pre consultation business case can be found at Annex 2.

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10.0 Consultation and engagement 10.1 Engagement Over the last three years BHR CCGs have undertaken extensive engagement with local people, stakeholders and patient representatives to gather views on how we can transform urgent care services.

This includes the Barking and Dagenham, Havering and Redbridge (BHR) urgent care conference held on 1 July 2015, engagement with the CCG patient engagement forums and a comprehensive UEC co-designed research survey which included many patient events.

Our research study in March 2016 involved more than 4,000 people and included a telephone survey, 10 focus groups and two workshops.

The clear and consistent message from all of our engagement is that all stakeholder groups view urgent care as complex and confusing and endorse the need to look at simplifying the pathway and helping local people and staff to understand what urgent care services are available and how to access urgent care when they need it.

This year, the CCGs commissioned the Healthwatch organisations in all three of our boroughs to talk with local people about some of our emerging ideas. They spoke with more than 500 people: a mix of parents, young adults (15-24) and older people aged 65 and over as these groups are our biggest users of urgent care services.

This engagement found that while most people can confidently describe the difference between ‘urgent care’ and ‘emergency care’, it’s clear more needs to be done to help people feel confident to make the right choices for their urgent health needs. Simplifying the system and providing better support and advice through NHS 111, as well as from your local pharmacist, will help patients.

While patients would prefer to see their own GP, there is significant support for more appointments within the local community (at a GP hub or bookable service) when your own GP is not available. There’s also good recognition of the role of pharmacies in providing expert advice for minor illnesses.

People welcomed news of the improvements to NHS 111 and felt this would make it easier to get health advice quickly, to book an urgent appointment and would reduce the number of people who go to A&E when they have a minor illness or injury. But people told us we need to do more to raise awareness about what NHS 111 can now help with.

10.2 Community urgent care consultation From Tuesday 29 May to Tuesday 4 September 2018, Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs) carried out a 14 week consultation: ‘Right care, right place, first time’. The consultation was originally planned for twelve weeks in line with local Compacts and best practice guidance, but was extended by a fortnight following representations from local scrutiny committees.

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This sought local people’s views on proposals for changes to community urgent care services, named as GP out of hours services, GP access hubs and walk in services.

The proposals were built on key factors:  Extensive engagement with local people in the last three years  National guidance including on integrated urgent care (IUC) and urgent treatment centres (UTCs)  Projected population growth in BHR in the next 15 years, contributing to increased demand  The digital future for the NHS.

The NHS is facing a challenging time and there is a rising demand for all NHS services, including urgent care, while costs continue to rise. It is essential that the CCGs spend their limited resources in the most effective way, and both proposals for the model of community urgent care services will provide cost-savings. But this has not been a key factor, our priority being to improve quality and patient experience.

The CCGs did not consider any alternative models that would have required additional investment, and our proposals set out two options that would deliver on our key factors and also deliver cost savings.

The proposals which were consulted on, set out in full in the CCGs’ consultation and easy read documents, asked for views on two options where local people could walk in and queue or wait to see a doctor or nurse. These were published on our three websites, together with the pre- consultation business case and the initial Equality Impact Assessment (EIA). A set of FAQs (Frequently Asked Questions) and a copy of the glossary of terms were also published following feedback from stakeholders.

During the 14-week consultation, the CCGs’ independent clinical lead, Redbridge CCG’s Lay Member for Patient and Public Participation and CCG staff gave presentations to community groups, health scrutiny committees and healthcare professionals. They also held drop-in sessions in public places and carried out traditional media and social media activity in order to reach as many people as possible across the three boroughs.

Headline results from the online consultation survey The community urgent care consultation generated our largest consultation response ever, with 1,062 people sharing their feedback through the online survey.

In response to the two options presented, the majority of consultation respondents (67%) favour Option 1, which comprises four UTCs and eight bookable-only community urgent care services.

One in five, 19%, favour Option 2 (two UTCs and ten bookable-only community urgent care services). The remaining 14% have no preference.

Half (50%) of all responses were from residents living in Havering, and this must be considered when analysing the preference for the options.

The majority of residents in all three areas prefer Option 1 (60% Barking and Dagenham, 78% Havering and 50% Redbridge). The lower support among Redbridge respondents is due to both increased support for Option 2 (29%) as well as more residents there expressing no preference (21%).

There is also concern about a detrimental rather than beneficial impact on A&E demand. This is because respondents believe that more bookable appointments will result in people simply 95 20 showing up at A&E rather than booking an appointment. In this context, any additional capacity the new service structure provides perhaps needs to be emphasised more strongly.

However, to put these concerns into perspective, it should be noted that, in regard to bookable appointments, 74% of respondents say more bookable appointments will make it easier to get urgent care when they need it. This agreement peaks at 82% for respondents aged 75+ and 80% for disabled respondents. Furthermore, almost nine in ten respondents (87%) think weekend appointments would be useful to them.

Positivity towards the proposals is evidenced by the fact that 69% of respondents agree that BHR’s proposals will make it easier to know where to go if they need urgent care. This rises to 75% for those who are disabled and to 76% among those who are NHS staff. One in five (19%) residents disagree that the proposals will make it easier to know where to go for urgent care.

Common themes Accessibility of locations was the most frequently raised issue at engagement events by both stakeholders and from those who completed the survey. Concerns about access by public transport and parking facilities at sites was highlighted in both the online survey and through the engagement events. This was particularly emphasised as having a potential impact on older and disabled residents.

A number of people commented on existing issues with accessibility and quality of our existing GP and primary care services, including lack of same-day appointments with GPs and long waits for even routine appointments.

Some people questioned how the proposals would affect A&E attendance from people who did not choose to call NHS 111 or make an appointment, but instead chose to walk in.

The CCGs received 10 letters or responses from stakeholders during the consultation timeframe. In addition, Havering Council also discussed the proposals at a meeting on 12 September and their response is published in the meeting minutes on the Council’s website. The key themes and comments are summarised in the consultation report and published in full as an appendix to the report.

Of the key stakeholders who wrote in to share their views, the majority expressed a preference for Option 1.

In Havering, members of the public and stakeholders initially raised concerns over whether the proposals would mean removal of the urgent care service at Harold Wood Polyclinic. The CCGs were able to provide reassurance that both options demonstrated a commitment to maintaining urgent care services at the polyclinic site through engagement activity, briefings and meetings with councillors from the London Borough of Havering. Unanimous support was given to a motion discussed by Havering Council at its meeting on 12 September, which urged the Clinical Commissioning Group to support the continuation of the health services provided at the Harold Wood Polyclinic and urged all members of the Council to participate in the current public consultation by supporting Option 1.

Proposals to change the way people could access the urgent care service at Loxford Polyclinic from a walk-in service to a bookable service with appointments available by calling NHS 111 raised concerns from stakeholders in Redbridge. These concerns related to a perceived impact on health inequalities for a diverse and deprived part of the borough (south Ilford), concerns about existing poor quality and accessibility of primary care services in south Ilford and issues with using NHS 111 for people who spoke little or no English.

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There were also questions on the modelling assumptions and about provision for residents living in the west of Redbridge with comments that this had no clear recognition of the importance of Whipps Cross Hospital - a point also raised by the Whipps Cross Patients’ Panel.

The Joint Health Overview and Scrutiny Committee (JHOSC) did not state a preference of option, but expressed concerns relating to the proposal to change the urgent care service at Loxford Polyclinic to a bookable service. The committee response also recommended consideration was given to ensuring all community urgent care locations had sufficient parking provision.

On 12 October, the CCGs received a letter from the London Borough of Redbridge reiterating their opposition to proposals to change the urgent care service at Loxford Polyclinic from a walk- in service to a bookable service. This letter explained that the Council had received a petition signed by 3,889 people which sets out the petition signatories’ opposition to ‘closure of the walk- in services at Loxford Polyclinic’. The letter states that the petition was debated by Councillors on 20 September and received unanimous support. The Council requested that the CCGs reconsidered the proposals to change the walk-in service at Loxford Polyclinic for the reasons stated in the petition.

The full consultation report can be found in Annex 4.

The full consultation documents can be found at: http://www.barkingdagenhamccg.nhs.uk/Our-work/community-urgent-care-consultation.htm http://www.haveringccg.nhs.uk/Our-work/community-urgent-care-consultation.htm http://www.redbridgeccg.nhs.uk/Our-work/community-urgent-care-consultation.htm

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11.0 Equality impact assessment (EIA) North East London Commissioning Support Unit was commissioned to produce an EIA for the proposed changes to the community urgent care pathway. The recommendations from the equality impact assessment are:

Overall recommendation - equality consideration of Option one and Option two: The EIA considers that there is no adverse impact of the proposed changes to the urgent care pathway under Option one: 12 sites in total, with four Urgent Treatment Centres (UTCs) and eight bookable locations. It was identified that Option two would have a small, potentially disproportional impact due to a lower number of community locations being available that can manage injuries for traveller communities and those in areas of deprivation, homelessness and car ownership.

Further recommendations for consideration The Health and Social Care Act 2012 requires CCGs to reduce heath inequalities, therefore the risk of reducing access or introducing barriers should be avoided.

BHR CCGs should be mindful of the effort that is needed to support positive change in community behaviours/expectations.

It is recommended that BHR CCGs consider options to mitigate this risk, taking into consideration each group’s behaviours:  A commitment from BHR CCGs to carry out community engagement activities, focussing on supporting the local communities to better navigate the chosen community urgent care pathway and effective communication to support a smooth transition to the new model. This should target the impacted groups identified in the EIA.

 During the consultation, BHR CCGs were committed to exploring the potential to installing telephone access for public use in Loxford walk-in centre in order to allow residents who walked in to call NHS 111 for health advice and for those who need to make bookable appointments. This should be extended to any site where walk-in access is changed to a bookable service.

 ’Care Navigators’ are an initiative that some CCGs are introducing within A&E departments during busy times to raise awareness of both primary care and community based urgent care services and support registration with a GP. This principle should be considered for the new model, particularly during the mobilisation phase.

 Consider a phased replacement of the walk-in appointments to bookable appointments.

 Notify Transport for London of the changes to the model so they can take these into account during their planning cycles.

The full EIA can be found at Annex 5.

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12.0 Financial impact The activity and finance modelling has been refreshed in line with the most recent activity data available, using the same assumptions as published in the pre-consultation business case (Annex 2). The new baselines are based on July 2017 to June 2018 activity data:

Activity Cost Saving

Do nothing 447,459 £38,237,794

Option 1 403,941 £37,638,941 £598,852 per year Option 2 351,571 £37,371,893 £865,901 per year

In the pre-consultation business case the modelling, using the 17/18 baseline activity for Option 1, suggested savings of c£1.07m, and for Option 2 c£1.19m.

There are a number of intricacies which have not been modelled and which will provide a positive financial benefit, compounded with a strong prudent approach to modelling, the bridge of the gap between the current and original estimated savings should be eliminated. These include the use of conservative unit costs, redirection at the front door of A&E and UTCs and duplication of attendance activity.

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13.0 Consultation theme analysis The consultation report sets out statistical results for the questions posed in the Consultation and themes relating to feedback from both stakeholders and the public.

All responses to the Consultation have been taken into account and have been grouped into themes. This section considers each of the consultation themes and outlines how they will be addressed. Most of the consultation themes were in relation to both Option 1 and Option 2 and so our response is structured to clarify whether they relate to both options or just Option 1 or Option 2.

Consultation themes CCGs’ response Consultation themes consistent in both Option 1 and Option 2 Support that the proposals 69% of respondents agree that BHR’s proposals will make it easier to would make accessing know where to go if they need urgent care. This rises to 75% of those urgent care easier who are disabled and to 76% among those who are NHS staff. One in five (19%) residents disagree that the proposals will make it easier to know where to go for urgent care.

This view was also supported by members of the public and community interest groups and some stakeholders during the engagement events. Support for either option (no 14% (B&D 16%, Redbridge 21%, Havering 10%) in the surveys and preference) supported by members of the public and community interest groups during the engagement events. Comprehensive People are already confused by the current services. We need to learn communications and from this as we make changes. Both options will require careful engagement with the public planning for how we tell people about the changes and about how they on how to access urgent can get help and care in the future. We need to make sure people are care under the new model aware of the benefits of calling NHS 111 such as the clinical advice service, the enhanced clinical pathway for over 65s and under 1s, the availability of translation services including language, BSL and text phone services and awareness for traveller communities. This will help build understanding and confidence and ensure local people are not further confused when we are ready to make the changes.

We need a mix of communications, engagement and education to help support patient confidence and a change in patient behaviour. While this needs to be delivered by all health and social care partners to achieve maximum impact, this piece of work needs to be developed by the CCGs.

In BHR, NHS and social care partners already work together to plan, develop and co-ordinate communications for urgent care. We will build on this positive relationship and also involve Healthwatch, our patient engagement forums and the community and voluntary sectors.

We have previously committed to engaging with local people on the naming of the new service(s) to help build greater understanding of what patients can expect from a service. We aim to work with our local Healthwatch organisations to plan and deliver this work in 2019.

Learning from feedback from the consultation, we will also make sure that information, including signage, is clear and visible and is accessible to all local people. 100 25

Impact on A&E due to Under both options access to services will be consistent with a clinical removal of some walk in assessment or being undertaken at the point of access, whether this is points of access as part of a 111 call or as people walk into any of our UTCs. People will receive a more consistent quality assessment of their health needs

before they see a clinician. This will help to address the issues of perceived vs urgent care need and help people get the right care in the right place, first time, with those with the most serious needs seen as a priority - not on the basis of who called or turned up first. This will reduce duplicate attendances and wasted journeys. Consistent assessment would mean that presenting at A&E would not automatically mean treatment there, and patients suitable for treatment by a GP may book an appointment at another site more suitable for their needs or even be re-directed away. This happens at our hospital sites now and would continue under the new model. At Queen’s hospital during September 2018 15% of people who walked into the service were re-directed into more appropriate services including the GP access hubs.

Our modelling accounts for activity shifts to local emergency departments and urgent treatment centres. This covers King George, Queen’s, Newham and Whipps Cross hospitals. Workforce – concern over There are high and competing demands for our NHS urgent care how the proposals would workforce. Almost all urgent care injuries are treated by nurses and impact on the NHS GPs manage most urgent care illnesses, with some support provided workforce by health care assistants. By ensuring patients are treated in the right place first time we will reduce duplication and therefore reduce a little of the pressure on our workforce. This will be supported by the work already in place in BHR and across North east London to recruit and retain GPs and other health professionals including nurses and therapists.

Under Option 1 the emergency nurse practitioners (ENPs), radiologists etc working at the existing walk-in centre services would operate from the new Community UTCs (on existing sites). Under Option 2 they would operate from the hospital based UTCs. Concern for the deaf, hard of National standards for NHS 111 mean our local service has hearing or those without accessibility built into the service specification. This includes English as a spoken interpretation services for people whose first language is not English, language accessing urgent and a text phone service and video conferencing for people who are care via NHS 111 deaf or hard of hearing. The service also has assistance for callers who may have a learning disability which could affect their understanding. As part of the NHS 111 service, translation services are available within 15 minutes of initial contact and are in place for the entire patient journey for the service. Access same-day primary In March 2018 BHR CCGs carried out a survey of GP practices to care appointments better understand the primary care role in the wider current urgent care patient pathway. Of the 46 practices who responded to the survey 100% declared that they provided same day appointments. Providing same day access to GP practices is part of the GP contract. Loxford and Cranbrook All of the 13 practices in this patch have lists open to new patient primary care quality issues registrations. The CQC ratings for the 13 Practices located within the Cranbrook and Loxford network is: 12 practices rated good, with one practice rated at requiring improvement.

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Capacity of the new service The CCG has ensured the service capacity is fit for expected future to manage demand demand by building an activity and cost growth rate of 2 times the GLA population projections. This reflects the actual growth trend in urgent care activity over the last 3 years. Perceived downgrading of The CCGs are committed to retaining and building on the health and services at Harold Wood and care services operating from Loxford and Harold Wood polyclinics. Loxford polyclinics Recent examples of our commitment to provide more services at Loxford Polyclinic are:  In October, the CCGs through the primary care commissioning committee agreed a change to how GPs property costs are funded in order to make Loxford Polyclinic a more appealing site for practices and are now approaching practices to discuss moving into Loxford Polyclinic  As part of our commissioning process, we can promote and encourage a new service to operate from a specific site. We have done this as part of our Ophthalmology procurement to provide community ophthalmology procedures. The new service will mobilise before Christmas at Loxford. Opposition to removing walk In both of our options the walk-in services based at South Hornchurch in access to the urgent care and Loxford retain an urgent care service and this would be a bookable service based at Loxford due urgent care service accessed through NHS 111. to the deprivation levels of the local population To meet the national strategy walk in centres must be rebranded as bookable sites, or upgraded to meet the national UTC specification. It is not possible to upgrade Loxford to the UTC specification for the following reasons:  To meet the national UTC specification and to deliver the consistency in service required, these sites would need to provide diagnostics including x-ray  The existing service is provided by GPs with only limited diagnostics such as blood pressure and temperature. There are no enhanced tests provided such as x-ray or ECGs. Under the proposals this will be continued with no reduction to the clinical service delivered from Loxford Polyclinic  The staff required to deliver to the UTC specification are a highly skilled workforce with significant recruitment challenge  The demand level on these sites is not sufficient to utilise a UTC effectively, even including growth  Booking via 111 would reduce waiting times and inappropriate attendances resulting in duplicate journeys.

Additionally the CCGs have agreed to:  Ensure there is telephone access to NHS 111 in Loxford Polyclinic to allow residents who walk in to call 111 for health advice and bookable appointments. The CCGs will ensure that telephone access to NHS 111 is provided at any site where walk in access is changed to bookable  The CCGs committed to maintaining existing commissioning levels for the new Loxford urgent care service of 14,000 urgent care.

There is close proximity between Loxford and the UTC at Barking community hospital under Option 1 (1.5 miles):

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In both of our options accessing urgent care by calling NHS 111 will make it easier and quicker to get help from a health professional without needing to go into a busy health centre and see someone. Many people won’t even need to leave their home, as they’ll get advice on the phone, and for those who do need to see someone, they will be booked an appointment in the right place for their needs. They will be seen at their appointment time and saved time both on wasted duplicate journeys and sitting in waiting rooms.

In our consultation almost three in four respondents (74%) agree that more bookable appointments for people with urgent healthcare needs will make it easier for people to get urgent care when they need it. By borough this agreement rises to 88% in Barking and Dagenham and 83% in Redbridge, but falls to just 63% in Havering. People with disabilities more commonly believe bookable appointments will make it easier to get urgent care when they need it (80% cf. 71% among those without a disability). Furthermore, four in five (80%) NHS employees agree that more bookable appointments will help compared to 71% of the wider population.

The most deprived areas within BHR are located in the south west and north east:

Under Option 1 there are UTCs proposed near each of these areas. Under Option 2 UTCs are centralised to the two hospital sites, and would therefore have a higher equality impact to those in the more deprived areas within B&D, Redbridge and Havering due to a need to travel further to a UTC for injury management.

Unregistered population - walk-in services can encourage patients to avoid registering with a GP. As published in our PCBC around 9% of patients attending our 4 WIC services are not registered with a practice

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- with significant variation between sites from 15% and 3%. Primary care should be the first place for urgent health needs as the GP practice provides care closest to home with the best continuity of care. This is beneficial especially for those with complex or long term conditions, as a patient’s GP practice takes a more holistic view of care including preventative healthcare (such as immunisations and health checks) as well as referral onward to specialists where required e.g. specialist diagnostics or surgery. The unregistered population miss the benefits the enhanced care provided by general practice. Signage at Loxford for The current provider and the building manager have ordered new current services signage for the walk in service reception at Loxford Polyclinic.

Access to Harold Wood The walk from Harold Wood polyclinic to the bus stop on Gubbins Lane polyclinic from public is 0.4 miles which is approximately a 7 minute walk transport

Importance of Whipps Cross Our neighbouring CCGs are also working with the providers of their hospital for those based in urgent care centres at Whipps Cross and Newham hospitals to the west of Redbridge upgrade services to meet the national UTC specification. This means there will be a consistent UTC offer in place for all the UTCs within BHR and extended outside of our boundaries to Whipps Cross and Newham. This includes the ability for NHS 111 to book into these services for patients that need to be seen, reducing waiting times for those who call first. Location of services As part of the consultation, we have committed to delivering urgent care across 12 sites in the community as well as the two hospital sites. We also confirmed that the new model will operate from following sites which are our current walk in and urgent care centres:  Queen’s Hospital  King George Hospital  Harold Wood Polyclinic  South Hornchurch Health Centre  Barking Community Hospital  Loxford Polyclinic

The CCGs have reviewed the other sites which our urgent care services operate from and we cannot confirm all sites, as ownership and lease arrangements for some sites are outside of the control of the CCGs.

If at procurement stage site changes become necessary BHR CCGs commit to ensuring an accessibility measure (such as PTAL, see below) and parking is used as key criteria in the selection process. Accessibility of service The Public Transport Access Level (PTAL) is a measure of access to locations the public transport network calculated by transport for London (TfL). - For any given point in London, PTALs combine walk times from a - chosen point (the building) to the public transport network (e.g. stations - and bus stops) together with service frequency data at these locations. This provides an overall access score. There are 9 accessibility levels between 0 and 6b (6b would be achieved by the most accessible sites in London). PTAL 2015 is the most recent year published and PTAL 2021 is the projected rating for 2021 after planned transport enhancements.

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The current BHR urgent care sites PTAL scores are in the table below - the highest score is 4 and the lowest is 1b. This demonstrates BHR has accessibility as would be expected for outer London.

PTAL PTAL Site Postcode 2015 2021 Queens Hospital RM7 0AG 2 2 King George Hospital IG3 8YB 2 2

Harold Wood Polyclinic RM3 0FE 1b 1b

Barking Community Hospital IG11 9LX 2 3

Loxford Polyclinic IG1 2SN 2 2 South Hornchurch RM13 7XR 2 2 Broad St RM10 9HU 1b 1b

Rosewood RM12 5NJ 1b 1b

Southdene E18 1BD 4 4 Newbury Park IG2 7LE 3 3 Fulwell Cross IG6 2HG 3 3 North St RM1 4QJ 3 3 Grays Court RM10 9SR 2 2

Urgent treatment centre locations: the proposed sites for community UTCs are Barking Community Hospital and Harold Wood Polyclinic. Both of these sites have very good free on-site parking.

GP bookable locations: in common with many GP practices the bookable appointment sites do not all have on-site parking. However only 2 of these are located in controlled parking zones: Southdene (where there are a number of council-run car parks nearby) and North Street (which has some on-site parking). Additionally the hours of operation for parking zones finish at 18.30, so would not be in force for most of the out of hours period.

If at procurement stage site changes become necessary we commit to ensuring an accessibility measure (such as PTAL, see below) and parking is used as key criteria in the selection process. Reduction of opening hours The activity modelling undertaken does not indicate a need for BHR CCGs to reduce opening hours of sites that deliver urgent care. Utilising NHS 111 as a route to access urgent care would mean urgent care advice can be accessed 24 hours a day 365 days per year. ‘Wasted appointments’ due Did not attends (DNAs) are unfortunately common occurrences in NHS to patients who do not attend planned care / booked services. Services can effectively avoid wasted booked appointments clinical time by routinely ‘overbooking’ clinics e.g. where a service usually experiences 2 DNAs per session they will book 2 extra patients to avoid any wasted time. This is common practice in the NHS. Modelling assumptions are As outlined in our pre consultation business case, our modelling uses unrealistic the best available data to calculate the impact of each of the options. For example: 1. The current usage of services at a network (geographical) level was used to inform activity shifts, i.e. where patients will go if the model is changed. Patients based in the B&D west network will present at Newham 20.4%, Whipps Cross Hospital 2%, King George Hospital 42.3% and Queens Hospital 35.3%. The modelling therefore assumes that if the WIC service at Barking Community Hospital (BCH) were to 105 30

be altered, the patients of that network would present at the various urgent care sites in the proportionate manner outlined above.

2. We have extensive data on the NHS 111 service which has been operational for over 3 years. This data details the outcomes achieved where a patient calls the NHS 111 service. We have utilised these outcomes in the modelling where the option assumes patients will be using NHS 111 to access bookable services. Access and sharing of health There is limited sharing of health records across BHR currently, records although most of our urgent care services use the same IT platform which means some information is shared and a message about the urgent care episode is automatically sent back to the patient’s GP. All urgent care services have access to the ‘national shared care record’ which can be used to view allergies and medications.

Going forward, each STP has to develop a shared care record as part of the Five Year Forward View. City & Hackney, Newham, Tower Hamlets and Waltham Forest already have a well-developed shared care record called the east London Patient Record (eLPR). This is improving the quality of care being given to patients, improving administration issues between providers, and is popular with the clinical workforce. A programme of work is being launched currently to extend this into BHR. Unregistered population Where under our options walk-in access becomes bookable, during the mobilisation phase the unregistered population will be encouraged and supported on these sites and at our urgent treatment centres to register with a GP practice.

The unregistered population miss the benefits of the enhanced care provided by general practice. Primary care should be the first place for urgent health needs as the GP practice provides care closest to home with the best continuity of care. This is beneficial, especially for those with complex or long term conditions, as a patient’s GP practice takes a more holistic view of care including preventative healthcare (such as immunisations and health checks) as well as referral onward to specialists where required e.g. specialist diagnostics or surgery.

Under both options, the un-registered population resident in our boroughs would have equal access to the booked appointments accessed via NHS 111. Homeless patients BHR CCGs aim to support patients registering within BHR to ensure equality of access to the best possible care. Helping patients registering with a GP is a priority due to the benefits of registration. GP practice takes a more holistic view of care including preventative healthcare (such as immunisations and health checks) as well as referral onward to specialists where required e.g. specialist diagnostics or surgery.

Under both options, the homeless residing in our boroughs would have equal access to the booked appointments accessed via NHS 111. Wound care and stitch The CCGs are reviewing wound care. During June 2018 the CCGs removal have undertaken patient engagement on simple wound care. This has highlighted that some A&E and UCC attendances could potentially be avoided if adequate service provision was made available within a community service that included extended hours and weekend provision. The proposed service commencement date for the new simple wound care service is 1 April 2019. Therefore, wound care 106 31

covered by this service is excluded from consideration within this business case.

Phlebotomy The CCG is commencing a high level review during October and November 2018 to map the full range of services and sites, spend and look at what is working well and what could be better, including best practice. From this key themes will be identified and determine how phlebotomy will be commissioned going forward. Consultation theme CCG response

Consultation themes for Option 1 - 2 UTCs in community settings Support for Option 1 67% (B&D 60%, Redbridge 50%, 78% Havering) in the surveys and supported by members of the public and community interest groups during the engagement events.

Consultation theme CCG response Consultation themes for Option 2 - 100% bookable Support for Option 2 19% in the surveys (B&D 23%, Redbridge 29%, 13% Havering) and supported by members of the public and community interest groups during the engagement events.

Impact on patients from Our modelling for Option 1 accounts for 1306 units of activity shifting moving the diagnostics off- from Harold Wood Polyclinic to Queen’s hospital. Approx. 11.8% of site from Harold Wood to urgent care activity currently delivered at Harold Wood Polyclinic is for Queens: activity and travel injuries. impacts

Travelling from Harold Wood Polyclinic to Queen’s hospital is a 19 minute car journey of 4.6 miles, or by public transport it is 1 bus journey taking 18 minutes.

In both of our options, accessing urgent care by calling NHS 111 will make it easier and quicker to get help from a health professional without needing to go into a busy health centre and see someone. Many people won’t even need to leave their home, as they’ll get advice on the phone, and for those who do need to see someone they will be booked appointment in the right place for their needs. They will be seen at their appointment time and saved time both on wasted duplicate journeys and sitting in waiting rooms.

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14.0 Description of the new urgent care pathway Both of our options enhance current services in line with the standards set out in the government’s Five Year Forward View which all CCGs are required to implement.

BHR CCGs want to make it easier for local people to access help for urgent health needs. We want people to click or call before they come in, and to trust the advice they receive about what to do or where to go when they have an injury or illness.

To make it easier we need to simplify the pathway, so both our options have just two points of access and a common name for services:  Bookable services accessed through NHS 111  Urgent Treatment Centres (UTCs).

Click or call before you come in – bookability Both options include a move towards booked appointments for urgent care needs - click or call before you come in. Both of our options will utilise NHS 111 as a way for us to help people get the right care, right place, first time. The message to our population would be to click or call 111 before you come in, in order to benefit from being seen in the right place, first time and shorter time spent in our waiting rooms.

‘Click’ or ‘Call’ before you ‘Come in’  ‘Click’ - NHS111 online to provide support and information. This will help people to self- care and book urgent appointments when needed. NHS 111 online is being tested elsewhere now, and there are other systems being tested across the country.  ‘Call’ - NHS 111 telephone line for those who need more advice and reassurance or to book an appointment to come in if this is required.  ‘Come in’ - Urgent Treatment Centres (UTCs) where patients who need to come in can access urgent care.

Both our options will offer more pre-booked appointments with GPs and nurses in community locations away from hospital sites. People who need to come in for a booked appointment following click or call would be seen at their appointment time (or within 30 minutes), rather than the current commitment to see people within 4 hours of arrival at our urgent and emergency services. This will mean people won’t waste time sitting in a waiting room, and if they do need to see someone they will be booked an appointment at the right place for their needs. Appointments will fit around an individual’s life and responsibilities, such as work, collecting children from school or other caring responsibilities.

We’ll continue to build on improvements to NHS 111, and will ensure services and organisations link up to share information including electronic health records. This will improve the quality of the care patients receive and tackle the challenge of those who visit several services for the same issue. Also, national tools such as the summary care record will be used.

We think moving away from walk-in services will make it easier for local people to get help with their urgent health needs. We will make it easier to call (and, in future, click), get clinical advice from home and be guided to the right place for the care needed.

Both of these changes will help to reduce the pressure on our busy A&E departments, and will reduce waiting times for patients.

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Walk-in centres Where under our options walk-in access becomes bookable, during the mobilisation phase the population will be supported on these sites and at our urgent treatment centres to register with a GP practice, often called ‘care navigation’. Primary care should be the first place to consider for urgent health needs as your practice provides care closest to home with the best continuity of care. This is beneficial, especially for those with complex or long term conditions, as a patient’s GP practice takes a more holistic view of care including preventative healthcare (such as immunisations and health checks) as well as referral onward to specialists where required e.g. specialist diagnostics or surgery.

In both of our options, the walk-in services based at South Hornchurch Health Centre and Loxford Polyclinic will offer a bookable urgent care service accessed through NHS 111. Under Option 2, Harold Wood Polyclinic and Barking Community Hospital also change to a bookable urgent care service.

During the 14 consultation period, the CCGs committed to exploring the potential to install in Loxford Polyclinic telephone access for the public to allow residents who walk in to call NHS 111 for health advice and bookable appointments. This commitment will be extended to any site where walk-in access is changed to bookable.

Grays Court As stated in the pre-consultation business case, the council own the Grays Court site and have alternative plans for its use in the future (subject to confirmation from London Borough of Barking and Dagenham).

Consistent assessment Access to services will be consistent with a clinical assessment being undertaken at the point of access, whether this is as part of a 111 call or as people walk into any of our UTCs. People will receive a more consistent quality assessment of their health needs before they see a clinician. This will help to address the issues of perceived vs urgent care need and help people get the right care in the right place, first time, with those with the most serious needs seen as a priority - not on the basis of who called or turned up first. This will reduce duplicate attendances and wasted journeys.

Consistent assessment would mean that presenting at a UTC would not automatically mean treatment there. As happens now, patients suitable for treatment by another service may be given a booked appointment at another site more suitable for their needs or even re-directed away.

Changes that will happen irrespective of this business case The improvements to NHS 111 and the urgent treatment centres at King George and Queen’s hospitals will happen, irrespective of the changes set-out within this business case.

Integrated Urgent Care - ‘the smart call to make’, providing clinical advice, triage and booking. There are some key aspects to the current NHS 111 service which will be promoted as part of the model:  Clinical advice service (or CAS) - for those who will benefit from telephone advice  Bookability - for those who do need to come into one of our services, NHS 111 will book an appointment at one of our community urgent care services  Interpretation services  Out-of-hours dental and prescription services (6.30pm - 8am).

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UTCs will have access to simple diagnostics such as urinalysis, ECGs and simple x-rays, as well as treatment for ailments like wound closure and management of minor head injuries. Staff will also be able to issue e-prescriptions and urgent repeat prescriptions.

These enhancements are being addressed at King George and Queens Hospitals as part of this year’s winter plan.

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14.1 Description of the urgent care pathway under Option 1

Option 1 To help people access the right care, right place, first time and to simplify the urgent care pathway, both of our options have just two points of access and a consistent name for services: - Bookable services accessed through NHS 111 - Urgent Treatment Centres (UTCs)

Option 1 would see urgent care operating from 12 sites in total: - 4 Urgent Treatment Centres open within Barking and Dagenham, Havering and Redbridge (2 on hospital sites and 2 in the community) - 8 locations for booked community urgent care services.

Both options also include a move towards booked appointments for urgent care needs, building on click or call before you come in. Both of our options will utilise NHS 111 as a way for us to help people get the right care, right place, first time, and for those who need to be seen Urgent Treatment Centres which can be accessed by calling NHS 111 or by walking in, and provide care for both minor illness and minor injury with access to simple diagnostics such as simple x-rays.

The message to our population would be to click or call before you come in, in order to benefit from shorter times spent in our waiting rooms and fewer handoffs.

Many people won’t even need to leave their home, as they may get all the advice they need through their phone, smartphone, tablet or PC.

If you need to be seen, people who come in for a booked appointment following click or call would be seen at their appointment time, rather than the current commitment to see people within 4 hours of arrival at our urgent and emergency services. There will be occasions when emergencies happen and our clinical staff will always make sure that these are managed appropriately. Because of this we are making the commitment that booked appointments will be seen within a maximum of 30 minutes of the appointment time.

During 2018 our two existing Urgent Care Centres at King George and Queen’s Hospitals are being upgraded to become Urgent Treatment Centres in line with national policy.

Under Option 1 there will also be two Urgent Treatment Centres in the community so people could walk into community located urgent treatment centres located at Barking Community Hospital and Harold Wood Polyclinic sites. Facilities at these locations would be upgraded to meet the national Urgent Treatment Centre requirements.

Financial modelling results conclude that this option would save £598,852 per year. 111 36

14.2 Description of the urgent care pathway under Option 2

Option 2 To help people access the right care, right place, first time and to simplify the urgent care pathway, both of our options have just two points of access and a consistent name for services: - Bookable services accessed through NHS 111 - Urgent Treatment Centres (UTCs)

Option 2 would see urgent care operating from 12 sites in total: - 2 Urgent Treatment Centres open within Barking and Dagenham, Havering and Redbridge on our hospital sites - 10 locations for booked community urgent care services.

Both options also include a move towards booked appointments for urgent care needs, building on click or call before you come in. Both of our options will utilise NHS 111 as a way for us to help people get the right care, right place, first time, and for those who need to be seen Urgent Treatment Centres which can be accessed by calling NHS 111 or by walking in, and provide care for both minor illness and minor injury with access to simple diagnostics such as simple x-rays.

The message to our population would be to click or call before you come in, in order to benefit from shorter times spent in our waiting rooms and fewer handoffs.

Many people won’t even need to leave their home, as they may get all the advice they need through their phone, smartphone, tablet or PC.

If you need to be seen, people who come in for a booked appointment following click or call would be seen at their appointment time, rather than the current commitment to see people within 4 hours of arrival at our urgent and emergency services. There will be occasions when emergencies happen and our clinical staff will always make sure these are managed appropriately. Because of this we are making the commitment that booked appointments will be seen within a maximum of 30 minutes of the appointment time.

During 2018 our two existing Urgent Care Centres at King George and Queen’s Hospitals are being upgraded to become Urgent Treatment Centres in line with national policy.

Financial modelling results conclude that this option would save £865,901 per year.

The activity modelling assumptions for Do Nothing, Option 1 and Option 2, are set-out in the pre- consultation business case, Annex 2. 112 37

Options - at a glance

Option 1 Option 2 Service provision Twelve sites in total: Twelve sites in total: . 4 UTCs (2 on hospital sites and 2 in the community, all . 2 UTCS (both on hospital sites accessed via both walk-in and accessed via both walk-in and bookable via NHS 111). bookable via NHS 111). . Bookable appointments via NHS 111 at 8 locations for . Bookable appointments via NHS 111 at 10 community urgent booked community urgent care services. These would care service locations across Barking and Dagenham, Havering include South Hornchurch Health Centre and Loxford and Redbridge. These would include Harold Wood Polyclinic, Polyclinic. South Hornchurch Health Centre, Loxford Polyclinic and Barking Community Hospital. Consultation 67% (B&D 60%, Red 50%, 78% Havering) in the surveys and 19% (B&D 23%, Red 29%, 13% Havering) in the surveys and supported responses supported by members of the public and community interest by members of the public and community interest groups during the groups during the engagement events. engagement events. Stakeholder support Five: BHRUT, Healthwatch Havering, Hurley Group, One: North East London Local Pharmaceutical Committee (NEL LPC). Healthwatch Barking and Dagenham, Havering Council. EIA The EIA considers that there is no adverse impact of the The EIA identified that Option two would have a small potential proposed changes to the urgent care pathway under Option disproportional impact due to a lower number of community locations one: 12 sites in total, with four Urgent Treatment Centres being available that can manage injuries for traveller communities and (UTCs) and eight bookable locations. those in areas of deprivation, homelessness and car ownership. Patient experience PCBC Patient experience score: 1.50 PCBC Patient experience score: 1.18 Comments - simpler access through one telephone call, retains Comments - simpler access through one telephone call, retains current current service locations as bookable services. At least 1 UTC service locations as bookable services. in each borough for injury management. Clinical PCBC Clinical score: 1.32 PCBC Clinical score: 1.18 Comments - new model supports shared records and improved Comments - new model supports shared records and improved outcomes outcomes Deliverability PCBC Deliverability score: 1.40 PCBC Deliverability score: 1.14 Comments - move to more bookable services is in line with Comments - move to more bookable services is in line with national national policy. Additional UTCs allow for greater capacity for policy. diagnostics to support minor injury management away from the Workforce in place at BCH and Harold Wood would need to be TUPE’d main hospital sites and closer to home. Workforce currently to hospital UTCs. delivering diagnostics and injury management at BCH and Harold Wood will be retained on-site.

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Efficiency PCBC Efficiency score: 1.34 PCBC Efficiency score: 1.38 Comments - patients are clinically assessed by NHS 111 so Comments - more patients are clinically assessed by NHS 111 so they they receive the right care in the right place, first time; reduces receive the right care in the right place, first time; reduces duplication by duplication by reducing access points. reducing access points. Affordability £598,852 per year £865,901 per year c15% c15% Benefits Greater capacity for diagnostics to support minor injury management away from the main hospital sites and closer to home will aid delivery of the 4 hour A&E wait target. 70% bookable capacity - this allows for both the management of injuries as walk-in whilst reflecting a sensitivity analysis of people’s compliance with the click/ call/ come in message. Risks Patient behaviour does not follow the modelling assumptions - Patient behaviour does not follow the modelling assumptions - i.e. where i.e. where WICs become bookable services (Loxford and South WICs become bookable services (Harold Wood Polyclinic, South Hornchurch) that 70% of patients will book appointments. Hornchurch Health Centre, Loxford Polyclinic and Barking Community Hospital) that 100% of patients will book appointments. Opposition to proposals to change the way people could access the urgent care service at Loxford Polyclinic from a Opposition to proposals to change the way people could access the walk-in service to a bookable service from stakeholders in urgent care service at Loxford Polyclinic from a walk-in service to a Redbridge. bookable service from stakeholders in Redbridge. There is no UTC facility in B&D.

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15.0 Recommendation for decision making The Community Urgent Care Programme Board considered the greater savings forecast for Option 2 of £267k, but determined that Option 1 is more economically advantageous with more quality benefits for patients whilst contributing to our ability to live within our financial means. As the evidence presented in this business case sets out Option 1 has greater support from: the consultation responses, stakeholders, within the EIA and was scored higher by the CCGs scenario scoring panel.

The Community Urgent Care Programme Board and the financial recovery programme board have reviewed the case for change, along with the evidence presented in this business case, and recommend that the CCGs joint committee endorse Option 1 to be commissioned as the future community urgent care pathway.

The CCGs joint committee is asked to: 4. Agree Option 1 as the future urgent care pathway:  To help people access the right care, right place, first time and to simplify the urgent care pathway, urgent care will have just two points of access and a consistent name for services: − Bookable services accessed through NHS 111 − Urgent Treatment Centres (UTCs)  This will be delivered from 12 sites in total including 4 UTCs (2 on hospital sites and 2 in the community - accessed via both walk in and bookable via NHS 111) and bookable appointments accessed via NHS 111 at 8 locations.

5. Agree the Community Urgent Care Programme Board will progress to the procurement stage which will be overseen by the Procurement Oversight Group.

6. Subject to agreement of the above it is recommended that:  A comprehensive communications and engagement plan to support these changes is developed including the continued involvement of all three Healthwatch organisations A plan to enhance the utilisation of the Loxford polyclinic site is developed.

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16.0 Annex 1 - Case for change

Community urgent care case for change_July 2017.pdf

17.0 Annex 2 - Pre-consultation business case

CUC pre-consultation business case_Final.pdf

18.0 Annex 3 - Consultation documents

The consultation documents can be found at: http://www.barkingdagenhamccg.nhs.uk/Our-work/community-urgent-care- consultation.htm http://www.haveringccg.nhs.uk/Our-work/community-urgent-care-consultation.htm http://www.redbridgeccg.nhs.uk/Our-work/community-urgent-care-consultation.htm

19.0 Annex 4 - Consultation report

Consultation report.pdf

20.0 Annex 5 - Equality Impact Assessment

BHR EIA CUC November 2018_final.pdf

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21.0 Glossary

CAS The clinical assessment service provided by NHS 111

CCG Clinical Commissioning Group

Clinical Observation, assessment and treatment of disease and other illness in a patient

Diagnostics Procedures to identify a condition or disease, e.g. X-ray, urinalysis, ECG (a simple test that can be used to check your heart's rhythm and electrical activity. Used alongside other tests to help diagnose and monitor conditions affecting the heart)

Emergency care Emergency care is provided in a medical emergency when life or long term health is at risk. This could include serious injuries or blood loss, chest pains, choking or blacking out

GP General Practitioner. Your family doctor

Minor illnesses or Common health problems like aches and pains, skin conditions and stomach upsets ailments

Minor injuries These could include:

GP access hub Urgent, same day GP appointments that can be pre-booked by telephone. Primarily for urgent care.

GP out of hours Medical care provided outside the normal working hours of GP practices. Available via NHS 111 service from 6.30pm to 8am on weekdays and throughout weekends and bank holidays

Phlebotomy Blood testing services

Primary care Services which are the main or first point of contact for the patient, usually GPs, practice nurses and pharmacies

Urgent care Urgent care is care needed the same day. This could include anything from cuts, minor injuries, wound infections, tonsillitis, urinary infections, or mild fevers etc.

Urgent Care Centre These are centres, usually located on a hospital site next to an A&E, which offer urgent care. or UCC Led by GPs supported by nurses.

Walk-in centre or WIC This service offers urgent care to people who walk in, without pre-booking an appointment. See Annex 2 for the local variations.

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Right care, right place, ﬁ rst time

Consultation on making changes to community urgent care services

What do you think about our plans for local GP hubs, walk-in services, and GP Out of Hours services?

118 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Contents About this document

About this document...... 2 This document explains why we want to change and improve the way we provide community urgent care services in Barking and Introduction...... 3 Dagenham, Havering and Redbridge (BHR) and our proposals for doing this. What is urgent care?...... 4 Community urgent care services provide urgent same-day care and advice for people with urgent, but not emergency or life- What have local threatening, physical and mental health issues. They are the people told us?...... 6 services you use when you have an urgent problem but you cannot see your own GP, such as GP hubs and walk-in centres. Why community urgent care in our area needs to change...... 7 Our consultation is about improving urgent care across our area. What do we mean by urgent? We mean things like cuts, How did we decide minor injuries, urinary infections or mild fevers etc. – so not an on our options?...... 10 emergency or something life threatening, but things that can’t and shouldn’t wait. Our proposals for changes to community urgent We want to make it easier to get this care if you care services...... 11 need it by: • Making it easy to book a same-day appointment if Our options...... 12 your GP can’t see you Summary of the options...... 13 • Upgrading facilities at some locations so more places can help with injuries or illnesses that need tests or x-rays How services might look Making it easier to know how to get the care you need first in the future...... 14 • time with more consistent opening times and help available from different places. Questionnaire...... 16 To do this, we want to: Have your say...... 17 • Make NHS111 the number to call for urgent health care How we will use advice or services (999 is still the emergency number) your feedback...... 21 • Maintain a wide choice of community locations where you can book an urgent appointment, but have fewer places Glossary...... 22 where you can walk in and wait without seeking advice first. This will reduce waiting times.

119 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Introduction

People are confused by the community urgent We are taking the fi rst steps towards this simpler care services currently available, and want it to model of care, by making it easier to book an be easier to get help when they need to see a urgent appointment by calling an improved GP or nurse on the same day. We know many NHS 111 and moving away from walk-in services. services are similar or even duplicate each other This consultation is not about emergency care – so we need to make it easier for you to get the services or changes to the A&E services at any of right care in the right place, fi rst time when you our local hospitals, nor are we proposing changes need it. to how GPs run their practices. In future, people will get healthcare and services We are asking for your views on our proposals in a very different way from today. Using the for changes to community urgent care services. latest technology, patients will be able to click or call before they come into a service. We’re No decision has been made. We want to know already seeing Skype and online tools being used what you think and if there is anything else you in parts of London, and a virtual NHS GP service want us to consider. Your feedback will inform launched in London last year. the decision-making process.

We also need to ensure we are meeting national Dr Arnold Khalil Ali – standards for urgent care and, as always, Fertig – Lay Member spending NHS money wisely. Independent for Public GP, BHR Participation, CCGs Redbridge CCG

Co-chairs of the Community Urgent Care Programme Board

How to have your say

We want to hear from as many people as we This document summarises our thinking can so we can make the best possible decision. and we recommend that you read this before completing the questionnaire. We are asking you to share your views through an online questionnaire. We’ve used this approach for For more information visit other consultations and it helps us to reduce costs our websites: and to spend NHS money wisely. www.barkingdagenhamccg.nhs.uk/urgent-care We are also working with GPs, patient groups, www.haveringccg.nhs.uk/urgent-care local Healthwatch organisations and community and www.redbridgeccg.nhs.uk/urgent-care voluntary organisations to make sure we reach as many local people as possible. If you would like us to come and talk to your group about these proposals please All responses must be get in touch. Comments from health professionals received by 5pm on are welcomed. 21 August 2018.

120 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

What is urgent care?

Urgent care is care needed on the same day. This could include anything from cuts, minor injuries, wound infections, tonsillitis, urinary infections, or mild fevers etc.

Urgent care is not emergency care, which is provided in a medical emergency when life or long term health is at immediate risk. This could include serious injuries or blood loss, chest pains, choking or blacking out.

These descriptions were agreed with our Healthwatch colleagues as part of the BHR urgent and emergency care research study in 2016.

At the moment, urgent care is delivered in many ways across Barking and Dagenham, Havering and Redbridge:

Seeing a GP Minor illnesses Most people will call their GP practice if they need an urgent same-day appointment. and injuries People are not always sure where to go to get the If their practice is busy or closed, there are care they need when they have a minor illness or appointments available on weekday evenings and injury. While some will choose to ask their local at weekends at our seven GP hubs across the pharmacist for advice, most want to speak to or area. You can call NHS 111 or the separate GP see a GP. In our area, many urgent care services hubs booking line (not 24/7). have different names and are open at different If your GP practice is closed and you call times, but offer the same thing – an appointment NHS 111, you may be booked an appointment with a GP or nurse. with the GP Out Of Hours service (GPOOH) which The GP hubs see people who book appointments. sees people at three locations. Four walk-in centres (or WICs) in our area see Youcanfindouthowtochooseandregisterwith people who walk in without an appointment. a GP by visiting the NHS Choices website. These walk-in services are at Barking Community Hospital, Harold Wood Polyclinic, South Hornchurch Health Centre and Loxford Polyclinic. People can also call NHS 111 and be booked into Loxford Polyclinic. These services are open at different times. Details are available on our websites.

People with minor illnesses and injuries who walk intoourlocalhospitalswillusuallybeseenfirstby a GP or nurse in the Urgent Care Centres (UCCs). NHS 111 can also book you an appointment at a UCC if they think this is the right place for you to be seen.

121 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Where are services located now?

GP hubs: Redbridge: Southdene surgery, South Woodford; Newbury Group Practice, Newbury Park; Fulwell Cross Medical Practice, Barkingside Barking and Dagenham: Broad Street Medical Centre, Dagenham; Barking Community Hospital Havering: North Street Medical Centre, Romford; Rosewood Medical Centre, Hornchurch.

A better NHS 111

NHS 111 is the NHS free non-emergency telephone In our area, NHS 111 health advisors fast-track number where you can speak to a highly trained parents of children aged under 12 months and people adviser, supported by healthcare professionals. aged over 65 to speak directly with a GP or other You can call 24 hours a day, 365 days a year – just health professional. dial 111. Calls are free from landlines and mobile phones. There is also a textphone service and a NHS 111 can already book you into an appointment confidentialtranslatorservicewhichisavailable at some of our existing community urgent care in many languages. services, and we plan to add more – meaning one call to NHS 111 will be the only call you need to make. NHS 111 helps people who want advice for an urgent health need on the same day. It will be an important In future, they will be able part of giving people joined-up urgent care services, to book you an urgent andshouldbethefirstcallyoumakeifyoucan’tsee appointment with your own your GP or if a pharmacist can’t help. GP. NHS tools to help you get advice online and a digital app We’re already making improvements to our local are also being tested in other NHS 111 service, so you’ll be able to get more than parts of London before being just advice and signposting to services in future. rolled out across the capital.

122 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

What have local people told us?

We’ve talked extensively to our residents to find opening hours and a mix of walk-in services or out what you think of local community urgent care pre-bookable appointments to pick from. People said services. Our research study in 2016 involved more they can’t always get a same-day appointment with than 4,000 people and included a telephone survey, their own GP, so some will just head to A&E instead 10 focus groups and two workshops. of using an alternative, more appropriate service – even though it is likely to mean a longer wait for help. People told us that the wide range of services available is confusing and means they don’t know which service to choose. Even finding the right service is complicated – with different numbers, different

Key findings

33% of those who went 37% of people had seen to A&E said that they could not their GP with the same issue get a timely appointment before going to A&E. with their GP

A&E is seen as a reliable 24/7 service, long waits are not a deterrent; only 6% of People in Barking and people said they went to Dagenham and Havering are A&E because they thought 26% of people had been to more aware of walk in they got better care there A&E before with the same issue centres than those in Redbridge

This year, the Healthwatch organisations in all three of better support and advice through NHS 111, as well as our boroughs worked with us to talk with local people from your local pharmacist, will help patients. about some of our emerging ideas. They spoke with more than 500 people - a mix of parents, young adults While patients would prefer to see their own GP, there (15-24) and older people aged 65 and over as these is significant support for more appointments within groups are our biggest users of urgent care services. the local community (at a GP hub or bookable service) when your own GP is not available. There’s also good A report on the findings is available on our websites recognition of the role of pharmacies in providing alongside the other documents supporting this expert advice for minor illnesses. consultation. People welcomed news of the improvements to While most people can confidently describe the NHS 111 and felt this would make it easier to get difference between ‘urgent care’ and ‘emergency care’, health advice quickly, to book an urgent appointment it’s clear more needs to be done to help people feel and would reduce the number of people who go to confident to make the right choices for their urgent A&E when they have a minor illness or minor injury. But health needs. Simplifying the system and providing people told us we need to do more to raise awareness about what NHS 111 can now help with.

123 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

What services and GP practices told us

Managing demand, staffing levels and communication We will continue to work closely with providers and between service providers are some of the main issues GP practices on how we can make urgent care better we’ve heard from GPs and other healthcare providers in Barking and Dagenham, Havering and Redbridge in our area. Everyone accepts that change needs to because any change would affect them too. National happen but ‘when’ and ‘how’ is now the challenge. issues around recruitment and staff shortages mean That’s why we’ve worked closely with and involved that staff are under increasing pressure. clinicians from the start to help develop the proposals in this consultation. Why community urgent care in our area needs to change

Services are We also know that many of public transport links across the confusing and our services offer the same three boroughs. vary across our thing at the same time – an three boroughs appointment with a GP or Because you’ll need to call for nurse. Some people also go to an appointment, we think this People have told us they want it lots of different services for the will also encourage people to to be simpler to get the urgent same health need. register with and visit a GP. This care or advice they need quickly is better for your health as a and in a timely way. We want to make it easier GP can help patients manage for everyone to call (and in their existing conditions and We know that the mix of future, click) and be guided deal with minor illnesses and services is confusing, for to the right place for the care other health issues before they patients and for many you need, first time. We’re become more serious. professionals too. This can already improving the NHS 111 mean people aren’t seen in the telephone advice service. In People who haven’t registered most appropriate place first future, there will be an online with a GP can visit a walk-in time. That can be frustrating, version so you can click for service without making an as it means extra travel, longer advice too. appointment first. This means waits and delays in getting the walk-in services often see help you need. We also want to move away patients who wouldn’t need from walk-in services and urgent care if their condition Some people have a telephone make more bookable urgent was properly managed. assessment before they see appointments available for or speak to a doctor or nurse, those who need to be seen. We want these changes to help others are booked in before This will help people to go to people find it easier to get the a detailed assessment, and the right place for their needs, urgent care they need first you can just walk into others, and reduce travel and waiting time at a place and time that is regardless of your need. This times. We’ve looked at travel convenient for them. isn’t fair and we want to make times and the vast majority of sure that all services prioritise local residents will be within a Continued overleaf… those in most need in a 15 minute drive of a community consistent and clear way. urgent care service, with good

124 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Continued from previous…

Our population own area, GPs from NHS 111 time. It’s confusing for patients, is growing and are using video consultations and not the best use of our changing, and so with care homes when a limited NHS resources. is the demand resident is unwell, so staff can care for them safely Some people visit a number People are living for longer, and in the home and avoid an of services before they get the healthcare needs are increasing. often unnecessary journey right treatment. Sometimes In BHR, as with other parts of by ambulance to A&E. this is because their symptoms England, more and more people worsen, but sometimes it’s are using NHS services every year. In future, it will be easier and because the first place they go This is not a good experience for quicker to get help from a can’t meet their needs. It could patients who may have a long health professional without be because they need to see wait to see a GP or in A&E, and needing to go into a busy a nurse for a wound dressing also puts increasing pressure on health centre and see someone. or need an X-ray. It can also our hard-working frontline staff Many people won’t even need be because they believe they and clinicians. to leave their home, as they’ll need a specific medicine or test get advice through their phone, or just reassurance, so they go Over the next 15 years, the smartphone, tablet or PC. to another service if this isn’t population of Barking and provided at their first visit. Dagenham, Havering and You won’t waste time sitting Redbridge is expected to grow around waiting and if you In our 2016 survey, 37% of by 143,000 extra people. That’s do need to see someone, you people said they had seen their a 19% increase – and equivalent will be in the right place for GP with the same issue before to the size of Basildon. This your needs. Your appointment attending A&E. All of this costs is partly due to the large- will fit around your life and money which could be spent scale housing developments responsibilities – collecting more effectively. So we need to planned in Ilford and Barking your children from school, help patients by directing them town centres, Romford, your work, or caring for to the right place, first time. Rainham and Beam Park, a relative or neighbour. and Barking Riverside. While our proposals are not just We’ll continue to make about improving quality and We need to make plans now NHS 111 better for patients patient experience, we have a to make sure our services can including introducing an online duty to use our funds carefully provide appropriate urgent version. We’ll make sure services to ensure that local people care for all local people in and organisations link up to can access the healthcare the future. share information including that is most needed and that electronic health records. This people with equal need have A digital future will improve the quality of equal opportunity to access for healthcare care patients receive. treatment. Advances in digital We need to spend We believe our proposals technology are already making NHS money wisely will not only improve the it easier to get health advice quality of services and patient and services online. Across We spent £14.3 experience, but will also be London, doctors and patients million on community urgent more cost-efficient than our are talking via Skype and we’ve care in 2017/18. Too many of current confusing system. seen the launch of the ‘GP at our existing urgent care services Hand’ virtual NHS service. In our provide similar care at the same

125 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Meeting national standards

We have used national guidance to shape our National UTC Urgent Care Urgent thinking. Not only will this help us deliver the best requirements Centres at Treatment possible care and services for local people, but it may King George Centres at support our case for investment into local services (KGH) and KGH and where this is needed, now and in the future. Queen’s Queen’s NHS England guidance says we need to establish (April 2018) urgent treatment centres (or UTCs) in our area. Open 12 24/7, every day 24/7, every day These will be GP-led, open at least 12 hours a day, hours a day, of the year of the year every day, and be equipped to diagnose and deal every day of with many of the most common non-emergency the year ailments people attend A&E for. Bookable KGH only Yes Urgent treatment centres (or UTCs) are designed to appointments ease the pressure on hospitals, leaving A&Es free (via NHS 111) to treat the most serious cases. This should mean Sees walk-in Yes Yes fewer people need to go to A&E and when UTCs are patients located next to an A&E department, they will be able to deal with those people who go directly to hospital All patients KGH only Yes but who do not have life-threatening or emergency assessed by health issues. GP-led service on arrival at UTCs will be part of a joined up system of urgent hospital/ ED and emergency care which, in our area, will include Access to No Planned an improved NHS 111 service and a network of patients’ GP services offering pre-booked urgent appointments health records with a GP. Able to No Yes Our two current hospital urgent care centres – refer people again, we are not talking about A&E departments with other – will be upgraded to UTCs to offer the best medical community testing available (also known as diagnostics) and and hospital allow appointments and tests to be pre-booked via services if NHS 111, so patients, you and your family, will avoid needed the usual long waits. Access to Access to some Yes We have to deliver those ‘upgrades’ in any case – diagnostics diagnostic we’re not consulting on them - as they are part of (x-ray, ECG, services at the latest national guidance in the government’s urine and Queen’s. At NHS Five Year Forward View plan. They are also blood testing) KGH, patients good news for patients and staff. referred into A&E if they need diagnostics

126 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

How did we decide on our options?

We developed a number of scenarios and tested The Clinical Commissioning Groups (CCGs) delivered these against what local people have told us, clinical £32.3 million in savings in 2017/18 (against a £55 standards, and national guidance. We also looked at million savings target. 2018/19 will be just as tough the financial cost of different scenarios. and we’re currently aiming to deliver £45million in savings. This means we need a simpler, more cost- Doing nothing is not an option. More and more effective system of care that will meet the needs of people are using A&E when it’s not an emergency, our growing population. This is why we also ruled out because they find choosing an alternative too any scenario that would cost more money than we complicated. As our population increases, this would spend if we carried on with current services. pressure on A&E and our GPs, the first place people call, will continue. It will mean longer waits and an You can read more about how we developed and increasingly poor patient experience, and will not help decided on our options on our CCG websites at: reduce the pressure on our dedicated workforce or our A&Es. www.barkingdagenhamccg.nhs.uk/urgent-care www.haveringccg.nhs.uk/urgent-care It’s also unaffordable. We’ve already talked to local www.redbridgeccg.nhs.uk/urgent-care people about our local financial challenges – not just to NHS services but also social care services.

127 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Our proposals for changes to community urgent care services

We are proposing to:

Improve the way you Change the way you get Change where you would go access services urgent GP appointments for minor illness and injuries

NHS 111 will be the one call you People with an urgent health need The Urgent Care Centres at King need for all urgent care advice will call NHS 111, be assessed and George and Queen’s Hospital will and services (if you can’t see if they need to be seen, offered an be upgraded to become Urgent your own GP). We won’t have a appointment at a convenient time Treatment Centres. These will offer separate number for the GP hubs and location in their local area. booked appointments as well as in future. You should still call 999 More same-day appointments will seeing people who walk in or are for all emergencies. 111 is just for be bookable, in advance, at 12 taken in by ambulance. urgent advice or services. locations across our area, making it more convenient and easier to With more bookable appointments When you call, NHS 111 advisors get the care you need when you available at 12 locations across the will assess your needs, give you need it. You’ll be seen within a area, we will make sure resources, health advice and if you need to maximum of 30 minutes of your including staffing and facilities be seen, either help you speak appointment time. such as x-ray and testing, are in directly to a GP or other health the right places to meet demand. professional or book you a timed Most of our GP hubs are currently appointment at a community located at existing GP practices. This consultation is not proposing urgent care service. In future, we will look to have any changes to emergency GP bookable services at the same care services or changes to In future, you will be able to call locations or from centres that are the A&E services at any of our or click before you come in as we as conveniently located for local local hospitals. roll out new technology such as a people. These bookable services digital version of NHS 111. will offer a standard approach to urgent care, so patients know what to expect when they attend.

128 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Our options Pharmacy G E P & A Wal There are two options for k i or bo n changes to community 99 t ok 9 ec in ll ir a d urgent care services that we C e R n w r rso it would like your views on. o e h P

These are about services outside W

i U a u n

l of our hospitals that people can d r k r g g e s choose to go to directly (i.e. e e e n b n n t e u t car k walk into without booking an o H T o r b y appointment). e d 1 t an 1 i a Triage 1 t HS n x2 m via N u Both options will help to make e m hospital n m t o it easier for people to choose Ce C nt the right service when they have res x8 an urgent health need and will x2 provide improved care for local community people in the future. Option 1 Our existing Urgent Care Centres at King George and Queen’s Hospitals will be upgraded and become Urgent Treatment Centres in line with national policy. These will see patients who walk in or who are booked into a timed appointment by NHS 111. Patients will be encouraged to call NHS 111, rather than walk in.

As well as the two existing Urgent Care Centres, people could also continue to walk into Barking Community Hospital and Harold Wood Polyclinic, and services at these locations would be upgraded to become community Urgent Treatment Centres.

There would also be eight other community urgent care services across the area where you can be booked in following a call to NHS 111. You will be seen within a maximum of 30 minutes of your appointment time.

129 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Pharmacy Summary of G E P & A Wal k i the options or bo n 99 t ok 9 ec in ll ir a d C e R n w r rso it Option 1 o e h P

W Patients can walk in or book

i U a u n

l d r k r urgent appointments at four g g e s e e e n b Urgent Treatment Centres n n t e u t car k o H T o r b y King George Hospital e d 1 t • an 1 i a Triage 1 t HS n Queen’s Hospital m via N u • e m n m Harold Wood Polyclinic t o • Ce C x2 nt Barking Community hospital res x10 • Hospital Bookable appointments available at eight community Option 2 urgent care service locations. No walk in service at Under option 2, the Urgent Treatment Centres at King George Loxford Polyclinic or South and Queen’s Hospitals would be the only places you could walk in Hornchurch Health Centre – withoutmakingacallfirstorgettinganappointment. bookable only By calling NHS 111, you would be booked a timed appointment at 10 community urgent care service locations across Barking and Option 2 Dagenham, Havering and Redbridge, or at one of the two UTCs. Patients can walk in or book These community locations would include Harold Wood Polyclinic, urgent appointments at two South Hornchurch Health Centre, Loxford Polyclinic and Barking Urgent Treatment Centres Community Hospital. You would no longer be able to walk in King George Hospital without an appointment at these four centres. • • Queen’s Hospital This option means all community urgent care services outside Bookable appointments of the hospitals would be bookable. We would make sure more available at ten community appointments were made available so services could see everyone urgent care service locations at a convenient time. No walk in service at Harold Patients would spend much less time waiting around as you will be Wood Polyclinic, Barking seen within a maximum of 30 minutes of your appointment time. Community Hospital, Loxford Polyclinic or South When you call NHS 111, you will be assessed and given advice or Hornchurch Health Centre – booked into the right service for your needs. This means you will bookable only gettherightcareintherightplace,firsttime,andyouwon’tbe redirected to another service.

Option 2 means most patients will call or click before they come in. This matches our vision for the future of urgent care and will provide local people with a simpler system of quality urgent care.

130 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

How services might look in the future

Current services Future services Getting advice You can get advice and over- Pharmacies and NHS 111 will continue to help and looking the-counter medicines for minor as they do now. after yourself illnesses and injuries from your local pharmacist or you can call NHS 111 for advice. Seeing a GP Most people call their GP for an You should contact your GP or NHS 111 first. urgent appointment. If your practice is closed or busy, NHS 111 can Urgent GP appointments are give you advice and if you need to be seen, available in the evenings and at book you a convenient, timed appointment weekends at seven GP hubs across with a GP in one of 12 community urgent care the area. services located across the area (including our Urgent Treatment Centres). When your GP practice is closed, you can call NHS 111 and you may get Appointments will be available in the daytime, an appointment with the GP out of evenings and at weekends. hours service (three locations). These will have a mix of GPs and nurses so they all offer the same wide range of care. Minor illness Four centres see patients who walk Our existing Urgent Care Centres will be or injuries in without an appointment. upgraded and become Urgent Treatment Centres in line with national policy. These will These are: see patients who walk in or who are booked • Barking Community Hospital into a timed appointment. • Harold Wood Polyclinic Under option 1, people could also continue • South Hornchurch Health Centre to walk into Barking Community Hospital and • Loxford Polyclinic Harold Wood Polyclinic, and facilities would be upgraded to become community Urgent These services are not all the same, Treatment Centres, open at least 12 hours with different opening hours and a day. days. Different diagnostics tests are also available at each location Only NHS 111 will also be able to book you an Barking Community Hospital and appointment at these centres and at eight Harold Wood Polyclinic offer x-rays. community locations including Loxford Polyclinic and South Hornchurch Health Centre. These You can also walk in and be seen would offer a standard approach to urgent care at Urgent Care Centres at King so patients know what to expect. George and Queen’s Hospitals (as well as Whipps Cross for some Under option 2, the Urgent Treatment Centres Redbridge residents). located at King George and Queen’s Hospital would be the only place you could walk in without making a call first or getting an appointment. But there will be ten locations where you book appointments by calling NHS 111.

14 IMAGE 131 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Future vision

ervice sig Click n s n o po Call m st i m l develop n o ta m g C i e ig n t D

C a s r d e or and Rec

Come in

Right care in the right place, fi rst time through cohesive and joined up urgent and emergency care services

132 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

We want to hear from as many people as we can so that we can make the best possible decision. Views can be shared via an online questionnaire Questionnaire or by completing this paper version. The survey is being administered by an independent organisation called BMG Research in Birmingham. Just to confirm, your responses will be Please complete this questionnaire on our website: treated in the strictest confidence. BMG Research abides by the Market Research Society Code of • www.barkingdagenhamccg.nhs.uk/urgent-care Conduct at all times. www.haveringccg.nhs.uk/urgent-care • You can find out more information about BMG • www.redbridgeccg.nhs.uk/urgent-care Research surveys and what they do with the information they collect in their Privacy Notice Or you can fill it in and post it to FREEPOST BHR CCGs which is here www.bmgresearch.co.uk/privacy . (no stamp needed). The survey will take around 5 to 10 minutes to complete. Please make sure we receive your By completing and returning this questionnaire, we will take this as your consent for BMG Research response before 5pm on 21 August 2018. to process and analyse the data you have provided.

Tell us about you We want to see what sorts of people are responding to our proposals. This helps us to understand if our proposals might have more of an impact on some groups of people than others. We recognise that you might consider some of these questions to be personal or sensitive, in which case you are free not to answer them. The information you provide will be used for the sole purpose of understanding the views of different groups.

Please tick as appropriate

1. Are you?

Male Female Other Prefer not to say

2. How old are you?

Under 18 years 18 to 24 years 25 to 34 years 35 to 44 years

45 to 54 years 55 to 64 years 65 to 74 years 75 years or older

Prefer not to say

3. Do you consider yourself to have a disability?

Yes – a physical/mobility issue Yes – learning disability/mental health issue

Yes – a hearing issue Yes – another issue No

4. Which borough do you live in?

Barking and Dagenham Havering Redbridge

Other (please tell us which borough)

133 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

5. What is your ethnicity?

This is not about place of birth or citizenship. It is about the group you think you belong to in terms of culture, nationality or race.

Any white background Any mixed ethnic background

Any Asian background Any black background

Any other ethnic group (please tell us what it is) Prefer not to say

6. Are you an employee of the NHS?

Yes No

7. Are you responding as

An individual A representative of an organisation or group (please tell us which)

Have your say We want to understand your views about what we’re proposing.

You don’t have to answer the whole questionnaire if you don’t want to – only answer the sections you’re interested in.

We want to know what you need from community urgent care services in Barking and Dagenham, Havering and Redbridge. We want to know what you think of our proposals and how you feel about changes to services that are currently available to people who have an urgent, same day healthcare need.

8. We think our proposals will make it easier to know where you go if you need urgent care? By this, we mean treatment for minor illnesses and minor injuries that mean you need care or advice from a health professional on the same day. Please tell us if you:

Strongly agree Agree Don’t agree Strongly disagree Don’t know

9. We are proposing to provide more bookable appointments for people with urgent healthcare needs who need to be seen on the same day. Do you agree this will make it easier to get urgent care when you need it?

Strongly agree Agree Don’t agree Strongly disagree Don’t know

10. Our travel analysis shows that the vast majority of local residents will be within a 15 minute drive of a community urgent care service. If your own GP can’t see you, would you be happy to have a urgent appointment at another practice or location in Barking and Dagenham, Havering or Redbridge (within 15 minutes’ drive) if this meant you would be seen more quickly?

Yes No Don’t know

134 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

11. The proposals will ensure that there is greater availability of bookable appointments for urgent care at the weekend. Based on how and where you normally spend your week and your weekends, do you think that weekend appointments would be useful to you?

Yes No Don’t know

Why? Please use the box to tell us.

12. We will be upgrading services at some locations to become Urgent Treatment Centres. These will see people with urgent, but not life-threatening or emergency, health needs. Appointments can be booked by NHS 111 or people can choose to walk in. Staff will have access to your health record and to more specialist diagnostic tests so can help with minor illnesses and injuries that may require tests that a GP can’t do in a practice or community location.

Which of our two options for where you could continue to walk in and get urgent care do you prefer?

Option 1 – Four Urgent Treatment Centres (at King George and Queen’s Hospitals and two in the community at Harold Wood Polyclinic and Barking Community Hospital), and eight bookable-only community urgent care services located across Barking and Dagenham, Havering and Redbridge.

Option 2 – Two Urgent Treatment Centres (at King George and Queen’s Hospital sites) and 10 bookable-only community urgent care services located across Barking and Dagenham, Havering and Redbridge.

No preference

13. If we go ahead with Option 1, what else should we consider? Please use the box for your comments.

135 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

14. If we go ahead with Option 2, what should we consider? Please use the box below for your comments.

15. Are there any other suggestions you have to improve community urgent care in Barking and Dagenham, Havering and Redbridge?

16. If you would like to hear about the outcomes of this consultation, please let us have your name and email address and/or your home address so we can send this to you. These contact details will be passed by BMG Research to Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups. All your other survey responses will remain confidential. Click one box only.

I give permission for my contact details to be passed to Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups so that I can be informed of the outcome of this consultation

I do not wish to be informed of the outcome of this consultation

Name: Email:

Address:

17. Would you be interested in helping us gather feedback about local services? We are looking at setting up an online panel which will regularly receive surveys about health services or issues that affect the community of Barking and Dagenham, Havering and Redbridge. If you are interested or would like more information, please provide us with an email address so we can contact you with more information. Again these contact details will be passed by BMG Research to Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups. All your other survey responses will remain confidential. Click one box only.

I give permission for my email address to be passed to Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups so that I can be contacted about future research

I do not wish to be contacted in this way

Email:

136 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

How we are engaging with local people

We want to hear from as many people as No decisions have been made. Over the next possible so we can make the best possible decision. 12 weeks (until 21 August 2018) we are engaging We are providing the opportunity for everyone to with local people in order to explain the changes to have their say. community urgent care services and the reasons for developing these proposals, outline what this will We are also working with GPs, patient groups, mean for BHR residents and encourage them local Healthwatch organisations and community to respond. and voluntary organisations to make sure we reach as many local people as possible. If you would like All responses will form a report, which will go to our us to come and talk to your group about these Governing Bodies to consider and make a decision. proposals please get in touch. We will put that report and details of whatever decisions are made on our websites:

www.barkingdagenhamccg.nhs.uk/urgent-care www.haveringccg.nhs.uk/urgent-care www.redbridgeccg.nhs.uk/urgent-care

137 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

How we will Equality Impact use your feedback Assessment (EIA)

When you share your views – through our An EIA is a process to make sure that a policy, project online survey or at any of the events we will or proposal does not discriminate or disadvantage be attending – we will ensure your personal against any of the following characteristics: information is kept secure and confidential. We age will not share it and it will only be used to help us • analyse the feedback we receive. • disability gender reassignment When the consultation closes, we will read • marriage and civil partnership and consider all the responses we receive. We • appreciate you taking the time to respond. • pregnancy and maternity race We will use what you tell us to write a report • religion or belief for the three CCGs’ decision-making Governing • Bodies to consider, alongside any other evidence • sex and/or information available. This includes the • sexual orientation Equality Impact Assessment (EIA). The Governing Bodies will make a decision about what to do. As part of this work, we will carry out an initial EIA and publish a draft on our websites. We will take We will publish the dates of the CCGs’ Governing into account people’s responses to our proposals and Bodies’ decision-making meeting on our three this will inform a more detailed final EIA, which will CCG websites. These are meetings held in public be considered before any decision is made about so you can come along and listen. All the reports these proposals. that the Governing Body members read will be on our websites so you can read them too.

If you are responding on behalf of an organisation or you represent the public (as an MP, Councillor or similar), your response may be made available for the public to look at. If you are responding in a personal capacity, we will not publish your name or response in full but we may use some of what you’ve said to show particular points of views.

If you let us know your contact details when you complete the questionnaire, we can keep you up to date about any decisions we make.

If you want to comment on our proposals, we must receive this by 5pm on 21 August 2018.

138 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Glossary

Accident and Emergency (A&E) ECG Electrocardiogram. A simple test that A 24 hour service provided by an acute hospital can be used to check your heart’s rhythm and for conditions that need immediate medical electrical activity. Used alongside other tests to attention for emergency or life-threatening help diagnose and monitor conditions affecting health conditions, e.g. a serious accidental the heart. injury, a heart attack, difficulty in breathing. Also known as an Emergency Department (ED) Emergency care Emergency care is provided in a medical Carer emergency when life or long term health is at A carer is anyone who cares, unpaid, for a friend risk. This could include serious injuries or blood or family member who, due to illness, disability, loss, chest pains, choking or blacking out. a mental health problem or an addiction, cannot cope without their support. GP General Practitioner Your family doctor CCG Clinical Commissioning Group NHS organisations that plan, design and buy Long term conditions (commission) local health services. Long-term conditions are conditions that cannot be cured but can be managed through Clinician medication and/or therapy. They include a broad A healthcare professional. Can be a GP, range of medical issues, for example asthma, hospital doctor, nurse or pharmacist. diabetes, cancer and arthritis.

Diagnostics Minor illnesses or ailments Procedures to identify a condition or disease, Common health problems like aches and pains, e.g. X-ray, blood tests, ECG, urine tests fevers, skin conditions and stomach upsets

Minor injuries These could include: • Bites, human and animal • Cuts and lacerations • Foreign bodies in the eyes, nose and ears • Fractures that require plaster only • Minor burns and scalds • Minor head injuries (with no loss of consciousness) • Soft tissue injuries, for example sprains and bruises • Wound infections

139 NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

NHS 111 Urgent care A free 24/7 telephone advice service for people Urgent care is care needed the same day. who require urgent healthcare treatment and This could include anything from cuts, minor advice but who don’t know where to go. injuries, wound infections, tonsillitis, urinary infections, or mild fevers etc. GP access hub Urgent, same day GP appointments that can be Urgent Care Centre or UCC pre-booked by telephone. Primarily for urgent These are centres, usually located on a hospital care. Appointments available from 6.30pm site next to an A&E, which offer urgent care. to 10pm on weekdays and 8am to 8pm at Led by GPs supported by nurses. weekends. Seven locations across Barking and Dagenham, Havering and Redbridge, Urgent Treatment Centre or UTC Open at least 12 hours a day, 365 days a year, GP out of hours service these centres will provide urgent care. Led Medical care provided outside the normal by GPs supported by nurses and other health working hours of GP practices. Available via professionals. Access to better diagnostics and NHS 111 from 6.30pm to 8am on weekdays and able to deal with a wide range of minor injuries throughout weekends and bank holidays. Sees and illnesses, including minor head injuries. people at three locations – King George and Queen’s Hospital and Grays Court, Dagenham Walk-in centre or WIC This service offers urgent care to people who Primary care walk in, without pre-booking an appointment. Services which are the main or first point of contact for the patient, usually GPs and pharmacies

140 How we are engaging with local people

This document is about changes we want to make to some health services in Barking and Dagenham, Havering and Redbridge. We want to know what you think about this.

If you would like to know more, please email [email protected] or call 020 3688 1615 and tell us what help you need. Let us know if you need this in large print, easy read or a different format or language.

141

Consultation Report

Community Urgent Care Consultation Prepared for: NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

142 Community Urgent Care Consultation

Prepared for: Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups Prepared by: Steve Handley, Research Director Date: September 2018

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143 Table of Contents

1 Introduction ...... 1 1.1 Consultation Background ...... 1 1.2 Analysis and reporting ...... 3 2 Urgent Care Options ...... 7 2.1 Option preferences ...... 7 3 Wider urgent care options ...... 15 4 Suggestions and improvements ...... 21 5 Key messages from the consultation ...... 24 6 Appendix: Statement of Terms ...... 25

144 145 Introduction

1 Introduction

1.1 Consultation Background

Urgent care is care needed on the same day, but not when life or long term health is at immediate risk. Currently, in Barking and Dagenham. Havering and Redbridge there are a variety of options for residents to access in order to receive urgent care. Many will attempt to get a same-day urgent appointment with their GP, but as this is not always possible some will instead make the journey to A&E and wait to be seen, rather than seeking an alternative, more appropriate service. Locally, £14.3 million was spent on community urgent care in 2017/18, and a simpler, more cost-effective system of care is needed in order to meet the needs of a growing population. NHS Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups are looking to simplify and clarify the community urgent care services currently available in the area. This report summarises the responses received to a public consultation regarding the potential structuring of urgent care in the future. The consultation presented two options. Both of these options are underpinned by the ambition to make it easier for people to get the right care in the right place first time when they need it, while ensuring all national standards are met and that NHS money is spent wisely. NHS England guidance states that urgent treatment centres (UTCs) need to be established in BHR. These will be GP-led, open at least 12 hours a day, every day, and be equipped to diagnose and deal with many of the most common non-emergency ailments people attend A&E for. They’re designed to ease the pressure on hospitals, leaving A&Es free to treat the most serious cases. UTCs will be part of a joined up system of urgent and emergency care which will include, an improved NHS 111 service and a network of services offering pre-booked urgent appointments with a GP. BHR’s current two urgent care centres will be upgraded to UTCs (King George Hospital and Queen’s Hospital). In addition to the planned upgrades, BHR Clinical Commissioning Groups developed and tested a number of scenarios, (in line with local people’s experiences, clinical standards, and national guidance), in order to find the most suitable options to improve urgent care services in the area. Following this, two potential options were selected for changes to community urgent care services.

146 1 Community Urgent Care Consultation

Option One is that patients can walk in or book urgent appointments at four UTCs (King George Hospital, Queen’s Hospital, Harold Wood Polyclinic and Barking Community Hospital), with bookable appointments at eight other community urgent care service locations.

Option Two is that patients can walk in or book urgent appointments at two UTCs (King George Hospital, and Queen’s Hospital), with bookable appointments at ten other community urgent care service locations.

Having established these two options, an open consultation was held over 14 weeks in summer 2018 (29th May – 4th September) with the aim of engaging as many individuals and organisations as possible and consulting them on their opinions and preferences regarding these two options. Participation in consultation was possible via an online questionnaire promoted via each of the CCG websites or via a simplified easy read questionnaire in paper format (see overleaf). These two strands of the consultation had continuity in their design wherever possible, allowing the question responses from each to combined where possible to create a single data set.

2 147 Introduction

1.2 Analysis and reporting

In total 1062 responses were received (of which 28% were easy read). The data used in this report is rounded to the nearest whole percentage, so this is why some tables or charts may not add to 100%. Where tables and graphics do not exactly match the text in the report this occurs due to the way in which figures are rounded up (or down) when responses are combined. Results that do differ in this way should not have a variance which is any larger than 1%. This written report, and accompanying data tables, is based on valid responses, i.e. if a respondent did not answer a question, or answered it incorrectly, they were excluded from the analysis for that question. Responses to the open/free text questions have been reviewed and grouped into themes, in order to quantify the prevalence of particular viewpoints. This coded data is shown in the analysis, along with illustrative quotes to explain the opinions being expressed. Throughout this report, the term ‘significant’ is only used to describe differences within groups that are statistically significant. These are differences that are proven to be real by use of the T-test, which is a statistical method used to evaluate the differences between two opposing groups. Given that this was an open consultation, no correction for weighting is made in the data. The consultation was open to members of the public, local interest groups and stakeholders, and healthcare professionals. Those responding on behalf of an interest group are given equal weight in the analysis as responses from individual members of the public, even though these interest groups may be representing larger sections of the population.

148 3 Community Urgent Care Consultation

For reference, the organisations and interest groups that completed the consultation questionnaire include:  Nia Hugget Women’s Centre;  Patient Participation Group Chair Kings Park Surgery;  Highgrove Patient Participation Group;  Havering Health GP Federation;  Friends of Barking Hospital (Chairman on behalf of Charity members);  Healthwatch Redbridge;  One Place East;  Redbridge Asian Mandal;  Havering Dementia Carers support group;  NELFT;  Barking and Dagenham Diabetes UK Support Group;  Richmond Fellowship Mental Health Charity in Romford;  Havering Asian Social Welfare Association;  Redbridge Carers’ Support Service.

The consultation was available in all three boroughs, Barking and Dagenham, Havering, and Redbridge. Half of all responses were from Havering residents (50%), twice that of any other group, as shown in the table below. This geographical variation should be noted throughout the subsequent analysis.

Table 1: Geographical breakdown of consultation responses

Borough % Barking and Dagenham 22% Havering 50% Redbridge 25% Other 3%

Of the 3% of respondents living outside of BHR, their homes included:  Waltham Forest;  Essex (including: Brentwood and Chelmsford);  Newham;  Tower Hamlets.

In terms of demographic breakdown of respondents, 60% come from those aged over 55. This puts a skew towards an older demographic, and should be considered in regards to the overall results. Furthermore, 73% of respondents are women and 73% have a white background. The tables below summarise the composition of the respondents by age, cross referenced by borough and ethnicity, and also gender cross referenced by ethnicity, so the data must be interpreted with this in mind.

4 149 Introduction

Table 2: Age profile of responses by borough and ethnicity Total Barking and sample Dagenham Havering Redbridge Responses received 1062 235 523 262 Under 18 years <0.5% 0% <1% 0% 18 to 24 years 2% 1% 2% <1% 25 to 34 years 9% 11% 9% 5% 35 to 44 years 14% 15% 17% 6% 45 to 54 years 15% 21% 16% 6% 55 to 64 years 22% 24% 23% 19% 65 to 74 years 23% 19% 20% 31% 75 years or older 15% 7% 10% 31% Prefer not to say 1% 1% 1% 2% Total Barking and sample Dagenham Havering Redbridge

1060 235 524 262 Any white background1 73% 77% 86% 44% Any mixed ethnic background 1% 2% 1% 1% Any Asian background 18% 11% 7% 47% Any black background 2% 4% 1% 3% Any other ethnic group *% *% 0% 0% Prefer not to say 5% 6% 5% 4% White Mixed Asian Black Responses received 773 13 196 24 Under 18 years <1% 0% 0% 0% 18 to 24 years 2% 8% 1% 0% 25 to 34 years 9% 0% 8% 17% 35 to 44 years 13% 38% 14% 21% 45 to 54 years 17% 23% 7% 17% 55 to 64 years 25% 23% 15% 21% 65 to 74 years 20% 8% 34% 13% 75 years or older 14% 0% 21% 13% Prefer not to say 1% 0% 0% 0%

1 Please note that white background will include respondents who are non-British white e.g. those from Eastern Europe

150 5 Community Urgent Care Consultation

Table 3: Gender profile of responses by ethnicity Total sample White Mixed Asian Black Other Responses 773 13 195 24 1 received 1061 Male 27% 25% 8% 32% 33% - Female 73% 75% 85% 67% 67% - Other <0.5% <1% 0% 0% 0% 100% Prefer not to 0% 8% 1% 0% - say 1%

Furthermore, just under one in five (19%) of respondents to the main online consultation said that they were an NHS employee. An additional 4 respondents within the easy read data classed themselves as a healthcare professional.

6 151 Urgent Care Options

2 Urgent Care Options

This section of the report summarises the balance of opinion with regards to the two urgent care structures presented within the consultation and explores the key considerations for the options presented. 2.1 Option preferences

In response to the two options presented, the majority of consultation respondents (67%) favour Option One, which comprises four UTCs and eight bookable-only community urgent care services. One in five 19% favour Option Two (two UTCs and ten bookable-only community urgent care services). The remaining 14% have no preference.

Figure 1: Options preferences summary (Base, all questionnaires, where provided a response: 1048)

Almost three in four respondents (72%) to the main survey prefer Option One, with just under one in five (17%) selecting Option Two. This differs from those who completed the easy read questionnaire. For this group the results are more mixed. The majority (53%) still prefer Option One, but this is 19 percentage points less than those who completed the main questionnaire. Furthermore, the number of respondents with no preference is double for the easy read questionnaire (22% compared to 11%). Yet, Option Two is preferred by a quarter (25%) of easy read respondents, just 8% more than main survey respondents. 72% of responses are from the main questionnaire, and this was the core consultation route, with respondents being directed to this method. Therefore, although there are different outcomes based on methodology, it should be taken in to account that the main questionnaire was the core approach and consequently had a larger volume of responses and a greater impact on the overall result.

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Figure 2: Options preferences by response method (Base, all questionnaires, where provided a response: 1048)

Easy read 53% 22% 25% (297)

Main (751) 72% 11% 17%

Option One No Preference Option Two

It should be reiterated that half (50%) of all responses were from residents living in Havering, and this must be considered when analysing the preference for the options. The majority of residents in all three areas prefer option one (60% Barking and Dagenham, 78% Havering, and 50% Redbridge), The lower support among Redbridge respondents is due to both increased support for Option 2 (29%) as well as more residents here expressing no preference (21%).

Figure 3: Options preferences by area (Base, all questionnaires, where provided a response: 1048)

Redbridge 50% 21% 29% (257)

Havering 78% 10% 13% (521)

Barking and Dagenham 60% 16% 23% (230)

Option one No Preference Option two

8 153 Urgent Care Options

The above geographical variations in opinion could be due to the location of proposed UTCs in BHR. Under Option One, four UTCs would operate, two in Havering and one each in both Redbridge and Barking and Dagenham. This variation in facilities across the boroughs is potentially why support for option one is strongest in Havering and weakest in Redbridge. Consultation respondents tended to be from older age groups, with 60% of responses from people aged over 55, and 15% from people aged over 75. This skew towards an older demographic should be taken in to account when reviewing the results. As shown by the figure below, all age groups, under 75, have a preference for Option One, (67%-77%). Those aged 75+ also prefer Option One (41%), but by a far smaller margin, with 31% preferring Option Two. When analysing additional suggestions for BHR to consider in relation to community urgent care, 34% of over 75s (answering the main questionnaire) referred to ease of travel, and 26% of over 75s (answering the easy read), comment on people using public transport and people who can’t/don’t drive. This may suggest why Option Two is not preferred overall among those aged 75+, and also why 28% express no preference, as Option Two proposes walk-in facilities at only two locations.

Figure 4: Options preferences by age (Base, all questionnaires, where provided a response: 1033)

90% 80% 77% 69% 70% 67% 60% 50% 41% 40% 31% 28% 30% 22% 18% 20% 16% 15% 9% 10% 7% 0% 18-34 (109) 35-54 (303) 55-74 (469) 75+ (151) Option One No preference Option Two

154 9 Community Urgent Care Consultation

Overall, 72% of respondents report that they do not have a disability. Among this non- disabled cohort 71% prefer Option One. This is significantly higher than respondents who have a disability, of whom 56% prefer Option One. This is still the majority, but those with a disability were significantly more likely to have no preference (20%) or prefer Option Two (24%).

Figure 5: Options preferences by disability (Base, all questionnaires, where provided a response: 1033)

Yes - disability 56% 20% 24% (290)

No - disability 71% 12% 18% (743)

Option One No preference Option Two

As will be shown later in the report, almost three in four respondents (74%) agree that more bookable appointments for people with urgent healthcare needs will make it easier for people to get urgent care when they need it. Over four in five (81%) of respondents who prefer Option Two, agree more bookable appointments for people with urgent healthcare needs will make it easier to get urgent care when they need it. This is significantly higher than those who prefer Option One (70%). All respondents in the main online survey were asked in their own words what further considerations should be made for Option One. The comments at this question have been grouped into themes and quantified. This shows that consideration of those who cannot drive (17%) and people using public transport (15%) is most frequently suggested (See Figure 6 overleaf). Many of the answers also note the affordability of taxis for those who cannot drive or depend on public transport, and public transport accessibility for to the Harold Wood Polyclinic. Furthermore, this concern for those who cannot drive peaked in Redbridge with 33% of respondents from there listing it as a concern. Respondents who at this question feel walk-in centres are a better option are younger (26% of those aged 18- 34) and living in Havering (22% of Havering respondents). Concerns over parking were highest in Havering (11%), with both Queen’s Hospital and Harold Wood Polyclinic being directly referenced.

10 155 Urgent Care Options

Figure 6: Option one additional considerations (Base, main questionnaire, where provided a response: 376)

Consider those who can't drive/don't drive 17% People using public transport 15% Walk in centres are better option 15% Extend opening hours 10% Impact on appointment demand 10% Parking facilities 9% More advice/guidance about urgent/emergency … 9% Community based services 9% Impact of A&E demand 7% Impact on waiting times 7% More staff/resources 7% Improve telephone booking system 6% Impact on elderly/disabled people 5% Option One is better 4% Improve accessibility 2% Changes are good/will help 2% Appointment vetting 2% More GP practices 1% Continuity of care/see my own Dr 1% Easier access to medical history <1%

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

A selection of illustrative comments in relation to Option One are provided in the table overleaf.

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Table 3: Selection of verbatim comments on additional considerations for option one Marketing the scheme in a Make sure people can get to Online page showing much better way than now. Harold Wood Polyclinic more waiting times to patients Easy read version, Braille, easily by bus especially can decide which treatment community organisations people with disabilities as at centre to use or promoting the scheme. the moment it involves a long communication to patients walk from the bus stop in to recommend going to a Gubbins Lane including a certain location which steep slope. might be less busy than another. What happens if all bookable Ease of access by Public Reducing walk-in options is appointments are taken? How Transport. If people are wrong and a mistake; the do you build in extra capacity unwell they often are unable lesson of A&E use is that during the period of winter to drive and not everyone can it's preferable to walk in pressure? afford taxis even if waits are very long.

Queens is far too busy, I am one of approx. 30% of Book able appointments especially now the A+E dept is Redbridge residents who live need to be plenty. The smaller. Parking is not easy, in Wanstead and Woodford; reason people don’t go to and will get worse when the as such, our choice of their GP as they don’t new flats are built, as staff hospital, is and always has know how to wait. We have currently use the old ice rink been Whipps Cross which is developed a culture where car park. So having 4 centres within a W12 bus ride for we have told people that will be a much better option. those without cars, or within they can’t self diagnose or The population is ever walking distance. I would not treat and it must be done increasing, so the more be happy if 111 sent me to by a professional. centres, the more chance of KGH, Barking or Queen’s Therefore the NHS is a being seen in a timely manner. when WXH is on my doorstep victim of its own success. and has always served our Need to address the family well. If admission was underlying issue of why necessary, it would be easier people are accessing so for family to visit and I am many services. thinking also, of friends with elderly relatives too. Availability of paediatric Parking should be reasonably Ensuring that all appointment in the community. priced and easily available. appointments are not gone Public transport must be first thing in the morning frequent and reliable to each but released throughout of the UTC's. the day.

12 157 Urgent Care Options

Respondents were also given the opportunity to suggest what should be the key considerations in relation to Option Two. As was the case for Option One the potential impact on those who cannot drive is most commonly mentioned (17%). Beneath this a notable proportion of respondents voice concern on the impact of A&E demand (14%), with the worry that more bookable services will lead to people simply heading to A&E if they are unable or unwilling to get an appointment. This concern peaks at 19% among Havering residents answering this question. Also, 14% express concern over appointment demand itself, claiming bookable appointments lead to ‘no- shows’ and in traditionally stretched periods (like winter) the system will be unable to cope.

Figure 7: Option Two additional considerations (Base, main questionnaire, where provided a response: 264)

Consider those who can't drive/don't drive 17% Impact of A&E demand 14% Impact on appointment demand 14% People using public transport 13% Walk in centres are better option 9% Option One is better 8% Parking facilities 8% Community based services 8% More advice/guidance about urgent/emergency care 7% Impact on elderly/disabled people 6% More staff/resources 6% Extend opening hours 5% Improve telephone booking system 3% Impact on waiting times 3% Impact on walk in demand 2% Appointment vetting 2% Improve accessibility 1% Changes are good/will help 1% More GP practices <1%

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

A selection of the comments given in relation to Option Two can be found overleaf.

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Table 4: Selection of verbatim comments on additional considerations for option two Availability of public Extending Dial-a-Ride Taxi option to all Flexible hours 24/7 transport to the those who cannot "drive 15 minutes" centres for those who don't drive Adequate parking I currently work at Queens/King George Please remember to factor facilities for those - a good portion of people that use UCC in people who have no unable to be at both sites have no idea that they can transport or in my case no transported by be referred to see a GP instead of support (and there will be public transport and being seen in A&E (for example minor plenty of people in this need to avoid folk injuries from RTC). Option One is position). This last Easter I calling an similar to the system in place now - had to go twice over the ambulance because option two is too complicated without a weekend to Queens after somewhere is HUGE education plan in place hours. It cost me £42 in difficult to access. I explaining what sites deal with what taxis. Older people and live in Wanstead injuries/illnesses. What would probably those on benefits won’t be and always use end up happening is people not using able to afford this. I keep WXH. the bookable service, and heading money aside for things like straight for Queens, which will overload this but as I get older and a system that barely manages some am on a pension I have no days (especially if you take winter show of affording this. I season into account). Case in point - have multiple chronic upon phoning queens you are advised conditions as will other to NOT attend with diarrhoea/vomiting. people. For you your Yet there are still a lot of people who proposals will be factoring attend with those symptoms - simply in things that cost you as because they do not pick up the phone little as possible. first. That an appointment Some people, particularly in my It's better to have a greater will ALWAYS be experience the elderly don’t like to use choice of options thus a available within a the phone and then may have difficulty 2/10 split is worse than a few hours. That a following instructions on when and 4/8 spilt. Furthermore, the phone call will where to go for appointments. tendency with bookable ALWAYS be Therefore I believe more walk in appointments is that they answered by a options with face to face contact get fully booked! Thus person within five provide more flexibility. more walk in centres would minutes. be preferable to less. The appointment A bookable slot is more likely to be Protests especially from booking system abused as it's easy to make a phone people in Barking who are needs to be easy to call and then not turn up. If you have to distant from other hospitals use go there and wait then you really want & for whom the Barking to be seen. Less chance of time Hospital walk-in is needed. wasters.

14 159 Wider urgent care options

3 Wider urgent care options

As well as seeking views on the urgent care service structure proposals, the consultation also included broader questions about the potential impact of the changes and how individuals believe they are likely to interact with these services in the future. Positivity towards the proposals is evidenced by the fact that 69% of respondents agree that BHR’s proposals will make it easier to know where to go if they need urgent care. This rises to 75% of those who are disabled and to 76% among those who are NHS staff. One in five (19%) residents disagree that the proposals will make it easier to know where to go for urgent care. Geographically, a majority of respondents in each borough agree that the proposals will have a positive impact on the ease of understanding how to access urgent care. This agreement is significantly higher among Barking and Dagenham residents (77%) and Redbridge residents (76%), with agreement dropping significantly to 63% among Havering respondents. Disagreement is also far more common in Havering, where over one in four (26%) respondents do not feel the proposals will help. This compares to just 16% in Redbridge and 7% in Barking and Dagenham.

Figure 8: We think our proposals will make it easier to know where you go if you need urgent care? (Base, main questionnaire, where provided a response: 752)

Agree 41%

Strongly agree 28% Disagree 13%

Strongly Don't know disagree 12% 7%

Analysis by age shows that older residents are most likely to agree that the proposals will make it easier to know where to go if urgent care is needed. Among those aged 75 and over (85%) gave this response compared to 64% of those aged 18-34 and 63% of those aged 35-54.

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Among those who took part in the consultation via read the easy read questionnaire, almost four in five (77%) respondents would be happy seen by a different GP practice if that meant they would be seen more quickly. Emphasising the potential speed of service access that the propososals may deliver may therefore be beneficial as they are implemented.

Figure 9: If your own doctor can’t see you, would you be happy to be seen at a different GP practice if this meant you would be seen more quickly? (Base, easy read questionnaire, where provided a response: 297)

Older respondents are, the less likely they are to be willing to be seen by a different GP practice, even if it meant being seen quicker. For example, 89% of those aged 18- 34 said yes, compared to 65% of those aged 75+. Travel concerns, as highlighted earlier, may be the reason fewer older people said yes, as travelling to alternative practices may simply not be convenient for them.

16 161 Wider urgent care options

Among respondents to the main online questionnaire, a majority of residents (71%) would be willing to travel within 15 minutes drive to an alternative practice if it meant they would be seen more quickly. Views on this do not differ significantly by borough or by age group.

Figure 10: If your own GP can’t see you, would you be happy to have an urgent appointment at another practice or location in Barking and Dagenham, Havering or Redbridge (within 15 minutes drive) if this meant you would be seen more quickly? (Base, main questionnaire, where provided a response: 761)

162 17 Community Urgent Care Consultation

Almost three in four respondents (74%) agree that more bookable appointments for people with urgent healthcare needs will make it easier for people to get urgent care when they need it. By borough this agreement rises to 88% in Barking and Dagenham and 83% in Redbridge, but falls to just 63% in Havering. People with disabilities more commonly believe bookable appointments will make it easier to get urgent care when they need it (80% cf. 71% among those without a disability). Furthermore, four in five (80%) NHS employees agree that more bookable appointments will help compared to 71% of the wider population.

Figure 11: We are proposing to provide more bookable appointments for people with urgent healthcare needs, who need to be seen on the same day. Do you agree this will make it easier to get urgent care when you need it? (Base, main questionnaire, where provided a response: 757)

Agree 37%

Strongly agree 37%

Disagree 12% Strongly disagree Don't know 8% 7%

18 163 Wider urgent care options

The overwhelming majority of respondents to the main online consultation (87%) think weekend appointments would be useful to them. Just 7% indicate that this would not be the case. No significant differences are evident by borough, age, gender and disability regarding the usefulness of weekend appointments. Among those who prefer Option Two, 92% feel weekend appointments would be useful for them as do 86% of those who prefer Option One suggesting there is an clear appetite for such appointments to be available.

Figure 12: Based on how and where you normally spend your week and your weekends, do you think that weekend appointments would be useful to you? (Base, main questionnaire where provided a response: 757)

Of those who said they do not think weekend appointments would be useful to them (Sample base of 42), over one in three (36%) say this is because weekday appointments suit them. Although the sample size at this is question it low it is notable that 26% of the responses in relation to weekend appointments suggests these would put pressure on A&E walk-in centres rather than alleviating this pressure. Some respondents did recognise that weekend appointments may benefit people with traditional working hours (14%).

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Figure 13: Reasons given as to why weekend appointments would not be useful? (Base, main questionnaire, where proposal is not useful and provided a response: 42)

Weekday appointments suit me 36%

Will put pressure on A&E/walk-in's 26%

I'm retired/unemployed 19%

Appointment avaliability 19%

Weekend appointmnets good for workers 14%

Urgent care can be needed at any time 10%

Other 12%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Table 5: Selection of verbatim comments on reasons why weekend appointments are not useful I can use Monday to Friday Because you don’t know if Most problems will wait leaving weekend you will become ill or have an until the working week. appointments to working accident in advance! I like to Emergencies will be people. It would however; be a know that if me or my child is available at A&E. it is good thing to have weekend suddenly ill or had an better to ensure that appointments available. If all accident we can go to the people learn to wait rather appointments are taken, will Harold wood polyclinic than expect everyday we still have to use A & E? straight away as it’s only 5 problems to be dealt with mins away! at their convenience. If I am that unwell, I would go I think that those who work I don't work a standard to a pharmacy weekdays will cause greater Mon-Fri, 9-5 so weekends demand for weekend are no better or worse than appointments, limiting week day appointments availability for others.

20 165 Suggestions and improvements

4 Suggestions and improvements

Both the main online survey and the paper easy read questionnaire gave respondents the opportunity to make further suggestions about how community urgent care might be improved (main survey) or any further considerations for the decision making on service provision (easy read version). A variety of suggestions regarding improvement to community urgent care in BHR were made. In line with the principles of the proposals, 16% suggested that more appointments are needed. Similar proportions mentioned the need for improved signposting/guidance regarding urgent and emergency care (15%) and for more staff (14%). More staff would seem to be a further proxy indicator of the desire for more capacity to be provided in the reformed system. A further 13% mentioned travel issues which have been picked up upon earlier in this report.

Figure 14: Further suggestions to improve community urgent care in Barking and Dagenham, Havering and Redbridge? (Base, main questionnaire, where provided a response: 389)

More appointments 16%

More advice/guidance about urgent/emergency care 15%

More staff 14%

Ease of travel 13%

Extend opening hours 11%

Community based services 8%

Increase walk-ins/clinics 7%

Reduce waiting times 6%

Improve telephone booking system 6%

Maintain/don't close walk-ins/clinics 6%

No 5%

More funding/don't waste money 3%

Improve the 111 service 3%

Assistance for the elderly/disabled 3%

Appointment vetting 1%

Bigger waiting rooms prevent over crowding 1%

Don't know <0.5%

Other 19%

166 21 Community Urgent Care Consultation

Table 6: Selection of verbatim comments on additional suggestions for BHR’s community urgent care GP's to operate Monday to Considering growing older Ensure the urgent Friday with no closures as it population and more new treatment centres can do damages the spirit of patients arrivals, need more surgeries X-rays to prevent A&E Tuesday closure due to PLT, and GPs for urgent care. attendances. Thursdays doctors surgery close half day no GP surgeries are open Saturday Use a triage system and have Care and Nursing homes to Give feedback to 3 main categories minor, have alternative pathways individuals as to whether major, and urgent and stream (OT's) etc for more patients they made an appropriate them straight into these being be left and treated in choice. Have triage staff to categories so more are being nursing homes rather than approach people in the seen and sent home quicker conveying to ED's? walk in queue and advise without affecting hospital them. Maybe even have a casualty areas thus freeing up shuttle vehicle or use staff casualty for seriousness cases shuttles if exist to transfer and bed space patients to more appropriate venues. Communicate very clearly with Weekend appointments I find at present that the people about this idea. useful - GPs are closed at 111 service takes too long Otherwise they will just go to weekends and the wait at to process and actually get the nearest hospital and cause Queen's A&E is horrendous a call back from a jams there. Have a good Better bus routes to Harold practitioner. Some of the staffing level, so that people Wood Polyclinic. No buses questions asked by the 111 do not have to wait many run from Upminster or staff are repeated in my hours. Enough doctors to see Cranham and people who experience (I am a people quickly. A thorough don't drive have to pay for qualified nurse) and are triage system and clear taxis. unnecessary. They need to communication on what is be streamlined. being done for them. More doctors and more Remains to be seen if this will My comment here is on surgeries. Extended opening make it easier to know where behalf of elderly people hours of current ones as some to go. How will you inform living adequately on their still close on Wednesday and people? I think you are own who have a minor don't offer appointments after missing the needs of an injury that is difficult to 5pm. For those that work, this increasingly older population. manage on their own but makes it near on impossible to I don't drive. I don't have don't have anyone suitable get an appointment with our anyone to drive me. I need to call on for help. e.g. a own GP and we tend to rely on an option in the north of badly cut finger, a severe the out of hours service which Redbridge e.g. Gants Hill, graze from falling. Is there is an unnecessary strain. Barkingside, Ilford easily any help for a nurse or reached by public transport. other professional to come Loxford is not an acceptable and attend to the patient at option. Keep the GP hubs at home? Would 111 be the present available, Increase appropriate place to seek their numbers and opening help at home? It may only hours. More hubs in the north require a dressing but one- of Redbridge. This helps our handed is difficult. GPs. We need to protect hubs and GP practices.

22 167 Suggestions and improvements

Reduce the paper trail in all Up-to-date information should Bookable appointments - locations by improving IT be made clear in GP children at school on the systems. Links to patient surgeries recorded message weekdays/ When they are records etc. Improve triage at when surgeries are closed, free on weekend, it’s easier all locations. Look to separate and on the CCG website. to take them. Also working A&E from general medical parents, it's much easier It needs should be more walk-in clinic in the boroughs. Utilise the local community Recruiting more GPs and More availability of hubs pharmacy network to provide Health professionals locally. urgent care

Among respondents to the easy read element of the consultation, transport considerations are most prominent alongside the potential impact of service restructuring on appointment demand.

Figure 15: Further suggestions to consider before making decisions about these urgent care services? (Base, easy read questionnaire, where provided a response: 88)

Impact on appointment demand 17%

People using public transport 16%

Consider those who can't/don't drive 16%

Impact on elderly/disabled people 14%

Advice/guidance about urgent/emergency … 10%

Walk in centres are better option 9%

Option one is better 8%

Extend opening hours 8%

Improve telephone booking system 8%

Community based services 7%

Continuity of care/see my own Dr 7%

Impact on waiting times 5%

More staff/resources 3%

Appointment vetting 2%

Easier access to medical history 2%

Impact on A&E demand 1%

Changes are good/will help 1%

Consider facilities location 1%

Keep existing system 1%

Other 9%

168 23 Community Urgent Care Consultation

5 Key messages from the consultation

The consultation on community urgent care services in Barking and Dagenham, Havering and Redbridge was open to all members of the public. No adjustments have been made to the responses received, meaning that the responses presented must be viewed in the context of the demographic profile of the consultation participants. In this case, 60% of responses come from those aged 55+, 73% of respondents are women and 73% have a white ethnicity. Consequently, the results are skewed towards an older, female and white demographic. Moreover, half of all responses came from residents living in Havering (50%), double that of Barking and Dagenham (22%) and Redbridge (25%). The focus of the consultation was to understand respondents’ preferences for BHR’s proposals on UTCs. Option One (four UTCs and eight community urgent care services) is the preferred option overall (67%). Just one in five (19%) express a preference for Option Two (two UTCs and ten community urgent care services), In all three boroughs, Option One is the preferred choice but preference peaks in Havering at 78% and drops to 50% in Redbridge. Moreover, preference for Option Two is higher in Redbridge (29%) than in Barking and Dagenham (23%) and Havering (13%). A majority of all age groups give a preference for Option One, but those aged over 75 prefer Option One significantly less than other age groups. For example, 77% of those aged 35-54 prefer Option One, yet only 41% of those aged 75+ prefer Option One. When considering Options One and Two, responses suggest that ensuring the new service structure is accessible for those who do not drive/have a car is an important consideration. There is some concern about a detrimental rather than beneficial impact on A&E demand. This is because respondents believe that more bookable appointments will result in people simply showing up at A&E rather than booking an appointment. In this context, any additional capacity the new service structure provides perhaps needs to be emphasised more strongly. However, to put these concerns into perspective, it should be noted that in regards to bookable appointments, 74% of respondents say more bookable appointments will make it easier to get urgent care when they need it. This agreement peaks at 82% for respondents aged 75+ and 80% for disabled respondents. Furthermore, almost nine in ten respondents (87%) think weekend appointments would be useful to them. Positivity towards the proposals is evidenced by the fact that 69% of respondents agree that BHR’s proposals will make it easier to know where to go if they need urgent care. This rises to 75% of those who are disabled and to 76% among those who are NHS staff. One in five (19%) residents disagree that the proposals will make it easier to know where to go for urgent care.

24 169 Appendix: Statement of Terms

6 Appendix: Statement of Terms

Compliance with International Standards BMG complies with the International Standard for Quality Management Systems requirements (ISO 9001:2015) and the International Standard for Market, opinion and social research service requirements (ISO 20252:2012) and The International Standard for Information Security Management (ISO 27001:2013). Interpretation and publication of results The interpretation of the results as reported in this document pertain to the research problem and are supported by the empirical findings of this research project and, where applicable, by other data. These interpretations and recommendations are based on empirical findings and are distinguishable from personal views and opinions. BMG will not publish any part of these results without the written and informed consent of the client. Ethical practice BMG promotes ethical practice in research: We conduct our work responsibly and in light of the legal and moral codes of society. We have a responsibility to maintain high scientific standards in the methods employed in the collection and dissemination of data, in the impartial assessment and dissemination of findings and in the maintenance of standards commensurate with professional integrity. We recognise we have a duty of care to all those undertaking and participating in research and strive to protect subjects from undue harm arising as a consequence of their participation in research. This requires that subjects’ participation should be as fully informed as possible and no group should be disadvantaged by routinely being excluded from consideration. All adequate steps shall be taken by both agency and client to ensure that the identity of each respondent participating in the research is protected.

170 25

With more than 25 years’ experience, BMG Research has established a strong reputation for delivering high quality research and consultancy. BMG serves both the public and the private sector, providing market and customer insight which is vital in the development of plans, the support of campaigns and the evaluation of performance. Innovation and development is very much at the heart of our business, and considerable attention is paid to the utilisation of the most up to date technologies and information systems to ensure that market and customer intelligence is widely shared.

171

Right care, right place, first time

A report on the community urgent care services consultation responses.

Prepared by Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

October 2018

172 Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Contents

1. Executive summary ...... 34

2. ‘Right Care, Right Place, First Time’ in numbers ...... 34

3. Background ...... 45

3.1. Objectives of the consultation ...... 45 4. Proposal ...... 56

5. Governance and responsibilities ...... 67

5.1. Clinical leadership ...... 67 5.2. Policy overview ...... 67 6. Consultation preparation ...... 78

6.1. Pre-engagement ...... 78 6.2. Timing: Compacts and local elections ...... 78 7. Consultation materials ...... 89

7.1. Consultation document ...... 89 7.2. The questionnaire ...... 910 7.3. Other consultation materials ...... 1011 7.4. Equality Impact Assessment (EIA) ...... 1011 8. Consultation activity ...... 1112

8.1. Consultation launch ...... 1112 8.2. Ongoing consultation methods and activity ...... 1112 8.3. Engagement approach ...... 1213 8.4. Attending meetings ...... 1213 8.5. Drop-in sessions ...... 1314 8.6. Themes from the engagement events ...... 1415 8.7. Engagement with GPs, pharmacists and local clinicians ...... 1516 8.8. Engagement with seldom-heard groups ...... 1516 8.9. Engagement with health scrutiny committees ...... 1617 8.10. MP engagement...... 1718 9. Other interest ...... 1718

9.1. Correspondence and calls ...... 1718 9.2. Webpage views and downloads ...... 1819 9.3. Media coverage ...... 1819 9.4. Social media ...... 1920 9.5. Other mentions: newsletters and stakeholder communications ...... 2021 10. Analysis of responses ...... 2021

11. Analysis of responses from stakeholders ...... 2122

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11.1. Responses received by letter or email ...... 2122 11.2. Support for Option 1 ...... 2223 11.3. Support for Option 2 ...... 2324 11.4. Other responses ...... 2324 11.5. Responses by organisations to the online survey...... 2425

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1. Executive summary Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs) carried out a consultation –‘Right care, right place, first time’ from Tuesday 29 May to Tuesday 4 September 2018. This sought local people’s views on proposals for changes to community urgent care services, named as GP out of hours services’, GP access hubs and walk in services. Community urgent care services provide urgent same-day care and advice for people with urgent, but not emergency or life-threatening, physical and mental health issues. They are the services you use when you have an urgent problem but you cannot see your own GP, such as GP hubs and walk-in centres. The proposals were built on key factors:  Extensive engagement with local people on this topic in the last three years  National guidance from the Five Year Forward View on integrated urgent care (IUC) and urgent treatment centres (UTCs)  Projected population growth in BHR in the next 15 years, contributing to increased demand  The digital future for the NHS. The NHS is facing a challenging time and there is a rising demand for all NHS services, including urgent care, while costs continue to rise. It is essential that the CCGs spend their limited resources in the most effective way. While both options for the future model of community urgent care services provide cost-savings, this has not been the driving factor as we are focused on improving quality of our services and patient experience We did not consider any alternative models that would have required additional investment. Our proposals set out two options that would deliver on our key factors and also deliver cost savings. The proposals consulted on, which are set out in full in the CCGs’ consultation document and easy read document, asked for views on two options for the future provision of community urgent care services. During the 14-week consultation, the CCGs’ independent GP lead, Redbridge CCG’s Lay Member for Patient Participation and CCG staff presented to community groups, health scrutiny committees and healthcare professionals; held public drop-in sessions; and carried out traditional media and social media activity, in order to reach as many people as possible across the three boroughs. Feedback from our stakeholders and from those who completed our online survey, as well as themes from the engagement workshops and drop-in sessions, are all included in this document and will inform the decision-making business case.

2. ‘Right Care, Right Place, First Time’ in numbers

. 12 – public drop-in sessions – where we spoke to more than 2,000 people

. 25 – public meetings and events attended, where we spoke to more than 800 people

. 2,000 + – leaflets distributed at meetings and events

. 3,378 – total number of consultation website views

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. 1,467 – number of consultation related documents downloaded from websites

. 11 – media articles about the consultation

. 177 – tweets about the consultation

. 71,600 - potential number of people the tweets could have reached

. 1,062 – total number of responses received to online survey

3. Background We know from extensive engagement that local people are confused by the community urgent care services currently available in BHR, and want it to be easier to get help when they need to see a GP or nurse on the same day. We know many community urgent care services in our area are similar or even duplicate each other – so the CCGs need to make it easier for patients to get the right care in the right place, first time when they need it. We also need to ensure we are meeting national standards for integrated urgent care, which we plan to deliver through an improved NHS 111 service, Urgent Treatment Centres and a move towards more bookable appointments. We also need to plan now for the significant growth in population expected for Barking and Dagenham, Havering and Redbridge in the next 15 years, which will lead to a growth in demand for urgent care services. We also expect people to make more use of technology to get health care advice and services in future and, as always, we need to spend NHS money wisely. This consultation was not about emergency care services or changes to the A&E services at any of our local hospitals, nor are we proposing changes to how GPs run their practices. Following a detailed review process, we launched a 12-week consultation on our ‘Right care, right place, first time’ proposals on Tuesday 29 May 2018. After considering a representation from the Outer North East London Joint Health and Overview Scrutiny Committee (ONEL JHOSC), received on 8 August, we extended the consultation for a further two weeks, ending on Tuesday 4 September. The consultation asked patients, residents, stakeholders and healthcare providers to become involved with helping the CCGs decide on a new model for community urgent care services by providing their feedback on proposals for changes to GP out of hours services, GP access hubs and walk-in services.

3.1. Objectives of the consultation

The aims of the consultation were to:  inform and engage local residents, community groups, healthcare professionals and other interested stakeholders about the proposals on change to community urgent care services  receive feedback from people on the CCGs’ proposals.

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4. Proposal

The CCGs want to make it easier for local people to access same-day urgent care if they cannot see their own GP.

The proposed new model will meet the national standards expected for urgent care by

 Improving access to care via NHS 111 so people can call and speak to an expert when they need urgent care  Changing the way people access urgent GP appointments and care by moving away from walk-in services and offering more bookable appointments via NHS 111  Upgrading facilities at specified locations to become Urgent Treatment Centres which offer the best medical testing available and allow appointments to be booked in advance through NHS 111 so people avoid long waits. The consultation did not propose any changes to emergency care services or changes to A&E services at any of our local hospitals.

The consultation focused on describing the new model and asking for views on two options for the future provision of community urgent care services.

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5. Governance and responsibilities

5.1. Clinical leadership The vast majority of local clinicians, including our own GPs, are involved in running or delivering community urgent care services and this creates a potential conflicts of interests. Legal advice was obtained and the CCGs were advised that CCG clinical directors and local GPs could not act as clinical leads for the urgent care review or lead the consultation.

We appointed Dr Arnold Fertig as an independent clinical advisor for the Community Urgent Care review. Dr Fertig is a highly experienced former GP who held senior leadership roles in the Cambridgeshire area. He is an independent GP member of BHR CCGs’ Primary Care Commissioning Committee, providing him with knowledge of healthcare services and the population health of our area. He has been supported with clinical expertise from CCG clinicians including senior managers from our nursing and quality directorates as well as from public health teams from across BHR.

Dr Fertig also co-chaired the Community Urgent Care programme board alongside Khalil Ali, Redbridge CCG’s Lay Member for Patient Participation and Involvement. Mr Ali is also Vice Chair of the BHR Primary Care Commissioning Committee. Both were involved in identifying and agreeing proposals for consultation (as outlined in the previous section) and they reviewed and signed off the consultation document. They presented the proposals to local community groups and participated in public Q&A sessions. They will consider the information contained in this report and ensure that it informs the recommendations made to the joint committee of the governing bodies of the three CCGs to consider and make decisions about the proposals for changes to community urgent care. 5.2. Policy overview The CCGs have a legal duty to involve the public in commissioning plans. There are two main relevant legal requirements relating to consultation and engagement:

For the NHS to promote public involvement and consultation (Section 14Z2, Health and Social Care Act 2012, as amended) This duty applies where there are changes proposed in the way in which services are delivered, or in the range of services available. The duty applies to health services commissioned by clinical commissioning groups, which are responsible for involving or consulting the people who are or may be using the service.

For the local authority to review and scrutinise the NHS (Part 4, Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013) Under the Local Authority Regulations 2013, local authorities may review and scrutinise any matter relating to the planning, provision and operation of the health service in their area.

Cabinet Office and NHS England statutory guidance, as well as other best practice guidance was followed for the consultation process, timeline, document and questionnaire.

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6. Consultation preparation 6.1. Pre-engagement

The CCGs had previously completed extensive engagement with residents to find out their views on existing local community urgent care services.

A research study in 2016 involved more than 4,000 people and included a telephone survey, 10 focus groups and two workshops. This was co-produced with Healthwatch, with the research conducted by BMG Media, a highly-rated independent market research company (telephone survey) and all three Healthwatch organisations (1:1 interviews, focus groups and workshops).

The CCGs held two further workshops to discuss the feedback and themes from the research study with local stakeholders, patient representatives, clinicians and the public.

In March 2018, the CCGs commissioned the Healthwatch organisations in all three of the local boroughs to talk with local people about some of our emerging ideas including introducing more bookable appointments as well as talking about improvements to NHS 111.

Using a co-produced survey, Healthwatch spoke with more than 500 people – a mix of parents, young adults (15 – 24) and older people aged 65 and over as these groups are our biggest users of urgent care services

The CCGs has also provided ongoing updates and information about the community urgent care review to local stakeholders and to our three Patient Engagement Forums, held clinical workshops involving GPs and other local clinicians and shared progress on the community urgent care review with local partners through statutory partnership boards such as the A&E Delivery Board, which includes representatives of providers and local authorities.

Feedback from all the engagement informed the review and shaped the consultation proposals.

6.2. Timing: Compacts and local elections All BHR CCGs are also signatories to borough-level compacts, joint agreements between public bodies and voluntary groups that help partners improve their relationship for mutual advantage and community gain. The Redbridge Compact states that public bodies will offer ‘clear explanations and rationales’ for consultation time frames shorter than 12 weeks. The Compact also states that some public bodies will on occasion ‘need to conduct consultations for longer or shorter periods’. Local Council elections took place on 4 May 2018, and the election ‘purdah’ period began on 27 March 2018 The Community Urgent Care Programme Board considered these factors and advice on good practice consultation before proposing a 12 week consultation. The decision was made to start this on Tuesday 29 May, well before the school summer holidays period. In March 2018, the CCGs informed the three BHR Councils of the proposed dates. It was agreed that the consultation would be discussed at the Joint Health and Overview Scrutiny Committee at its July meeting. Redbridge Council also asked that a presentation was made to its July Health Overview and Scrutiny committee meeting.

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On 8 August, the CCGs received a formal request from the JHOSC to extend the consultation for a further four weeks due to the summer holiday period. After consideration, the CCGs agreed to extend the consultation by two weeks to Tuesday 4 September.

7. Consultation materials The 14-week public engagement exercise ran from Tuesday 29 May and closed at 5pm on Tuesday 4 September 2018. In line with the successful approach taken for our previous consultations (and those of a number of our local stakeholders), a decision was made not to produce printed copies of the consultation document and questionnaire due to the cost of design, print and distribution. The public and stakeholders were encouraged to view the consultation document online and complete the online questionnaire. Printed copies of the full engagement document, and an easy read version, were available on request. They were also distributed at engagement events or meetings where members of the public specified that they were not able to access the internet. A freepost address – BHR CCGs - was publicised so people could post their responses without incurring cost. This online approach was proven to be an effective strategy during the previous CCGs’ consultations, which received over 1,400 responses from across BHR for both ‘Spending NHS money wisely’ 1 and 2. The community urgent care consultation has generated our largest consultation response ever, with 1,062 people sharing their feedback through our online survey. It was also decided not to pay for any advertising to promote the consultation, but instead focus on promoting the consultation through our partners and via traditional media and social media. This was proven to be an effective promotion strategy during the ‘Spending NHS money wisely’ consultations. In Barking and Dagenham, both the Council and Healthwatch Barking and Dagenham both actively promoting the consultation through their digital and social media channels. Healthwatch Barking and Dagenham also ran a workshop with local people and provided a report on the feedback which is included in this report. Voluntary and community organisations across BHR also worked with us to share materials and information with local people. This helped us to speak with large numbers of people at events hosted by groups including Redbridge Asian Mandal, Age UK – Voices of Experience members (Redbridge), Redbridge Gujarati Welfare Association and Havering Healthwatch and Over 50s forum and our own Patient Engagement Forums.

7.1. Consultation document A consultation document was written to clearly set out the CCGs’ proposals. The document explained that the CCGs were proposing changes to community urgent care services and gave the reasons why. The consultation document included information about existing community urgent care services; what local people had told us in our previous engagement work; about the national standards we needed to address; and why we needed to make changes. It set out the proposed model for community urgent care services and the options for where people could continue to walk in and wait.

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It aimed to provide the information needed to be able to respond to the proposals and was written in plain English and designed to be as easy to understand by the general public as possible. A glossary of terms was included and an Easy Read version was produced. The document included a statement in seven other languages asking people to contact the CCGs if they wanted to know more about the proposals but could not read the document. It asked them what help they might need and if they needed a large print version or different format. The decision about which languages to include was based on information from local councils about the most frequently-requested languages for translation. No requests for other formats or translations were received. The CCGs also took learnings and feedback from previous consultations into account as well as those from previous engagement work focused on urgent care which was co-produced with Healthwatch. Healthwatch representatives from each borough, the local authority health scrutiny committee co- ordinators and the chairs of the CCGs’ three Patient Engagement Forums were asked to review and comment on the consultation document at draft stage. The document also included contact details – a dedicated consultation email address [email protected], and phone number 020 3688 1615. These were publicised so people could direct any questions and queries to the CCGs. The public and stakeholders were encouraged to view the consultation document online and complete the online questionnaire. Printed copies of the full document and easy read version were made available throughout the consultation at engagement sessions, with large numbers made available to a number of community groups visited.

7.2. The questionnaire The consultation document included a questionnaire, where respondents were asked to indicate their preference for the two options described (or indicate no preference) and also how they felt about a set of statements. The questions were developed in line with Cabinet Office, NHS England and The Consultation Institute best practice guidance and were tested with volunteers before the questionnaire was finalised. BMG Research, a market research agency, also advised on the questionnaire format. The questionnaire also included open-ended questions where respondents were asked to comment on each of the two options, as well as providing comment on anything else about the topic that they felt it was important for the CCGs to consider. Respondents could choose to only respond to the sections which were relevant or of interest to them, or complete all of the sections. At the end of the questionnaire there were sections to provide any further comment and any other suggestions for how the CCGs could improve community urgent care services. An easy read version of the questionnaire was also produced and included in the easy read consultation document. The public and stakeholders were encouraged to complete the questionnaire online via links on all the CCGs’ websites. The link to the questionnaire was provided in all digital communications and promoted through the community urgent care consultation webpages on the CCGs’ websites and their Twitter accounts.

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Printed versions of the questionnaire were handed out at engagement events and meetings where members of the public said they were not able to access the internet. Age UK BHR also provided copies of the questionnaire to its Voices of Experience group in Redbridge and provided the CCGs with a pack of the collated responses.

7.3. Other consultation materials A standard set of slides was developed for the CCGs to present the proposals to health scrutiny committees, patient engagement forums, community groups on request, and more widely. These were revised depending on the audience and its areas of interest. A short, simple, black and white information leaflet was produced which was handed out at drop-in sessions and at engagement events, signposting people to the website for more information and to complete the questionnaire. More than 2,000 leaflets were distributed at meetings and events. The community urgent care consultation webpage on all three CCGs’ websites was updated to reflect the current proposals. The consultation document, easy read document, pre-consultation business case (PCBC), initial Equality Impact Assessment (EIA) and questionnaire were also available to download. After discussions with Redbridge Council’s Chair of Health Scrutiny Committee, a set of Frequently Asked Questions (FAQs), focusing on changes proposed at Loxford Polyclinic, were also published on the Redbridge CCG website. The glossary of terms, included within the full consultation document, was also published as a separate document on the consultation webpages on the advice of the Joint Health Overview and Scrutiny Committee.

7.4. Equality Impact Assessment (EIA) An initial Equality Impact Assessment (EIA) was carried out during which the CCGs assessed if the proposals might discriminate or disadvantage against the following characteristics:  Age  Disability  Gender reassignment  Marriage and civil partnership  Pregnancy and maternity  Race  Religion or belief  Sex  Sexual orientation The initial EIA was available to download from the CCGs’ websites. The CCGs will take into account the responses received to the proposals and this will inform a more detailed EIA, which will go to the joint committee of governing bodies to consider before any decisions are made.

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8. Consultation activity 8.1. Consultation launch The consultation launched on Tuesday 29 May 2018. The consultation was scheduled to run for 12 weeks until Tuesday 21 August, but was extended by a further two weeks following a request from the Joint Health and Overview Scrutiny Committee. It closed at 5pm on Tuesday 4 September 2018. On the day the consultation launched, emails were sent to stakeholders telling them the consultation had launched, with a link to the consultation page on each CCG’s website and information on how to respond. The stakeholders contacted were:  GPs  MPs and London Assembly members  Council health scrutiny committee chairs and officers, cabinet members for health and adult services  Council leaders, chief executives and directors of public health and adult services (or equivalent)  Health and wellbeing board chairs and officers  Core providers - NELFT, BHRUT, Barts Health and Partnerships of East London Co-Operative  Providers that could be affected by the proposals (NHS and private)  Professional organisations (Local Medical Committee, Local Pharmaceutical Committee, Local Optical Committee)  Healthwatch (in the three boroughs)  Neighbouring CCGs (including Newham, Waltham Forest, Tower Hamlets, Basildon and Brentwood, West Essex and Thurrock)  CCGs in North East London Commissioning Alliance  BHR CCGs patient engagement forums  Patient groups, interest groups and community and voluntary organisations Each CCG website had a news item on the engagement, including a link to the consultation document, easy read document, online questionnaire, list of public events and initial EIA. The consultation was prominently advertised on the homepage of each CCG website throughout the consultation period. Tweets were also sent from each of the CCG Twitter accounts with links to the news page on the website throughout the consultation period.

8.2. Ongoing consultation methods and activity Throughout the consultation, the CCGs continued to promote the proposals and raise awareness of how to provide feedback on them. This was done through the CCGs’ Twitter accounts, websites, and responding to correspondence from stakeholders, interest groups and members of the public. It was also promoted at the BHR CCGs’ three patient engagement forum meetings during the consultation period. The CCGs received support from local partners who retweeted our messages and shared information through their digital channels e.g. Council e-newsletters, websites and Twitter accounts. Barking and Dagenham Council and Healthwatch Barking and Dagenham in particular provided significant support. The CCGs also encouraged stakeholders who contacted us with questions on behalf of their constituents to share our responses with their community through their own channels.

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8.3. Engagement approach The CCGs engaged with a diverse range of groups and organisations during the consultation period, ensuring a geographical spread across the area. Building on the successful relationships developed through previous engagement work and consultations, the CCGs engaged with a large number of local groups. The engagement team searched for relevant groups online and requested recommendations from groups who had already been presented to. Key stakeholders (Health Scrutiny committees, Healthwatch and the Councils for Voluntary Services) were also asked for assistance in engaging with groups in these boroughs.

8.4. Attending meetings A large number of groups were proactively approached and offered CCG representatives to present on the proposals to their members. A number of those contacted responded inviting us to do so. Other groups contacted the CCGs asking us to present on the proposals. The CCGs were also asked to present to two groups by representatives who had attended the Havering Compact meeting. The format of these meetings usually involved Dr Fertig, Khalil Ali or CCG managers presenting, followed by a question and answer session. Attendees discussed the proposals, asked questions and then some submitted responses. The meetings at which the clinical leads and CCG representatives presented were as follows:

Date Borough Name of meeting Estimated numbers of people engaged

11 June Redbridge Age UK 30

14 June Barking and Barking and Dagenham Council for 12 Dagenham Voluntary Services

18 June Redbridge Redbridge Gujarati Welfare 100 Association

18 June All three North East London Local 16 boroughs Pharmaceutical Committee 300 19 June Redbridge Redbridge Asian Mandal

21 June Redbridge Redbridge Older Carers – coffee 20 morning

25 June Barking and The Learning Disabilities Advisory 12 Dagenham Partners 40 26 June Havering Havering Compact Forum

28 June Barking and Somali Women’s Association 25 Dagenham 70 2 July Redbridge Redbridge Pensioners Forum

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Date Borough Name of meeting Estimated numbers of people engaged

3 July Barking and Barking and Dagenham Carers’ 20 Dagenham Forum

4 July Havering Havering CCG’s Patient Engagement 12 Forum

9 July Barking and Barking and Dagenham Diabetes 20 Dagenham Support Group 80 10 July Havering Havering Over 50s Forum 10 10 July Havering Independent Living Association 20 11 July Havering Havering Health and Wellbeing Board

11 July Redbridge Redbridge Council for Voluntary 25 Services

16 July Havering Havering Dementia Carers Support 35 Group

17 July Redbridge Redbridge Patient Engagement 13 Forum

18 July Redbridge Redbridge Children and Young 12 People’s Network

18 July Redbridge Redbridge Health Overview and 43 Scrutiny Committee 28 24 July Redbridge Redbridge Faith Forum

24 July Barking and Barking and Dagenham CCG’s 12 Dagenham Patient Engagement Forum

26 July All three Joint Health Overview and Scrutiny 14 boroughs Committee 50 31 July Havering Havering Hub Carers Forum

Approximate number of people engaged with through 1,019 engagement events, meetings and drop-in sessions

8.5. Drop-in sessions A number of drop-in sessions were held to promote the consultation to the general public. These were designed for, and open to, all members of the public, local stakeholders and potentially interested parties known to the project team were asked to ‘drop by’. All of the sessions were advertised prior to the events on each CCG’s website and promoted via Twitter. CCG representatives listened to feedback, answered questions and encouraged people to complete the questionnaire.

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The drop-in sessions took place as follows:

Date Borough Name of meeting Estimated numbers of people engaged

13 June Redbridge Redbridge Carers Support Service event 20 300 20 June Havering Romford Market, Romford 10 22 June Redbridge Fullwell Cross Library, Ilford 400 27 June Havering Sainsbury’s, Hornchurch

5 July Barking and Vicarage Fields Shopping 300 Dagenham Centre, Barking 60 6 July Havering Harold Wood Polyclinic 400 11 July Redbridge Ilford Town Centre

12 July Barking and Barking Market, Barking 425 Dagenham

18 July Redbridge Redbridge Disability 150 Festival, Wanstead

21 July Havering Ingrebourne Valley Visitor 40 Centre, Havering

25 July Redbridge Redbridge Central Library, 70 Ilford

31 July Barking and Becontree Leisure Centre, 50 Dagenham Dagenham 2,225 Number of people engaged with at drop-in sessions

Special thanks go to all the companies and organisations that allowed the CCGs to hold drop-in sessions on their premises without charge and to the partners who promoted these events through their own digital and social media channels.

8.6. Themes from the engagement events Common themes discussed by members of the public and community interest groups during the engagement events, included:  Recognition that the proposals would make it easier to get urgent care when you needed  Observations that the CCGs needed to communicate with and educate the public about available services

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 Workforce – concerns about GP numbers and known issues with retention and recruitment, and how the proposals would impact on the NHS workforce  NHS 111 – proposals for better telephone access through NHS 111 was generally welcomed. Increased telephone access to a clinician through the new NHS 111 Clinical Assessment Service was viewed as positive. Some mixed feedback on the existing service, ranging from positive experiences to unsatisfactory outcomes  Availability of urgent care appointments – concerns re availability and timeliness of routine GP appointments and whether getting same-day urgent care appointments will also be difficult  Travel time and access to services – concerns that service locations needed to be accessible by public transport, not just by car. Need for adequate parking at sites also raised as a concern, with Queen’s Hospital cited as an example of a site with parking problems.  Access to patient records – questions about whether community urgent care services would be able to share health records to support patient care and decisions. In Havering, discussions were generally positive and focused on what the proposals meant for Harold Wood Polyclinic. In Redbridge, discussions at engagement events were generally positive, with consistent recognition from participants that the proposals meant it would be easier to get urgent care when you needed it. At a number of events, the CCGs clarified that Loxford Polyclinic was not closing, but that the proposal was to change the way people accessed the urgent care service located in the building. Feedback and comments at events in Barking and Dagenham focused on changes to services currently provided at Barking Community Hospital and in Dagenham, but people generally welcomed the proposals.

8.7. Engagement with GPs, pharmacists and local clinicians Local GPs were emailed encouraging them to respond when the consultation launched and again during the consultation period. We also emailed them to confirm an extension of the consultation once this was agreed. The proposals were also presented to a clinical workshop on 12 June. This was attended by GPs, representatives from Barking and Dagenham, Havering and Redbridge University Hospital Trust (BHRUT), NELFT (the community services and mental health provider trust), PELC (which provided the GP Out of Hours service), the Hurley Group (which currently runs the two walk-in services in Havering), the GP Federations for BHR, and the Local Pharmaceutical Committee. The proposals were also shared with the BHR Clinical Senate, and clinical representatives were encouraged to respond to the consultation. The CCGs also presented the proposals to the North East London Local Pharmaceutical Committee on 18 June, which later provided a formal response. In addition, the consultation was featured in the CCGs’ regular GP newsletters and on its intranets. We also asked local partners to share information through their usual channels and networks, with both staff and the public.

8.8. Engagement with seldom-heard groups To ensure a diverse set of interest groups were engaged with, meetings were held with a range of seldom-heard groups across Barking and Dagenham, Havering and Redbridge. The proposals were presented to a number of older people’s, BAME (black and minority ethnic) and disability organisations, including:

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 Age UK (BHR)  Redbridge Gujarati Welfare Association  Barking and Dagenham Somali Women’s Association  Havering Dementia Carers Association  Redbridge Asian Mandal  Barking and Dagenham Learning Disability Advisory Partners Group  Havering Compact  Barking and Dagenham Carers Forum  Redbridge Faith Forum  Redbridge Pensioners Forum  Havering Over 50s Forum

8.9. Engagement with health scrutiny committees Our clinical lead and senior managers discussed the proposals in detail with councillors at the Joint Health Overview and Scrutiny Committee (JHOSC) and at the Redbridge Health and Overview Scrutiny Committee (HOSC). Councillors discussed the proposals, asked a number of questions, with formal responses submitted later by both committees. At Redbridge HOSC, councillors and a member of the public expressed significant concerns regarding the change to the community urgent care service at Loxford Polyclinic. Concerns focused on the potential impact on health care provision and health inequalities in south Ilford, which has a diverse community with high levels of deprivation. Concerns raised included:  Issues with using NHS 111 for people who spoke little or no English  Highly transient population which may mean people are not registered with a GP, so cannot access GP services and therefore use the walk-in service for all health needs  Poor quality of existing primary care services in south Ilford e.g. poor GP to patient ratio  Poor availability of primary care services in south Ilford which meant local people could not get GP appointments – even for routine care – in a timely way  The health needs of the diverse and deprived population of south Ilford had not been taken into account in the modelling or the proposals  Provision for residents living in the west of Redbridge were not clear including no recognition of the importance of Whipps Cross Hospital  Concerns around access by public transport and parking provision at service sites  Impact on A&E of changes from a walk-in service to a bookable service  Perception that this was a downgrading of the urgent care service and demonstrated a lack of NHS commitment to services at Loxford Polyclinic At the Redbridge HOSC meeting, the CCGs made a commitment to maintain the provision of 14,000 urgent care appointments at Loxford Polyclinic in the new service and emphasised a commitment to retaining and building on health and care services operating from Loxford Polyclinic. Assurance was given that the published initial Equality Impact Assessment (EIA) was built into the modelling and that a full Equality Impact Assessment would be made on the final proposals and form part of the decision-making process in line with our usual process Following the presentation at Redbridge HOSC, the CCGs provided additional information and responded to questions raised in the meeting through an ongoing correspondence. Senior managers also met with the committee Chair, Cllr Neil Zammett, and scrutiny officer, Jilly Syzmanski on two further occasions to discuss specific questions around the proposals. In the meeting, the CCGs committed to exploring the potential to installing telephone access for public use in Loxford Polyclinic to allow residents who walked in to call NHS 111 for health advice and bookable appointments.

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At the JHOSC meeting on 26 July, concerns were raised included:  Perception that the Harold Wood and Loxford polyclinics were being ‘run down’  Equality of services between the three boroughs  Quality of and access to primary care services in Redbridge The JHOSC formally wrote to the CCGs on 8 August, requesting an extension to the consultation. The CCGs considered the request and agreed to extend the consultation by two weeks, meaning it closed at 5pm on Tuesday 4 September instead of the original closing date of 21 August. Senior managers also attended a meeting with members of Havering Health Overview and Scrutiny Committee to discuss the proposals and the impact on services within Havering. The CCGs also provided additional information on issues regarding services at Harold Wood Polyclinic not directly related to the consultation proposals.

8.10. MP engagement All Barking and Dagenham, Havering and Redbridge MPs were sent an email on the day of launch (29 May 2018) updating them on the consultation. The emails included links to the relevant page on each CCG’s website, information on how to respond, and a request for suggestions of local groups the CCGs should approach. Mike Gapes, MP for Ilford South, wrote to the CCGs about the proposals and expressing opposition to the changes at Loxford Polyclinic. The CCGs responded to this enquiry during the consultation period. No further correspondence was received from any MPs. The CCGs’ Managing Director, Ceri Jacob, met with Wes Streeting, MP for Ilford North, Mike Gapes, MP for Ilford North, and Cllr Mark Santos, Cabinet member for Health and Social Care, Redbridge Council on 16 August. The consultation proposals were discussed during this meeting.

9. Other interest 9.1. Correspondence and calls Throughout the engagement period, the CCGs responded to correspondence and calls from medical professionals, politicians, patient groups, community organisations and members of the public.

In total, the CCGs received 69 emails via the dedicated BHR consultation inbox ([email protected]). All of these emails were from local residents except one correspondence from a local councillor.

The CCG team responded to all of these emails, and requested that these individuals visit the CCG website, read the consultation engagement document and complete the online survey and formally provide feedback to the proposals.

Of the 69 emails received, 61 emails were sent regarding the urgent care service at Harold Wood Polyclinic, and eight emails did not refer to a specific service. As these views came from individuals who only provided basic information, viewpoints are not directly attributable to a borough.

The incoming communications included feedback (both formal and informal), questions and requests for further information about the proposals themselves. Key themes of the email correspondence were:

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 Concerns about the impact on an already overstretched Queen’s Hospital  Strong opposition to ‘closing’ Harold Wood Polyclinic  Concerns about access to Queen’s by road (including lack of parking) and public transport for residents  Questions on whether the proposals were financially driven  Concerns re the impact on all services of the projected population growth  Impact on elderly patients of travelling further for services if no walk-in service at Harold Wood  Concerns that the proposals for Harold Wood Polyclinic did not take account of local needs. In addition, the CCGs received ten letters which were formal responses to the consultation. The CCG responded to each request for additional information and expanded on the consultation proposals when asked to do so. 9.2. Webpage views and downloads The consultation webpage of each of the three CCGs was updated, with supporting documents hosted online and linked to from the page – namely the full proposals document, the easy read version of the proposals, the initial EIA and the pre-consultation business case (or PCBC).

Each of the documents was available to download as a PDF. This was the preferred format as the Adobe software required to read a PDF document is free to obtain. Page impressions were as follows:

 Consultation webpage views o Barking and Dagenham CCG: 529 o Havering CCG: 1,955 o Redbridge CCG: 894

 Downloads o Consultation document: 854 o Easy read version of document: 613 o Initial Equality Impact Assessment: 136 o Pre-consultation business case: 260 o Frequently asked questions (Redbridge): 101 o Glossary of community urgent care services: 90

Page views are not a true picture of how many people have read a page, as one individual could theoretically access the page multiple times. It is, however, a good indicator of general levels of interest in a topic.

There is a disparity between the high numbers of webpage views and questionnaire responses, and the comparably lower number of times the consultation document was downloaded. This suggests that many people went straight to the questionnaire after visiting the consultation page. 9.3. Media coverage

Media releases for each CCG were sent to local media on the day the consultation launched and in July another release was sent promoting the public drop in events. Finally, a reminder release was issued with information around the consultation extension two weeks before the new closing date.

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Media coverage focused on providing readers with information around why community urgent care services needed to change locally, the proposals included in the consultation and how people could provide their feedback. The majority of the articles directed readers to the relevant CCG’s website for more information about the proposals. The articles featured across the consultation period.

Articles appeared in both print and online publications, and included:

 ‘Have your say on upcoming changes to borough's urgent healthcare services’, 01/06/2018, Barking and Dagenham Post, Ilford Recorder and Romford Recorder.  ‘Clinical group want more emergency appointments but fewer walk-ins’, 08/06/2018, East London and West Essex.  ‘Ilford, more than 1,500 sign petition’, 26/07/2018, Ilford Recorder (p.14)  ‘Healthwatch: Have your say on future of healthcare’, 11/08/2018, Barking and Dagenham Post.  ‘CCG wants to cut walk-in centres and make more emergency appointments’, 19/08/2018, East London and West Essex Guardian.  ‘Barking and Dagenham residents have until September to have their say’, 22/08/2018, Barking and Dagenham Post (p.7).  ‘Petition fighting closure of walk-in centre gets more than 4000 signatures’, 21/09/2018, East London and West Essex Guardian.  ‘Redbridge Council backs petition against closing Loxford Polyclinic walk-in service’, 24/09/2018, Ilford Recorder.

The following table shows all coverage, across both print and online editions:

No of No of Title Circulation[1] web newspaper Total articles articles Barking and Dagenham Post 4,271 2 1 3

Ilford Recorder 5,130 2 1 3

Romford Recorder 11,145 1 0 1 East London and West Essex 10,051 3 0 3 Guardian Yellow Advertiser (free sheet) 17, 552 1 0 1

Total 48,149 9 2 11

9.4. Social media Social media was a significant way of promoting the consultation. Each of the three CCG Twitter accounts tweeted regularly, and tweeted about upcoming events, including those open to the public.

[1] All newspaper circulation figures are January to December 2016 averages obtained via Audit Bureau of Circulations.

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The following table breaks down related Twitter activity from the three CCG accounts, showing the number of tweets about the consultation by each CCG during the period:

No of No of Twitter account Followers tweets retweets Barking and 1,423 35 13 Dagenham

Havering 5,938 32 28

Redbridge 1,304 33 36

Total 8, 665 100 77

Using Twitter analytics, a basic estimate of ‘impression numbers’ can be calculated, this is the number of times tweets showed up in followers feeds. Across the three CCG accounts, the potential number of people the tweets could have reached is 71,600.

Potential reach indicates the absolute maximum number of people who could have potentially been exposed to the Twitter activity. It does not adjust for individuals who may follow more than one of the Twitter users whose followers were counted.

As well as the three CCGs’ Twitter activity, the consultation was also the subject of 106 tweets by other Twitter users, including community healthcare organisations, charities and individuals.

9.5. Other mentions: newsletters and stakeholder communications Following active engagement with community groups, together with emails to partners and stakeholders requesting assistance in promoting the consultation to their staff and service users, the community urgent care consultation was promoted in stakeholder emails and newsletters and on their websites. These included GP newsletters across BHR; newsletters circulated by community and voluntary organisations across BHR; website updates and email distributions from Redbridge CVS; and a partnership news e-publication from the East London Health and Care Partnership. We particularly thank the London Borough of Barking and Dagenham and Healthwatch Barking and Dagenham for their considerable support through social media and e-newsletters to help promote drop-in events and the online consultation survey.

10. Analysis of responses A consultation is a valuable way to gather opinions about a topic, explore the issues and understand the reasons behind them. However when interpreting the responses, it is important to note that:  the respondents were self-selecting, and certain types of people may have been more likely to contribute than others - typically, there can be a tendency for responses to come from those more likely to consider themselves affected and particularly from anyone who believes they will be negatively impacted upon by the implementation of the proposals;

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 the responses therefore cannot be assumed to be representative of the population as a whole;  a consultation is not a poll or referendum.

BHR CCGs commissioned BMG Research to analyse the responses received through the online survey and prepare a report on the findings, which forms section two of this report. BMG Research is a Market Research Society Company Partner and is fully compliant with the MRS Code of Conduct.

The decision to commission BMG Research was taken as they were able to analyse the responses and write the report in the available timeframe; they are impartial; and they worked on the ‘Spending NHS Money Wisely’ consultations for BHR CCGs and the urgent care research in 2016, thus ensuring consistency.

11. Analysis of responses from stakeholders

11.1. Responses received by letter or email

Ten responses were submitted in letter or email format that did not directly address the specific questions posed in the questionnaire but which gave views about the proposals for changes to community urgent care services. Havering Council also discussed the proposals at a meeting on 12 September and their response is published in the meeting minutes on the Council’s website. Redbridge Council also submitted a letter on 12 October following a Council debate on 20 September of a petition it received signed by 3,889 people.

One response was from a Councillor in Havering, and the other nine were from organisations as listed below:

1. Councillor Darren Wise - Havering Councillor representing Harold Wood, Hill, Park Residents, Association and North Havering Residents Group (NHRG)

2. Mike Gapes, MP for Ilford South

3. Outer North East London Joint Health Overview and Scrutiny Committee (JHOSC)

4. Whipps Cross Hospital Patients’ Panel

5. Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT)

6. Healthwatch Barking and Dagenham

7. Healthwatch Havering

8. London Borough of Redbridge – Health Overview and Scrutiny Committee

9. Hurley Group

10. North East London Local Pharmaceutical Committee (NEL LPC)

11. London Borough of Barking and Dagenham

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12. London Borough of Redbridge – letter received 12 October 2018

11.2. Support for Option 1 Of these respondents, five stated support for Option 1. These were

 BHRUT  Healthwatch Havering  Hurley Group  Healthwatch Barking and Dagenham  Havering Council

Both BHRUT and Healthwatch Havering emphasised the need for effective communications to ensure local people were well informed about the services available and any future changes.

Healthwatch Havering also raised concerns about existing availability of same-day appointments at GP practices, and asked for clarity about what services are available at GP practices e.g. wound dressing, removal of stitches or blood testing

The Hurley Group, which currently provides the walk-in services in Havering, provided comments on issues associated with bookable-only services relating to patient behaviour. Lack of primary care provision and the impact on demand for community urgent care services was also highlighted. Travel time from the Harold Wood area to Queen’s Hospital was raised as a concern for some patients.

They also asked specific questions relating to provision for unregistered patients and expressed concern that the impact and needs of patients with minor injuries and the staffing skill mix required for this element of care had not been fully considered.

Healthwatch Barking and Dagenham provided a report summarising feedback from a workshop held with residents to discuss the consultation proposals.

Most workshop attendees were supportive of option 1, but comments were made about location of services, opening hours and the capacity of a single service at Barking Community Hospital to meet local needs.

Attendees felt the proposals would make it easier to know where to go for urgent care and that bookable appointments would particularly help those with children or vulnerable residents. Weekend appointments were also welcomed. Concerns were however raised by participants who were deaf or hard-of-hearing about being able to use the NHS 111.

Other issues highlighted in the feedback report were travel time to community urgent care locations by public transport; the need for sufficient parking facilities; GP workforce capacity and existing issues with access to primary care.

Recommendations focused on providing clear information about the location and promotion of services and responding to the issues highlighted in the report.

Unanimous support was given to a motion discussed by Havering Council at its meeting on 12 September, which urged the Clinical Commissioning Group to support the continuation of the health

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Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups services provided at the Harold Wood Polyclinic and urged all members of the Council to participate in the current public consultation by supporting Option 1.

11.3. Support for Option 2 The North East London Local Pharmaceutical Committee (NEL LPC) supported Option 2, suggesting this provided greater patient choice and provided potential for community pharmacies to be part of the new service.

11.4. Other responses Mike Gapes MP, and the London Borough of Redbridge did not express a preference for the options. Both responses stated their opposition to the proposal to change the urgent care service at Loxford Polyclinic from a walk-in service to a bookable service with appointments available by calling NHS 111.

The detailed response from the London Borough of Redbridge is included in Appendix A, including comments on the Pre-consultation Business Case by Councillor Neil Zammett, Chair of the Health Overview Scrutiny Committee and a review of the proposals by the Council’s Public Health team, which were both submitted with the Council’s response.

The JHOSC did not state a preference but expressed concerns relating to the proposal to change the urgent care service at Loxford Polyclinic to a bookable service, adding:

“The Committee would like to record its concern at the position with Loxford Polyclinic which has had a number of services withdrawn and is not, in the Committee’s view, being used to its full capacity. Whilst there is currently a walk-in service, this is not clear to the public and better signage is needed. The Committee is also disappointed that a walk-in service is not due to be provided at Loxford Polyclinic under either option being consulted on.”

The Committee responses also recommended consideration was given to ensuring all community urgent care locations had sufficient parking provision.

Cllr Wise (Havering) commented on the proposals for Harold Wood Polyclinic, expressing concern that changes would mean residents would need to travel further for blood tests and x-rays, and that Queen’s Hospital would be placed under considerable pressure.

Whipps Cross Hospital Patients’ Panel welcomed the proposals, but did not express a preference on the two options. Comments focused on need for clarity for provision for residents from the west of Redbridge, and on the CCGs’ commitment to Whipps Cross Hospital.

Barking and Dagenham Council supported the formal response from the JHOSC, and noted that services at Loxford Polyclinic were a potentially useful option for residents in the west of the borough. It was suggested publicity around the new system of services would be a good opportunity to raise awareness of what services were available from Loxford Polyclinic and would help to encourage greater use by the public.

The Council opposed option 2, stating concerns about the impact on people attending A&E and the need to ensure a wide range of options amid concerns about existing service quality.

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On 12 October, the CCGs received a letter from the London Borough of Redbridge, reiterating their opposition to proposals to change the urgent care service at Loxford Polyclinic from a walk-in service to a bookable service. This letter explained that the Council had received a petition signed by 3,889 people which sets out the petition signatories’ opposition to ‘closure of the walk-in services at Loxford Polyclinic’. The letter states that the petition was debated by Councillors on 20 September and received unanimous support. The Council requested that the CCGs reconsidered the proposals to change the walk-in service at Loxford Polyclinic for the reasons stated in the petition.

11.5. Responses by organisations to the online survey Fourteen organisations responded through the online survey and their feedback is incorporated into the independent evaluation report. These organisations were:  Nia Hugget Women’s Centre (Barking and Dagenham)  Redbridge Asian Mandal  Patient Participation Group Chair, Kings Park Surgery (Havering)  Highgrove Patient Participation Group (Barking and Dagenham)  Friends of Barking Hospital (Chairman on behalf of Charity members)  Healthwatch Redbridge.  One Place East (Redbridge)  NELFT (community and mental health provider)  Barking and Dagenham Diabetes UK Support group  Richmond Fellowship Mental Health Charity in Romford  Havering Health GP Federation  Redbridge Carers’ Support Service  Havering Asian Social Welfare Association  Havering Dementia Carers Association

The consultation was open to members of the public, local interest groups and stakeholders and healthcare professionals. Those responding on behalf of an interest group are given equal weight in the analysis as responses from individual members of the public, even though these interest groups may be representing larger sections of the population.

SECTION TWO BMG RESEARCH - CONSULTATION REPORT

APPENDIX A ALL STAKEHOLDER RESPONSES

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Dear NHS,

On behalf of my Harold Wood Councillor colleagues and I, we were disappointed to read the below news in respect of the Harold Wood Polyclininc and that there are plans to potentially close the walk-in centre.

We do feel that the walk-in centre should remain as this does provide a vital service to our community as well as those further afield. If services were to transfer to Queens Hospital then further travel for blood tests and x-rays would have to be endured by our residents especially the elderly and vulnerable in our community. It will also put Queens Hospital and its staff under considerable pressure.

It would be helpful if you could share the reasoning behind the factors why you have come to this decision. Is there a consultation paper on this matter that you can provide please.

Extract below provided via a Resident

HAVE YOUR SAY...In the next coming weeks a decision will be made whether to close the Walk-In Centre ( PolyClinic)and make it into a out of hours appointment only Hub (dealing with illnesses only) which will mean no more injuries, no x-ray and no blood tests, Directing these to Queens hospital, putting more pressure on A&E, Now you can have your say. If you wish to keep this service please contact 02036881615 or email

[email protected]

Thanks and regards

Councillor Darren Wise| Harold Wood, Hill, Park Residents, Association| North Havering Residents Group (NHRG) London Borough of Havering Town Hall, Main Road, Romford, RM1 3BB t 01708 342369 | m 07956 443279

197 198 Anthony Clements

Principal Democratic Services Officer

DEMOCRATIC SERVICES London Borough of Havering Town Hall Main Road Romford RM1 3BD

Please contact: Anthony Clements Telephone: 01708 433065 Fax: 01708 432424 email: [email protected]

Essex County Council

TO:

Community Urgent Care Services Consultation Team C/o FREE POST BHR CCGs

Date: 8 August 2018 Your Reference: Our Reference:

By Post and E-mail

Dear Colleagues

Outer North East London Joint Health Overview and Scrutiny Committee – Response to Right Care, Right Place, First Time consultation

As the current Chairman of the Outer North East London Joint Health Overview and Scrutiny Committee I wish to write to you to summarise the Committee’s views on the proposals for changes to Community Urgent Care Services which are currently the subject of consultation. This follows your presentation at the meeting of the Committee held on 26 July 2018 and, as the main consultee, the Committee wishes to make the following comments on behalf of its participants:

Extension of Consultation Period – The Committee wishes to formally request that the consultation period is extended from its current closing date of 21 August for a period of four additional weeks. Members expressed disappointment that the consultation had been run across the main holiday period when it can be difficult for Members and appropriate officers to meet and discuss the proposals. Additionally, as you are aware, Members from Redbridge in particular would like further time to consider and respond to the detail of the Pre-consultation Business Case.

The Joint Health Overview and Scrutiny Committee is exercising its powers as conferred under the NHS Act 2006, section 245 (as amended by the Health and Social Care Act 2012). This is distinct from and separate to those powers exercised by the Executive of the constituent Councils. 199 You indicated at the meeting of the Committee that it may be unlikely that the consultation period can be extended due to the procurement timetable and you undertook to consider this and confirm the position. If this is the case, again as stated at the meeting, please could you supply the specific detail of the impact on your procurement workflows and why such an extension to the consultation period may not be allowed.

The Consultation Document itself – Members felt that the language used in the consultation document was unclear and likely to cause confusion. The Committee therefore requests that a glossary of terms such as GP Hub and GP Federation be produced and widely disseminated. Members are also concerned that the document is not sufficiently accessible to local communities where English is not the first language. To that end, the Committee feels that the whole document should be easier to read and that items such as a glossary of terms are therefore essential.

Loxford Polyclinic – The Committee would like to record its concern at the position with Loxford Polyclinic which has had a number of services withdrawn and is not, in the Committee’s view, being used to its full capacity. Whilst there is currently a walk-in service, this is not clear to the public and better signage is needed. The Committee is also disappointed that a walk-in service is not due to be provided at Loxford Polyclinic under either option being consulted on.

Harold Wood Polyclinic, Loss of Pharmacy – The Committee wishes to support the point, raised at the meeting by Healthwatch Havering, that it is essential that a pharmacy is reinstated at Harold Wood Polyclinic. Whilst it is accepted that this issue is not directly part of the consultation, the Committee feels that every effort should be made to persuade the relevant Authorities to ensure that pharmacy services are returned to the site to support the walk-in service there as proposed under option 1.

Parking Issues – As stated during the meeting, the Committee recommends that every effort is made to ensure that all sites chosen as either Urgent Treatment Centres or Community Locations have sufficient, affordable patient parking.

Individual Borough Consultation Responses – As you are aware, the Health Scrutiny Committee at London Borough of Redbridge will also make a response to the consultation and this will follow in due course.

I look forward to receiving your response to the above points in due course.

Yours sincerely

Councillor Nisha Patel Current Chairman, Outer North East London Joint Health Overview and Scrutiny Committee and Chairman, Health Overview and Scrutiny Sub-Committee, London Borough of Havering

CC:

All Members and Supporting Officers, Outer North East London Joint Health Overview and Scrutiny Committee

The Joint Health Overview and Scrutiny Committee is exercising its powers as conferred under the NHS Act 2006,2 section 245 (as amended by the Health and Social Care Act 2012). This is distinct from and separate to those powers exercised by the Executive of the constituent Councils. 200

Department of Nursing

Colin Anderson BEM

Chair Patients’ Panel

Whipps Cross Hospital

C/O Patient Experience

2nd Floor Aspen House

Whipps Cross Road

Leytonstone

London E11 1NR Date: 15 August 2018

@bartshealth.nhs.co.uk Dr Arnold Fertig Khalil Ali www.bartshealth.nhs.uk Co-chairs of the Community Urgent Care Programme Board Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups By email: [email protected]

Dear Sirs,

Consultation on making changes to community urgent care services

I am writing to you in my role as Chair of the Whipps Cross Hospital Patients’ Panel, in response to your consultation paper. The Panel discussed your proposals at its most recent meeting and asked me to write to you setting out its concerns. Much of this arises from the fact that the consultation document makes no reference to Whipps Cross at all in what it says about future urgent care services, despite its being the local hospital for at least a third of Redbridge residents.

While the arrangements for out of hours access to GP services set out in the consultation paper are welcome, neither of the two alternative proposals you put forward for the future location of UTCs appear to take account of the needs of residents in the western part of Redbridge, where a significant proportion of Panel members live. King George’s and Queen’s are a lot further away for them than Whipps, and with totally inadequate public transport links. Barking Community Hospital is little better and the Harold Wood Polyclinic even more distant. Access to an appropriate facility at Whipps Cross or elsewhere in the east of Waltham Forest would make much more sense.

That this is so obvious leads to a wider concern about the BHR CCG’s attitude to Whipps Cross. Since Whipps does not appear to feature in the CCG’s plans for the future, is what is proposed in fact part of a strategy to help bolster up the BHR Hospitals Trust’s disastrous

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financial position by using NHS111 and other sources of advice to steer patients away from Whipps – so damaging both the hospital and the financial position of the Barts group?

The Panel would very much welcome reassurance that the CCG was, after all, planning to put in place urgent care arrangements reasonably accessible to residents in the west of Redbridge and a clear statement from the CCG of its commitment both to the future of Whipps Cross and to the access of Redbridge residents to its services.

I look forward to receiving your response,

Yours sincerely

Colin Anderson BEM Chair, Whipps Cross University Hospital Patients’ Panel Mobile: 07770 236691 Email: [email protected]

Copies to: Melissa Hoskins, BHR Clinical Commissioning Groups Email: [email protected]

Jamie Whitburn, Head of Stakeholder Relations Barts Health Email: [email protected]

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PRIVATE & CONFIDENTIAL Executive Offices, Trust Headquarters Barking and Dagenham, Havering and Redbridge Queen's Hospital Clinical Commissioning Groups Rom Valley Way, Romford, Essex RM7 0AG

BY EMAIL TO: [email protected] Tel: 01708 435 009 www.bhrhospitals.nhs.uk @BHR_hospitals Date: 21 August 2018

Dear Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups,

I am writing on behalf of Barking, Havering and Redbridge University Hospitals NHS Trust. We have reviewed your consultation document at our Operational Management Group and our Trust Executive Committee.

We are formally writing to feedback on the Urgent Treatment Centre options you have proposed to commission. Please note that we remain concerned as to how you are engaging with the populations of Barking and Dagenham, Havering and Redbridge in increasing their awareness and understanding of out of hospital services, and making the urgent and emergency care services and their access less confusing. We would be interested in working with you to ensure that our communications teams are aligned in promoting key messages regarding the services that are available and how the public can access them.

BHRUT are supportive of option 1 and welcome the opportunity to work with commissioners in ensuring future quality health services are sustained.

Yours sincerely,

Kathryn Halford OBE Chief Nurse

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August 2018

205 Contents

Contents ...... 2 1 Introduction ...... 3 1.1 Acknowledgements ...... 3 1.2 Disclaimer ...... 3 2 Background ...... 4 3 Methodology ...... 5 5 Feedback from local people ...... 6 6 Recommendations ...... 10

2 206 1 Introduction

Details of report This report is based on an engagement session held by Healthwatch Barking & Dagenham, asking local people their views on the CCG’s consultation “Right care, right place, first time”.

Author of report Manisha Modhvadia Contact details Healthwatch Barking and Dagenham LifeLine House Neville Road Dagenham RM8 3QS [email protected] 0800 298 5331

1.1 Acknowledgements

Healthwatch Barking and Dagenham would like to thank all the individuals who contributed to this report.

1.2 Disclaimer

Please note that this report relates to findings from the people we spoke to. Our report is not a representative portrayal of all the residents of Barking and Dagenham.

3 207 2 Background

People are confused by the community urgent care services currently available, and want it to be easier to get help when they need to see a GP or nurse on the same day. Barking Havering and Redbridge Clinical Commissioning Group (BHR CCG) know many services are similar or even duplicate each other and that the system needs to make it easier for local people to get the right care in the right place, first time when care is needed.

BHR CCG want to change and improve the way community urgent care services are provided and therefore launched a consultation in seek the views of the public on the proposals.

Healthwatch Barking and Dagenham carried out an engagement session with local people. We asked for people’s views and opinions concerning proposals put forward by BHR CCG on making changes to community urgent care services.

This document represents a response to the consultation which has been anonymised. This has been conducted impartially - Healthwatch Barking and Dagenham have no organisational view.

4 208 3 Methodology

Healthwatch Barking and Dagenham held a round table discussion with local people who live in the borough to seek their views on the proposals made in the “Right care, right place, first time” document.

Participants were advised that their views were being collected and would be included in this report which would be passed to the BHR CCG for inclusion in the responses to their consultation. Participants were also informed that this report would be made publicly available when it was completed.

To enable individuals to give their views without the fear of their personal details being shared or any impact on the services they receive, Healthwatch explained the following:

 Participation is voluntary, and individuals are not required to answer the questions posed.

 Participation or non-participation will not affect access to any services currently being accessed

 Information collected is kept strictly confidential.

Each individual had a consultation document and the response questionnaire. The background to the consultation was read before having discussions and answering the consultation questions.

5 209 5 Feedback from local people

Healthwatch provided some background as to why the CCG are proposing changes to the way urgent care is being delivered currently. The engagement event was based around the questions which are within the consultation document. Discussions were held around the questions and feedback sought for each area.

Question from consultation document: We think our proposals will make it easier to know where you go if you need urgent care? By this, we mean treatment for minor illnesses and minor injuries that mean you need care or advice from a health professional on the same day.

People felt that the proposals would make it easier if information was provided to the public about the different locations services are being provided from. Clear advertising about what diagnostics are available at each site is needed aswell as opening times and days. Opening times of out of hours’ pharmacies should also be included in communication materials so those who need to pick up a prescription can do so.

Question from consultation document: We are proposing to provide more bookable appointments for people with urgent healthcare needs who need to be seen on the same day. Do you agree this will make it easier to get urgent care when you need it?

People agreed that providing more bookable appointments would make it easier for people to be seen especially those with children and those who are vulnerable, however concerns were raised about capacity and if there will be enough bookable appointments due to demand. People raised concerns about local services not being able to keep up and provide services in line with the predicted population growth. Concerns were raised as to whether all urgent out of hours’ services would be able to refer patients for blood tests if needed, as otherwise patients will need to go back to their GP which will be a waste of resources.

6 210 Question from consultation document: Our travel analysis shows that the vast majority of local residents will be within a 15-minute drive of a community urgent care service. If your own GP can’t see you, would you be happy to have an urgent appointment at another practice or location in Barking and Dagenham, Havering or Redbridge (within 15 minutes’ drive) if this meant you would be seen more quickly?

People would ideally like to seen at the closet location to where they live. The CCGs “travel analysis shows that the vast majority of local residents will be within a 15-minute drive of a community urgent care service.” The CCG need to take into account that some residents do not drive or have access to a car, therefore their travel time will be longer. Additionally, everyone cannot afford to pay for a cab, Parking needs to be adequate and affordable across all sites. A closer look needs to be taken at the potential poverty gaps, especially for families on low incomes and benefits. For some family’s they are just about getting by and the cost of parking may be unaffordable for them.

Question from consultation document: The proposals will ensure that there is greater availability of bookable appointments for urgent care at the weekend. Based on how and where you normally spend your week and your weekends, do you think that weekend appointments would be useful to you?

People agreed weekend appointments would be useful, people gave a number of reasons as to why they felt this was the case:  Parents of young children would be able to book a bookable appointment and been seen quicker over the weekend rather than take their child to a walk in or A&E and wait for hours.  The GP hub currently offers weekend appointments which work well, why would we want to lose weekend appointments? More are needed.  The option of bookable appointments appealed to most people as they want to be at home resting where they are comfortable.  Help reduce waiting times for those who are vulnerable.

7 211 People were asked which option they preferred and why.

People felt some of the information within the document was not clear and does not state where the community urgent care services will be delivered from. It was felt this information should be highlighted within the proposals as adequate information has not been provided for people to make an informed decision.

Which option do people prefer? In principal most people were supportive of option one, many comments were made and also questions raised which are highlighted below: Questions Where are the 8 community urgent care services going to be delivered from? Will there be one in Dagenham? When calling NHS 111 will people have a choice of options, or will they be told which location they need to attend to be seen.

Comments The consultation document states that “NHS England guidance says we need to establish urgent treatment centres (or UTCs) in our area. These will be GP- led, open at least 12 hours a day, every day, and be equipped to diagnose and deal with many of the most common non-emergency ailments people attend A&E for. Currently Barking walk in center is open 7am to 10pm during the week, if this will be 12 hours’ local people do not agree with the proposals as there is a reduction in the amount of hours the services will be delivered.

8 212 People also felt that all UTC should be open late in the evenings to stop people from going to A&E.

Barking Walk in Center and the GP Hub are both currently situated within Barking Community Hospital, at the moment people can access either service. According to the proposals the Walk in Center will be upgraded to an Urgent Treatment Center, local people queried if this would have the capacity to see as many people as the walk in and hub do currently?

People felt that appointment systems would work in principal but had concerns if everyone would be seen as there is such high demand.

If all urgent services will be accessed by calling NHS 111, local people want assurance that someone will answer their call in a timely manner.

Concerns were raised by those who are deaf and hard of hearing around the accessibility of bookable appointments. It was felt that they would not be able to use NHS 111 to book an appointment and the online service is not currently available. This was also raised as an issue by others and people felt this should be a priority so there is more than one way to book.

Two deaf people did not agree with the proposals as it was felt their needs were not being taken into account. The online booking system is not available and therefore is a I direct barrier for those who are unable to use the phone.

Other comments and questions in relation to the proposals The recruitment of GPs is already a challenge, is there capacity locally to have GPs available to provide the services alongside nurses?

If there are people accessing a service with a bookable appointment and individuals are walking in how will this be managed? People who have booked an appointment will be expecting to been seen quicker as reflected in the consultation document.

People raised concerns about GP services not seeing as many patients as they could locally and now this is leading to patients accessing community urgent care services as a first point of call.

9 213 6 Recommendations

There were in depth conversations around the table, every individual made a contribution to all the proposals. During our engagement session it was very clear that although people agree that an appointment system will make it easier and quicker, the demand on the service is high and questions were raised about weather this is realistic.

As a result of the discussions, Healthwatch Barking and Dagenham recommend:  BHR CCGs inform the public what locations are being looked at for the community hubs.  Work with partner organisations once a decision has been made to ensure people are aware of the decisions.  Ensure the services are adequately advertised in a clear format.  Clarify questions highlighted under the proposals.  Ensure the online system is developed as soon as possible to stop it being a barrier some of the groups who are unable to use the telephone system.

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Consultation by BHR Clinical Commissioning Groups on future provision of Urgent and Emergency Care in Barking & Dagenham, Havering and Redbridge

Response of Healthwatch Havering

The consultation document makes clear that the CCGs’ preferred choice is Option 2:

“Option 2 - most patients will call or click before they come in. This matches our vision for the future of urgent care and will provide local people with a simpler system of quality urgent care.”

Unfortunately, this is not the Option that we believe will offer the comprehensive primary care service that residents need.

Option 1 is our preferred choice. We believe that this is the service which is most likely to encourage residents not to attend A & E unnecessarily. The opportunity to have a wider range of clinical care available 12 hours a day 365 is a far more robust primary care service model.

It is a model that inspires confidence with local people and the evidence is easily found in the attendance numbers at Harold Wood Polyclinic.

A concern for residents has been the total inability of the CCGs to be able to publish the services available at every GP practice and this is again the concern with the reliance of GP practices to offer appointments. Our reviews to date of GP services in Havering suggest that the majority of practices are unable to offer same-day or near dated appointments, without inconvenience to patients such as having to attend at an early time of day or making numerous phone calls.

Examples of these services are removal of stitches, wound dressings and phlebotomy – all simple, easy procedures but still not identifiable as a standard item across the borough. In most cases residents are still receiving this care via BHRUT.

The provision of this care by BHRUT can hardly be value for money or good use of a scarce clinical resource at a time when BHRUT are still struggling to meet national targets in A & E and to cope with one of the largest overspends in the country

The CCGs’ proposal to offer two UTCs would inevitably result in halving the current service model. Concerningly for your proposed new service model, the UTC at King Georges Hospital has recently been placed in Special Measures by the CQC. Conversely, the CQC rating at the Polyclinic which the CCG are, in effect, proposing to close, is Good.

The document lacks precision on the new appointments to be offered by NHS111:

“Appointments will be available in the daytime, evenings and at weekends”.

Will this be as comprehensive as 12 hours a day 365 days of the year currently on offer at the Polyclinic for example?

Earlier this year, the three BHR Healthwatches carried out a survey of people’s understanding of the terms Urgent and Emergency Care. The responses showed clearly that people do not easily distinguish between “urgent” and “emergency”, and in Havering at least, do not turn to NHS111, by

215 phone or online, as their first “port of call”. The CCG have been reminded on numerous occasions that, at the very least, any change in the role of the Polyclinic will need to be very carefully publicised, and some sort of public education campaign carried out.

The concept of the Polyclinic was that it should be a place to which people could go for urgent care without requiring prior appointment and that is firmly fixed in the public mind. Any change in that status will bring confusion, at least in the short term. Overall, we think this proposal lacks clarity, does not grasp the opportunity to develop primary care, and fails to capitalise on the distinction between Emergency Care and Urgent Treatment Centre, all to the patient’s advantage.

Anne-Marie Dean Chairman, Healthwatch Havering

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Commentary on the CCG Urgent Care Consultation August 2018

Summary It is very likely the proposals will: • Increase costs • Lead to an increase in A&E attendances • Make it harder for Black and Asian users to access services • Lead to an overload on the UCTs at Queen’s and KGH The consultation document The consultation document is twenty-two pages long. It gives a definition of urgent care and a description of an improved NHS 111 services something on national standards and outlines of the proposed options. It identifies four key drivers for change: • Confusing and variable services • Growth in population and demand • A digital future • Spending money wisely Generally, the consultation document is positive about the changes proposed but it does not point up the fact that 40% of users of the NHS 111 system will not receive a face to face service. Other documents Behind the consultation document is the Pre-Consultation Business Case (PCBC) which is a 46-page document covering the context, the case for change, engagement activity and option development. This is not the whole story however because the PCBC draws on other material: • A telephone survey by a private research organisation BMG in 2016 • A study by Healthwatch in 2016 • A conference on Urgent Care in 2017 • More recent studies undertaken by Healthwatch

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Although these can be found on the CCG Website they are difficult to trace and are very poorly referenced in the PCBC. To make matters worse some are undated and have no page numbers. This makes it very difficult to form a full picture of the CCG’s work and leads to a “stratification” of knowledge where only the CCG and those few determined enough to track down the supporting documents are fully appraised of the facts. The Pre-Consultation Business Case (PCBC) This is the detailed document which backs up the consultation exercise and should provide an integrated explanation of the proposals and set a contextual framework to help readers understand why changes are proposed. The document sets the objectives clearly on page 4 and also gives a detailed statement of context on pages 5-11. This reflects new national requirements form the “Five Year Forward View” and a comprehensive description of the existing service. The key themes developed in this section are: • The complexity of existing services with different opening hours staffing levels and services • Cost pressures which have resulted from population growth • Patient behaviours using A&E as a duplicate service for primary care. Pages 12-17 review the “Case for Change” and gives more detail on the key themes and summaries of previous work undertaken by Healthwatch and a private research company BMG. These covered: • Clinical audits showing duplication, • Engagement work showing multiple attendances • The use of prior advice by patients. There is a separate section reviewing engagement work which again emphasises the confusing nature of local services and records the preference of patients to see their own GP, support for more appointments in the local community, recognition of the role of pharmacists and a welcome for the improvements to NHS 111. Although the options chosen for detailed evaluation are described in the main document on pages 18-24 it is necessary to refer to Appendix 4 for a fuller account of their generation and appraisal.

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To make matters worse this Appendix is very difficult to follow not least because there are errors on page 36. M1 should read months 1-10 and the numerical values are also incorrect. It describes in outline how a model was used to forecast the effects of changes in provision. The key assumptions underlying this model are as follows: • All attenders at the A&E departments at Queen’s and KGH will pass through the UCT. • Any closure of a walk-in service will result in a 15.9% reduction in activity. • 100% of attenders will access services through NHS 111. • In Option 2 where Barking and Harold Wood remain open the 100% assumption is modified to incorporate a 30% walk-in factor. • Displaced activity will be reproportioned according to existing patient flows. It should also be noted that the sensitivity analysis is not included in the Business Case. Testing the model assumptions The most reliable source of information about patient behaviours comes from the BMG study completed in 2016. This showed in Table 5 on page 15 that only 24% of A&E attenders had called NHS 111 first. The base assumption, Option 1, that 100% of attenders will come through NHS 111 is therefore unrealistic. Further information obtained indicates that the break even point from the sensitivity analysis is 90%. This means that any value below 90% will cost more which obviously conflicts with the financial imperatives. In Option 2 the break-even position is between 53-56% which also looks very optimistic when compared with the 24% from the BMG study. It seems very likely therefore that either option will cost more. This should really have been explored in more depth in the business case which should have included a section on sensitivity analysis in any event. Equally the assumption that all attenders will go through an UTC before attending A&E should have been highlighted. The implications for capacity should have been clearly laid out and do not appear to have been considered at all. 3

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The 15.9% reduction in attendances due to the dissipation of activity when a centre is closed is based on one study of Nuffield private health facilities, and should also have featured in the sensitivity analysis to allow for the very weak supporting evidence. One of the most important aspects of the model relates to the way in which activity is attributed to different services shown in an unnumbered table on page 37. This is based on recent past experience with NHS 111 and what is termed Clinical Assessment Logic (CAS). Patients are routed to the most appropriate service A&E or walk-in centre for example. Reference to the commentary on page 44 indicates that attendances are reduced by 40% using CAS logic. It is not clear from the tables, which are in any event are not proportions as stated in the text but actual numbers, just how the 40% in the commentary relates to the unnumbered tables. Reference to the second table however shows that by by using the 70% figures those patients whose telephone triage or CAS logic told them they did not need a face to face contact can be calculated. This is around 50%. Because this is such an important fact it warrants much fuller explanation in the document and represents one of many areas where the document is confusing and very difficult to follow. Impact on A&E There is a widely held belief that NHS 111 has led to an increase in referrals to A&E. Again, using the second table on page 37 it is possible to calculate that an additional 6123 patients or around 4%, by dividing by 153,438 taken from the figure, unnumbered, on page 39 would be referred to A&E as a first point of contact. Confusion Although statements about the confusing nature of existing services are made frequently in the document, for example on page 16“The clear message from all of this engagement is that all stakeholder groups view urgent care as complex and confusing and endorse the need to look at simplifying the pathway”, there is virtually no evidence to support them.

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The one reference to this directly in “What you told us” from the October 2017 Workshop is “Information about existing services is too complicated”, which is a very different proposition. In fact, as the PCBC later acknowledges on page 17 patients do have a remarkable understanding of the nature and location of walk-in centres. It is unfortunate therefore that a more in depth look at what respondents meant by “confusing” was not undertaken but it seems most likely that this referred to the information from the CCG and other NHS sources rather than the services themselves. Ethnicity and deprivation As an equalities impact assessment was not available it was not possible to see how the CCG intended to deal with issues related to ethnicity or other protected characteristics and in particular the engagement of people from ethnic minorities with the NHS 111 service. NHS Direct used to be a telephone service providing 24/7 health care advice and information to the public in England and Wales. NHS Direct ceased operation in 2014 and was replaces by the NHS 111 service. Both services are similar in concept. Research evaluating the uptake of NHS Direct has suggested disparities in the utilisation of this service related to ethnicity. Lower than expected uptake was found for Black (African/Caribbean) and Asian (Bangladeshi/Indian/Chinese) ethnic groups, which held consistent by age and gender (source: “Who uses NHS Direct? Investigating the impact of ethnicity on the uptake of telephone based healthcare”, International Journal for Equity in Health 2014, E J Cook et al). It is likely that many of the population in Cranbrook & Loxford do not have English as their first language and therefore will struggle with the proposed changes to make services bookable via NHS 111. Additionally, those from ethic minority groups and more deprived backgrounds are less engaged with health care services and will be ’hard to reach’ with regards to how the services changes are communicated. Discussion and conclusions To some extent the shortcomings of the PCBC are the result of the way in which the work it is based on has been conducted over several years without any evident overall plan or design. Key themes such as “confusion” may have felt intuitively correct but given that this is one of the main stated reasons for 5

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change there really should have been a sounder evidence base or more correctly an evidence base which spelt out more clearly what this meant and how it affected patients. The result has been a document which is difficult to follow and appears to pick out those parts of earlier studies which support the key themes while ignoring others. It contains errors, inconsistent diagrams and unnumbered tables. There is also the omission of a sensitivity analysis and an equality impact assessment which are particularly important in a piece of work which covers very different communities and makes very optimistic assumptions about the percentage of people using NHS 111 and dropping out of services when centres close. The Loxford Polyclinic currently serves a highly deprived and ethnically diverse local population and the health outcomes for this population are among the worst in the borough. It is therefore crucial that access to health care is not diminished. Any restriction on healthcare access will further reduce health and social outcomes for this population thereby exacerbating inequalities in Redbridge and the wider BHR area. All round this is a very worrying piece of work because it is proposing changes to an urgent and emergency care system which is already under considerable stress. It is very likely the proposals will: • Increase costs • Lead to an increase in A&E attendances • Make it harder for Black and Asian users to access services • Cause an overload on the UCTs at KGH and Queen’s An alternative view that the walk-in centres provide a cheap and accessible option to A&E is supported better by the evidence presented. The consultation document should have made it clear that a much smaller proportion of patients would receive a face to face service as a result of the proposals. Neil Zammett

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hurley clinic kennington 4 September 2018 Ebenezer House Kennington Lane London, SE11 4HJ Sent by email to: [email protected] Mobile: 07973 830586 Email: [email protected] www.hurleygroup.co.uk

Dear Sir/Madam

RE: BHR Community Urgent Care Consultation I am writing this letter on behalf of the Hurley Clinical Partnership. We are extremely concerned about the impact on patients, practices and local unscheduled care services if the Harold Wood Polyclinic (HWP) becomes a Community Hub (CH), rather than an Urgent Community Hub (UCH1), as a result of the ongoing Consultation. On this basis, we are firmly in favour of Option 1 which would avoid this happening. The response that follows sets out our reasons for stating this preference and also provides our response to the individual questions set out in the Consultation questionnaire. For the past eight years we have been the incumbent provider of the walk-in, minor injuries and minor ailments, service at HWP and the nurse-led walk-in service at South Hornchurch Health Centre (SHHC)2. This means that we have considerable experience and understanding of the current service in Havering. In addition, we currently provide urgent care services in Bexley where we have implemented direct booking from NHS 111 in both UCCs. We have interoperability with the GP clinical system and we are working on Child Protection Information Sharing (CPIS) interoperability. These are all initiatives that BHR proposes to implement along with: direction away from Walk-in services to other pathways, increased access to patient records and a ‘click first’ approach. HWP & SHHC currently provide care to an average of 1503 patients per day and we see, on average, 600 injuries a month. X-ray and phlebotomy services are available on site and we have a dedicated emergency room complete with emergency trolley, resus equipment and staff trained to deal with minor emergencies. HWP is already more closely aligned to an Urgent Treatment Centre (UTC) than the original Walk-in Centres (WICs) which were set up, predominantly, to see patients with minor ailments. We agree that the provision of some appointments that can be directly booked by patients via NHS 111 for minor ailments would be a positive move and we have indicated that we would be happy to establish this at HWP4. This model allows for patients to be advised that another pathway might be appropriate and it will reduce the waiting times frequently experienced by patients in a walk-in service both of which are positive.

1 Is this the same as a UTC or something different? – discussed in more detail at a later stage 2 How ever, to be very clear our current contract expires in 2019 and if the decision is taken to retain HWP as an Urgent Community Hub a procurement process w ould have to be undertaken. 3 An average of 100 patients per day if only considering those presenting w ith minor illness or injury 4 Direct booking from NHS 111 into our Bexley UCC service is currently being piloted via Adastra w hich is the same clinical system used at HWP

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Although supportive of this model, realistically, there are associated issues which mean that a totally bookable service is not practical such as:

 Patients who DNA5 their appointment block appointments that could have been used by others thus reducing capacity. In addition, once a patient has been booked in to an appointment by NHS 111 the accountability sits with the provider to safely close down the referral meaning that having not seen the patient the provider still has to take the time to assure themselves that the patient is safe.

 Patients unable to get an appointment at the time they want continue to attend unscheduled care services

 The availability of more booked appointments in all settings is filled by overflow from patients who should be seen at their own GP practice where there frequently is a shortage of regular appointments with both GPs and nurses In addition, we believe that the number of patients attending HWP with minor injuries needs to be considered very seriously as part of this Consultation.

 The impact of these patients adding to the numbers attending Queens is significant

 It is questionable whether the X-ray6 service at HWP would remain a viable option without the minor injury workload.

 The staffing complement required to provide treatment for minor injuries requires different skills from that needed for minor ailments. Minor injuries are not treated routinely by GP Hubs /GP practices or their primary health care team so they will need to attend a service elsewhere with appropriately trained staff At HWP there is an existing team of Advanced Nurse Practitioners (ANPs), Emergency Nurse practitioners (ENPs), GPs and administrative staff. Many have worked at the site for several years and, together, they provide a financially viable7, flexible service meeting the needs of the range of patients presenting with minor ailments or minor injuries. The staff support the introduction of direct bookings (via NHS 111) into ‘the mix’ of services offered. However, alongside this it needs to be recognised that the way to achieve the maximum output of a team such as that at HWP is through incorporating some areas where flexibility is available so that the demands of unpredictable urgent/unscheduled care activity such as responding to minor injuries / times when the entire health service is under pressure/ can be delivered. Travel - If HWP was to be down-graded to a CH (Option 2) only offering bookable appointments via NHS 111 we draw the conclusion from the Consultation document that patients with minor injuries would have to travel to Queens or King George’s Hospital for treatment8. On this basis we would question the reference made in the Consultation document and questionnaire that ‘the vast majority of local residents will be within a 15 minute drive of a community urgent care service’. It may be the case that the vast majority of residents across BHR will be within a 15 minute drive of a community urgent care service but we suspect that if one looked at Havering,

5 Did not attend 6 X-ray services support the diagnosis and treatment of minor injuries patients in addition to providing a service for the local GP practices 7 Acknow ledging this is from the view of the provider 8 In some consultation meetings it w as suggested that some Community Hubs might offer slightly different services but this is not stated in the Consultation document and the challenges cited in our response about availability of suitably trained staff to offer a broad service at HWP under Option 2 w ill make this difficult to achieve.

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where HWP is located, a significant proportion of the residents would not be in this position if Option 2 is selected.

To get from HWP to Queens is about a 20 minute drive or for those who do not have a car / cannot afford the hospital parking charges9 there is a walk to Romford station (approx. ½ a mile) and then a 20 minute walk at the other end. For King Georges it is further. Given that the location of HWP is not on the outer border of Havering there will be a considerable number of residents who have to travel further than this to reach the hospital (their community urgent care service) under Option 2.

Access to appointments in other locations – the key features required to ensure this model works successfully and avoids duplication for patients include, from experience,

 The ability to access the patient’s medical records at the point of the consultation  A method of updating the patient’s medical records in a timely way to reflect the outcome of the Consultation  The ability to make referrals and issue fit notes – the inability to offer these services has proved very frustrating for patients.

Weekend access to appointments - Having worked closely with GP access hubs10 in Bexley experience has shown that the Sunday appointments have not been as well utilised because the usual process for booking has been that the patient has to go through their GP practice so a condition needing treatment on a Sunday that begins on a Saturday cannot be booked in. The introduction of direct booking via NHS 111 will hopefully improve uptake and reduce the number of walk-in attendances on a Sunday.

There is an absence of information about accessibility to GP practice services in this Consultation document which is absolutely key to understanding the ramifications of a change in Urgent/unscheduled care service provision – a few examples are shown in the following section but all too often capacity in primary care is not considered at the same time.

There are a number of other services currently provided from HWP that are not addressed in the Consultation document. Three key areas being

a. Services to patients that are unregistered with a general practice – on average HWP and SHHC see 150 unregistered patients each month. Although a considerable amount of work is going into improving access to GP practices there are still areas where it is very difficult to register with a GP. These patients, along with those who cannot get an appointment with their GP, attend HWP. Details about access to treatment for unregistered patients is not included in the Consultation document but we understand from the minutes of the JCC Committee in July 2018 that the expectation is that if an unregistered patient contacts NHS 111 they will be provided with details of the three closest practices to their home – to register11. We believe that there are many areas in Havering where the patient’s registered address will not fall into the catchment area of more than one practice. Current guidance is that if an un-registered patient calls NHS 111 for a condition that needs to be booked in to an appointment NHS 111 will have to book this into a UTC direct booking appointment and not into a GP/Community hub. Under Option 2 this would mean any un-registered patients would need to be booked

9 At HWP there is free parking 10 These are equivalent to the Community Hubs in this model 11 In the South-East area if an unregistered patient rings because they have a health condition that requires treatment rather than to find out about w here to register they w ill not be provided w ith information about three local practices so this answ er may be different in each area how ever in all cases they have to be booked into a UTC & not a hub.

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into one of the UTCs whereas currently HWP takes a considerable amount of this workload in Havering.

b. Post -operative dressing service and routine re-dressing service (especially at weekends). HWP and SHHC see an average of 480 patients a month as part of the post-operative dressing service and 453 patients a month for routine dressings. This service has been in place for the past seven years and it is very clear that local practices do not have sufficient nursing appointments provided by suitably skilled nurses to repatriate this workload12.

The nursing staff providing this service at HWP are highly skilled at treating a wide range of dressings including abscess packing, staple/stitch removal and the treatment and management of infected wounds.13 The local district nursing teams no longer undertake any dressings unless the patient is housebound and the tissue viability service is a referral service only and is very stretched.

c. Special Allocation Service (violent patient scheme) – this is currently commissioned from the Kings Park practice (KPP)14 which is co-located in the same building as HWP. However, offering this service from the site if HWP were not present with the range of staff available to support KPP to manage these patients would be difficult.

Although the consultation document clearly states that a decision has not been taken there are a few areas where a preference for Option 2 appears to be presented in a more positive light and yet the same positives appear to apply to Option 1 as well – examples of this are on p13 of the Consultation document where it sets out under Option 2 that ‘by calling NHS 111 you would be booked a timed appointment at 10 community urgent care service locations ….. or at one of the two UTCs’ why does it not say the same under Option 1 with a simple change in the numbers i.e. ‘8 community urgent care service locations or at one of the four UTCs’.

Option 2 also states ‘when you call NHS 111, you will be assessed and given advice or booked into the right service for your needs. This means that you will get the right care in the right place, first time and you won’t be redirected to another service’ . This also applies for Option 1 and from experience the most important way to ensure that this is the case is for the provider to work closely with the DOS team to ensure that the profile of the service is set correctly as this will mean that patients will benefit in terms of right care, in the right place, at the right time.

There are other similar examples in the comparison between the two models.

On the questionnaire, having stated that you are not consulting on the transition of the two hospital sites into Urgent Treatment Centres, it states:

We will be upgrading services at some locations to become Urgent Treatment Centres. These will see people with urgent, but not life-threatening or emergency, health needs. Appointments can be booked by NHS 111 or people can choose to walk in. Staff will have access to your health record and to more specialist diagnostic tests so can help with minor illnesses and injuries that may require tests that a GP can't do in a practice or community location’ and it then goes on to ask …

12 We recognise that an alternative pathw ay could be commissioned for this w orkload but w ish to make clear that this w ould be a direct impact/cost of changing the caseload attending HWP and SHHC 13 There is a 10 point w orkforce plan underw ay for Practice Nurses but this w ill take some time to come to fruition 14 The Hurley Clinical Partnership is commissioned to provide services from the KPP until 31 December 2023

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Which of our two options for where you could continue to walk in and get urgent care do you prefer?

If Option 1 were to be agreed there appears to be a lack of clarity from the statement above as to whether HWP and Barking Community Hospital would become UTCs or an Urgent Community Hub as described in the Consultation document and what the difference is between the two especially in the context of the sentence underlined in the paragraph above.

Other suggestions - Having recently commissioned the eConsult15 online consulting module in BHR we think exploring the urgent care eConsult module which facilitates an integrated primary and secondary care model of online entry to urgent/unscheduled care would be a positive way forwards, see https://econsult.net/econsult-for-urgent-and-emergency-care/ for more information

Yours sincerely,

Rylla Baker CEO, Hurley Group

On behalf of Dr Clare Gerada, Dr Arvind Madan, Dr Murray Ellender, Dr Ben Shankland, Dr Ross Dyer-Smith, Dr Nishma Shah and Dr Gavin McColl

CC; Carla Morgan

15 eConsult Ltd w as originally developed by the Hurley Clinical Partnership under the name of WebGP Ltd – it is now a standalone Ltd Company

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Feedback form BHR Community UEC consultation: North East London Local Pharmaceutical Committee response

Consultation Questions:

Are you? Male Female Other Prefer not to say

How old are you? Under 18 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older Prefer not to say - variety of age ranges represented (25 to 64)

Are you disabled? Physical/ mobility issue Learning/

238 mental health issue Visual impairment Hearing problems Another issue No issues

Where do you live? Barking and Dagenham Redbridge Havering Other: BHR

Are you telling us your thoughts as: A local person On behalf of an organisation or group If so, which? North East London Local Pharmaceutical Committee A healthcare professional Someone who would be affected by the changes Other If so, why? As a local representative committee on behalf of community pharmacy teams across Barking, Dagenham, Havering and Redbridge, we wish to contribute

What background are you from? Any white background Any mixed background Any Asian background Any black background Any other group. Please tell us what? Prefer not to say – variety of backgrounds represented by the LPC

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What do you think about Question 1: If your own doctor can’t see you, would you be happy to be seen at a different GP practice if this meant you would be seen more quickly? Yes, but please note, depending on the nature of the complaint, would also be happy to go to a local community pharmacist, ie. minor ailment such as: ➢ Athlete’s foot ➢ Back pain ➢ Cold sores ➢ Conjunctivitis ➢ Constipation ➢ Contact dermatitis ➢ Cough, colds and sore throat ➢ Cystitis ➢ Diarrhoea ➢ Dyspepsia and indigestion ➢ Earache ➢ Haemorrhoids ➢ Hay fever and allergies ➢ Head lice ➢ Headache and fever ➢ Insect bites and stings ➢ Minor injuries ➢ Nappy rash ➢ Ringworm ➢ Sprains and strains ➢ Teething ➢ Threadworm ➢ Vaginal thrush ➢ Warts and verrucas No Don’t know

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Question 2: Which of our 2 options for how and where you could see a doctor or nurse do you prefer? Option 1 – Walk in and queue or book an appointment at King George and Queen’s Hospitals, Harold Wood Polyclinic and Barking Community Hospital. 8 different places where you can just book an appointment located across Barking and Dagenham, Havering and Redbridge. Option 2 – Walk in and queue or book an appointment at King George and Queen’s Hospitals. 10 different places where you can just book an appointment located across Barking and Dagenham, Havering and Redbridge. • We believe option two provides greater patient choice and access and enables the potential for community pharmacy to be part of the Hub development, as currently only four have been identified. • As part of the Hub, community pharmacy are ideally placed to support NHS 111 referral, provide extended hours to improve patient access, and a clinical skill base that offers patients an alternative when dealing with minor ailments.

No preference

Is there anything else you want to tell us, or think we should consider before making decisions about these urgent care services?

We would hope that this consultation and outcomes consider and reflects the role of community pharmacy in supporting patient experience of accessing the UEC system, patient outcomes as well supporting the system in terms of clinical capacity and demand management, such as admissions avoidance.

Community Pharmacy across BHR is a professionally trained and clinically qualified workforce, and has more to offer than just the traditional provision, ie. medication optimisation and management,

241 dispensing, public health advice and information, etc.. Over the past 15 years and particularly in the past 5 years community pharmacy in North East London has developed its workforce in terms of: • clinical skills - a range of health conditions and social care needs • enhanced skill base - management of LTCs, Health Coaching, Motivational interviewing, • enhanced assessment skills in terms of health and wellbeing - PAM, BioPsychoSocial, Person-centred WellBeing Plans, • locally enhanced provision - Independent Prescribing, specialist clinics (warfarin, diabetes, etc),

If you would like us to tell you what decisions we make about these proposals, please write your name and email address in the box below.

We will keep your details safe and won’t share them. Name: Rebecca Dew Email: [email protected]

Thank you for taking the time to let us know what you think.

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Community Urgent Care Consultation Our address: BHR CCGs Ground Floor, Barking Town Hall, Becketts House 1 Clockhouse Ave, Barking IG11 7LU 2-14 Ilford Hill Website: www.lbbd.gov.uk Ilford Essex IG1 2QX. Date: 4th September 2018

To whom it may concern,

Community Urgent Care Services Consultation

On behalf of the Health Scrutiny Committee for the London Borough of Barking & Dagenham, I would like to add further comments to the submission already made by the Joint Health Overview & Scrutiny Committee for Outer North East London. We are fully supportive of that response, but would wish to amplify some points that are or greater relevance to our residents.

Firstly, we support the observation that neither option includes walk-in services at Loxford Polyclinic. For residents in the west of our borough, this is a potentially useful option. We also note that it may be underused, but would suggest that the publicity that will accompany the new Urgent Care system launch would be a prime opportunity to improve awareness of what it offers.

We also do not support the second option which removes walk-in opportunities from Barking Community Hospital. We are strongly of the view that the more open access facilities that are available, the less people will resort to A&E inappropriately. Furthermore, having recently received the poor inspection report into the Urgent Care Centre at King George Hospital, it is clear that services in this area are fragile and that there needs to be a wide range of options so that people can have some back-up options when there are quality is variable like this.

I trust this is helpful to your consideration of the options, and look forward to further discussion in due course.

Yours faithfully,

Cllr Eileen Keller Chair, Health Scrutiny Committee London Borough of Barking & Dagenham

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•

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Improving Community Urgent Care Equality impact assessment (EIA) October 2018

About this document This equality impact assessment (EIA) takes account of the two community urgent care pathway options proposed by Barking and Dagenham, Havering and Redbridge CCGs (BHR CCGs) through a public consultation.

An equality impact assessment (EIA) is the process of assessing the impact of a proposal and its consequences for equality. There is a legal obligation to undertake EIAs to assess the impact of proposals on equality groups identified by the Equality Act 2010 (called protected characteristics):  Age  Disability  Gender reassignment  Marriage and civil partnership  Pregnancy and maternity  Race  Religion and belief  Sex  Sexual orientation

Equality analysis is a way of considering the effect of a proposal or policy on different groups and serves to:  consider if there are any unintended consequences for some groups  consider if the proposal/policy will be fully effective for all target groups.

It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of functions, contracts, policies or decisions.

Barking and Dagenham, Havering and Redbridge CCGs are subject to the general public sector equality duty required by Section 149 of the Equality Act 2010.

This states that the CCGs must “have due regard to the need to: 1. Eliminate discrimination, harassment, victimisation, and any other conduct prohibited by the Act 2. Advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it 3. Foster good relations between persons who share a relevant protected characteristic and persons who do not share it.”

This involves:  Removing or minimising disadvantages experienced by people due to their protected characteristics  Taking steps to meet the needs of people from protected groups where these are different from the needs of other people  Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low.

Carrying out an equality impact assessment helps BHR CCGs to make sure it has considered the needs of people with protected characteristics.

This means it can:  identify unintended consequences and mitigate them as far as possible  actively consider how the proposed change might support the advancement of equality and fostering of good relations.

This equality analysis should be reviewed in conjunction with the:

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 pre-consultation business case document which is located on BHR CCG websites: http://www.barkingdagenhamccg.nhs.uk/Our-work/community-urgent-care-consultation.htm  full consultation documents which are located on BHR CCG websites: http://www.barkingdagenhamccg.nhs.uk/Our-work/community-urgent-care-consultation.htm http://www.haveringccg.nhs.uk/Our-work/community-urgent-care-consultation.htm http://www.redbridgeccg.nhs.uk/Our-work/community-urgent-care-consultation.htm

Introduction Barking and Dagenham, Havering and Redbridge (BHR) Clinical Commissioning Groups (CCG) are the NHS organisations that plan, design and buy (commission) local health services.

Below are extracts from the pre-consultation business case: In Barking and Dagenham, Havering and Redbridge (BHR), as with other parts of England, increasing numbers of people are using NHS services every year. The current urgent and emergency care system does not provide a good experience for patients as it can lead to a long wait to see a GP or in accident and emergency (A&E), and also puts increasing pressure on the hard-working frontline staff and clinicians.

The clinical commissioning groups (CCGs) cannot leave the system as it is currently. Doing nothing will not help to resolve the challenges in the urgent and emergency care system and will not ease the pressure on the emergency department, leading to an un-sustainable model of care for the population. There is a need to deliver a simpler, cost-effective system that meets future needs.

Two options have been developed for the future model that has been shared with the public as a formal consultation to determine the best fit for the future (see boxes below).

Both options also include a move towards booked appointments for urgent care needs, building on call or click before patients come in. They will utilise NHS 111 as a way to help people get the right care, right place, first time.

Audits have demonstrated that people are attending, and being seen in A&E for conditions that can be managed in an Urgent Treatment Centre (UTC) or in the community. BHR CCGs are currently working with providers in the system to strengthen the streaming in the urgent treatment centres and ensure the maximisation of attendances that can appropriately be seen in this setting. This will reduce the number of patients seen in A&E and ensure that performance is improved.

During BHR CCG engagement work the public has consistently given a clear message that urgent and emergency care services are confusing. BHR CCGs feel both options will help to address this critical issue - and future-proof urgent care.

All sites (including UTCs) would have bookable appointments through NHS 111.

Option 1 would see 12 sites in total, with four Urgent Treatment Centres (UTCs) open within Barking and Dagenham, Havering and Redbridge (2 on hospital sites, and 2 in the community), plus eight locations for booked community urgent care services.

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Transport consideration for both Options BHR travel analysis shows that the vast majority of local residents are currently and will be within a 15 minute drive of a community urgent care service.

Option 1 - map of services and drive time analysis for services within the BHR geography:

Option 2 - map of services and drive time analysis for services within the BHR geography:

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Accessing centres without a car

BHR CCGs will ensure that alternative methods of reaching the centres are publicised on their websites and this will be included in the communications and engagement plan put into place during mobilisation to support change. Below are examples of the information that will be available: All three boroughs have access to the London Taxi Card Scheme which provides subsidised door to door journeys in licensed taxis and private hire vehicles for London residents who have serious mobility or visual impairments. https://www.londoncouncils.gov.uk/services/taxicard

Transport for London operate a ‘Hopper fare’ that allows passengers to have unlimited bus and tram journeys in one hour for the price of one fare. This scheme keeps the cost of travel to the centres to a minimum if patients need to use more than one bus to reach a centre or if they are sign-posted to an alternative centre within one hour. https://tfl.gov.uk/campgn/hopper-fare Each councils website transport section: http://careandsupport.lbbd.gov.uk/kb5/barkingdagenham/asch/adult.page?adultchannel=4_1 https://www.havering.gov.uk/info/20027/travel https://www.redbridge.gov.uk/roads-and-pavements/transport-services/passenger-transport-service/

TFL Public Transport Access Level (PTAL) scores for each of the centres The PTAL is a measure of access to the public transport network calculated by transport for London (TfL). For any given point in London, PTALs combine walk times from a chosen point (the building) to the public transport network (e.g. stations and bus stops) together with service frequency data at these locations. This provides an overall access score. There are 9 accessibility levels between 0 and 6b (6b would be achieved by the most accessible sites in London). PTAL 2015 is the most recent year published and PTAL 2021 is the projected rating for 2021 after planned transport enhancements.

The current BHR urgent care sites PTAL scores are in the table below - the highest score is 4 and the lowest is 1b. This demonstrates BHR has accessibility as would be expected for outer London.

Site Postcode PTAL 2015 PTAL 2021 Queens Hospital RM7 0AG 2 2 King George Hospital IG3 8YB 2 2 Harold Wood Polyclinic RM3 0FE 1b 1b Barking Community Hospital IG11 9LX 2 3 Loxford Polyclinic IG1 2SN 2 2 South Hornchurch RM13 7XR 2 2 Broad St RM10 9HU 1b 1b Rosewood RM12 5NJ 1b 1b Southdene E18 1BD 4 4 Newbury Park IG2 7LE 3 3 Fulwell Cross IG6 2HG 3 3 North St RM1 4QJ 3 3 Grays Court RM10 9SR 2 2

Consultation process

Included the following: 249 4

 A 14 week, three-borough consultation, running, running from 29 May to 4 September 2018  Online consultation in line with previous successful Spending Money Wisely consultations  Consultation promoted through social media and other established channels, through media releases, posters, and advertisements, and via newsletters, stakeholders and existing forums  Printed copies of a flyer (written in plain English) promoting the consultation to be widely circulated throughout the three boroughs  Presented at the BHR patient engagement forums (PEF)  Actively engaged with Healthwatch and other local stakeholders  Attended meetings with local stakeholders as requested  Proactively engaged the voluntary and community sector  Key stakeholders identified, with a targeted focus on hard to reach groups, parents of young children and young adults as high or frequent users of UEC services

A large number of groups were proactively approached and offered CCG representatives to present on the proposals to their members. A number of those contacted responded inviting us to do so. Other groups contacted the CCGs asking us to present on the proposals. The CCGs were also asked to present to two groups by representatives who had attended the Havering Compact meeting. The format of these meetings usually involved a presentation, followed by a question and answer session. Attendees discussed the proposals, asked questions and then some submitted responses. The meetings at which the clinical leads and CCG representatives presented were as follows: Date Borough Name of meeting 11 June Redbridge Age UK 14 June Barking and Dagenham Barking and Dagenham Council for Voluntary Services 18 June Redbridge Redbridge Gujarati Welfare Association 18 June All three boroughs North East London Local Pharmaceutical Committee 19 June Redbridge Redbridge Asian Mandal 21 June Redbridge Redbridge Older Carers – coffee morning 25 June Barking and Dagenham The Learning Disabilities Advisory Partners 26 June Havering Havering Compact Forum 28 June Barking and Dagenham Somali Women’s Association 2 July Redbridge Redbridge Pensioners Forum 3 July Barking and Dagenham Barking and Dagenham Carers’ Forum 4 July Havering Havering CCG’s Patient Engagement Forum 9 July Barking and Dagenham Barking and Dagenham Diabetes Support Group 10 July Havering Havering Over 50s Forum 10 July Havering Independent Living Association 11 July Havering Havering Health and Wellbeing Board

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Date Borough Name of meeting 11 July Redbridge Redbridge Council for Voluntary Services 16 July Havering Havering Dementia Carers Support Group 17 July Redbridge Redbridge Patient Engagement Forum 18 July Redbridge Redbridge Children and Young People’s Network 18 July Redbridge Redbridge Health Overview and Scrutiny Committee 24 July Redbridge Redbridge Faith Forum 24 July Barking and Dagenham Barking and Dagenham CCG’s Patient Engagement Forum 26 July All three boroughs Joint Health Overview and Scrutiny Committee 31 July Havering Havering Hub Carers Forum

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Demographic profiles Barking and Dagenham The overall population of Barking and Dagenham is currently 190,560 people (based on 2012 ONS figures). And 225,327registered with a GP as at 1 October 2018 (NHS Digital https://app.powerbi.com/view?r=eyJrIjoiNjQxMTI5NTEtYzlkNi00MzljLWE0OGItNGVjM2QwNjAzZGQ0IiwidCI6IjUwZjYwNzFmLWJi ZmUtNDAxYS04ODAzLTY3Mzc0OGU2MjllMiIsImMiOjh9)

Age Since 2001, Barking and Dagenham has seen rapid population growth, linked to both new housing development and birth rate changes. The population structure has changed significantly with particularly large increases in the numbers of younger people living in the borough. The main component of population change across the London boroughs over the last decade has been and remains natural increase which is the result of having more births than deaths.

Children and young people place particular demands on urgent and emergency care services as do older and frail elderly people. 0 – 19 Barking and Dagenham has a young population, with the highest proportion of 0–19s in the UK (32%). More than one in four (26%) residents is aged 0–14, compared with 18% across England and 25% in London, and this proportion has increased from 22% in 2001.

Barking and Dagenham had the highest birth rate in England and Wales in 2016; there were 3,973 live births - a rate of 86.5 live births per 1,000 women aged 15–441.

Older people 12.03% of the patients registered with a local GP are aged between 60 and 90+ years. This is the lowest percentage of older adults in the BHR region.

Disability In Barking and Dagenham the recorded prevalence of dementia (aged 65+) was 4.32% in Barking and Dagenham in 2016, similar to both London and England (4.54% and 4.31% respectively).

It is estimated that 3.9% of adults in the Barking and Dagenham adult population were in contact with secondary mental health services in 2014/15. This is slightly below the London and national averages of 4.7% and 5.4% respectively.

Complex health and social care needs and disability Barking and Dagenham has the second lowest disability-free life expectancy for women aged 65 in London, which is also significantly lower than the England estimate.

Essentially this means that women over the age of 65 in Barking and Dagenham are more likely to live with limiting longstanding illness or disability at age 65 than women living in other areas of London and some parts of England. Years of living with disability in particular at an old age increases dependence on the health and care system.2

Deaf and hearing impairment Action on Hearing Loss estimate that 1 in 7 of the UK population has some level of hearing impairment, there are likely to be approximately 24,000 people in the borough with hearing loss. 847 people who use adult social services provided by the Council are known to have some level of hearing loss of whom 516 are registered with Barking & Dagenham Council as being Deaf or hard of hearing (19% from BME

1 https://www.lbbd.gov.uk/sites/default/files/attachments/JSNA-2017-report.pdf

2 https://www.lbbd.gov.uk/sites/default/files/attachments/JSNA-2017-report.pdf 252 7

backgrounds) and 133 are known to use BSL (British Sign Language). This low proportion of people with hearing impairment reaching the Council’s register indicates that large numbers of people are not accessing specialist services that could help them. https://www.lbbd.gov.uk/sites/default/files/attachments/7.5-Sensory-disability-eye-health-and-low-vision- 2016.pdf

Ethnicity 49.52%, white population, 50.48% BAME population.

Barking and Dagenham has seen a rapid shift in the proportions of various ethnic groups, with a large decrease in the White British ethnic group and a large increase in the Black African ethnic group.

Languages spoken 81.3% of people living in Barking and Dagenham speak English. The other top languages spoken are 2.3% Lithuanian, 2.0% Bengali, 1.7% Urdu, 1.0% Polish, 0.9% Panjabi, 0.8% Albanian, 0.8% Portuguese, 0.7% French, 0.7% Romanian.3

Long term condition prevalence in ethnic groups Barking and Dagenham has the sixth highest prevalence of diabetes in London. People of Asian ethnic origin are six times more likely to have diabetes, while people of black ethnic origin are four times more likely to have diabetes than the white population.

Traveller population There is limited evidence on the number, however the local authority aims to provide essential services to the Traveller and Gypsy communities in the borough demonstrating their presence.

Pregnancy and maternity Barking and Dagenham had the highest birth rate in England and Wales in 2016; there were 3,973 live births - a rate of 86.5 live births per 1,000 women aged 15-444. Urgent care services undertake pregnancy testing as a part of diagnosing minor illness, however pregnancy and maternity care is delivered by specialist maternity / pregnancy services which are not part of the current or proposed urgent care pathways.

Gender Barking and Dagenham has the second lowest disability-free life expectancy for women aged 65 in London, which is also significantly lower than the England estimate.

Women over the age of 65 in Barking and Dagenham are more likely to live with limiting longstanding illness or disability at age 65 than women living in other areas of London and some parts of England. Years of living with disability in particular at an old age increases dependence on the health and care system5.

Deprivation Barking and Dagenham is one of the most deprived boroughs in England. It has the twelfth highest index of multiple deprivation (IMD) score in England (based on 326 local authority districts, where one is the most deprived and 326 is the least deprived) third highest IMD score in London.

Gascoigne, Heath, Thames and Village wards all had neighbourhoods amongst the 10% most deprived in the country. Alibon and Mayesbrook wards were amongst the 20% most deprived in the country. Longbridge was the only ward without any neighbourhoods amongst the 30% most deprived in the country6

3 http://localstats.co.uk/census-demographics/england/london/barking-and-dagenham

4 https://www.lbbd.gov.uk/sites/default/files/attachments/JSNA-2017-report.pdf

5 https://www.lbbd.gov.uk/sites/default/files/attachments/JSNA-2017-report.pdf

6 https://www.lbbd.gov.uk/poverty-and-deprivation 253 8

The health of people in Barking and Dagenham is varied compared with the England average. Life expectancy for both men and women is lower than the England average.*

Homelessness directly links to health, as homeless individuals and families are likely to be less healthy than the general population. Homelessness is associated with poor health, educational, and social outcomes, especially for children.

Shelter report in December 20167 shows homeless figures for three boroughs:  Barking and Dagenham – 1 in 40 people are homeless  Havering – 1 in 128 people are homeless  Redbridge – 1 in 48 people are homeless

Car ownership According to the 2001 census, 62% of households in the borough have access to at least one car. This compares to 63% and 71% for London and outer London respectively.

The borough also has lower than average households with one, two or more cars. The level of households without access to a car is similar to all of London, though more than Outer London8.

Havering There are 256,039 (https://www.haveringdata.net/population-demographics/) people living in Havering and 279,321 people registered with a Havering GP as at 1 October 2018.

Age 0-19 From 2009 to 2014, Havering experienced the largest net inflow of children across all London boroughs, with 4,606 children settling here from another London borough.9

As well as increases in the number of births, there has been an increase in the general fertility rate from 54 births per 1,000 women aged 15-44, in 2003 to 66 in 2014. From 2009 to 2014, Havering experienced the largest net inflow of children across all London boroughs, with 4,606 children settling here from another London borough.

Age older people Havering has the oldest population in London with a median age of 40 years, as recorded in the 2011 census. There is a much older age structure for the population of Havering compared to London but similar to England.

Notwithstanding Havering having oldest population in London, an increasing older population across the UK leads to frail elderly residents who live alone and are often isolated. This can result in patients presenting at A&E and/or requiring ambulance services even if their presenting medical condition could be managed at home if the necessary support was in place in the community.

Disability

7https://england.shelter.org.uk/media/press_releases/articles/life_on_the_margins_over_a_quarter_of_a_million_witho ut_a_home_in_england_today

8 https://www.lbbd.gov.uk/sites/default/files/attachments/Chapter-2.pdf 9 https://www.haveringdata.net/wp-content/uploads/2018/09/Published-201819_Havering-Demographic-Profile- v4.1.pdf

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The prevalence of depression ranges from 53.6 per 1,000 persons aged 17 and over in Upminster - to 111.5 per 1,000 persons aged 17 and over in Gooshays (i.e. more generally more common with increasing deprivation).

Dementia is more common in Havering than London but similar to England; and it will be an increasing problem for Havering because of its ageing population.10

Complex health and social care needs, and disability There is an increasing number of Havering residents living with long term conditions (LTCs) - this has a significant impact on daily lives including the use of urgent and emergency health and social care services. Havering CCG patients with five or more LTCs are five times more likely to attend A&E, 20 times more likely to be admitted for an emergency, and the average number of inpatient bed days will be 37 times greater compared to patients with no LTC.

Deaf and hearing impairment There is limited data available on deafness and hearing impairment in Havering; however, there are currently 44 people in Havering registered with a dual sensory loss. Out of these, 2 people are registered as severely sight impaired and severe hearing loss. The Centre for Disability Research has estimated that the number of people with deaf blindness will increase by 60% in the next 16 years. (https://www3.havering.gov.uk/Documents/Adults-and-older-people/Disabled-adults/strategy-for-eye-care- and-inclusion-2013-16.pdf)

Ethnicity 86% white population, 14% BAME population.

Havering is one of the most ethnically homogenous places in London, with 83% of its residents recorded as White British, higher than both London and England. About 90% of the population were born in the United Kingdom. It is projected that the Black African population will increase from 3.8% (2015) to 5.2% in 2030.

Languages spoken The latest School Census (January 2014) reported that 9.4% of school-aged children in Havering speak a language other than English, with 10 most spoken languages (after English) in Havering being: Yoruba, Lithuanian, Urdu, Polish, Bengali, Romanian, Punjabi, Albanian, French & Turkish.11

Traveller population There were 137 caravans occupied by travellers in Havering as at January 2018. This number is an increase of seven from the last six-month count - there has been a steady increase in the total number of travellers over the past four counts. About 83% of the traveller caravans in Havering were on unauthorised sites, as at July 2015.

Long term condition prevalence in ethnic groups In Havering, the number of people living with diabetes is on the increase. The prevalence of diabetes is lowest in Romford Town (47.5 per 1000 persons aged 17 and over) and highest in South Hornchurch (68.3 persons aged 17 and over) where there is the highest proportion of non-white ethnicities.12

Pregnancy and maternity

10 https://www.havering.gov.uk/download/downloads/id/1533/havering_health_and_wellbeing_strategy_2017.pdf

11 https://www3.havering.gov.uk/Documents/Equality-and- Diversity/Demographic_and_Diversity_Profile_of_Haverings_Population_Mar-14.pdf

12 https://www.havering.gov.uk/download/downloads/id/1533/havering_health_and_wellbeing_strategy_2017.pdf 255 10

As well as increases in the number of births, there has been an increase in the general fertility rate from 54 (per 1,000 women aged 15-44) in 2003 to 66 in 201413. Urgent care services undertake pregnancy testing as a part of diagnosing minor illness, however pregnancy and maternity care is delivered by specialist maternity / pregnancy services which are not part of the current or proposed urgent care pathways.

Gender There are no significant statistics on gender to be reported here.

Deprivation Havering ranks 102 out of 152 upper tier local authorities in England with rank one being the most deprived. Havering is a more affluent area than Barking and Dagenham and Redbridge, being ranked 166th overall out of 326 local authorities for deprivation.

However the borough still has pockets of poverty. Two wards, Gooshays and Heaton, fall into the 20% most deprived areas in England. When compared to Barking and Dagenham, Havering has a relatively small proportion of children living in poverty, however this has risen in recent years, bucking the trend seen in most other London borough of declining levels of child poverty.

Unemployment levels in 2015 were lower than London and national rates (5.3%).

The people of Havering are generally fairly healthy. Life expectancy is long and residents and visitors to the borough benefit from plenty of high quality parks and open spaces.

The borough has a rate of short-term international migrants of 77 per 100,000 population, the lowest of all London local authorities. A short-term international migrant is someone who visits a country other than that of his or her usual residence for a period of between 1 and 12 months, as opposed to a long-term migrant, who changes their country of usual residence for a year or more. (https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/internationalmigration/bull etins/shortterminternationalmigrationannualreport/mid2015estimates)

Homelessness Rates of statutory homelessness are significantly higher in all three boroughs than the national average with Barking and Dagenham, and Redbridge six and seven times the national rates respectively. Homelessness directly links to health, as homeless individuals and families are likely to be less healthy than the general population. Homelessness is associated with poor health, educational, and social outcomes, especially for children.

Shelter report in December 201614 shows homeless figures for three boroughs:  Barking and Dagenham – 1 in 40 people are homeless  Havering – 1 in 128 people are homeless  Redbridge – 1 in 48 people are homeless

Car ownership

13 https://www.haveringdata.net/wp-content/uploads/2018/09/Published-201819_Havering-Demographic-Profile- v4.1.pdf

14 https://england.shelter.org.uk/media/press_releases/articles/life_on_the_margins_over_a_quarter_of_a_million_witho ut_a_home_in_england_today 256 11

The number of cars and vans available to households in Havering was 117,634 in 2011. 77% of households in Havering have at least one car and compared to other local authorities in London, Havering has the second highest proportion of households (32.8%) with two or more cars.15

Redbridge The overall population of Redbridge is currently 296,800 people (based on 2015 ONS figures), and 324,021 registered with a GP as at 1 October 2018.

Redbridge has a growing and mobile population. In 2014 the population was estimated to be 293,055 (ONS mid-year estimate). It is predicted that the population will grow by another 40,000 (13.5%) by 2021, with the greatest growth being in numbers of children. By 2021 it is predicted that 28% of the population will be aged under 20 years.

Age 0-19 There are is a greater proportion of children and young people aged under 19 years (27.6%) than in comparison to London (24.7%) and England (23.7%). https://redbridge.gov.uk/media/3496/jsna-in-breif.pdf

There was a 34% increase in births between 2004 and 2014 although the rate of increase appears to be levelling off.

Age over 65 / older adults There is projected to be a 19% increase in the numbers of people aged over 85 years by 2021, with a consequent effect on demand for services for this age group

Extract from Redbridge Pharmaceutical Needs Assessment 2010: Many users of urgent care are from the more vulnerable members of society, such as children under five years of age, older people, people living in deprivation, and individuals with complex health needs.

Social deprivation and age related vulnerability are considered to be two of the most important determinants of the demand for urgent care out-of-hours. (Shah and Cook 2008, NJ Mclellan 2004).16

Disability Mental health There is limited data to demonstrate the mental wellbeing of Redbridge residents.

An estimated 18% of the population, around 46,000 people, are affected by a common mental disorder like depression and anxiety, with more women (56%) affected than men (44%). Estimated prevalence rates of severe mental illness, including schizophrenia are 0.7%, equivalent to 1,138 people; estimated prevalence of Post Traumatic Stress Disorder is 3%, personality disorders 0.4%, eating disorders 6.4%. An estimated 10,000 people in Redbridge will have had an episode of self harm in their lifetime.

Risk factors for mental illness include black ethnicity, unemployment, low educational level, low income, insecure or poor housing, living alone, experiencing domestic violence. In general the levels of these risk factors are lower in Redbridge than in London as a whole. Mental and physical illnesses often co-exist and can result in higher mortality. Physical illness can make people more prone to depression, and people with mental disorders may take less care of themselves.

On average people with mental illness die 5-20 years younger than the general population. • Redbridge has a higher rate of admission for mental health conditions than England but not significantly different to London.

15 https://www.haveringdata.net/wp-content/uploads/2018/09/Published-201819_Havering-Demographic-Profile- v4.1.pdf 16 https://redbridge.gov.uk/media/2199/pharmaceutical-needs-assessment.pdf

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• In 2012/13 44% of mental health admissions in adults were due to mental and behavioural disorders due to the use of alcohol. This represents a very considerable burden. • Analysis of admissions by ethnicity show that there may be under-representation of admissions among people with Bangladeshi, Pakistani and Indian backgrounds. (https://www.redbridge.gov.uk/media/2189/jsna-executive-summary.pdf)

Complex health and social care needs, and disability There are increasing numbers of residents who experience long term and sometimes complex conditions such as diabetes and dementia which significantly impact use of health and social care services.

Deaf and hearing impairment There is predicted to be a 12% increase in numbers of adults who have a moderate or severe hearing impairment, from 20,855 in 2012 increasing to 23,487 in 2020.There are 1,293 adults and children who have registered as having deafness or hearing loss. This includes 198 residents who are deaf without speech. (https://www.redbridge.gov.uk/media/2189/jsna-executive-summary.pdf)

Ethnicity 37.58%, white population, 62.42% BAME population.

Languages spoken 75.4% of people living in Redbridge speak English. The other top languages spoken are 3.8% Urdu, 3.1% Panjabi, 2.6% Tamil, 2.5% Bengali, 2.3% Gujarati, 1.0% Lithuanian, 0.9% Polish, 0.7% Hindi, 0.7% Romanian.17

Traveller population - Redbridge There is limited evidence on the Traveller population in Redbridge, however, in 2018 Travellers have attempted to settle in the borough only twice since a temporary injunction was introduced during the summer by Redbridge Council, according to official reports.

Long term condition prevalence in ethnic groups People of Asian ethnic origin are six times more likely to have diabetes, while people of black ethnic origin are four times more likely to have diabetes than the white population. A higher proportion of residents have diabetes than the average for London or England - with an estimated 12% of residents projected to have type 2 diabetes by 2030. Type 2 prevalence is related to a higher risk of diabetes among South Asian communities and increasing numbers of residents who are overweight or obese. In addition, it is very likely that there is a high level of undiagnosed/unreported diabetes among Redbridge residents as levels of recorded diabetes are lower than predicative models would suggest18.

Pregnancy and maternity Between 2005-2015 Redbridge saw a large percentage rise in the number of births, although the rate of increase appears to be levelling off. (https://files.datapress.com/london/dataset/birth-trends-in-london/2016- 12-01T15:26:00/update-08-2016-birth-trends-london.pdf). Urgent care services undertake pregnancy testing as a part of diagnosing minor illness, however pregnancy and maternity care is delivered by specialist maternity / pregnancy services which are not part of the current or proposed urgent care pathways.

Gender There are no significant statistics on gender to be reported here.

Deprivation

17 http://localstats.co.uk/census-demographics/england/london/redbridge

18 https://redbridge.gov.uk/media/3496/jsna-in-breif.pdf 258 13

Redbridge ranks 138th out of 326 local authorities on 2015 Index of Multiple Deprivation (with one being the most deprived), but there is wide variation across the borough with some wards predominantly in the lowest two quintiles for deprivation and some in the highest two quintiles. Overall the borough has a deprivation score or ranking (see above) of 5.2 compared with 4.8 for London and 5 for England, implying slightly less deprivation than in other areas. There is variation across the borough with Cranbrook and Loxford with a score of 3.9 indicating more deprivation, and Wanstead and Woodford with a figure of 6.9 indicating a less deprived area19.

The health of people in Redbridge is generally better than the England average. About 14% (8,900) of children live in low income families. Life expectancy for both men and women is higher than the England average. However, life expectancy is 7.8 years lower for men and 4.3 years lower for women in the most deprived areas of Redbridge than in the least deprived areas.20

Extract from Redbridge Pharmaceutical Needs Assessment 2010: Social deprivation and age related vulnerability are considered to be two of the most important determinants of the demand for urgent care out-of-hours. (Shah and Cook 2008, NJ Mclellan 2004).21

Shelter report in December 201622 shows homeless figures for three boroughs:

 Barking and Dagenham – 1 in 40 people are homeless  Havering – 1 in 128 people are homeless  Redbridge – 1 in 48 people are homeless

Car ownership Average cars per house in Redbridge in 2011 was 1.1, which is unchanged since 2001. There was in fact little change in the proportions of households who had no car, one car, two cars, or three or more cars23.

19 https://www.redbridge.gov.uk/media/4392/redbridge-draft-pna-report-2018-for-consultation.pdf 20 Public Health England Health Profiles 2018

21 https://redbridge.gov.uk/media/2199/pharmaceutical-needs-assessment.pdf

22 https://england.shelter.org.uk/media/press_releases/articles/life_on_the_margins_over_a_quarter_of_a_million_witho ut_a_home_in_england_today

23 https://www.redbridge.gov.uk/media/2319/draft-redbridge-borough-profile_reduced.pdf 259 14

Updated equality impact assessment (EIA) The following tables set out EIA considerations of the two community urgent care pathway options proposed by BHR CCGs in a recent public consultation. The first table sets out potential EIA considerations and how the proposed urgent care pathway changes will respond or mitigate them, the second table sets out positive impacts of the proposed urgent care pathway changes.

The two options have been analysed against the protected characteristics to understand any unequal impacts on particular groups. The table sets out the findings of that analysis, identified themes from consultation responses, and potential mitigating strategies.

Protected Initial EIA Potential EIA EIA impact – response / mitigations groups recommend considerations ations/ mitigating actions Age No impact - Accessibility for older NHS 111 clinical advice service (or CAS) - allows telephone people and children NHS 111 health advisors to fast-track transfer children and online aged under one and people aged 65 and older to a access will GP or other health professional for advice and be available assessment.

NHS 111 provides training for staff regarding patients with specific issues such as:  The elderly and confused patients  Calls relating to under fives

Care home staff have priority access to the NHS 111 clinical advice service through the *5 advice line

Equality impact is equal for both option one and option two of BHR CCGs proposals for community urgent care pathways. Disability No impact - Accessibility for: NHS 111 staff are trained to ensure call handlers as NHS 111 manage patients in line with local mental health crisis has access  Mental health plans when they are available and are aware of the to a BSL  learning specialist services available in BHR for mental health interpreter for disabilities patients. those unable  Anxiety to and in the disorders The local NHS 111 service has enhanced links with future a  Autism the local mental health crisis line so patients calling public on-line  Deaf or 111 can safely be transferred to a local mental health NHS 111 professional. hearing clinical assessment impaired NHS 111 requires providers to have systems,

tools service technology and procedures in place to enable access for persons with hearing impairment or requiring interpretation services and the provider will be monitored on their adherence to standards set regards access for these services.

NHS 111 also has processes in place to improve access to callers who may other communication challenges for example learning disabilities, anxiety disorders, autism. This is achieved by appropriate training for front line staff to recognise these issues quickly and pass the call to a clinician who will have 260 15

greater ability to identify the issue quickly and determine the course of action needed.

NHS 111 is legally required to follow the NHS Accessible Information Standard.

Equality impact is equal for both option one and option two. Race and Ethnicity – Accessibility for: NHS 111 has systems, technology and procedures in ethnicity No impact – Non English speakers place to enable access for persons with hearing as NHS 111 or people for whom impairment or requiring interpretation services and the has access English is not their first provider will be monitored on their adherence to to interpreter language standards set regards access for these services. This services includes a text phone service.

There is potential for a disproportionate effect if people for whom English is not their first language are not aware that calling NHS 111 will give access to translation services. It is therefore recommended that engagement with and publicising the change is carried out as widely as possible with BAME and non-English speaking communities. This would be further mitigated by the commitment to explore installing telephone access for residents who walk in to call NHS 111 for health advice and bookable appointments at sites where walk in access is changing to bookable.

Equality impact for languages spoken is equal for both option one and option two.

Long term condition Long term condition prevalence in ethnic groups prevalence in ethnic Most complications of long term conditions (LTCs) groups such as diabetes are best managed by primary care; while some of the acute symptoms such as strokes

are emergencies and need to be seen in specialist emergency departments such as Queen’s Hospital. When calling NHS 111 people with LTCs will be clinically assessed and clinical advice offered. Many people may get all the advice they need through the

phone. For those who need to be seen, both options will offer more pre-booked appointments with GPs and nurses in community locations. 111 will dispatch an ambulance for those who have an emergency and need to be seen as an emergency.

Equality impact for LTCs is positive and is equal for both option one and option two

Travellers will not be There is potential for a disproportionate effect if aware of the new model Traveller and Gypsy communities are not aware that some locations have changed from walk-in services to bookable services. This would be mitigated by the commitment to explore installing telephone access for residents who walk in to call NHS 111 for health

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advice and bookable appointments at sites where walk in access is changing to bookable.

Equality impact for the Traveller and Gypsy population is greater under option two. Pregnancy / No impact No negative equality Maternity impact identified for this group Gender No impact No negative equality impact identified for this group Sexual No impact No negative equality orientation impact identified for this group Religion No impact No negative equality impact identified for this group Gender re- No impact No negative equality assignment impact identified for this group Marriage/ No impact No negative equality civil impact identified for this partnership group Deprivation The proposed sites for The most deprived parts of BHR are in the south west UTCs are not located and north east: near areas of highest deprivation.

Under option one there are urgent treatment centres (UTCs) proposed near each of these areas. Under option two UTCs are centralised to the two hospital sites and therefore would have a higher equality impact to those in the more deprived areas within Barking and Dagenham, Havering, and Redbridge due to a need to travel further to a UTC for minor injuries.

There is potential for a disproportionate effect if communities in areas of deprivation are not aware of the change to bookable services. This would be mitigated by the commitment to explore installing telephone access for residents who walk in to a site where walk in access changes to bookable to call NHS 111 for health advice and bookable appointments. 262 17

There is potential for a disproportionate effect if homeless people are not aware where walk in services change to bookable services; this would be Homeless people would mitigated by the CCGs commitment to explore have reduced access to installing a telephone for residents who walk in to call urgent care under the NHS 111 for health advice and bookable new model. appointments.

Under option two UTCs are centralised to the two hospital sites and therefore would have a higher equality impact to those without a car due to a need to Car ownership travel further to a UTC for injury management. This has potential for a disproportionate effect on people who do not own/have access to a car to take them a 15-minute drive to any of the locations under option two.

Positive Impacts The following impacts have been identified as positive consequences of implementing the proposed community urgent care services:

Positive impact Group(s) impacted

The current confused model will be simplified to make it easier for ALL people to know where to go for help ALL Some people will be supported by NHS 111 on the phone and not need People with mobility issues, to travel at all people in areas of deprivation, people without access to a car. ALL Ability for unregistered patients to call NHS 111 and be booked an Homeless people appointment into all 12 sites (currently they can only access the 4 walk Traveller communities in centres and hospital sites) People new to the borough Booked appointments accessed via 111 will ensure that those needing to be seen are booked into the right place first time; this will reduce the wasted journeys that happen under the current model due to people ALL accessing services which do not meet their needs and then need to go onto another service. Whilst clinical services may currently access language translation Non English speakers or services the access hub call centre and receptionists do not, so the people for whom English is not translation services available through 111 are a benefit to non English their first language speakers or people for whom English is not their first language

The EIA considers that there is no adverse impact of the proposed changes to the urgent care pathway under Option one: 12 sites in total, with four Urgent Treatment Centres (UTCs) and eight bookable locations. It was identified that Option two would have a small, potentially disproportional impact due to a lower number of community locations being available that can manage injuries for traveller communities and those in areas of deprivation, homelessness and car ownership.

Further recommendations for consideration

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The Health and Social Care Act 2012 requires CCGs to reduce heath inequalities, therefore the risk of reducing access or introducing barriers should be avoided.

BHR CCGs should be mindful of the effort that is needed to support positive change in community behaviours/expectations.

 Consider a phased replacement of the walk-in appointments to bookable appointments.

 Ensure that transport options are publicised on CCG websites and be included in the communications and engagement plan put into place during mobilisation to support change.

 Notify Transport for London of the changes to the model so they can take these into account during their planning cycles.

Next steps This is the updated EIA, taking into account the proposed options and the consultation report. This will be included, along with the report on the consultation feedback, in the business case on making changes to community urgent care services will go to the BHR CCGs’ Joint Committee for consideration.

264 19 Appendix five How have the CCGs given due consideration to the government’s ‘four tests’ of service change as part of the community urgent care (CUC) consultation? o Strong public and patient engagement.

Our pre consultation engagement for this work began back in 2015 with a local urgent care conference which informed our NHSE Vanguard bid. In March 2016 the CCGs commissioned a large research study which saw more than 4,000 responses from local people. This was followed by two further stakeholder workshops in 2016 and 2017. In March of this year we presented an outline of the consultation proposals to all three of our patient engagement forums across BHR and commissioned a further engagement exercise via our local Healthwatch. Post local elections in May 2018 we began a 12 week public consultation that was extended, following a request from the local JHOSC, to 14 weeks, and ended on 4 September. The public consultation saw our largest ever response with more than 1000 responses. Our recommendation is to agree the option supported by the majority of local people and stakeholders, and mitigations have been made to respond to points raised in relation to the changes to walk-in services. Full details of our extensive engagement can be found in the consultation report. o Consistency with current and prospective need for patient choice.

While directly reflecting guidelines in the government’s Five Year Forward View (increased use of NHS 111, more bookable appointments and the introduction of Urgent Treatment Centres (UTCs)), both of our proposals still offer 12 urgent community care sites and the full range of services – bookable rather than walk-in (albeit patients can still walk-in and book at UTCs if they wish). So patient choice is still key, but balanced with clinical signposting to the appropriate/right care. When patients call 111 they are assessed first to identify their need and how soon they need to be seen in line with clinical guidelines. Patients are then offered a choice of services, appointment time and location which meet their clinical and personal needs. o A clear, clinical evidence base.

Our community urgent care proposals are informed by latest national guidance, itself informed by a clear clinical evidence base. We want to deliver the right care in the right place by the right professional – and with ED capacity freed up for those who really need it. Clinical audits identified the need to reduce duplication as we are seeing multiple attendances by the same patients for the same condition – seeking a second opinion. We identified that duplication adds to pressure in EDs to deliver the 4 hour standard. It also leads to delay in the patient journey, antibiotic resistance and a lack of continuity of care. The Five Year Forward View’s guidance on delivering integrated urgent care - bookable appointments and UTCs – is based on its own clinical evidence. o Support for proposals from clinical commissioners. BHR CCGs are the clinical commissioners for the area. They are the body that have developed the proposals and are making the decision. The CCGs have previously considered and agreed the case for change and the pre-consultation business case that set out the proposals that have been consulted on. To address issues around conflict of interest and the possibility that local clinicians may look to provide services as part of any future procurement, the CCGs appointed an independent clinical lead for this work

265 at the start. We discussed the proposals at a series of clinical workshops, which included GPs and other providers, where our case for change and consultation proposals were reviewed. All local clinicians were encouraged to respond to the consultation.

N.B. The recently introduced 5th test for change concerns those proposals that it is not relevant for this consultation

The CCGs are discharging their statutory duties and in particular the duty to have regard to the need to reduce health inequalities between patients (as set out in the Equalities Impact Assessment).

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