AGENDA
Meeting Health Committee Date Wednesday 19 April 2017 Time 10.00 am Place Chamber, City Hall, The Queen's Walk, London, SE1 2AA Copies of the reports and any attachments may be found at www.london.gov.uk/mayor-assembly/london-assembly/health
Most meetings of the London Assembly and its Committees are webcast live at www.london.gov.uk/mayor-assembly/london-assembly/webcasts where you can also view past meetings.
Members of the Committee Dr Onkar Sahota AM (Chair) Andrew Boff AM Shaun Bailey AM (Deputy Chair) Unmesh Desai AM Jennette Arnold OBE AM
A meeting of the Committee has been called by the Chair of the Committee to deal with the business listed below. Mark Roberts, Executive Director of Secretariat Friday 7 April 2017
Further Information If you have questions, would like further information about the meeting or require special facilities please contact: Vishal Seegoolam, Principal Committee Manager; telephone: 020 7983 4425; email: [email protected]; minicom: 020 7983 4458
For media enquiries please contact: Lisa Lam; Telephone: 020 7983 4067; Email: [email protected]. If you have any questions about individual items please contact the author whose details are at the end of the report.
This meeting will be open to the public, except for where exempt information is being discussed as noted on the agenda. A guide for the press and public on attending and reporting meetings of local government bodies, including the use of film, photography, social media and other means is available at www.london.gov.uk/sites/default/files/Openness-in-Meetings.pdf.
There is access for disabled people, and induction loops are available. There is limited underground parking for orange and blue badge holders, which will be allocated on a first-come first-served basis. Please contact Facilities Management on 020 7983 4750 in advance if you require a parking space or further information.
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If you, or someone you know, needs a copy of the agenda, minutes or reports in large print or Braille, audio, or in another language, then please call us on 020 7983 4100 or email [email protected].
Certificate Number: FS 80233
Agenda Health Committee Wednesday 19 April 2017
1 Apologies for Absence and Chair's Announcements
To receive any apologies for absence and any announcements from the Chair.
2 Declarations of Interests (Pages 1 - 4)
Report of the Executive Director of Secretariat Contact: Vishal Seegoolam, [email protected], 020 7983 4425
The Committee is recommended to:
(a) Note the list of offices held by Assembly Members, as set out in the table at Agenda Item 2, as disclosable pecuniary interests;
(b) Note the declaration by any Member(s) of any disclosable pecuniary interests in specific items listed on the agenda and the necessary action taken by the Member(s) regarding withdrawal following such declaration(s); and
(c) Note the declaration by any Member(s) of any other interests deemed to be relevant (including any interests arising from gifts and hospitality received which are not at the time of the meeting reflected on the Authority’s register of gifts and hospitality, and noting also the advice from the GLA’s Monitoring Officer set out at Agenda Item 2) and to note any necessary action taken by the Member(s) following such declaration(s).
3 Minutes (Pages 5 - 52)
The Committee is recommended to confirm the minutes of the meeting of the Committee held on 15 March 2017 to be signed by the Chair as a correct record.
The appendix to the minutes set out on pages 9 to 51 is attached for Members and officers only but is available from the following area of the Greater London Authority’s website: www.london.gov.uk/mayor-assembly/london-assembly/health
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4 Summary List of Actions (Pages 53 - 60)
Report of the Executive Director of Secretariat Contact: Vishal Seegoolam, [email protected], 020 7983 4425
The Committee is recommended to note the completed and outstanding actions arising from its previous meetings.
5 Offender Mental Health (Pages 61 - 68)
Report of the Executive Director of Secretariat Contact: Lucy Brant; [email protected]; 020 7983 4000
The Committee is recommended to:
(a) Note the report as background for the discussion with invited guests and note the subsequent discussion; and
(b) Delegate authority to the Chair, in consultation with the Deputy Chairman, to agree any output from the discussion.
6 Deaf and Disabled Londoners Access to Mental Health Services (Pages 69 - 90)
Report of the Executive Director of Secretariat Contact: Lucy Brant; [email protected]; 020 7983 4000
The Committee is recommended to agree its report Mental Health – Disabled and Deaf People, as attached at Appendix 1 to this report.
7 Health Committee Work Programme (Pages 91 - 94)
Report of the Executive Director of Secretariat Contact: Lucy Brant; [email protected]; 020 7983 4000
The Committee is recommended to: (a) Note the topics covered during 2016/17; (b) Agree its priority topics for 2017/18; (c) Delegate authority to the Chair, in consultation with the Deputy Chair, to agree: The terms of reference and scope of the proposed review of the Mayor’s Health Inequalities Strategy;
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Any further outputs relating to the Committee’s investigations into mental health inequalities and Sustainability and Transformation Plans; Arrangements for any site visits, informal meetings or engagement activities before the Committee’s next formal meeting.
8 Date of Next Meeting
Subject to confirmation at the Annual Meeting of the Assembly on 3 May 2017, The next meeting of the Committee is scheduled for Tuesday 27 June 2017 at 10 am in Committee Room 5, City Hall.
9 Any Other Business the Chair Considers Urgent
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This page is intentionally left blank Agenda Item 2
Subject: Declarations of Interests
Report to: Health Committee
Report of: Executive Director of Secretariat Date: 19 April 2017
This report will be considered in public
1. Summary
1.1 This report sets out details of offices held by Assembly Members for noting as disclosable pecuniary interests and requires additional relevant declarations relating to disclosable pecuniary interests, and gifts and hospitality to be made.
2. Recommendations
2.1 That the list of offices held by Assembly Members, as set out in the table below, be noted as disclosable pecuniary interests1;
2.2 That the declaration by any Member(s) of any disclosable pecuniary interests in specific items listed on the agenda and the necessary action taken by the Member(s) regarding withdrawal following such declaration(s) be noted; and
2.3 That the declaration by any Member(s) of any other interests deemed to be relevant (including any interests arising from gifts and hospitality received which are not at the time of the meeting reflected on the Authority’s register of gifts and hospitality, and noting also the advice from the GLA’s Monitoring Officer set out at below) and any necessary action taken by the Member(s) following such declaration(s) be noted.
3. Issues for Consideration
3.1 Relevant offices held by Assembly Members are listed in the table overleaf:
1 The Monitoring Officer advises that: Paragraph 10 of the Code of Conduct will only preclude a Member from participating in any matter to be considered or being considered at, for example, a meeting of the Assembly, where the Member has a direct Disclosable Pecuniary Interest in that particular matter. The effect of this is that the ‘matter to be considered, or being considered’ must be about the Member’s interest. So, by way of example, if an Assembly Member is also a councillor of London Borough X, that Assembly Member will be precluded from participating in an Assembly meeting where the Assembly is to consider a matter about the Member’s role / employment as a councillor of London Borough X; the Member will not be precluded from participating in a meeting where the Assembly is to consider a matter about an activity or decision of London Borough X.
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Member Interest Tony Arbour AM Member, LFEPA; Member, LB Richmond Jennette Arnold OBE AM Committee of the Regions Gareth Bacon AM Member, LFEPA; Member, LB Bexley Kemi Badenoch AM Shaun Bailey AM Sian Berry AM Member, LB Camden Andrew Boff AM Congress of Local and Regional Authorities (Council of Europe) Leonie Cooper AM Member, LFEPA; Member, LB Wandsworth Tom Copley AM Unmesh Desai AM Member, LFEPA; Member, LB Newham Tony Devenish AM Member, City of Westminster Andrew Dismore AM Member, LFEPA Len Duvall AM Florence Eshalomi AM Member, LB Lambeth Nicky Gavron AM David Kurten AM Member, LFEPA Joanne McCartney AM Deputy Mayor Steve O’Connell AM Member, LB Croydon Caroline Pidgeon MBE AM Keith Prince AM Member, LB Redbridge Caroline Russell AM Member, LFEPA; Member, LB Islington Dr Onkar Sahota AM Navin Shah AM Fiona Twycross AM Chair, LFEPA; Chair of the London Local Resilience Forum Peter Whittle AM
[Note: LB - London Borough; LFEPA - London Fire and Emergency Planning Authority. The appointments to LFEPA reflected above take effect as from 3 April 2017]
3.2 Paragraph 10 of the GLA’s Code of Conduct, which reflects the relevant provisions of the Localism Act 2011, provides that:
- where an Assembly Member has a Disclosable Pecuniary Interest in any matter to be considered or being considered or at
(i) a meeting of the Assembly and any of its committees or sub-committees; or
(ii) any formal meeting held by the Mayor in connection with the exercise of the Authority’s functions
- they must disclose that interest to the meeting (or, if it is a sensitive interest, disclose the fact that they have a sensitive interest to the meeting); and
- must not (i) participate, or participate any further, in any discussion of the matter at the meeting; or (ii) participate in any vote, or further vote, taken on the matter at the meeting
UNLESS
- they have obtained a dispensation from the GLA’s Monitoring Officer (in accordance with section 2 of the Procedure for registration and declarations of interests, gifts and hospitality – Appendix 5 to the Code).
3.3 Failure to comply with the above requirements, without reasonable excuse, is a criminal offence; as is knowingly or recklessly providing information about your interests that is false or misleading. Page 2
3.4 In addition, the Monitoring Officer has advised Assembly Members to continue to apply the test that was previously applied to help determine whether a pecuniary / prejudicial interest was arising - namely, that Members rely on a reasonable estimation of whether a member of the public, with knowledge of the relevant facts, could, with justification, regard the matter as so significant that it would be likely to prejudice the Member’s judgement of the public interest.
3.5 Members should then exercise their judgement as to whether or not, in view of their interests and the interests of others close to them, they should participate in any given discussions and/or decisions business of within and by the GLA. It remains the responsibility of individual Members to make further declarations about their actual or apparent interests at formal meetings noting also that a Member’s failure to disclose relevant interest(s) has become a potential criminal offence.
3.6 Members are also required, where considering a matter which relates to or is likely to affect a person from whom they have received a gift or hospitality with an estimated value of at least £25 within the previous three years or from the date of election to the London Assembly, whichever is the later, to disclose the existence and nature of that interest at any meeting of the Authority which they attend at which that business is considered.
3.7 The obligation to declare any gift or hospitality at a meeting is discharged, subject to the proviso set out below, by registering gifts and hospitality received on the Authority’s on-line database. The on- line database may be viewed here: http://www.london.gov.uk/mayor-assembly/gifts-and-hospitality.
3.8 If any gift or hospitality received by a Member is not set out on the on-line database at the time of the meeting, and under consideration is a matter which relates to or is likely to affect a person from whom a Member has received a gift or hospitality with an estimated value of at least £25, Members are asked to disclose these at the meeting, either at the declarations of interest agenda item or when the interest becomes apparent.
3.9 It is for Members to decide, in light of the particular circumstances, whether their receipt of a gift or hospitality, could, on a reasonable estimation of a member of the public with knowledge of the relevant facts, with justification, be regarded as so significant that it would be likely to prejudice the Member’s judgement of the public interest. Where receipt of a gift or hospitality could be so regarded, the Member must exercise their judgement as to whether or not, they should participate in any given discussions and/or decisions business of within and by the GLA.
4. Legal Implications
4.1 The legal implications are as set out in the body of this report.
5. Financial Implications
5.1 There are no financial implications arising directly from this report.
Local Government (Access to Information) Act 1985 List of Background Papers: None Contact Officer: Vishal Seegoolam, Principal Committee Manager Telephone: 020 7983 4425 E-mail: [email protected]
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Page 4 Agenda Item 3
MINUTES
Meeting: Health Committee Date: Wednesday 15 March 2017 Time: 10.00 am Place: Chamber, City Hall, The Queen's Walk, London, SE1 2AA
Copies of the minutes may be found at: www.london.gov.uk/mayor-assembly/london-assembly/health
Present:
Dr Onkar Sahota AM (Chair) Jennette Arnold OBE AM Andrew Boff AM Unmesh Desai AM
1 Apologies for Absence and Chair's Announcements (Item 1)
1.1 Apologies for absence were received from Shaun Bailey, AM.
2 Declarations of Interests (Item 2)
2.1 The Committee received the report of the Executive Director of Secretariat.
2.2 Resolved:
That the list of offices held by Assembly Members, as set out in the table at Agenda Item 2, be noted as disclosable pecuniary interests.
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3 Minutes (Item 3)
3.1 Resolved:
That the minutes of the meeting held on 12 January 2017 be signed by the Chair as a correct record.
4 S ummary List of Actions (Item 4)
4.1 The Committee received the report of the Executive Director of Secretariat.
4.2 Resolved:
That the completed and outstanding actions arising from previous meetings of the Committee be noted.
5 Action Taken under Delegated Authority and Mayor's Response to the Committee's Letter on Transport for London's Role in Promoting Health in London (Item 5)
5.1 The Committee received the report of the Executive Director of Secretariat.
5.2 Resolved:
(a) That the recent action taken by the Chair under delegated authority be noted, namely to agree, in consultation with the Deputy Chairman:
(i) The letter to the Mayor on suicide prevention in London, as attached at Appendix 1 of the report; and
(ii) The scope and terms of reference for the Committee’s review of NHS Sustainability and Transformation Plans.
(b) That the response from the Mayor in relation to the Committee’s letter on Transport for London’s role in promoting health in London, as attached as appendix 2 of the report, be noted.
6 LGBT+ Mental Health (Item 6)
6.1 The Committee received the report of the Executive Director of Secretariat.
6.2 Resolved:
That the Committees’ LGBT+ Mental Health report be agreed.
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Page 6 Greater London Authority Health Committee Wednesday 15 March 2017
7 Sustainability and Transformation Plans in London (Item 7)
7.1 The Committee received the report of the Executive Director of Secretariat as background to putting questions on NHS Sustainability and Transformation Plans (STP) to the following invited guests: Dr Gary Marlowe, Chair of London Regional Council, British Medical Association; Dr Victoria Tzortziou Brown, Chair of London Region, Royal College of General Practitioners; Grainne Siggins, Member, Association of Directors of Adult Social Care Services; Neil Tester, Director of Policy and Communications, Healthwatch England; Amber Davenport, Head of Policy, NHS Providers; Vivek Kotecha, Research Officer, Centre for Health and the Public Interest; Dr Mohini Parmar, Chair, Ealing Clinical Commissioning Group and STP Lead, North West London; David Stout, Programme Director, South East London STP; Jane Milligan, STP Lead, North East London STP; Mark Easton, Programme Director, South East London STP; Steve Russell, Executive Regional Managing Director (London), NHS Improvement; and Daniel Elkeles, Chief Executive of Epsom and St Helier University Hospitals Trust, attending on behalf of South West London Footprint.
7.2 A transcript of the discussion is attached at Appendix 1.
7.3 Resolved:
(a) That the report, and subsequent discussion, be noted; and
(b) That authority be delegated to the Chair, in consultation with the Deputy Chair, to agree any output and further information required arising from the discussions.
8 Health Committee Work Programme (Item 8)
8.1 The Committee received the report of the Executive Director of Secretariat.
8.2 Resolved:
(a) That the work programme be noted;
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Page 7 Greater London Authority Health Committee Wednesday 15 March 2017
(b) That authority be delegated to the Chair, in consultation with the Deputy Chair, to agree the scope and terms of reference for the Committee’s next meeting on 19 April 2017 on mental health issues of ex-offenders; and
(c) That the proposed site visit on 29 March 2017 to Springfield Hospital in Tooting, to visit the National Deaf Mental Health Service, be agreed.
9 Date of Next Meeting (Item 9)
9.1 The date of the next meeting of the Committee was confirmed as Wednesday, 19 April 2017 at 10am in the Chamber, City Hall, The Queen’s Walk, London SE1 2AA.
10 Any Other Business the Chair Considers Urgent (Item 10)
10.1 There were no items of business that the Chair considered to be urgent.
11 Close of Meeting
11.1 The meeting ended at 12.55pm.
Chair Date
Contact Officer: Rachel Greenwood, Committee Officer; telephone: 020 7983 4285; email: [email protected]; minicom: 020 7983 4458
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Appendix 1
London Assembly Health Committee – 15 March 2017
Transcript of Item 7 – Sustainability and Transformation Plans in London
Dr Onkar Sahota AM (Chair): This brings us to the main discussion this morning. We have two panels of experts this morning. Can I please welcome our first panel. First is Dr Gary Marlowe, Chair of the London Regional Council of the British Medical Association (BMA); Dr Victoria Tzortziou Brown, Chair of the London Region, Royal College of General Practitioners (GPs); Grainne Siggins, Member of the Association of Directors of Adult Social Services; Neil Tester, Director of Policy and Communications at Healthwatch England; Amber Davenport, Head of Policy, NHS Providers; and Vivek Kotecha, Research Officer at the Centre for Health and the Public Interest. Thank you. You are all very welcome.
We will probably direct questions to some of you at the beginning but if you feel like you need to contribute something or you want to contribute to them, please feel free to come in. Hopefully, this session will last about one hour. We will then have a five-minute break and go into the second panel. Some of the answers you give us will inform the discussion we have later on with the second panel.
First of all, let me start the ball rolling to ask all of you, but let us start with you, Gary. What are Sustainability and Transformation Plans (STPs) and what do you expect them to deliver? How do you see STPs? What are they and what are they expected to deliver, from your point of view?
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): STPs grew out of many transformation plans across London which had been in gestation for some time. Those plans were, primarily, clinically driven and were around looking at reconfiguration that was most appropriate, looking at better pathways of work, looking at how we might blend or change some of the secondary case-based work because we were aware that there was a problem, especially in the face of the fact that London’s population is growing, especially in East London, which has quite a large projection.
However, the STPs that then came out of that foundation, we very much feel at the BMA, is a plan primarily based around finance based upon trying to close the funding gap and so the focus, we felt and I certainly feel, has shifted from being about what is best for the population, how to best construct clinical pathways that provide patient-centred care that is efficient and cost-effective but not necessarily cost-saving, to one that is primarily about control totals. The control total is about the funding gap that has been established amongst all the various STPs. We very much feel that the shift, although there is still a clinical underpinning, the focus is about the funding gap. I probably should stop there.
Dr Victoria Tzortziou Brown (Chair of London Region, Royal College of General Practitioners): I agree with Gary [Marlowe]. In terms of the focus of the STPs is really on collaboration among providers. STPs are placed-based plans and they want to bring together providers from mental health, community services, the acute sector and general practice but also social care to work together. They talk about integration, person- centred care, improving access and GP federations.
When I talk about ‘person-centred’ care, it is important to think about it with its three elements, really, the physical, mental and also social elements that contribute to a person’s wellbeing. All of these have been championed by the Royal College of GPs and so we very much support such an approach. Page 9
From the College’s perspective, the main anxiety on STPs is that, during this effort of transferring a lot more care from the hospital or the acute sector to the community, we need to make certain that general practice, which is the main element of this community delivery, is adequately funded in order to respond to the increasing demand that is going to be created.
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): Thank you. Just quickly, all of the plans are hugely predicated on a shift of work from secondary care to primary care and some of the plans do not even mention primary care. For example, the North Central plan does not mention the GP Forward View at all in the whole of the document, as far as I am aware. These plans are hugely predicated on shifting work to general practice without any real fleshing-out of how that happens, how that is funded and the time period over which that will happen.
Grainne Siggins (Member, Association of Directors of Adult Social Services): From the Directors of Adult Social Services perspective - and I will also give some views today about just general local government because I notice that I am the only witness with that background - and in terms of STPs, there is generally broad support for STPs from local government and also the relevant professional groups: [the Associations of] Directors of Adult Social Services, Directors of Children’s Services and Directors of Public Health.
It is based on the principle that we were not necessarily planning strategically at a larger footprint. We have many of our local residents who use different hospitals. It has recognised the importance of having the right clinical care in the right place within acute settings but, equally, preparing people for going into acute settings and then getting them out quickly and providing enhanced care and support in the community with improved quality community services that can wrap around our local residents with social care support. The emphasis and drive and desire within STPs is something that is generally welcomed.
Colleagues have already spoken about the financial element and that is something that does cause us some concern and, also, the fact that it actually came from a health-driven requirement. Just as a reflection looking back, it would have been quite useful if, when people were thinking about establishing that, they had fully engaged with the Government departments responsible for local government so that it was something more of a shared agenda and something that we were part of the initial stages of.
From the perspective of the people that I have engaged with as part of providing the evidence today, there has generally been good engagement, but in the very initial stages of the preparation of the first elements of the draft STPs, I think that is where there was not sufficient attention placed on local areas and a local focus to get local government. Also, I do not think there has been a full appreciation of the democratic accountability of local areas in the decision-making elements of that. STP leads now fully embrace and understand that requirement, but it has been a slow burn in actually getting that emphasis and focus.
Generally, we are all planning already at a local level, through what we call our Better Care Fund (BCF), to plan for integration, integrated health and care, driving activity out of acute hospitals, providing more care and support at a local level, but we already had some concerns about how this different model of care is going to be funded when there are various different agencies that are involved in the delivery of that.
Neil Tester (Director of Policy and Communications, Healthwatch England): I am absolutely acknowledging what has been said about STPs being a mechanism for managing financial pressures. I will not add to that.
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It is worth also reflecting that they are or tend to be delivery vehicles for the aspirations set out in the Five Year Forward View. As the more detailed plan for the next two years emerges from NHS England very shortly, it will be really important to note how STPs are built into that two-year delivery plan.
From our point of view at Healthwatch, with our role being to hear what people are experiencing and what people think about local services both in terms of health and social care, which is very relevant to STPs, for us STPs are a massive opportunity if they are planned and implemented well to deal with a lot of the frustrations that people have in current services. That requires some genuine honesty and a bit of humility on the part of the whole system and everyone within it to acknowledge what does not work well at the moment and to build a shared case and a shared plan for handling some of those frustrations. Given that people absolutely acknowledge and understand the resource pressures and are often frustrated that things happen in a way that is not sufficiently joined up around them individually and them as their communities and that they think could be done much more efficiently and cost-effectively.
The big ‘if’ is that this can only be done well if people are genuinely engaged with and proper adult conversations are had with communities. That is the big challenge. There are some green shoots there, but that is the big challenge remaining for STPs.
Amber Davenport (Head of Policy, NHS Providers): The perspective that we are coming from on STPs -- I am from NHS Providers and we are a trade association representing trusts and foundation trusts. That spans across acute hospitals, mental health, community services and ambulance services. While I will not be commenting on London-specific plans, I can comment on the STP process from a national level and as a whole. We see STPs, as others have said, as a really good opportunity. It is one of the first times that commissioners, providers and providers of social care have really come together locally to develop a plan over a medium period of time to transform services and reach sustainability.
We would say that there were some challenges with the process from when the concept of STPs was first established. The process was challenging. It was very quick. Some areas have very strong historical working relationships with their local partners already; other areas were coming together for the first time. What we have seen - and I am sure it is true of London - is that STPs are all in different stages. Some might be a bit further on than others. That is OK and, actually, they should be supported going forward to progress at a rate that is right for them. Also, we need to be realistic on what they can actually achieve given where they are in their planning process.
I would agree with what everyone has said about meaningful engagement with local communities and engagement with social care as well. By ‘meaningful’, we do not mean just public consultation when we have to go to public consultation. We are talking about engagement both with frontline staff and clinicians and local communities throughout the process, testing what is going to work for them and how we can achieve the vision in the Five Year Forward View. It is a great opportunity, but there are some challenges going forward.
Vivek Kotecha (Research Officer, Centre for Health and the Public Interest): The Five Year Forward View, which set out what a lot of the STPs are driving towards, has some quite well-meaning ideals and intentions in there, but I feel that since then the financial issues have become a lot worse, worse than they envisaged at that time in 2013. STPs have been put in this position, as Gary [Marlowe] has said and as other people have said, where they have good clinical ideas in them and some untested ones as well, good ideas, but this financial situation is starting to envelope a few of them, and generally is a challenge for the whole system. What we worry about with STPs is that you have a very short timeframe in which to achieve quite a lot of savings. You are also having limits on how much capital funding there is available and there is a lot of complaints about that and worries about that. This makes it harder to invest in all of these changes. Page 11
At the same time, you have this system where it is great that different parts of the National Health Service (NHS) are collaborating with each other to varying degrees, but there is not really that structure in place to actual accountability, legal or otherwise. These are still memoranda of understanding. They are still based on a trust-based agreement. While it is working for now in most areas, as those issues develop and as it gets financially tougher over the coming years as the funding gap widens, I would worry about how those relationships and trust between providers, commissioners, other parts of the NHS and the social care system, will stand up. If things start to not deliver at the speed or in the way they expect, what does that mean for STPs going forward?
You can see potential risk issues just based on the assumptions that the Five Year Forward View said were going to be used to close this funding gap. The assumptions that they used were quite optimistic - even they admitted that - and yet we are now implementing them across STPs to the extent that they have to also take that share of the funding gap and close it. Finances are starting to take over a lot of the issues with the STPs and they are influencing them across the system.
Dr Onkar Sahota AM (Chair): Firstly, thank you very much for your opening contributions. We are going to explore those concepts you have talked about: finance, accountability, public engagement, the democratic deficit. We are going to explore those themes for a bit longer. I am going to ask my colleague Assembly Member Andrew Boff to explore them, but we will be exploring these concepts. They are of concern. Just to let you know, they were flagged up in our own research before we came here this morning and so we are aware of those.
Andrew Boff AM: Can I just say? I have not heard from anyone that the STPs are a really poor idea. Is that correct? The criticisms seem to be valid criticisms about the way in which they perhaps are running, being managed and engaging with you, but the core concept seems to be something of which there is a general consensus. Stick your hand up and say, “No, you are wrong”.
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): It is subtle. It is not binary. It is not and black-and-white good/bad. The problem with the STPs, just to caricature it, is that potentially what we are creating across England are 44 health republics. If we create 44 health republics, what is a ‘national’ health service?
One of the directions of travel - and already Simon Stevens [Chief Executive, NHS England] has been talking about this - is Accountable Care Organisations. Since the Health and Social Care Act was passed, it removed the Secretary of State’s responsibility for health. That means that, potentially, we could have Accountable Care Organisations that are in their own health republic and are able to then set up their own terms and conditions. They have always said that this is not the case, but there is the potential for that and, from the BMA, we are very concerned about things like national terms and conditions --
Andrew Boff AM: You would prefer a more centralised approach?
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): What we are anxious about is that there is equity across England. Do we have a national health service or do we have 44 individual services that then become Accountable Care Organisations? That is the worry. It needs to be properly explored with the public because, if that is the direction we are moving in, we need to be honest and discuss that. The other thing, as Vivek [Kotecha] has talked about --
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Andrew Boff AM: Is there, in any of these STP plans, a plan to depart from a health service that provides free care at the point of delivery?
Vivek Kotecha (Research Officer, Centre for Health and the Public Interest): I have something there, actually, as well. It has already happened. Clinical commissioning groups (CCGs) already have criteria on what, say, non-emergency care their patients in the area can access and that varies across the country. Some have been criticised recently for the fact that they have set eligibility criteria that are stricter than, say, other national criteria. We already have a disparity of access across the country.
Andrew Boff AM: Eligibility for care?
Vivek Kotecha (Research Officer, Centre for Health and the Public Interest): Yes, for non-emergency care. It already exists and that is due to funding issues at CCG level and their own financial problems, but that is already happening to an extent for certain types of care --
Andrew Boff AM: That is not an issue with regard to the STPs; you are talking about CCGs there.
Vivek Kotecha (Research Officer, Centre for Health and the Public Interest): That rolls into the STP. The CCGs and all of the financial issues are rolled into each STP area and so these problems are already boiled into a lot of them.
Andrew Boff AM: A lot of the public would be quite surprised to hear about this process because the STP was not something that was announced early enough, as was alluded to earlier. In the early stages, there was not a great deal of engagement. How engaged do you as organisations now feel with the STP process?
Neil Tester (Director of Policy and Communications, Healthwatch England): It has been really interesting to watch the development of the relationship between local Healthwatch and their STPs, let alone communities and STPs. Therefore, the first thing to say is that for most people, most clinicians and a significant number of NHS managers, all the research is showing that the ‘STP’ label has not even got through as a concept. What most people are experiencing are a set of individual discussions about particular changes where the grand vision has not been communicated and discussed with people anyway. There is often a trap for those of us who do spend a lot of time obsessing about this policy issue to forget that sometimes the language in itself does not mean anything to other people.
As the Committee has already identified in its pre-publicity for this hearing, there was significant criticism of the perceived secrecy at the start of the planning process and I think everybody, NHS England included, has acknowledged that it would have been much better not to have started from that point. Given that it has and in our conversations with local Healthwatches at that stage, they were hugely frustrated, particularly those who had been developing really effective relationships with their local health and social care economies about major change programmes and conversations about the BCF and conversations across the country about the new models of care vanguard programmes and, often, engagement was really starting to motor. It felt to them - and I think to their counterparts in their system - that a guillotine had come down.
I am pleased to say that we have been able to work closely with the new team at NHS England to start to improve that and to help to get a shared sense between local Healthwatch and those responsible for driving communications and engagement across STP footprints so that there is a shared understanding of the things that matter to people about this. As Amber [Davenport] said, it is not about just consulting at the end but about helping to get a shared understanding of what the point of change is and a shared view about what the options are, really understanding how people’s views have been taken into account and that being fed back to Page 13 people so that they can see what difference their views have made or have not made. If there is an overriding reason why people simply cannot provide what is being asked for, they need to be upfront about that.
What we have done there is to develop a range of support for local Healthwatches to help them engage in those processes because, on this point of local variation, different STPs are taking different approaches. Some have asked local Healthwatches to be on programme boards. Some have asked if they can play an assurance role. Some are commissioning local Healthwatch to do additional pieces of engagement. Some are asking them to help broker relationships with the voluntary and community sector to do that, all of which is welcome.
However, the key thing that I have noticed, really, from the autumn to now is that from the point where in September NHS England issued some very helpful new guidance, which we were able to help to shape, it really set out clearly what the expectations are around engagement and the difference between engagement and formal legal consultation which, frankly, is there just to avoid judicial review and does not get the full benefit that engagement does in terms of getting a better set of decisions and a better range of services for people. That enabled a different conversation to start to take place.
It is variable. I have to say that there are more challenges in London than there are in quite a few other parts of the country because of some of the historical challenges there have been around issues with the location of acute hospitals and some of the other big service-change programmes that there have been over the last couple of decades in London. London carries that baggage with it into this process. Nonetheless, there is still variability within London and even within STP footprints. In half of the boroughs who are in STP footprints, things are less controversial and if we can get into that adult conversation. In the other half of that footprint, there is a cycle of fear because people are terrified they are going to lose the local accident and emergency department (A&E) and decision-makers are terrified of having a conversation about that.
We are increasingly, I am glad to say, able to find ways to position local Healthwatch to be the bridge between the people in the system and the bridge across health and social care, to take that fear factor out it and to get some honesty and constructiveness into those discussions. I am cautiously optimistic about the prospects for engagement as a result of that.
Andrew Boff AM: Are we too late, though? The parameters have already been set with the professionals talking amongst themselves, pretty much. Are we too late in terms of getting those parameters influenced by the public?
Neil Tester (Director of Policy and Communications, Healthwatch England): It is never too late, I would say, with the process because, firstly, it is going to take years to implement the things that are included in this piece. The plans are still at a high enough level that a massive amount of detailed work and planning needs to go on. The point was made right at the start that, whatever the timeframe of the STPs, the Five Year Forward View or the two-year delivery plan, some of the changes that they are predicated on will take decades to see through. If you look very narrowly at this process, it looks potentially like too little too late, but in the grand scope of where will London’s health and care services go in the future, it is never too late to get the engagement right.
Amber Davenport (Head of Policy, NHS Providers): I just wanted to echo some of what Neil has said. One of the challenges with engagement in the initial stages of the process was how quickly the first drafts of STPs had to be developed and the time that it takes to develop and build some of the relationships that need to happen at a local health economy level. The engagement in terms of engagement with the public is really stepping up and I would echo what Neil has said there.
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I just wanted to come back on something that Gary [Marlowe] talked about earlier about STPs threatening a national health service. I would say that at the moment, commissioners, providers and social care providers are independent organisations that can be seen to be acting in isolation sometimes from each other, whereas the STPs are an opportunity for them all to come together as a collective to discuss and develop what is best for that local health economy. Really, I see them as an opportunity for ensuring that there is equity and there is a shared plan and that organisations do not continue to act in competition with each other. That can sometimes end up to the detriment of patients. I just wanted to make that point.
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): I just wanted to come back to some points that were made earlier. Sorry, I could take over the whole thing. I will try not to.
About the legals, we have not really explored the legal side of things at all. Simon Stevens has alluded to the fact that we are going around. Whatever one believes, whether one is for or against or ambivalent about the Health and Social Care Act 2012/13, it did go through Parliament and it is an Act of Parliament. It has set in place procurement laws. As I see it, the STPs are potentially trying to get around the Act. I am not a fan of procurement, but it is there. If we are going to have an STP that removes a purchaser/provider split, we are in essence going against the actual legal definitions of the Act. We are moving around procurement law. I know that we are about to come out of Europe and therefore we will not have to adhere to European procurement law, but there is equivalent British procurement law. The legality of what we are trying to do has not been very clearly defined. Perhaps NHS England knows what it is about and has some definition around that, but --
Andrew Boff AM: When you talk about procurement, you are talking about procuring for the whole service? We were specifically focused on consultation and the legal aspects.
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): Yes. This is the legals around procurement. In essence, the STPs are trying to go around the Health and Social Care Act. From a legal point of view, there is the legality about consultation, but on the legality about procurement and about the purchaser/provider split - and I would welcome seeing that go - we do not have enough clarity or definition about what is going on. There is a potential for legal challenge and judicial review around that purchaser/provider split. At the moment we have memoranda of understanding, but I do not know how well they would stand up to a legal challenge.
Grainne Siggins (Member, Association of Directors of Adult Social Services): In terms of local government engagement, to begin with people had to work really hard really quickly to develop the plan, the governance structure and the process. There was naturally an inward-looking focus, which has improved as time has progressed. I just felt that we needed to enhance the balance that was identified by Lucy.
Local government was engaged often in the programme boards and so was part of the process, but often with between 20 and 30 clinical leaders. In terms of the influence and ability to shape, we have ended up with something that is not embedded. It has not been coproduced. It is something that we now have, which is a plan, the core focus of it being, in my view, clinical redesign, which was essential as part of the element that we supported. However, at a local level, people have initially missed the importance of that political engagement and accountability and now, in some areas, they are struggling because of that where politicians are being challenged by scrutiny and are not supporting the plans as the currently stand. That is because, if you do not engage at the very beginning in a very open way, you end up where you are now.
From a perspective of our local residents, there has been this veil of secrecy, which means that people do not then trust the plan. The outline, I suppose, ambition of the plan could be very positive in what it means for
Page 15 people and the shape of people’s care on the ground, but there is going to be an awful lot of work required by the STPs to start engaging in a meaningful way with those local communities.
Andrew Boff AM: Is it unrecoverable? Mr Tester indicated that --
Grainne Siggins (Member, Association of Directors of Adult Social Services): If we take it in the spirit of what consultation means, then there should be a way of shaping what those local services look like. I agree with Neil [Tester] as part of that.
In terms of the clinical redesign of services and what that actually means, where there is the ability to say, “Hips and knees are at that hospital and specialised colectomies are at another hospital”, whether or not there will be the opportunity to shape that, I do not know. In terms of the emphasis on what it will mean for local residents personally to be able to shape and input in a meaningful way, I am hopeful in the spirit of what consultation means.
Dr Victoria Tzortziou Brown (Chair of London Region, Royal College of General Practitioners): STPs at this stage are much more high-level strategic documents and the principles that they want to promote are very much based on interventions and innovations that have happened locally, in a patchy way, but in response a lot of the time to what patients have asked; that is why they have been successful.
It is about really bringing together the successful but patchy innovations and making them the standard at a bigger scale. It is very difficult to engage when you have to write something at such a high level. More meaningful engagement for frontline staff and also patients and the public can happen when you talk about more specific issues. Therefore, there is a huge opportunity to start this now because now we move into the implementation phase.
When we talk about engagement, perhaps we should talk more about co-design. We should not see this as a one-off event. It needs to be a continuous process which is informed by data. The opportunity that STPs can offer is by collecting data at a much bigger level and by investing in information technology (IT) infrastructure can really assist people, the public, providers and frontline professionals to make a lot more informed decisions and choices.
Neil Tester (Director of Policy and Communications, Healthwatch England): Could I just add to what Victoria said? I absolutely agree and that was beautifully put: meaningful engagement will come around the subsets rather than around the STPs.
However, there is a point of principle and it is something that local Healthwatch have said to me almost unanimously. There does need to be a translation of the jargon-filled plans that currently exist into shorter, snappier, plain-English documents. Also, very disappointingly, a fairly low proportion of STPs - probably because of the time and speed they have been working at – very few have made the information available in a way that is accessible to everybody. That needs to be rectified because people need to be able to look back to those documents as they go through the more detailed discussions that Victoria was talking about.
Andrew Boff AM: As soon as you throw a three-letter acronym at the public, they switch off anyway. Perhaps we should stop calling them ‘STPs’.
Jennette Arnold OBE AM: To come in after - if I can call you – Victoria, in that I would challenge what you have just said because it did not make sense to me. You talked about it being a strategic tool and then there were, did you say, innovation projects that were already coming out of this strategic tool or documents or Page 16 whatever framework. Then, we heard previously about this impact. You talk about the public and elected responsibility lies within elected leadership within boroughs, and yet we have heard that there is a gap between those people who are held accountable to the public for many of the services that you are aiming to configure or do whatever with. Therefore, it did not make sense to me what you have just said.
Dr Victoria Tzortziou Brown (Chair of London Region, Royal College of General Practitioners): What I said was that a lot of the time what STPs have done is to try to take good examples of what has happened locally in certain areas in a very patchy way. I know that I am biased, but what we have achieved in Tower Hamlets by working together with the local authority on integrating care locally is a good example that probably STPs have used across the country; and they want to replicate this example on a bigger footprint.
In order to develop this integrated care approach in successful local areas, we responded to what patients and Healthwatch wanted and told us that we had to address. The success of these local innovations was a result of responding to local need and what people had asked us to achieve. It could only be successful by working with the local authority and local government. The point of the STPs is to work with the wider stakeholders and also the voluntary sector, not just local government, and other healthcare providers and patients.
Jennette Arnold OBE AM: Thank you.
Andrew Boff AM: Thank you. Can I just ask? The remit of the London Assembly in terms of health is about addressing inequalities in health in London. Perhaps you could let me know if you have seen any evidence - perhaps Mr Kotecha could give us an example - of engagement with under-representative groups such as London’s deaf community, older people and homeless people and other groups as well.
Vivek Kotecha (Research Officer, Centre for Health and the Public Interest): That is a very good point. With the Equalities Impact Assessments, some of them have been carried out and some have not. They are really not very detailed.
What I would say is that there are going to be big changes, potentially, for groups that are vulnerable. With the way they are changing access to services and some of the move to maybe shift access to appointments to telephones or internet services, that does affect people who may not speak English as their first language, the elderly, people with disabilities or people who do not have access to the internet regularly. Any changes to access to care impact them.
One of the other areas that has not been looked at in a very detailed way across all STPs is female carers or female family members in particular, who often have to care for the elderly or frail or family members with learning disabilities. A lot of them have not considered the impact on them. If, say, there is a funding gap in social care still or if, say, things do not work out as planned with STPs and we end up with people in between social care and the NHS, then there is an impact on family members. That has not necessarily been taken into account very clearly at the moment in these STPs.
Andrew Boff AM: Mr Tester, have you encountered any good practice or bad practice of engaging with hard-to-reach groups?
Neil Tester (Director of Policy and Communications, Healthwatch England): In terms of the STPs, there is variation but it is variation with a band in the middle. We have not seen anything absolutely atrocious with people just ignoring the issues completely but it still feels like it is on their to-do lists. Equally, we have not seen anything that stands out as a shining star.
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Reflecting on what Vivek [Kotecha] has just said, one of the opportunities it is vital that STP planners do not miss is the chance to really look at population need at a level of detail that will highlight the needs, the differential needs and the different delivery and access needs of groups that often fall through cracks in systems. I do not have confidence from what local Healthwatch have seen in the plans so far that that is being picked up consistently. That is another opportunity that good engagement will deliver.
We need to get a shift in culture and mind-set where people stop thinking about this as another administrative chore that they have to do when they have big plans to deliver and start seeing it as a source of insight that will help them to get decisions right and help them to make sure ahead of time that they do not miss out vital services, that they think through things like the transport implications for different groups of people and that they think about language needs and all of the other needs. They can get some of that thinking into the planning through the engagement activity if it is done well and early.
Andrew Boff AM: I am a bit worried that you cannot come up with any examples of good practice with regard to that.
Neil Tester (Director of Policy and Communications, Healthwatch England): I am worried as well.
Andrew Boff AM: What suggestions would you make? How should the STPs identify the requirements in their geographical areas? How should they go about doing that, briefly if possible?
Neil Tester (Director of Policy and Communications, Healthwatch England): I should say that just because I have not seen it, it does not mean that it does not exist. I am looking at the national level rather than knowing the detail of all of the London STPs. I am not saying that it is not there, but I have not seen it.
How should they go about it? There is, again, a huge opportunity here to bring in the voluntary and community sector, social enterprise and community groups across boroughs across the capital. That ecosystem and infrastructure is there, but I have to say that if people do not build it into this thinking and do not ensure the support is there for it, it will not be there forever. There is a narrowing window of opportunity to build those mechanisms for involving all of those groups into these plans and making them permanently part of the system in a way that will benefit people and also make life easier for decision-makers in the future.
Andrew Boff AM: Thank you. Could I just ask perhaps Dr Tzortziou Brown whether or not you have seen engagement of frontline staff in the construction of the STPs and whether or not that needs work? Is it important that frontline staff are involved in these plans?
Dr Victoria Tzortziou Brown (Chair of London Region, Royal College of General Practitioners): Absolutely because if STPs are going to be successful is if they change the behaviour of professionals and patients, really. In order to change behaviour and do things differently and add value to what you offer to patients, you absolutely need to believe that it is the right thing to do and also see it as feasible. Frontline professionals - and especially coming from the Royal College of GPs, GPs - are absolutely paramount to being engaged and leading the change. Also, we need to think of the wider teams that we need to develop and train and how we can develop this distributed leadership across all frontline staff, involving also the voluntary sector and patient leaders within that. We need to work together. It is not necessarily about one group or one representative professional leading the whole thing. We need to engage and inspire all frontline staff and patients to work together on this.
Andrew Boff AM: Thank you. Does anybody want to add to that?
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Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): At the BMA, we did a survey - I cannot remember the exact figures, but Andrew probably knows - of GPs and of hospital doctors across London. I would say that less than 20% or less than one in five - obviously even less than that - were even aware that there was such a thing going on. There is no real engagement on the front line. There is no real engagement. I will just emphasise that again. All of the STPs are clinically led but the clinical leaders tend to be an individual or a couple of individuals or a small handful of clinicians who are maybe doing a few sessions a week in the work but are very heavily involved in healthcare management and are not on the ground working. That is absolutely right and they cannot do both things together, but there is really no clinical engagement.
With all respect to Healthwatch, in terms of patient involvement, that is also very poor. None of the STPs really have any patient involvement committees. Some of the STPs have commissioned Healthwatch to go out and get the information but there is no actual detail co-production going on there.
Dr Onkar Sahota AM (Chair): Dr Marlowe, it says in our briefing that in November 2016 the BMA ran a survey of 615 GPs --
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): Yes, that is the one I was referring to.
Dr Onkar Sahota AM (Chair): -- and consultants in London, they found that 53% had not even heard of STPs and 88% felt unable to influence decisions. Is the survey you are referring to?
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): Yes, that is the survey. Thank you for the figures. That definitely is the survey. That feeling continues with very little engagement and very little feeling of being able to influence them. That is because they are very, very high- level documents. If I can, just quickly, because I know we are about to finish; from a BMA point of view, I am going to really return to this. As Bill Clinton [former President of the United States] would have probably said, it is about the money, stupid. It really is about the money. This is not my data; this is purely taken from the STP documents. Across London, the capital funds needed to implement the STPs as they stand is about £1.9 billion. That is just to implement them. That is not getting around to the health. We cannot do nothing because the gap is so huge and so we have to do something, but we need to be realistic about these figures. The STPs are basically a prospectus of false promises.
Andrew Boff AM: All right. Do you think it is all about the money or is it not all about the money? Earlier you were saying that the STPs --
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): There is a great deal of good work that the STPs have been built on and there are a lot of good ideas around them, but it is really all about the money at the moment. I am also a board member of a CCG and so I am aware of some of the financial pressures that we are under.
Andrew Boff AM: Yes, every single Government - with the exception, I think, of the Callaghan Government - has increased expenditure on the NHS. I am hoping that these STPs can clear their view of just saying, “More money”, and realise that there are some structural issues. Is that really what --
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): There are definitely some structural issues, but we need to be honest with the public about this.
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Jennette Arnold OBE AM: You cannot have structure without the money.
Andrew Boff AM: Yes, and the honesty is that we have constantly shovelled money into the NHS and increased it with every Government since.
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): We put in less than demand. We put money in, but the money that we put in is up about 1% whereas demand is increasing by 3%. We are not keeping up. We have to contain demand. The STPs are a way of containing demand and so I would totally agree with that.
Andrew Boff AM: Yes. Nobody is cutting it. Nobody is cutting the NHS. Can we just now move on, if possible, to your idea of what role the Mayor could play in helping Londoners to engage with local STPs as well? What could the Mayor do? Whom shall I ask? Everyone. Is there something that the Mayor can do to encourage people to get involved in their STPs?
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): A debate around estates would be a way of involving people. It is very unclear exactly what is happening around estates. To go back to the money, that is a significant part of the funding of the NHS and we need clarity around what happens to estates. Does that money go back into the local community? Does it go back into the local STP? Does it go to the London-wide region? Does it go to the Treasury? The Mayor could be a very powerful voice in helping us to work out exactly where that goes. If we all agree that we need to close a local hospital because it is not performing and we could consolidate the services better, what happens to that hospital capital fund when it is sold or developed? Does it go back into the local community? Does it go back into local government? That is a really quite important thing that the Mayor could get involved on.
Dr Victoria Tzortziou Brown (Chair of London Region, Royal College of General Practitioners): If we see STPs as a plan to improve the health and wellbeing of our population, focusing on London, there are a lot of common objectives with what the Mayor is trying to do. We need to think about the wider determinates of health and wellbeing from air pollution to inequalities to mental health to Healthy Schools. The Mayor has plans to address some of these issues and we absolutely need to work together on these.
Neil Tester (Director of Policy and Communications, Healthwatch England): That is a really helpful frame for this because, if the Mayor simply went out and started talking about STPs, he would repeat the problem with talking about something that turns people off because it is a three-letter acronym, as Mr Boff said. Whereas the Mayor thinking for each of the areas that relate to the health and the wider determinates of health that he has responsibility for, “How is this relevant to STPs and how do I get a debate going across London in relation to this issue?” He can do that in terms of air quality. He can do that in terms of the London is Open agenda and the workforce issues, which are some of the massive pressures that the London STPs need to deal with. There is space for the Mayor there.
Also, in terms of service reconfiguration, the Mayor controls transport and people’s ability to move between services and access services. This is something that he can influence and perhaps identify barriers where people might assume that transport is easier than in reality it will be. Building those conversations and those opportunities for people to engage through the Mayor and the Assembly’s consultation mechanisms alongside health and social care’s engagement and consultation mechanisms is a very practical way of taking us forward.
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): In our local hospital, about 20% of our non-doctor medical workforce are European. There is considerable anxiety
Page 20 amongst those workers and so that is quite an important thing. Just being a little bit flippant, he can license fried chicken shops and obesity is a really big problem across London.
Andrew Boff AM: We are coming to the obligatory Brexit question later on. Can we just move on? If I can ask Ms Siggins, you did allude to the fact - and tell me if I am wrong in misunderstanding what you said - that there was perhaps a heavy clinical lead on the development of the original STP plans. I am wondering whether or not you think that the requirements of social care have been adequately considered in the draft plans?
Grainne Siggins (Member, Association of Directors of Adult Social Services): My observations are that we had the BCF previously and then we have had the STPs and there is very little conversation about the BCF and the work. That means that the work we are operating at a very local level with our health partners collaboratively as local systems. There is not much talk about that at an STP level because it is something that is viewed as detailed and operational and on the ground, but it is essential in having those local conversations about how you are planning and delivering services at a local level.
The danger of the STP footprint is, “And what next?” There is concern from politicians and from local authorities about what the next level of decision-making is going to be taken up to STPs. Planning for acute care at an STP footprint in the main, from the feedback I have had, everybody is comfortable with that, but what does that mean about local democratic accountability for poor planning?
The STP was about health sustainability financially and the social care resource and the impact on that was not a core part of the original STP guidance and so some areas have built the impact on social care into their STPs; other areas have not. What I would argue is that things like the National Living Wage and the challenge to local authorities of that is not part of the STP anyway, but the shifting model of care from less hospital to more community-based care and enhanced care in the community will impact on social care. There does have to be a local conversation.
At the moment, the majority of the STPs only look at the health sustainability because that is all they were tasked with doing. If the social care conversation about the impact on social care in many areas if it has not been dealt with within the local BCF plans and if we have had not had the shift in resource there, then there is no opportunity within the STP to get it realised because it is not viewed as part of the deficit.
Andrew Boff AM: What needs to change now in order for local government to achieve what the STPs have set out to do?
Grainne Siggins (Member, Association of Directors of Adult Social Services): It is about being clear about what the parameters of the STPs and how far they are going to meet the financial requirement of that shifting landscape. At the moment, people are still not arguing about it but it is a known area where it is not always funded because it is not included and so you then have a separate conversation about social care. For me, it is an open and honest debate in the STPs about the full impact financially across health and care, what it means for the health system and also what it means for the social care system. In some of the STPs, that is covered and more at a local level, but it is not a uniform position across the board. How are STPs fully embracing the cost impact on social care of the changing models of care and support? That would be the question that might be posed.
Andrew Boff AM: Just for the sake of clarity, your criticism earlier of the starting point of the STPs. Does that apply to each of the footprints in London or is it just one or two of them?
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Grainne Siggins (Member, Association of Directors of Adult Social Services): In many areas, there have already been conversations about how we make the hospital system more sustainable and, clinically, how we shift care out of hospitals with enhanced primary care. Those conversations were already happening in local systems. The STP did not suddenly start that. In local areas, you have your clinical conversations and you have your local conversations with social care and so what does that mean for us on the ground. That was already underway.
It is about the broader configuration of acute care and what that means and specialities going to other hospitals where there has been high-level conversation, but the ability to build in what that means at a local level at the moment in the plans is not clear because they are high-level. I would be really interested to see what the next level of detail is on the plans to say how this is going to be delivered at a local level.
Andrew Boff AM: That is quite interesting because you have actually answered the next question I was going to ask, which is really about this idea of integration between the health service and social care services. It has been around for ages. We have wanted to achieve it and for all sorts of administrative reasons we have not been able to. To my knowledge, it has been going on since 1982 when I first became a councillor. We have been talking about how to integrate social services and the NHS. Do you think that the STPs give an opportunity of giving that a boost?
Grainne Siggins (Member, Association of Directors of Adult Social Services): It will enhance it a little bit further, but we do need to accept that we have been working towards this now for many years. There are already integrated health and care teams around the community already delivering services for people. One of the other areas of concern has always been the capacity within primary care to help to support that. In many areas now, there are social workers working around the patient and so there are individuals who are having very proactive and supported care at a local level with the social care input as well as the clinical care input there. It is about embedding that and making sure it advances to the next level. Generally, it is included in the plans at a high level, but you will not see the local.
What we are worried about is if these STPs become decision-making bodies with delegations from CCGs. We are already seeing CCGs merge as management structures. What does that do for the planning and delivery at a local level if our ability to plan at a local level with our local CCG and local authority is taken up that one step further? Already all of the money in the transformation funding goes to STP level and does not come down to the local CCGs anymore, albeit they are engaged, and so there is a significant challenge.
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): I would just like to follow up on that. I work in Hackney and we have an integrated commissioning project going at the moment. It is one of the key local projects. We have looked at integrated commissioning. We have joint boards for urgent care, planned care, etc, which are being chaired by someone from the local authority and from the CCG. We are worried that that project has just about hit a brick wall because we have been recently given notice that our plans for integrated commissioning will be subsumed into the STP.
That goes on to your point about the amalgamation of CCGs. What are CCGs for? What role do they provide if they are all being amalgamated? We already have North Central and I think South West has amalgamated. You have someone who is chief officer of an STP who is also chief officer of those combined CCGs. It is a very unclear position. Certainly in our particular case of Hackney, we were well along the way of progressing integrated commissioning with a good governance structure and that has been more or less stopped in its tracks.
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It also calls into question how des devolution or devolution pilots fit in with the STPs, which I am sure you will probably come to. I do not know.
Andrew Boff AM: Thank you very much.
Dr Onkar Sahota AM (Chair): Can I just pick this up on the BCF? Earlier on this year, Sir Amyas Morse, the head of the National Audit Office (NAO), said:
“Integrating the health and social care sectors is a significant challenge in normal times, let alone when both sectors are under such severe pressure. So far, benefits have fallen far short of plans, despite much effort. It will be important to learn from the over-optimism of such plans when implementing the much larger NHS sustainability and transformation plans.”
He is really saying that there is no evidence to suggest that integrating social care and healthcare is any cheaper than previously. The NAO is saying:
“Whilst there are some good examples of integration at a local level, evaluations have been inhibited by a lack of comparable cost data across different care settings, and difficulty tracking patients through different care settings. The NAO today reiterates its emphasis from its 2014 report on the Better Care Fund that there is a need for robust evidence on how best to improve care and save money through integration and for a co-ordinated approach.”
The whole emphasis of STPs is, if we integrate healthcare, we will save money. Where is that evidence?
Grainne Siggins (Member, Association of Directors of Adult Social Services): When we first entered into the BCF, there was never any evidence that integrated care would save money. If we look at the narrative behind it, it was all about improving patient outcomes. Somewhere along the road, this conversation about, “And it saves money”, came in.
Dr Onkar Sahota AM (Chair): Where did that come from?
Grainne Siggins (Member, Association of Directors of Adult Social Services): The BCF came in but there was never, in any of the policy guidance or the policy framework, there was never the comment about it needing to save money. It was about providing seamless care for people so that they had more proactive care.
What there is the potential to do is to reduce demand management. In social care, what we do know is that if people go into hospital in an unplanned way and come out, often, if they have been having a package of care and support previously, their care needs significantly increase. It is about the demand management element, but it was never about efficiency and saving money as a system.
Dr Onkar Sahota AM (Chair): Thank you.
Vivek Kotecha (Research Officer, Centre for Health and the Public Interest): Can I just add to that? When they talk a lot about shifting care into the community, often community care is more expensive because you have higher-level staff and you tend to have more one-on-one support. Compared to a hospital where you could have multiple patients per staff member and the costs are spread out and there are economies of scale, you do not necessarily get that at community level. That is not necessarily a bad thing because you can get better outcomes for the patients and it is generally preferable, but it does not necessarily save any money.
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There is a lot of mention in STPs about this as if shifting care to the community is going to save money. What they are trying to say often is that if we can get people to be treated in the community, we do not have to build extra beds for future population growth and demand needs. That is often where the saving is being made.
However, there is a question. If these moves to the community either do not work or if they do not deliver the improvements in healthcare that avoid people going into hospital, given the bed shortage we already have, if we do not build that extra bed capacity because we have assumed these are going to work, that is where the real risk is going to come in. We are going to end up with patients trying to enter a system that cannot handle that many patients. The report by the NAO hit the nail on the head when it comes to that assumption.
Jennette Arnold OBE AM: I want to get some answers to some questions about prevention and this whole idea about care closer to home.
Let me just read you some information that I have been provided with. I am told that all London STPs list prevention as a priority and here are some examples. North West London has work and health. South West London wants to work with local authorities on alcohol pricing and both South East and North East aim to improve early-years support. North Central London will be accrediting Healthy Schools.
Let me just go into this last one I just mentioned, accrediting Healthy Schools. We do not have anyone from North Central and so I am trying to get from you some ideas about what you understand by that. In my world, representing the community of three boroughs in North East London, the Healthy Schools programme there is, in some boroughs, absolutely very active. They have partnerships. Some of them have been having Healthy Schools programmes for at least eight years that I know about; in other parts of boroughs, less so.
I do not understand and I appreciate that you might not be able to tell me but I just wanted to get some sense of what do you understand the STP in this particular locality will actually do to enhance Healthy Schools and improve early-years support. Neil, from your Healthwatch perspective?
Neil Tester (Director of Policy and Communications, Healthwatch England): I am sorry. I just cannot pretend to be across the detail of every STP in London and so it would be wrong of me to comment.
Jennette Arnold OBE AM: It would be wrong for you to say that?
Neil Tester (Director of Policy and Communications, Healthwatch England): Yes.
Jennette Arnold OBE AM: That is fine. Let us go and see Victoria, a great advocate. You think that they are wonderful and will solve all of our problems. Can you tell me if you have insight into the next level? Just give me something so that I can go away and say to my constituents, “STPs are really going to be good this time around”.
Dr Victoria Tzortziou Brown (Chair of London Region, Royal College of General Practitioners): From what I understand about Healthy Schools and --
Jennette Arnold OBE AM: It was just an example.
Dr Victoria Tzortziou Brown (Chair of London Region, Royal College of General Practitioners): -- from a clinical perspective, we see an increasing level of diabetes and obesity in our population. This puts on a huge amount of demand and need. We need to address this issue. Starting from the early years, we can Page 24 have a much larger effect because we can potentially reduce the amount of obesity in children and the future problems associated with obesity. Also, there is some evidence that by targeting children, we can also influence their family’s habits and lifestyle choices. There is that potential by trying to educate children at schools.
Jennette Arnold OBE AM: Yes, I would support you there, but why is this not then a common goal for all of the STPs? Surely that would be appropriate for North East or South West. Is it statistically based? Do you have anything concrete? Are these goals based on evidence?
Dr Victoria Tzortziou Brown (Chair of London Region, Royal College of General Practitioners): I suspect that the set of priorities that has been set in each STP depends on the local population’s needs, perhaps. That is an assumption. At North Central, perhaps they identified that their younger population has increased levels of diabetes and that is a priority locally. I assume that this has been discussed with local public health representatives and has been identified as a need and a priority in the area.
Dr Onkar Sahota AM (Chair): Jennette, maybe you can pick this up with the second panel.
Jennette Arnold OBE AM: We can pick that up with the second panel.
Dr Onkar Sahota AM (Chair): We can pick it up with the second panel, which will have more details on this.
Jennette Arnold OBE AM: OK. Vivek, can you tell me? Let us go back to what Andrew [Boff AM] brought up. We know from evidence that it is those people who are most disadvantaged who are outside the ‘circle of action’, if you like. If we are going to target and do some work on prevention, then really this would be an opportunity to do this.
Do you see that prevention, working with disadvantaged groups and marginalised communities? Has that come up in your review or your understanding of the STPs for London?
Vivek Kotecha (Research Officer, Centre for Health and the Public Interest): I would say that, for London, London faces a particular issue even just reaching these people partly because there is a large population churn in some areas. There are people moving around a lot. A lot of people who then walk into A&E are not registered with a local GP, for example. It is hard to reach people when they are not even registered with a local GP.
Public health budgets have been cut across quite a few councils in London over recent years. If that continues and our national-level public health budgets are being cut, it makes it very hard to figure how they are going to help people reach these groups if they have less money to do so. Some of the proposals I have seen so far in STPs, which have been detailed, seem quite optimistic. I am a bit sceptical so far about how they are going to end up reaching these people and whether they will be able to given the shortage of funds available, if anything, to just spend on that.
Jennette Arnold OBE AM: Gary, on prevention, when I think about prevention, the GP’s role and the whole primary healthcare team is critical. I am a former health visitor and I am a nurse. Once a nurse, always a nurse. It concerns me when you say from your survey that local GPs were unaware when you asked them about STPs given their role in prevention.
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Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): I should just say that it is not just that GPs across London were. STPs are supposed to embrace local authorities and I do not know what the engagement or knowledge is across local authorities, much less GPs.
Just going back to the prevention issue, even if all of the prevention plans - but I do not think they are plans but prevention aspirations because they are aspirations and they are often with a fairly loose evidence base – if they are all achieved, they will have an achievement in maybe 10 or 15 years. These are long-term goals. Every single STP that I have read starts off with the word ‘prevention’, which is very laudable, but actually they are something that we need to work towards for the future. How they are able to be deliberate even within the STP, which as I see it is something that is looking over the next two, three, four or five years, it is very difficult to square that. As I said, they are purely aspirational. If we are looking at public health, it would be much better to have a public health plan across the whole of London rather than the individual five STPs.
From my point - and you talked about health visitors and nurses - we need to be engaging with schools really very strongly. My particular interest in prevention in schools is around mental health. That is something that is very important. We are seeing increased levels of anxiety and depression amongst adolescents and that will be a very very important aspect of prevention.
If you look at other things, I made a flippant comment about chicken shops, but across London we need to think about obesity. In North East London we have some of the most obese children and we have a very active public health policy to try to address that, but it is very very difficult to implement that in the face of free- market food and alcohol as well. We rejected the minimum pricing of alcohol. Maybe the Mayor needs to resurrect a London minimum alcohol price.
Jennette Arnold OBE AM: Just staying with you, Gary, no, I would not argue against the focus we are putting on young people, but what about disadvantaged older residents of London? They do not ever seem to feature when people are talking about prevention because it is never too late to bring prevention to an older person with whatever programme that you can.
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): We have a project locally around social prescribing, which is very much focused on older, isolated people with the very active involvement of the third sector and trying to bring social prescribing in. I suppose there is a bit of preventative work involved in that. As I said, there is lots of good stuff in the STPs and in the detail about it being locally implemented. Social prescribing to prevent isolation would be a very powerful way of doing that.
Jennette Arnold OBE AM: Let me just finish with prevention. Anyone can answer this. Could STPs, over a three-year period, given the partnerships they are working in, be able to tick the boxes because one or other of their partners are going to be doing something towards an aspiration?
Grainne Siggins (Member, Association of Directors of Adult Social Services): STPs do see prevention within the wider context. Health and wellbeing strategies is about supporting people in the general population to think about how they manage their health and wellbeing and quality of life. The majority of health and wellbeing strategies are being refreshed at a local level.
It is important that the STPs that health leaders continue to engage with a whole range of people within local authorities and communities about making health everybody’s business and thinking about how each of us individually engage with our own health and wellbeing and then thinking about how we utilise the health service. There are some behaviours that are not necessarily supportive and hence we see lots of people going into A&E and those sorts of things. Whilst you have your key priorities in your STP where they have tried to Page 26 look at some common themed areas - diabetes, for example, which every area is trying to focus on, reducing the increase in diabetes and how effectively it is managed at a local level - they need to think about how that fits in with the health and wellbeing strategies and changing population behaviours. But also many areas have joint prevention strategies, which focus then on specific things where areas are working together at a local level.
In relation to your query about older people, again, this will not be in STPs necessarily but it will be in the borough-level plans that we are working on together collectively as a partnership. For my own local area, we have focused very heavily on how do we engage with our communities to reach socially isolated older people and support them to engage more proactively within the community and think about their health and wellbeing. There is an external reaching into the communities, but you will not see that in STPs because it is too detailed. Many areas across London have the same type of approach where supporting older people to manage their health more effectively and making them have an improved quality of life and feel part of the community is a core part of keeping an older person healthy and active. They will be in the more focused borough-level plans rather than the STPs.
Jennette Arnold OBE AM: If we did not have STPs, this work would be going on where it is?
Grainne Siggins (Member, Association of Directors of Adult Social Services): Yes.
Jennette Arnold OBE AM: An STPs really is like a great big Hoover that will pull up all the information of good practice that is going on in an area?
Grainne Siggins (Member, Association of Directors of Adult Social Services): That is my view and I know that we are doing that in our area. That has worked really effectively in tackling diabetes at a local level. Your observation is correct that that is the intention, but recognising that there is a lot more activity happening at a local level.
Amber Davenport (Head of Policy, NHS Providers): There are a couple of things around prevention. One thing is that, as others have mentioned, it is a long-term strategy. One of the challenges for the STPs in the process that they went through was that there was quite a lot of focus on short to medium-term sustainability and that may be why prevention has not been as detailed in STPs as they might have been as the focus was more on sustainability.
Colleagues have raised important questions about what STPs should be responsible for delivering and what is better delivered at more of a local level. I do not know the detail about London, but I know that there are some STPs that have high-level aspirations and strategic plans and the detail is delivered at more of a local level. Sometimes footprints are quite large and so it is difficult for them to deliver all of the detail.
One of the key things as well in terms of prevention and STPs, as we mentioned earlier, is that a lot of additional funding is now coming through the STP. The focus on prevention and the need for adequate prevention needs to be raised in STPs so that prevention strategies are invested in in the long term and it is not just focused on short-term goals.
Neil Tester (Director of Policy and Communications, Healthwatch England): One of the opportunities here is that, as Grainne has said, all this very local work will have been going on and will not be visible in the STPs, but what the STPs can and should look at is where there is an overlap between the different agendas they are looking at. There are some issues that there is a preventative aspect; there is also an aspect in terms of cost efficiency; there is also an aspect in relation to access to services. The best example I can think of that Page 27 is not a London example; it is what has happened up in West Yorkshire, where for a really long time now there has been quite poor access to NHS dentistry for a number of boring contractual reasons. They have had a real impact on people, both in terms of crisis care, but also children’s oral health and also access to oral health services for people from more marginalised groups in those communities.
The STP has finally been the vehicle, because the work that a number of the local Healthwatch have done there was fed directly into the STP lead, who immediately saw the potential and that has gone into the plan, because that ticks an access box, it ticks a preventative box. There is potential for STPs to be able to look at some of these wicked issues slightly differently.
Jennette Arnold OBE AM: Thank you. Let me just briefly move on to care closer to home. As Andrew [Boff AM] mentioned, it is one of these aspirations that have been around for years and no one would argue about that aspiration. It is about how realistic it is to achieve. Grainne, all five London STPs want care to be closer to home, providing better quality care in a more comfortable setting and preventing unnecessary and costly hospital visits. Is there not a problem if the infrastructure has not been set up, if there is a lack of funding to enable this transfer?
Grainne Siggins (Member, Association of Directors of Adult Social Services): As I mentioned earlier, all areas are working towards delivering care closer to home. The financial pressures within local authorities to deliver that within new models of care is a significant challenge. It does not seem to be impacting negatively yet, because local councils are going into overspend positions. We are hoping that the budget position last week will have assisted that slightly, but Child and Adolescent Mental Health Services (CAMHS) are still reporting a significant deficit in the ability to be able to do it, hence my comment previously about the STPs and what they should include. It is just health and sustainability or should it also include the impact on social care? That is not for me to answer.
In terms of other elements of resource, I know you probably have a question on workforce, but it is making sure we have to the right workforce in the right places. The challenges on local systems, especially inner and outer London differences, Tower Hamlets you pay £6,000 more for a social worker, and so it is the ability for every area to be able to have the adequately resourced staff and be able to recruit the staff and the same with primary care. Also, you have to have a fit-for-purpose estate in order to actually deliver these from. What we do know is that historically there was a lot of money available for primary care investment in terms of fit-for- purpose primary care.
Dr Onkar Sahota AM (Chair): I am very mindful of the time and I am also very mindful of the fact that we have another panel and so I want to skip some of the questions. Unmesh, come over to workforce, OK?
Unmesh Desai AM: That is right, yes. You just started talking about that, Grainne. I have two sets of questions, Chair, and I am conscious of the time. My first set of questions is to you, Dr Marlowe, Dr Brown and Ms Davenport.
STPs are now moving into their delivery stage. Is the workforce, who, after all are the enablers of change, at the stage where they can deliver the proposals as they stand now? If not, what changes would be required to deliver the proposals and are these achievable within the STP timetable?
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): As I said, many of the STPs are predicated upon shifting care from hospital to primary care, and I am pretty sure primary care teams are not ready for this. Victoria may disagree with me. Certainly we have a workforce crisis in terms of doctors. Certainly in my own area, it is very difficult to get new partners, it is very difficult to get locums and it Page 28 is very difficult to get salaried doctors. It is almost impossible to get practice nurses. Health visitors, where are they?
Jennette Arnold OBE AM: It is turning into politics, can I say?
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): Yes. The workforce issue has not been properly addressed in terms of primary care. That is probably my main sort of concern, really. I alluded to the fact that - and probably NHS Providers have a different view - in terms of NHS Providers and certainly in terms of London, we have a very high percentage of European professionals working here, physiotherapists and occupational therapists (OTs), as well as doctors. They continue to be concerned about this.
Dr Victoria Tzortziou Brown (Chair of London Region, Royal College of General Practitioners): The workforce and the degree of the financial challenge are probably the two main challenges that STPs face. It is absolutely important for STPs to work with the local Health Education England (HEE) departments and the Royal College and obviously the BMA to ensure that there will be in place the extended teams that are required to deliver this shift of work from hospital to the community. We need to also think seriously about training and how we ensure adequate funding goes into training for all these new roles that are appearing, like pharmacists and physician associates, and also extra GPs, and also think a little bit more creatively about how we use existing staff working currently within hospital environments, the acute sector, and how we bring some of these out in the community if the work shifts that way.
Unmesh Desai AM: Can these changes be achieved within the timescale? Organisational changes always take time to see the very best --
Dr Victoria Tzortziou Brown (Chair of London Region, Royal College of General Practitioners): We need to be realistic. I see the STPs - and I know I have been described as very optimistic before - as the beginning of the work that needs to be done, but we need to be realistic. We need to be honest about how quickly changes can happen, but at the same time we should not lose hope and give up.
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): Can I just make a quick comment before we move on? Just going back to a project that I was involved in, the one thing I have to say is about moving specialists from hospitals to communities is that it has not been shown to be cost- effective or a good use of their time.
Amber Davenport (Head of Policy, National Health Service Providers): We recently surveyed our members on what their top concerns are at the moment. Workforce and finance, as others have said, are top of their concerns, whether that is at institutional level or at the STP level. STPs offer an opportunity to think about how we can use our workforce more effectively. Our members’ concerns are about having the right numbers of workforce with the right skills in the right place, as others have talked about. Again, it will take time. My opening comments earlier were around being realistic about what the STPs can deliver. I would echo what Victoria [Tzortziou Brown] has said in that this is the start of a journey and the STPs offer an opportunity to look at some of the workforce challenges that we have, but we definitely need to be realistic about what can be achieved in the timeframe.
Coming back to shifting care into the community, we are very clear that we need to have adequate investment into community services and ensure that those services are available before we start to shift things out. No one is ever really keen on double-running because it is double the cost, but if we are going to do with safety and if we are going to do it effectively, then that is something that needs to happen. Page 29
Unmesh Desai AM: In terms of the timescale, London has doubled the percentage of non-British staff in comparison to the national average, 22% to 10%. With the uncertainty of Brexit and the negotiations and so on, how do you see that affecting the timescale?
Amber Davenport (Head of Policy, National Health Service Providers): I do not know about timescales. NHS Providers is part of a coalition of different organisations looking at the specific workforce challenges that Brexit may pose. As an organisation, we would be keen for our European Union (EU) staff who are working in the NHS to have the right to remain, but I would not be able to comment on timescales.
Unmesh Desai AM: We could be here all day talking about Brexit. My final question is to all of you, very briefly, bearing in mind the time. We have the STP leads following you. What do they need to do to reassure the public that the STP process and proposals will not have a negative impact on the care they receive?
Dr Gary Marlowe (Chair of London Regional Council, British Medical Association): Be realistic about the savings and not come out with figures. I know that I keep going back to this, but they all talk about savings. Be realistic. Shifting care into the community probably does have much better outcomes, but it is not necessarily a cost saving.
Dr Victoria Tzortziou Brown (Chair of London Region, Royal College of General Practitioners): I say three things: be honest, engaging and reflective.
Grainne Siggins (Member, Association of Directors of Adult Social Services): From my perspective, it is about explaining things simply and being very clear about what this means for people at a local level.
Neil Tester (Director of Policy and Communications, Healthwatch England): Everything everyone has said already and also, if the people can convince clinicians, that is who the public will listen to.
Amber Davenport (Head of Policy, National Health Service Providers): Again, I would say be realistic, implement plans at an appropriate pace for that local area and operate within the current institutional and democratic structures that allow you to have that engagement.
Vivek Kotecha (Research Officer, Centre for Health and the Public Interest): I would say just to add to the ‘be honest’ point that they have to be honest about, if these do not work out, with their optimism and the assumptions they have made, what that means for the local services. What is the plan B? A lot of them do not talk about it, but what is the contingency if things go wrong? People want to know that at least so that they are aware of what could happen.
Dr Onkar Sahota AM (Chair): Thank you. Thank you, all members of the panel. I know it has been rushed towards the end, but we do have a second panel to go to. You have given us a lot of substance to work on and so thank you very much. If you think that we have missed some point you wanted to make, please feel free to write to us. We are still taking evidence.
You are welcome to stay for part 2, but I am going to take a short adjournment for about five minutes for us to restructure. Thank you very much for coming along and thank you very much for your input.
(Adjournment)
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Thank you very much for bearing with us. Sorry we are starting late, but can I please welcome the second panel? Mohini, if you start introducing yourself from there?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): Thank you. I am Mohini Parmar. I am a GP. I am Chair of the Ealing Clinical Commissioning Group (CCG) and I am also the North West London Sustainability and Transformation Plan (STP) Lead.
David Stout (Programme Director, North Central London STP): Good morning. I am David Stout. I am the Senior Programme Director for the North Central London STP.
Steve Russell (Executive Regional Managing Director (London), NHS Improvement): Good morning. My name is Steve Russell. I am the Regional Director for NHS Improvement in London.
Jane Milligan (STP Lead, North East London STP): Good morning. My name is Jane Milligan. I am the Chief Officer for Tower Hamlets CCG and am also the North East London STP Lead.
Mark Easton (Programme Director, South East London STP): I am Mark Easton, Programme Director, South East London.
Daniel Elkeles (Chief Executive, Epsom & St Helier University Hospitals Trust, attending on behalf of South West London footprint): Hello. My name is Daniel Elkeles. I am the Chief Exec of Epsom & St Helier Hospitals and I am here for South West London STP.
Dr Onkar Sahota AM (Chair): Great. Thank you, everybody, for coming this morning. You may have heard some of the discussion in part 1, but I am going to open it up with a general question to all of you. What are the specific challenges for London STP footprints as you see them? Mohini, shall we start with you?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): Thank you, Onkar. The STP delivery across health and social care will be a challenge. The specificity in the challenge for us is the scale of change and the timelines of what we need to deliver to ensure that we have quality of care and sustainable services, both from a workforce and from a financial perspective. The big challenge within health is that for the day job we still have to deliver high-quality services while we undertake transformation for what is right to address the needs of our population.
The other challenge is of course especially in London, we are working across multiple organisations. As you know, in North West London we have already been working together, the CCGs, for a period of time and as providers. Now we have our local government colleagues with us working very closely and we are working across multiple interfaces with the workforce. Therefore, the change management and how we take our workforce with us is a challenge.
David Stout (Programme Director, North Central London STP): We all face fairly similar challenges. I suppose I would start with how the STPs are intended not just to be about money but are also about improving quality of care and improving health outcomes. The challenge is to do all three, not just one of those. The panel you heard earlier talked about workforce challenges. They are real, the challenges around how we manage, as Mohini says, the transition at the same time as keeping the show on the road and focusing on delivery rigorously, not just thinking that the STP is a plan that we write and submit somewhere, but focusing on actually delivering the change for real at a local level, not simply at an STP level.
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Steve Russell (Executive Regional Managing Director (London), NHS Improvement): Great question. I would probably draw on four or five key challenges. The first is very common to all of the STPs, which is the changing needs of the population across London. It is very different now than it was years ago and that is what many of the STPs are trying to address, fundamentally.
The second is workforce. Notwithstanding the changes that STP areas are trying to make, I think all of us would recognise that London and indeed England faces quite significant workforce challenges across all professional groups. The third is trying to achieve all of that change and deliver good services for our citizens within the resources that are available. You heard the earlier panel touch on some of those challenges.
There are two that I might just call out. One is to build on Mohini’s point, there is a lot to do in delivery of the STPs. In their ambitions, they have positive and compelling arguments for change, but those things do not happen overnight and do not happen without very very significant effort and time commitment of people who are very busy treating and looking after people who become ill across London.
Then the last one that probably I expect you will probe us on later is taking people with us. STP is an acronym. It does not mean very much to people, but STPs are made up of health and care professionals who are trying to fundamentally change the system that serves residents across London. Trying to make sure that that is owned, understood and believed in by citizens across London and elected representatives is a big challenge for us all.
Jane Milligan (STP Lead, North East London STP): In North East London specifically, we have clear challenges in terms of our population growth, real pockets of change in boroughs such as Newham and Tower Hamlets, but also in other areas such as Havering and increasingly also Barking and Dagenham. Over the next 15 years we have a projection of about an 18% increase. That is already on a population which has quite a high level of variation with pockets of real deprivation in health inequalities but also pockets of wealth and to some extent a real churn of people across the patch often not necessarily moving out of North East London but moving between boroughs, which for a number of practices means that they have a turnover of about 40% to 50% each year. That is a significant issue.
The other thing is that, as I said, workforce is a real challenge for us. Grainne [Siggins] made the comment that we have perhaps areas where it is easier to attract staff, possibly in inner North East London as opposed to outer North East London. Part of that opportunity is to do something about that, but the other thing is that we have quite a large variety or variations in care, whether it is at an acute hospital base, social care or in primary and community care, but we also have some fantastic examples. For us, it is about how we really draw that across and do that sharing. As I say, we have had a long history of partnership working in the patch, but this is the first time that we have really tried to bring local authorities with us as well.
The other challenge I would say for North East London is when the STPs popped out of the system, we had three systems already working towards transformation. Trying to knit together the Barking, Havering and Redbridge devolution pilot and the City and Hackney devolution pilot together with the Waltham Forest, Newham and Tower Hamlets Transforming Services Together transformation plan, as I say, is also part of the challenge, but an opportunity as well.
Mark Easton (Programme Director, South East London STP): If we go back to what STPs are designed to do, they came out of the plans to implement the Five Year Forward View, and in particular to address three gaps that were identified in the Five Year Forward View. There is the health and wellbeing gap with an emphasis on prevention, there is the quality gap addressing questions of variation, and thirdly, there is the financial gap. Most STPs have three broad strands that try to address those gaps and South East London is no Page 32 different. We have one strand which is improving access to primary and community care with the development of things like local care networks across South East London and the expansion of access to primary care.
Secondly, we have a productivity strand, which is about getting our providers to work together in ways that are more efficient to reduce costs and, thirdly, we have a work stream that is about secondary and tertiary care pathway redesign. We have eight clinical leadership groups, as the name implies they are led and generally run by clinicians, aiming to improve pathways of care and aiming to hit quality standards. That is the STP in a nutshell.
Daniel Elkeles (Chief Executive, Epsom & St Helier University Hospitals Trust, attending on behalf of South West London footprint): My answer is very similar to the rest of the panel. In South West London, we have a growing population and it is an ageing population. There are a lot of diverse health needs. Lots of people who live in South West London would say that they do not experience the quality of healthcare both in hospitals and in community settings that they would like to receive. There are lots of workforce and estates issues. There is clearly delivering all the healthcare that people expect within the money that we have available. Then we need to also acknowledge the complexity of the landscape that healthcare is provided in and also the complexity of the conversation that we need to have with people about the future of how healthcare should be provided to enable them to live the best lives that they can.
Dr Onkar Sahota AM (Chair): Great. Thank you very much. There is consensus that we all want people to have better healthcare and we want it to be better delivered and to be integrated. Let us take that for granted. There are three things that came through that we need to explore. One is finance, the second is engagement and the third is the workforce. We will explore these in a bit more detail.
I want to talk about the finances. The STPs, when I read them, sit on the premise that, first, more healthcare can be shifted away from hospitals into the community and that this is cheaper and, second, by shifting this hospital care from the hospitals into the community, we can close some of the hospital beds because if you could not close those hospital beds you would not have the savings.
Can you first off tell me what the evidence is to say that shifting healthcare into the community is any cheaper than doing it in the hospital sector? What is the evidence on which your premise bases upon?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): Thank you, Onkar. What is important for us to deliver is that the patient or member of the public has the right care at the right care setting that is appropriate to their needs. That has always been the premise: that it is right for the patient, right for the family and right for the system. There are times when it is absolutely correct that the hospital is the right care setting for that patient but, but there are times for example, the evidence for that is for older people who get dementia, who get a minor illness and go to hospital. We know that day on day, after day 2, there is a stark deterioration. Therefore, the hospital is not the right care setting for that patient and it is appropriate to provide care for them, in the same quality care, in an out of hospital setting. That is what we are trying to do.
The question of whether it is cheaper is a good question because if you are going to provide the care and give the evidence and the assurance to the public and to the workforce that it is the same high quality, it may save money in certain settings and it may not save money in other settings, but it is also around the workforce and the sustainability of that. It is important for us to recognise that it is the right care setting for the individual rather than it being hospital or out of hospital and being that binary.
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David Stout (Programme Director, North Central London STP): Let me give you a specific example from my hospital. We now have a team of 60 clinicians who are made up of GPs, council social workers, reablement staff, the community nursing staff and our own staff. The purpose of this team is to see who could we look after in their home rather than admitting them to the hospital and, if you are admitted to hospital, how can we ensure that you spend only the appropriate time in the hospital and then your care is provided in your home. This team is looking after now 20 patients a day in the community. It is run based in the hospital. The impact on those patients is very profound. We have done lots of video blogs about what is it like for those patients to have their carer at home and they say, “This is so much better to have the reablement and the rehabilitation in my house rather than the hospital. I am getting better more quickly”. We have looked at the cost of providing that care and it is half the cost of someone being in a hospital bed.
Perhaps the most important thing about is that it has enabled us to have a much better flow through our hospitals, so that we are delivering the accident and emergency (A&E) standard, because we can admit the people who need to be admitted because we have the beds. Also, we have managed to bring back all our planned care surgery that last year we could not fit into the hospital because it was full and was done in the private sector. It is now all being done back in the NHS. The impact on the local NHS is huge. It is about improved quality for the patients and much better staff satisfaction. The people love working in the team and also we have improved the finances. It is a really good example of how everyone working together makes a big impact on improving healthcare and sorting out financial issues.
Steve Russell (Executive Regional Managing Director (London), NHS Improvement): Could I just comment on your premises? Because the first premise we work on is whether there is actually going to be money in the NHS in five years’ time. The resources available to South East London go up by something like £1 billion over the course of the next five years. Our problem is that if we are not careful, our costs will go up by more than the £1 billion that is available to us. It is about how we cope with the increase in work with the amount of extra money that is available. Our hypothesis is the way not to deal with this is simply to continue to expand secondary care as we have been doing, because if we do, we will need to build another hospital in South East London. We do not have a site to build a hospital in South East London and we do not have the workforce for another hospital in South East London.
Probably more fundamentally, that would not be the right care model because if you look at 100 years of investigations into the London health service, what they all say is that the London health service is too skewed towards secondary care and does not have enough primary and community care. Primary and community care has always been relatively underdeveloped in London compared to the rest of the country, so what our proposal is, we cope with the expansion in demand by improving access to primary care and community care and associated social care. We have lots of examples in London of how there are people currently sitting in hospital beds or sitting in A&E departments who could more effectively be treated in the community. Daniel has given you some examples of that.
The third premise we have is that the system can be more efficient. There are good examples of hospitals paying different prices for basic standard stuff. That is why we think it is a good thing for hospitals in South East London to work together on things like procurement, on things like back office, doing the kind of things that councils in London have actually been doing for quite a long time. If you do that, then the STPs can make a contribution to the funding gap that we are going to have in the Health Service over the next five years.
Dr Onkar Sahota AM (Chair): South East London is expecting £1 billion in the NHS budget or the social services budget or the combined budget together?
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Steve Russell (Executive Regional Managing Director (London), NHS Improvement): The amount of NHS resources available in South East London will go up by about £1 billion over the next five years. Health service budgets are going up in cash terms and those bits of the NHS that rely a lot on access to specialist commissioning, as we do in South East London, have a bigger increase. The increase in funding in specialist commissioning is actually bigger than the increase in funding for baseline CCG funding. One of your Members pointed out earlier that the health service budget is getting bigger. The problem we have is that the rate of increase in demand will outstrip the increase in funding if we are not careful.
Dr Onkar Sahota AM (Chair): There has been no cut in the social services budget - 40% right across the country - and you are not aware of any cuts in social services?
Steve Russell (Executive Regional Managing Director (London), NHS Improvement): Our STP sets out the reductions that local government is facing. We all know that local government is facing funding reductions and part of the work of the STP is to find ways of mitigating that. The bulk of the work actually takes place at borough level, because the borough relationship between CCGs and local authorities are clearly very strong. Local government does not particularly work on a six-borough basis in South East London, but there is lots of work we can do together between health and social care to mitigate the impact of the cuts. There is the Better Care Fund; there is the integration both of commissioning and provision of health and social care. Clearly, it is incredibly important we work together to try to address some of the issues that are coming up because of the reductions in social care funding.
Jane Milligan (STP Lead, North East London STP): I was just going to add that I suppose we just need to be a bit clear about what we mean by shifting care into the community. In many respects, that is where 90% of health and social care happens already. As other colleagues have said, it is about ensuring that we have got the whole system aligned to help support that. Daniel made reference to the fact that healthcare particularly - and social care to some extent - is delivered in quite a complex way. One of the opportunities with the STP or working in a partnership approach is to be working much more closely with our acute colleagues and the service models that do support primary and community care and social care to deliver that care back at the ranch. Essentially that is, as Daniel says, the same for everyone: people want to avoid hospital at all costs.
Again, we have models and I talk about hospitals having osmotic or leaky walls whereby clinicians and consultants do what they are supposed to do, which is to consult and reach out into supporting community teams in the locality model that wraps around, whether that is a diabetologist or a geriatrician, and mental health is another good example where we can help provide a way of managing risk, sharing expertise and really supporting patients and families back in their communities. When we talk about the definition of shifting care, it is not about lifting, shifting and dropping; it is about working across the whole pathway.
David Stout (Programme Director, North Central London STP): Just one point I would add is that, coming back to where Mohini started, we have done a bed audit across our acute and community beds. Like every other part of the health service in this country, we have hundreds of people who are in beds and do not need to be there. Not only is that bad for them and bad for the taxpayer because it is not very efficient, it is also bad for the individual who is losing independence, who is having muscle wastage and whose prospects get worse by being in the wrong place at the wrong time. If we can plan and deliver services in a better way, we will achieve better outcomes and better quality of care.
Dr Onkar Sahota AM (Chair): Your assumption is those people who are in beds will be provided for somewhere in the community and so there is a need to put the services in the community before you can do the change. You accept that?
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David Stout (Programme Director, North Central London STP): Yes, we need to invest in the capacity to enable people to move out when they are ready to go. There is a gap in capacity currently and so we need to invest upfront, absolutely, to achieve the change that we are --
Dr Onkar Sahota AM (Chair): Is there enough funding in the system to give you the opportunity of building the community services and the services in the community before you close the hospital beds down?
David Stout (Programme Director, North Central London STP): Yes. We have no plans to close hospital beds down. We plan to avoid having to --
Dr Onkar Sahota AM (Chair): Of course there are plans. I mean that we have had bed closures in my part of the world.
David Stout (Programme Director, North Central London STP): I am not in your part of the world.
Dr Onkar Sahota AM (Chair): My part of the world is North West London.
David Stout (Programme Director, North Central London STP): In North Central London, we are planning to invest upfront in increasing primary care capacity and community capacity - that could be health or social care - to enable us to achieve what I just described.
Dr Onkar Sahota AM (Chair): Yes, Dr Parmar, talking about North West London, there are hospital bed closures there.
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): As you can see from the North West STP, there is a clear shift of resource from the acute to community and mental health. I cannot remember the exact percentage shift. There is a complete recognition that over the last ten years, we have not resourced primary care and community effectively. As Mark pointed out, there is a skew in London towards the secondary care sector and this is about resetting some of that. From a patient perspective, the care that they should receive, whether it is primary care, community care, the hospital, it should be the same. It should be streamlined and should work across the system. It is fair to say as clinicians, it feels fairly fragmented at this point in time.
The STP allows us an opportunity to aggregate that up and to make it more streamlined. The investment in the community and primary care absolutely needs to happen. We have done. As you know, in Ealing, our integrated care service is a jointly-commissioned service with Ealing borough, where we have social workers and intermediate care service therapists sharing under one management team to provide a seamless service. That is absolutely the piece of work that needs to happen. There is a complete recognition that there will be absolutely no bed closures until such time as we can demonstrate we have the capacity, the capability, the workforce, the pathways and the assurance to the public that it is right to do so. I have already said that.
Dr Onkar Sahota AM (Chair): The challenge that the STPs have is that there have to be efficiency savings made. That is one challenge the STPs have. At the same time, the challenge is of course how you provide the good quality care reassurance for the public. Do you see this as fitting a round peg in a square hole or can this be achieved, in your views?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): It is a really important question, actually. How do we continue to deliver business as usual? Our business as usual is about safety and quality and about people’s lives, and we have to do that all the time. It is really Page 36 interesting that somebody was talking about discharge to assess and starting to think about discharging patients out. You talk to people who mobilise this service and they say, “We have a lot of resource in the community, a lot of resource and different organisations working differently and in different pockets and doing a lot of handoffs”. The STP and primary care and the community working in a more integrated way allows us to minimise these hand-offs and using the resources --
Dr Onkar Sahota AM (Chair): Does it save you money?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): In the plans, we are saying that if you do streamline some of these services and take some of the handoffs off, we may be able to drive some efficiencies within the system. There is an active recognition in the GP’s Five Year Forward View that we need to invest in primary care because there has been a real reduction in that over the last eight years.
Steve Russell (Executive Regional Managing Director (London), NHS Improvement): It is a very good question and it is not the case that every single part of the patient population that we treat in hospitals could be treated in the community. It would be absolutely more expensive and probably inappropriate to treat somebody who needs intensive care in their own home - that would be much, much more expensive - but there are good examples where it is more cost-effective in an alternative setting because hospitals are generally the more expensive part of the health and social care systems. For patients who do not have a life- threatening illness or an immediate serious health problem, it is more cost-effective for someone to be seen by their GP than in an A&E department. That is relatively well rehearsed. It is not as straightforward as A equals B, if that makes sense. You have to look at it in a slightly different way.
To your question of whether you can do both at the same time, there are some good examples where this has happened in the past. Stroke services have changed across England. I remember being a service manager of a stroke service in 1998. Stroke services now look very very different. In the northeast we were able to make changes to an old model of care that was a hospital bed-based model of rehabilitation after someone had a stroke and replace that with a community-based team. Which first and foremost, was what patients wanted because they preferred to be at home. Secondly, it led to better outcomes because people tended to get better faster in their own environment. Thirdly, it did save some money. It was not a huge cost saving but it did make better use of the resources we had. And all hospital systems, all health and care systems will have done that and do that every year. However, the challenge you are nudging at is that STPs have to do that faster and on a bigger scale. In some cases it will absolutely be more cost effective to look after patients in their own homes. In some cases it might not be, but it will still be a better thing to do for the patient than it is to look after them in a hospital setting.
Dr Onkar Sahota AM (Chair): The Nuffield Trust said the Government’s plan to save money by shifting care into the community is built on sand. The Royal College of Physicians said financial demands and severe pressures on services have acted as a barrier to transformation despite good collaboration between local authorities and NHS organisations. It then goes on to say:
“This background resulted in a double jeopardy, not having enough staff and resource to introduce new parallel services to see if they can really work in integrating health and social care, improving patient’s experience and producing efficient savings and the danger of any potential investment being siphoned to meet the acute crisis.”
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The experts are saying you need to run a parallel service and that transformation is being hampered by a lack of funding and human resources in the system. You have quoted examples of stroke care and heart centres. The Assembly agrees with them.
However, we are talking about a large-scale transformation of a service that is under pressure on resources and has a lack of human resources. At the same time you have been charged with saving money. How can you deliver it? How can members of the public living in London be reassured that these changes will work for them and that they can be delivered safely?
Mark Easton (Programme Director, South East London STP): It might be helpful to give a couple of examples. Two of the most common things people are admitted for are diabetes and asthma. How do we reduce the number of people admitted for that? One good way for asthma is the Mayor’s strategy on cleaning up London’s air. That is primary prevention and is a very good thing to do. That will, in the long term, help tackle admissions for asthma. A lot of modern medicine is managing long-term conditions in the community and managing them well so people do not have an exacerbation of their condition and end up needing to be admitted. I have gone on visits with specialist chronic obstructive pulmonary disease (COPD) nurses who have a caseload of people at high risk of admission. They visit people in their homes, monitor their condition very carefully and pick up when the patient’s condition is deteriorating so they can intervene before they need a hospital admission. That is the way medicine in the 21st century needs to be delivered. The population is getting older. People are living with multiple long-term conditions. We need to intervene directly earlier with the aim of preventing hospital admissions. That is a good example of how you can both reduce the number of admissions and help people live better and more productive lives in the community.
Dr Onkar Sahota AM (Chair): The converse evidence is that the demographic of the population is changing and that people admitted to hospital have more complex conditions. We are not talking about asthma or diabetic admissions. We are talking about more complex patients with multiple morbidities. What is clogging our hospitals are not asthma or diabetes patients.
Mark Easton (Programme Director, South East London STP): With respect, if you look at the admissions there are very, very large numbers of people being admitted for those conditions. I absolutely agree there are people coming in with multiple morbidities but they are the people who really need to be in hospital. It is the people we can prevent getting into hospital, with moderately simple conditions. That needs to be targeted.
Dr Onkar Sahota AM (Chair): That implies more investment in social and community services. There is a lack of 6,000 doctors and 10,000 nurses in this country and we cannot even find a health visitor. How do you address those issues?
Daniel Elkeles (Chief Executive, Epsom & St Helier University Hospitals Trust, attending on behalf of South West London footprint): Building on Mark’s example of how we can look after people with chronic conditions before they come to hospital, we have had lots of conversations in our hospital with the clinicians and asked, “What does it look like to get it right for the patients when they come to hospital? What does a good service look like?”
We ended up having a conversation with GPs. You might refer a patient you have seen in practice to our hospital. They come to A&E and are seen by the most junior doctor in A&E. You are a senior decision-maker and you think they need to come to hospital. In the conventional system they would come to hospital, be seen by a junior doctor in A&E, then a middle-grade doctor in A&E who would say, “Actually, this is a medical patient”, and then refer them to a medical middle doctor and finally you get to see a consultant. That is a whole heap of money to do all those consultations but it is not getting the patient the decision they need Page 38 made quickly and by the right person. In our hospitals we have completely changed it and said, “If a GP is referring someone to the hospital the GP wants the patient to be seen by a really experienced senior doctor”, and so they are now all seen by consultants directly. Because the consultants are senior decision-making doctors and they know the GPs, very often what happens now is the consultant picks up the phone to the GP and says, “I think we can look after your patient like this”. Very often that is by putting more support into their homes or, “Let us arrange this diagnostic on an out-patient basis”, or, “Let us do it like this”. A third of the patients do not get admitted to hospital. You have made a much better patient experience and also saved the NHS a lot of money.
If you couple that with the pathway Mark was talking about, letting us provide much better long-term condition management in the community in the first place, that is how you begin to make what the STPs are talking about, a real shift of, “Let us not make everything in hospital but make a joined-up health and care system real”. You can do it now with the resources we currently have.
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): Building on that, one is the rapid response, the front-end of the door. The second is the flow within the hospital. We know we have 300 people in North West London waiting for diagnostics. It is not a good use of resources. That is absolutely where health and social care work to take people out in the right care setting. That impacts very quickly in a mental health setting that is completely the wrong thing for patients. It is all three parts of the system coming together. The STP allows that opportunity for us, as providers and commissioners across a geographical footprint, to say “we are providing care for the needs of our population to look at the front-end, the middle and the back-end”. As you know, in North West London we have adopted the seven day. We are just starting to get some data coming through on that. However from the workforce perspective they find it much better to come to work a Monday morning and not feel they have to take over all the stuff that did not happen over the weekend. It is also better for patients. All parts of the system need to work together, including social care.
Dr Onkar Sahota AM (Chair): The other thing, of course, with the argument about shifting care into the community is that there is the assumption in the system that we can reduce the number of hospital beds. We are talking about right across the system. The argument seems to be that if you give better care in the community we need less hospital beds and that hospital beds can be closed. We already run an occupancy rate of 95% in this country and demographics show it is particularly in London. How do we justify that?
Last week a report was produced by Sir Brian Jarman [Emeritus Professor, Imperial College School of Medicine] who said that hospital beds and the number of doctors in the system are a great determinant of morbidity and here we already have a system that is running on this. How do we justify that argument that we can close more beds?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): There have been two other similar reports that have come out recently, The King’s Fund on the STP and the Nuffield report. It was a very good document, saying what actually works in a hospital.
Regarding the whole issue around beds, if we work on what every day-of-care audit is telling us there are people sitting in hospital beds who could be cared for in a better care setting. Therefore, how do we improve the flow - as Daniel quite correctly said - so that we can get some of our planned care stuff? If we are using all our beds for non-elective, people are not getting their elective hips done. That is the report that came out yesterday from The King’s Fund. Therefore we would improve that system as well. People are waiting for diagnostics across the piece. Reduction in the length of stay is where you could start to look at how you would use beds differently. Page 39
Also we are, in a lot of ways, providing care differently. We have moved away from people being admitted to hospitals for three days to an ambulatory care setting. Every hospital is now looking at a frailty assessment, recognising for older people we need to assess them in a different way. We have paediatric assessment units that are saying we can look at children and they do not necessarily need to be admitted, you can treat them and send them out. Different models are coming up. People used to be admitted for seven days for a cholecystectomy, they now go out in 24 hours. We are changing the way we provide care because of technology and different ways of working.
David Stout (Programme Director, North Central London STP): None of us thinks the current system is perfectly efficient. I am sure you, in your clinical experience, do not think the current system is perfectly efficient. There are plenty of things we can do to improve the way we deliver care. You would not start by taking beds out of the system. None of us are proposing that. We are proposing to improve the way we deliver care and monitor its impact on demand. The plans would seek to mediate the growth that would otherwise happen. We are assuming if we did nothing there would be 3% growth in demand on hospital activity. The things we are seeking to do initially are to avoid that happening through better co-ordinated care better invested out of hospital and to mediate against growth, and then if we can get to the point where we need fewer hospital beds and we can use those resources in a better way that is a great thing. If we cannot then at least we have maintained current activity without having to have massive capital investment in sites that we simply do not have, as we have already said.
Jane Milligan (STP Lead, North East London STP): Just to add to that that a part of the STP partnership is about sharing where it works well. In North East London we have the East London Foundation Mental Health Trust and the North East London Foundation Mental Health Trust. That is obviously a specific population but their bed occupancy levels are under 80%. The reason for that is because of the whole pathway approach, working with social care and voluntary organisations such as housing associations. There is a very clear place for people to move in and out of acute care when they need it and also supported, with health and social care, care into work and back to their homes. That is a really good model. In many respects from a physical health perspective some of the challenges we are trying to crack, mental health have already had a good go at it. It is about, “What do they do that we could share?”
Dr Onkar Sahota AM (Chair): The other thing was the upfront funding. I know North West London asked for £500 million to be upfront. Do I have the figure right, Mohini?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): That is our capital ask.
Dr Onkar Sahota AM (Chair): What we have been given is £250 million for the whole of the country. How does this lack of upfront funding affect the implementation of STPs?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): I probably have to take it in three parts. There is some stuff we could be doing in any case. We have discussed this, as you know, across North West London. We have a joint health and social care transformation group where we have leaders of the councils, NHS chairs and chief executives sitting together. That is starting to form a governance structure and saying, “There are places where we need to invest differently. Let us do it now because the evidence suggests that.”
We also know that as part of Shaping a Healthier Future and our consulted programme that we require capital investment to make some changes at scale. That requires investment both in the acute sector and in the Page 40 community. There are almost £150 million worth of requests for investment in GP premises and hubs to deliver that integrated model of care. It is very much linked to the primary care at home that has been talked about where you are wrapping services around a population of between 50,000 and 100,000. Yes, we need the capital to make that happen. Are we going to stop starting the delivery for that? No. We have been doing that for the last four years as part of our Shaping a Healthier Future whole system integration work and the Better Care Fund. That work continues irrespective. Yes, we do need the capital.
Dr Onkar Sahota AM (Chair): I will be handing that over to one of my colleagues later on. In a recent speech by Simon Stevens, Chief Executive of the NHS, when he was speaking to the Nuffield Trust Health Policy Summit, he said:
“More older patients inevitably means more emergency admissions and the pressures on A&E are being compounded by a sharp rise in patients spoke in beds awaiting home care and care at home places. There can no longer be an automatic assumption that it is okay to slash many thousands of extra hospital beds unless, and until, there are really better alternatives in place for patients.”
Why are there proposals to slash hospital beds? Is the system going to now stop and think about can we do this right? He has put a three-pronged test to be applied. The Shaping a Healthier Future relies upon slashing hospital beds at Charing Cross and Ealing. Are we going to put a stop to that, according to what Mr Stevens has now said?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): What Mr Stevens said is that there should be a clear process of assurance that we have the capacity, capability, workforce and pathways before we make the changes. That is absolutely right and correct. As you know, we have done that with the maternity and children’s services changes. We have ensured capacity in maternity. We have capacity in North West London to take 36,000 deliveries. We currently only deliver 29,000. We have built in capacity. Similarly with paediatrics, we went for 127% of capacity before we made the changes on the Ealing side. There is complete recognition that we need to have that in place. We have also agreed across our STP that when we do the assurance, and as and when the time is right, we will work with our local government colleagues because the impact that came out in the previous plan was the impact on social care. In North West London we have determined that and that is part of our STP that when you move care out of hospital it has an impact across the entire health and social care economy that needs to be taken into account. What Simon Stevens was saying is absolutely correct. That is exactly the principles we will be following in North West London, and have done in the two changes we have made.
Dr Onkar Sahota AM (Chair): I do not want to be dissecting North West London here because this would turn into a North London meeting. I want to put it on record that the STP is not signed by the London Borough of Ealing and also Hampstead and Fulham for obvious reasons. Those two leaders have refused to sign up to the STP. The amount of work in between those things is not ideal but I do not want to dissect that in detail here. As a principle it is well established that there will be no hospital closures unless there are provisions in the community, as outlined by Mr Stevens.
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): Although I completely recognise that Ealing, and Hampstead and Fulham have not signed up to the STP, but I can say that on a local level of delivery in Ealing I work hand-in-glove with my local government colleagues and we have jointly commissioned and delivered services and I do not see that changing.
Andrew Boff AM: The public know there needs to be transformation and would welcome any efforts to transform the NHS to be right for the 21st century. It really is not at the moment and the public realise that. Page 41
How would you respond, bearing in mind that the public are probably sympathetic to transformation in the NHS, to the criticisms about the lack of engagement with patients, frontline staff and wider stakeholders? How have you responded to that criticism? Do you think it is not deserved?
Steve Russell (Executive Regional Managing Director (London), NHS Improvement): It is a fair challenge. It is not an unfair criticism of the process we have been through. Although STPs arrived at a point in time, lots of health and social care systems already had arrangements in place to discuss the future of health and care services with their local populations. I would accept the point that they were sometimes variable and some were more effective than others. However, the health and social care system does have a history of talking to its local communities, imperfect though it has been. The STP process has brought into focus the need for a more coherent and stronger dialogue with local communities. I think all of us sitting around this part of the table would probably accept the challenge that we could always have done those things better. I am sure the STP teams will chip in but in many of those areas, in fact in all of them across London, there is now positive and constructive engagement going on - using existing forums where possible, to your earlier challenge that citizens do not recognise what a STP is - to discuss what the ambitions of the STP plans are and to get people’s views on them across the five STPs in London. It is not an unfair challenge.
Mark Easton (Programme Director, South East London STP): It might be helpful to set out some of the things we are doing. Of course, engagement, strategic planning and transformation did not start with the invention of STPs. Quite a lot of the STPs are building on a legacy of work that has happened over the last few years. In South East London we started a programme called Our Healthier South East London in 2013. The STP is a recognisable development of the work we started in 2013. Before the STP was even thought of we had embarked on a series of public engagement events. We had over 2,000 citizens in South East London involved in those. We have a joint overview and scrutiny committee. We were one of the first to publish our STP last year. All of our plans, delivery plans and all of the background work is available on our website.
We work with a patient and public involvement group. One of your previous witnesses said they were not aware of any groups of that kind. We have been running one in South East London for a couple of years. They have been involved in the design of all the clinical leadership groups. One of our most high-profile projects is on changes to orthopaedics and the possibility of centralising orthopaedic services. We have had patient representatives on the groups that have been designing that work. We have also established things like stakeholder reference groups where we have had particular services we wanted to get public engagement on. The next phase we are going into is what we slightly grandly called a period of civic engagement, whereby we are planning to hold a public meeting in every borough. We are taking advice from the local voluntary sector and from Healthwatch on how we access hard to reach groups, making sure we go both through digital channels and conventional channels to make sure we get as broad a scope as possible. We work very closely with Healthwatch. Healthwatch have provided a critique of our STP. We have responded to that critique. We are meeting with them again on Friday to develop discussions about how the STP is evaluated. I give South East London as an example of the kind of work that probably all of my colleagues in London are doing to make sure that we get the best possible public engagement.
I am not sure we should necessarily be too worried by surveys which say that people do not recognise the STP brand. It is an acronym that sounds like management speak. I suspect there are lots and lots of people whom we have involved in the STP who do not realise it is the STP, including some clinicians. When we have meetings about expanding access to primary care it is quite possible a lot of the people in that room do not realise that it is a STP initiative. They just think about extending the hours..
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Andrew Boff AM: The problem there, as was alluded to in our first session, is if people do not get the whole connected plan they might come to a view on one of the strategies that may change if they saw it as part of a whole.
Mark Easton (Programme Director, South East London STP): We have to recognise there is a branding issue with STPs. If you Google STPs what comes up is secret plans for cuts. That is not what I think a STP is but it is a public narrative that is out there.
Andrew Boff AM: Everyone should avoid three-letter acronyms (TLAs). They are very bad and not very transparent.
If there is significant political opposition to those STPs do you see room for the plans to be revised rather than completely abandoned?
Mark Easton (Programme Director, South East London STP): There is a long track record of the NHS revising its plans in the face of engagement with stakeholders. We have had some experience of that in South East London.
Andrew Boff AM: The Chancellor of the Exchequer has just had an experience of that as well.
Mark Easton (Programme Director, South East London STP): The important point I would make is that STPs are not blueprints chiselled out in stone. They are plans which will change and develop over the course of the next five years (a) as we engage more with the public and clinicians, and (b) as we get experience of what works and what may not be working so well. When I am challenged and people ask if I can guarantee that every line of the STP will work, my response is that it is not 100% going to work but over the course of the five years we will work out what is not working so well and try to fix it.
David Stout (Programme Director, North Central London STP): Picking up that point, we very explicitly published our plan as a draft. We published it as a draft because (a) it was not finished, and (b) we wanted it to change as we wanted to engage with stakeholders - be they politicians, local people or our staff - to improve our plan. Our plan in October undoubtedly was not finished. It is absolutely not chiselled in stone. It is set out there as something to work from. It is the first cut of a plan, not the final version.
Unmesh Desai AM: I have three questions, my first question is to all of you on the workforce. What steps need to be taken to ensure there is a workforce that can support the delivery of all these STPs?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): Across North West London - because we have a long history of working together, both as commissioner and providers - we have a workforce transformation programme that was set up three or four years ago. We have looked at the various changes we have done. For example, in maternity we recruited a whole lot of new midwives. From our paediatric changes we got 16 new paediatric nurses. We changed the way people work and it made it attractive for people to work there. We are working on a Capital Nurse programme. We are looking at clinical pharmacists and so across North West London we are looking at clinical pharmacists working in primary care. For example, in my practice we never had a clinical pharmacist. I now have one working five days a week. It has completely changed the way we work.
We are looking at recruitment and retention. We are working very closely with Health Education North West London, which is pretty much part of our delivery team, to map through what the workforce is, what the gaps
Page 43 are and how we need to address them. That workforce is one of the biggest challenges. The other thing is that it is not about numbers, it is about the work we do and how we work differently.
David Stout (Programme Director, North Central London STP): We have a workforce work stream, as we call it, which is linked into Health Education England. It has social care input. It is looking at both the changing roles we are going to need as we change clinical models, but also how we can work effectively as a whole system to attract new and retain existing staff and how we can reduce reliance on locum and interim staff so we get productivity gains without making any change to staff numbers. It is one of the biggest enabling programmes in our whole programme because we recognise it is probably the most limiting factor to change. If we get this wrong then the speed at which we will be able to implement the sorts of ambitions we have will be restricted. It is a very similar story.
Steve Russell (Executive Regional Managing Director (London), NHS Improvement): You will probably get a very similar answer from all of us. One of the key things that Mohini talked about was Capital Nurse. That is trying to co-ordinate the workforce for nursing much more effectively across London and to try to retain staff within the NHS. We are quite good at recruiting in general terms. What we are less good at is retaining people. That is for a whole combination of reasons. Most health and care systems will have quite a clear focus on how to make people’s working lives better so that there is better retention. Some of that is about working with local government and the Mayor on housing because housing is a very big barrier to workforce supply in London. The other thing that many systems are working on is new roles. With Health Education England there is a very significant programme of physician associate and nurse associate training going on across London in an attempt to try to manage the fact that both will need new roles and also that workforce supply of the traditional roles is perhaps not going to keep pace with historic demand.
Jane Milligan (STP Lead, North East London STP): As David said, it is the same for us. If you stripped everything else away and we had to just concentrate on one area this would be the key thing. It is also recognising that part of what we need to be putting in place is the change to the cultural aspects of workforce. I am a physiotherapist by trade. I have worked in multidisciplinary teams. I have managed multidisciplinary teams. Bringing people together in the same room, even in the same organisation, does not necessarily get what you actually need, which is about a holistic approach to managing or looking after patients, carers and their families. There is recognition of that organisation or system development that is required.
Thinking about North East London, given we have a lot of building going on we do have a real opportunity to be working with our local housing providers. We are establishing a Housing Forum to do some of this. We really need to be working with our local authority colleagues and the housing providers to look at supplying some really significant and actual ‘affordable’ affordable housing. Part of our approach is wanting to attract people to come and work and stay in North East London. We then need to wrap around and start to provide the career pathways to do that.
The GP workforce is a good example. The days of partners are pretty long gone. A shift has happened significantly in North East London, as I know it has elsewhere. For a budding young GP coming to North East London, what is going to keep them and light their fire? Part of that is working with our consultant colleagues in the acute hospitals to provide that sort of portfolio career. It is not just the technical numbers; it is about how we then support this. That is, as I say, pretty critical.
Mark Easton (Programme Director, South East London STP): I would agree with everything that you heard before. The only thing I could probably build on is that the relationship with Health Education England is very very important in two respects. One is in helping their workforce planning. They have helped us with modelling work and survey work on key skills gaps and key gaps in professions that we need to think about, Page 44 either boosting the workforce training numbers or thinking about other roles that can substitute for some of that work. That leads into the second thing they have been helping us with, designing new roles and thinking, for example, of the support that nurses and doctor’s assistants can give to increase capacity in primary care.
Daniel Elkeles (Chief Executive, Epsom & St Helier University Hospitals Trust, attending on behalf of South West London footprint): Just to echo what everyone else has said, the STPs are describing a different way of delivering health and care. It means you need your workforce to work differently and there are lots of examples going on about it. In South West London you have people going into people’s homes and providing care. It might be a therapist and a junior doctor working together in doing things that a social care person might traditionally have done. We have paramedics working in A&Es and we have new medical rotations that go between hospital and the community mental health services so that we are training people in physical and mental health at the same time.
Dr Onkar Sahota AM (Chair): Again, a question to all of you. How confident are you that all these STPs can be delivered within the defined timescales? We heard about some of the problems that we talked about earlier, post-Brexit and so on.
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): The NHS will adapt and change and modify things. As we go into the mobilisation and implementation, things will change. We will have to wait and see. The ambition is there but we need to make the scale of the change. We recognise that from a sustainability perspective, not just money but the workforce, we have to work differently. We are going to continue to deliver the NHS, which is our most valuable asset. We are all going to work differently.
David Stout (Programme Director, North Central London STP): Yes, I am confident we are doing the right things. I am confident we have leadership of the organisations working across North Central London, working together in a way that collectively they have not before, which gives us greater optimism that we will be able to achieve what we are seeking to do. But we should not shy away from recognising that the scale of what we are trying to achieve is phenomenal and the timeframe we are trying to do it in is probably more than we have achieved in the past. Could I guarantee it will work? No. Am I sure it will lead us to a better place than if we did nothing? Yes. Our job is to push this as far and as fast as we can and make sure we achieve what we can.
Steve Russell (Executive Regional Managing Director (London), NHS Improvement): I will repeat a little bit of what David said. I am confident that the STPs will deliver improvement and they will make much faster progress towards the ambitions that are set out than would have been the case otherwise. I have observed a very significant change in the five STPs in London over the last five months while I have been in this particular role. I think, though, David is right that we should not underestimate the challenge that we are facing. If you were to ask the question a slightly different way and ask what the alternative is, I am not sure, and you heard that from this morning’s panel as well. The stuff that is in the STPs, there is good consensus that it is the right thing to do.
If you were to ask the question a different way and ask how I could be more confident that they will deliver, my answer would be that we need to now move to backing the STPs and collectively supporting them to implement some of their aspirations, rather than constantly going around asking, “Can we develop the plan a bit further?” As others have said, that plan is not set in stone. It will change. I am perfectly confident that what David sets out for North Central London in year 2 today in year 2 will look slightly different and that is OK. That is absolutely fine. If in year 2 we are still talking about the plan, then we have lost two years. There
Page 45 is a piece about reflecting that they are not perfect but if they did not exist, we would need to design something else. There is consensus around what is in them. We need to collectively back them.
Andrew Boff AM: That sounds like the way Microsoft issues new software releases.
Steve Russell (Executive Regional Managing Director (London), NHS Improvement): Patch 22.
Andrew Boff AM: They get it out the door first and then they worry about whether or not it is perfect. I get the point.
Jennette Arnold OBE AM: You would not want them to be building your house, would you?
Jane Milligan (Lead, North East London STP): I am not sure I can talk about building a house. The critical thing is being clear of those things that can be put in place relatively quickly, and that might be how providers work together on a more comprehensive approach to delivering trauma and orthopaedic elective care. In relation to some of the ambitions around prevention, we all know - for us the focus is around diabetes and smoking - that that is a long game. We just need to be clear about the things we want to sprint towards and the things we want to put in place for that longer-term marathon. That is the way we describe it.
It is being clear about what the STPs are and about what they are not. For our STP, everyone is involved in that but it is about what the collective partnership can do to really drive through those ambitions, as I say, being really clear about what is going to be achieved when. As always, the ambitions are going to be in different layers.
Mark Easton (Programme Director, South East London STP): It is always a challenge going fifth, is it not? Yes, it could be worse. The NHS is generally better at planning than it is at delivery. When I speak to the public in South East London, there is less of a challenge about, “Are you doing the right thing?” and it is much more of a challenge about, “Is it really going to happen?” Steve [Russell] gave a very good response, which is that the direction is right. Undoubtedly the details of some of the things we are trying to implement will change as we learn and as circumstances change. Trying to predict what the British economy will be like, where we are, with Brexit in 2020, we are going to have to be adaptive. I am thinking about the house metaphor. If I give you the metaphor of a bridge, we are not trying to build a bridge, where you would want a precise blueprint before you started laying down steel –
Mark Easton (Programme Director, South East London STP): This is much more of a house renovation, where you might have a 1930s semi and you think there are some improvements you can make to make it more fit for your modern family.
Daniel Elkeles (Chief Executive, Epsom & St Helier University Hospitals Trust, attending on behalf of South West London footprint): I would say the thing that gives me confidence, after my 20 years so far in the NHS, is the degree of collaboration that the STPs have produced. It is collaboration between providers. I spent all of yesterday afternoon with my colleagues, general hospital chief executives from South West London, working together on how we were going to ensure that we could provide the care collectively that people expect of us. It is collaboration between different parts of the NHS. Who would have thought a few years ago that my hospital would be in two provider alliances with all the GPs with whom we serve? Perhaps most importantly of all, it is the collaboration between the NHS, social care and local authorities. I have never seen it so positive. That will be the secret as to how the STPs are successful in delivery, because of all those new collaborations.
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Dr Onkar Sahota AM (Chair): Name one thing that the Mayor could do to support the delivery of STPs in London.
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): London is one of the world’s premier cities.
Dr Onkar Sahota AM (Chair): The premier city in the world.
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): The premier city. Absolutely. It deserves and needs to be championing the best health and social care that exists. The Mayor could really work. He has some great assets in terms of Transport for London and the NHS. We own most of the estates in London. There is his influence and his impact on that, his influence on transport, his influence on workforce and how we are able to retain the workforce. We have huge training opportunities. We do not retain people. How do we make London a more attractive place for people to work? The Mayor could really champion that.
The other important thing is the conversation with the public. We all work in the NHS. We all use the NHS. What is our honest conversation.
Dr Onkar Sahota AM (Chair): Two things. David?
David Stout (Programme Director, North Central London STP): I agree with all of that. What else? We have already talked about workforce and housing. The Mayor has powers and influence in terms of affordable housing that could be one of the parts of the solution to our workforce challenge we talked about earlier.
Steve Russell (Executive Regional Managing Director (London), NHS Improvement): I was going to use the estates example but that has been taken. The public health agenda: air pollution, the point that was raised around fast food outlets and so on. That would make a very significant impact on both message and health impact and outcomes in later years.
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): There are a lot of commonalities across our five STPs that it makes sense sometimes to do once for London. A number of those relate to some of those that are part of the Healthy London Partnership programme anyway, but around mental health - I co-chair the Mental Health Transformation Board and so I will do a plug for that - and particularly some of the work we need to do around stigma, which often leads to people accessing mental health services not necessarily in the right or timely way. There are some key areas: mental health, cancer and prevention.
Mark Easton (Programme Director, South East London STP): In London, 10% of journeys are health- related. There is clearly a huge co-planning agenda around health and transport. The more we can make that transport operating on a clean air basis, the better it will be for those of us who suffer from asthma and other respiratory diseases in London.
Daniel Elkeles (Chief Executive, Epsom & St Helier University Hospitals Trust, attending on behalf of South West London footprint): I would just add two points. In many of the London boroughs, the NHS is by far the biggest employer. Making the boroughs really good places to work and using all your powers to help that happen is very important. Secondly, we have a shared endeavour in London, which is, “How do you get the many millions of people who live in the capital to have the best lives that they can have?” That is about how they live healthy lives, how we ensure their families work well, the education system, social care, Page 47 transport. It all comes together about how we make London a great place to live. We have a shared endeavour on that.
Dr Onkar Sahota AM (Chair): Thank you.
Jennette Arnold OBE AM: Chair, I have a whole heap of questions about prevention and health inequalities that we are not going to get through and so I would suggest, through you, Chair, that we send our questions out to our panel members.
I would just like to thank them for reminding us that historically London’s healthcare has been skewed towards hospital sickness and not enough towards primary and preventative care. So much I have heard this morning, especially from this panel, is that you have decided what is immediate and what you can get to and that there are some things that will come later. It seems to me that yet again prevention is something we will get to later.
Can I just say why I say this? We have looked at the STP plans. I will look at you, Sir David. Your plan had two pages about prevention compared to 18 pages of service transformation. I understand you need service transformation but prevention and health inequalities are as important at this time. From what you have said, I guess your answer is going to be that this is a draft and you will come to prevention and health inequalities later. Is that what is going to happen?
David Stout (Programme Director, North Central London STP): First of all, I am not -- you knighted me.
Dr Onkar Sahota AM (Chair): You heard it here first, people.
David Stout (Programme Director, North Central London STP): That is someone who is not here rather than me, but thank you very much. Our plan starts with prevention because we think it is important. Do not judge the plan by its length of content.
Jennette Arnold OBE AM: Sturdiness.
David Stout (Programme Director, North Central London STP): The point made in the earlier panel and indeed reiterated here was that STPs were constructed with a five-year timeframe. A lot of primary prevention clearly operates over a considerably longer period. Remember, public health and health promotion are a local government statutory responsibility, and they continue to be responsible for those things. The STP is looking to say, “What are we going to do on top of what is already in plans?” not simply replicate everything that every local authority is already doing.
I would still be keen to protect some added work on prevention in our plan. There is a financial challenge to that. We have not yet landed the money. It is a draft, you are right, and we will by the beginning of April have an updated version of the plan. If we are successful, we will have still emphasised elements of prevention, some of which do have quite quick benefits. Not all preventative interventions take years to deliver. Some are pretty quick in terms of return on investment, using an economic phrase.
Jennette Arnold OBE AM: One last question about health inequalities, Chair. Can you just nod if you have completed your Health Inequalities Impact Assessment? Is that everybody nodding or is there somebody who has not done it? Steve, you are not nodding. You have not done one?
Steve Russell (Executive Regional Managing Director (London), NHS Improvement): That is because I am not the author of an STP. Page 48
Jennette Arnold OBE AM: OK.
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): The Health Equalities Impact Assessment will be done at any time that there is a service change going to be instituted. It is done with that. Any change that happens, however small, will have a Health Inequalities Assessment. The STP as a planning document is just a planning document.
Just taking your previous point about prevention, for example in North West London diabetes and alcohol are two big things and so we are working with our local government colleagues. We have just got a whole pile of money to roll out education for pre-diabetes. Forget the diabetes. We do not want people to get there. That is about investing in pre-diabetics.
The other big issue is alcohol with health and social care. Considering most of it is commissioned through local government, it is about how we work together to deal with some of the alcohol issues in North West London.
Jennette Arnold OBE AM: On the point that you can say you are going to do it in the next stage, what I would have a problem with is if you are not mindful of the health inequalities that it is known you are dealing with at a strategic stage. I would say to you that is absolutely too late when you go to the implementation stage to be saying to people at that level, “We did not bother with this but now you can”. Is that not a big hole in your overall strategic planning?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): No. Sorry, I got that. Absolutely, according to our joint strategic needs assessment in Ealing - and that has been aggregated across North West London - we have a clear idea of the demographics and what the needs of the population are. Therefore our services are commissioned to reflect that. As and when the services are commissioned, each and every service has an inequalities assessment. It is standard practice. It is part of our governing board’s standard papers and our Joint Strategic Needs Assessment (JSNA), which comes to our Health and Wellbeing Board, absolutely reflects that.
Daniel Elkeles (Chief Executive, Epsom & St Helier University Hospitals Trust, attending on behalf of South West London footprint): I just wanted to go back to prevention, to end on a positive. Let me give you an example of a fantastic healthcare prevention scheme. There is the nursing home Vanguard. It is running in Sutton. In every nursing home there is now a team of GPs, social care, therapists and, when needed, hospital consultants who go in and do, every week or every month depending on how frequently the patients need, a proactive assessment of their health and care needs.
That means that more of the people in the nursing and residential homes and have their care delivered in the nursing and residential homes rather than coming to the hospital. They get better care, you are stopping them getting acutely unwell and you are releasing pressure on hospitals. It is a brilliant scheme. It is not only going to be rolled out right across the South West London STP, I suspect all the STPs will say, “This is a really good thing. Here is how it was piloted in this borough. Let us do it in 32 of them”.
Jennette Arnold OBE AM: Daniel, thank you for that. I have said it on a number of occasions across the table: I want to go and live in your area because when you look at health indicators, when you look at everything, you guys are in a much better position to where I am in North East London. Thank you for sharing. We will be writing to you about the other questions and concerns that we have about prevention and health inequalities. Thank you.
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Dr Onkar Sahota AM (Chair): I just want to pin something down before we wind up. I will ask each one of you this question. Has an inequalities impact assessment been done for the whole plan? You refer to bits of it but I am talking about the whole plan. Has anyone done an inequalities impact assessment on the whole plan of the STP in their area? Mohini?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): For Shaping a Healthier Future, we absolutely did one as part of our consultation.
Dr Onkar Sahota AM (Chair): Shaping a Healthy Future was part of the STP?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): In North West London, the STP, we already had --
Dr Onkar Sahota AM (Chair): The question is a yes/no. Has an inequalities impact assessment been done for the whole of the plan?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): Again, I am going to come back and say that the acute reconfiguration plans absolutely had their equalities impact assessment done and that was done as part of the consultation when that happened. As and when the service -- the plan is --
Dr Onkar Sahota AM (Chair): The whole STP has not had an equalities impact assessment?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): I am not sure that we have had the whole plan go through a -- we have had it in engagement, we have had the discussions --
Dr Onkar Sahota AM (Chair): An inequalities impact assessment has not been done for the whole plan?
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): No.
Dr Onkar Sahota AM (Chair): Thank you. That is what I wanted. It was a yes or no answer. David?
David Stout (Programme Director, North Central London STP): Yes. We have done the high level. We have done inequalities impact assessments of every element of the plan and then we have collated that into an overarching report, which we are looking at on Friday, funnily enough. Yes, a very initial one has been done. Mohini is right that as we get into finer detail of implementation --
Dr Onkar Sahota AM (Chair): I understand that, but no one has done an impact study --
David Stout (Programme Director, North Central London STP): We have done. We have, yes.
Dr Onkar Sahota AM (Chair): You have? OK. Jane?
Jane Milligan (Lead, North East London STP): Yes, we have.
Dr Onkar Sahota AM (Chair): Mark?
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Mark Easton (Programme Director, South East London STP): Yes, it is on our website.
Jane Milligan (Lead, North East London STP): Yes, it is on our website.
Dr Onkar Sahota AM (Chair): Daniel?
Daniel Elkeles (Chief Executive, Epsom & St Helier University Hospitals Trust, attending on behalf of South West London footprint): We had done one before we submitted the plan. I would also say to you that we have engaged with 88 different groups in South West London. We have covered every single protected group more than once to ensure that we have properly reflected in the plan what each of those groups thinks.
Dr Onkar Sahota AM (Chair): Your answer is yes, Daniel?
Daniel Elkeles (Chief Executive, Epsom & St Helier University Hospitals Trust, attending on behalf of South West London footprint): Yes.
Dr Mohini Parmar (Chair, Ealing Clinical Commissioning Group and STP Lead, North West London): Onkar, on that, North West London has. I think I am describing it in a very detailed way when you go to the service chain and, on the strategic level of the plan, yes. As you know, the devil is in the detail. When you get the detail, that is when it really needs to happen.
Dr Onkar Sahota AM (Chair): Great. Thank you. I know this has gone longer and we could have made it go on even longer. We cut out a lot of questions we wanted to ask. Thank you very much for your time and for your effort and for your appearance with us.
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Page 52 Agenda Item 4
Subject: Summary List of Actions
Report to: Health Committee
Report of: Executive Director of Secretariat Date: 19 April 2017
This report will be considered in public
1. Summary
1.1 This report sets out details of completed and outstanding actions arising from previous meetings of the Health Committee.
2. Recommendation
2.1 That the Committee notes the completed and outstanding actions arising from its previous meetings.
Meeting on 15 March 2017
Minute Subject and action required Status For Action item 7 Sustainability and Transformation Plans in London (item 7)
Authority was delegated to the Chair, in Completed. A letter from the n/a consultation with the Deputy Chair, to Chair has been submitted to agree any output and further information the Mayor of London relating required arising from the discussions. to the potential impact of Sustainability and Transformation Plans in London and further points for consideration.
Subsequent to the meeting, additional Completed. n/a information was received from the Chair of London Region, Royal College of General Practitioners to bring to the attention of the Committee, attached as Appendix 1.
8 Health Committee Work Programme (Item 8)
Authority was delegated to the Chair, in Completed. See agenda item n/a consultation with the Deputy Chair, to 5. City Hall, The Queen’s Walk, London SE1 2AA Enquiries: 020 7983 4100 minicom: 020 7983 4458 www.london.gov.uk Page 53
Minute Subject and action required Status For Action item agree the scope and terms of reference for the Committee’s meeting on 19 April 2017 on mental health issues of ex-offenders
It was agreed that a site visit to Springfield Completed. n/a Hospital in tooting, to visit the National Deaf Mental Health Service, take place on 29 March 2017.
Meeting on 12 January 2017 Minute Subject and action required Status For Action item 5 Mental Health and Disabled and Deaf People (Item 5)
During the course of the discussion, Ongoing. Scrutiny Members suggested that officers write to Manager all London boroughs to ascertain whether
they hold a register of visually-impaired people, and how often the register is updated.
It was also agreed that the Chair write to Ongoing. Scrutiny the Mayor to recommend that he attend Manager the World Congress on Mental Health and
Deafness, due to take place in London from 6 to 8 March 2018.
Authority was delegated to the Chair, in Ongoing. Scrutiny consultation with the Deputy Chairman, to Manager agree any output from the discussion.
6 Health Committee Work Programme (Item 6)
Authority was delegated to the Chair, in Completed. n/a consultation with the Deputy Chairman, to More information about this agree the scope and terms of reference for delegation of authority can be the Committee’s review of NHS found at Agenda Item 5. Sustainability and Transformation Plans.
Page 54
Meeting on 29 November 2016 Minute Subject and action required Status For Action item 6 Suicide Prevention in London (Item 6) During the course of the discussion, the Committee requested the following additional information: Data on how the suicide rate in Completed. n/a London compares with that of other This information has been UK cities; circulated to Members.
Forward notice of the mental health Outdated. Assistant strategy announcement due to be Director of This action is no longer Health and made by the Mayor in December relevant as the December 2016. Communities, 2016 deadline has passed. GLA
Authority was delegated to the Chair, in Completed. n/a consultation with the Deputy Chairman, to See Agenda Item 5 for more agree any output from the discussion. information about this delegation of authority.
Meeting on 19 October 2016 Minute Subject and action required Status For Action item 6 Transport for London’s Role in Promoting Health in London (Item 6) During the course of the discussion, the Chair of the Ongoing. Chair of the Faculty of Public Health’s Health Improvement Faculty of Committee undertook to provide the Committee with The Chair has Public a copy of the Faculty of Public Health’s report on written to request Health’s local action to reduce the health effects of cars. this information. Health Improvement Committee
List of appendices to this report: Appendix 1- Additional information was received from the Chair of London Region, Royal College of General Practitioners
Local Government (Access to Information) Act 1985 List of Background Papers: None
Contact Officer: Vishal Seegoolam, Principal Committee Manager Telephone: 020 7983 4425 Email: [email protected]
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Page 56 Appendix 1
Additional information from the RCGP for the London Assembly Health Committee discussion on Sustainability and Transformation Plans in London
Supplementary points on the main themes covered at the meeting on Wednesday the 15th March 2017 1. What are you expecting STPs to deliver? STPs talk about integration, person-centred care, improving access, GP federations: all principles which the RCGP supports. But our main concern is whether sufficient funding will be allocated for the significant planned shift of care from the acute sector to the community. We would like to see a clear commitment of STPs to deliver the GP Forward View (GPFV) aspirations, including:
Explicit ring fenced funds for general practice, including to support it (rather than only allocating money to new schemes or new models). This should include at least 15-20% of the Sustainability and Transformation Fund as NHS England recommended. To include money for estates (including awareness that the Estates and Technology Transformation Fund is oversubscribed, so incorporating alternative funding options). An increase in GP numbers and other practice staff proportionate to the GPFV commitment. Clear delivery plans and strategies for achieving the above.
2. How effective has engagement been to date, why is patient/frontline staff involvement important at this stage, and what more needs to be done to improve this. Engagement has been mixed at a national and London levels; in many cases front-line GPs have not been consulted on the plans. We recognise that meaningful engagement can be difficult with a high level/strategic document but as delivery plans and strategies start being developed, it is paramount that front-line staff, relevant stakeholders, the local authority and patients/the public are not only engaged but co-design these. Such an approach should be an ongoing process and not an one-off event and needs to be underpinned by data (including data on the impact of proposed changes on health inequalities) to allow informed decisions and choices.
3. The key challenges for shifting care from acute to community settings, and whether the London STPs have addressed these realistically. The lack of capacity and resources within London general practice needs to be addressed before any shifts of care occur. General practice is in crisis and needs resources in order to have the ability to continue functioning, before being in a place that it can readily accept much higher demand. There is a need for close working with HEE, BMA and RCGP to address the workforce crisis and a requirement for extra investment on training and retention.
4. Are the plans realistic given current financial constraints, and how can organisations make the savings required. The plans are high level and there is not enough convincing detail that the proposed changes will result in significant, quick savings while the quality of care is maintained. There needs to be a lot more detail on how value for money will be delivered and how this will be evaluated. The actual
Page 57 impact of any changes on the quality of care and on health inequalities will need to be closely monitored.
5. What are the workforce implications of the plans and are these achievable given the current issues with workforce recruitment and retention There should be far greater detail on the strategy around workforce – few STPs go into detail about the number of GPs and primary care professionals needed, with most saying they intend to plan this (rather than including it in the plan at this stage). The plans need as a minimum to commit to the GPFV aspirations on workforce development.
6. What do STP leads need to do to reassure the public that the STP process and proposals won’t have a negative impact on the care they receive? They need to be honest, engage better and be reflective:
Honest about the challenges they face especially in terms of the financial sustainability and workforce. They need to meaningfully engage with health care professionals, local authorities and patients/the public. Unless front line staff and patients are engaged, the STP aspirations will not be successful; it is important that people believe both that changes are needed and that these are feasible and they are supported to deliver. Finally, there is a need to incorporate the principles of quality improvement in the plans and commit to monitor and continuously reflect on the impact of any changes on health and wellbeing outcomes, health inequalities, workforce and the financial sustainability of their organisations and not just focus on the later.
Information on STPs (national level) The College’s recent interim assessment of the GP Forward View (accessible here) included a thematic analysis of the 44 STPs.
The key insights from the College’s STP analysis
1. The GP Forward View is not mentioned at all in a number of STPs. While a small number of STPs demonstrate significant engagement with the GP Forward View, it goes without mention in four STPs, with several others referring to it only in passing.
2. STPs are often driven by the need to tackle large deficits in the hospital sector, with very optimistic financial forecasts. This is likely to affect the level of investment available for general practice. If forecasts are not met, funding for general practice may well be at risk.
3. General practice is frequently seen as a solution to problems in secondary care, without sufficient efforts made to stabilize and support it. There is evidence that robust and effective general practice should be at the heart of a high quality and sustainable health service. However, given the recognition by many STPs that general practice is in crisis itself, insufficient regard is being paid to the need to put it on a stable footing. This has to be a precondition to creating a coherent platform for subsequent investment in the delivery of enhanced services in the community. General practice cannot have more pressure applied without significant financial support and an expanded workforce.
Page 58 4. Workforce plans for general practice are not sufficiently robust. There is often acknowledgement of a workforce shortfall or high anticipated retirement numbers, but steps to contend with these are largely absent.
5. Some STPs foresee a decrease or stagnation in GP numbers. This is entirely contrary to the vision of the GP Forward View and is especially alarming considering the high expectations for general practice to deliver more of the care in the community.
6. An increase in hubs and general practice working at scale is based on an assumption that the number of practices will reduce in some STP footprints. Where this is the case, it is often unclear how this will be approached, how GPs will be consulted and what the impact will be on patients, particularly in more rural areas.
7. STPs identify very limited ring fenced funds for general practice infrastructure. Often these are dependent on bids or delivery of other aspects of the STPs, with a failure to recognise the importance of vastly improved estate and digital capabilities in general practice in order to deliver new models of care.
8. Local demand for extended access is seldom being assessed. Most STPs have not demonstrated an understanding of local demand or indicated whether GPs have been consulted on how they will be required to deliver plans.
9. STPs are top down strategic outlines, which have seldom been developed in a transparent way, and in many cases GPs have not been consulted. Broad consultation could not always be achieved with tight reporting deadlines. While Trusts and larger GP federations may have been represented via CCGs the section of the GP community that appears to have been least engaged are mid to smaller sized GP practices. Their buy-in is vital to the success of the GP Forward View.
10. Many STPs lack detail, with further information either not publicly available or missing entirely. There is much that will not have been visible as the STPs have been analysed. The RCGP’s expectation is that several more months will pass until all plans are finalised. It is critical that GP voices are heard during this time and the numerous STP footprints that are lacking these should make substantial efforts to consult with their GPs and the RCGP.
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Page 60 Agenda Item 5
Subject: Offender Mental Health
Report to: Health Committee
Report of: Executive Director of Secretariat Date: 19 April 2017
This report will be considered in public
1. Summary
1.1 This report sets out background information and context to the Committee’s discussion with external guests on offender mental health in London.
2. Recommendations
2.1 That the Committee notes the report as background for the discussion with invited guests and notes the subsequent discussion.
2.2 That the Committee delegates authority to the Chair, in consultation with the Deputy Chairman, to agree any output from the discussion.
3. Background
3.1 At its meeting on 15 March 2017, The Committee agreed to use this meeting of the Health Committee to discuss mental health provision for offenders in London.
4. Issues for Consideration
Remit of the discussion 4.1 Throughout its 2016/17 work programme, the London Assembly Health Committee has been examining mental health inequalities in London. Previous work has focused on the LGBT+ and Deaf and disabled communities, and suicide prevention. This is the final proposed meeting on this specific work stream.
4.2 The Mayor has a statutory duty to produce a health inequalities strategy for London. As part of this work programme, the Mayor has acknowledged the need to improve access to mental health services for marginalised communities, and has committed to publishing a mental health road map for London on how services across the capital can be improved. The Mayor has also identified improving mental health care in the criminal justice system as a key goal for his recently published Police and Crime Plan.
City Hall, The Queen’s Walk, London SE1 2AA Enquiries: 020 7983 4100 minicom: 020 7983 4458 www.london.gov.uk Page 61
4.3 This meeting is intended to focus largely on mental health provision for both prisoners, and those released to the probation services. To achieve this, the meeting will look at the pathway of care that prisoners receive, including: Assessment on arrival at prisons, and how care is managed within the prison service; How prisoners are assessed coming up to release, and what individual plans are put in place to ensure that mental health support is available; and How probation services execute these plans, and the barriers that ex-offenders face in maintaining good mental health while back in the community.
4.3 The Committee is recommended to delegate authority to the Chair, in consultation with the Deputy Chairman, to agree any output from the discussion at this meeting.
Invited Guests 4.4 Guests invited to the session include: Sinéad Dervin, Senior Mental Health Commissioning Manager, Health in the Justice System, NHS England; Jacob Tas, Chief Executive, NACRO; Cassie Newman, Head of Contract and Partnerships, London Community Rehabilitation Company; Andy Bell, Deputy Chief Executive, Centre for Mental Health; and Representative, Prison Governors Association.
5. Legal Implications
5.1 The Mayor of London’s statutory responsibilities in relation to health matters, as set out in the Greater London Authority (GLA) Act 1999, are to develop a strategy which sets out “proposals and policies for promoting the reduction of health inequalities between persons living in Greater London”. The GLA Act 1999 defines health inequalities as inequalities between persons living in Greater London “in respect of life expectancy or general state of health which are wholly or partly a result of differences in respect of general health determinants” and also goes on to define “health determinants”. The Mayor of London has no statutory role in the commissioning of any health services or health service provision.
5.2 Officers confirm that the scope for this review falls within the Committee’s terms of reference.
5.3 The Committee has the power to do what is recommended in the report.
6. Financial Implications
6.1 There are no financial implications arising from this report.
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List of appendices to this report:
Appendix 1 - Scoping paper for the committee’s work on offender mental health.
Local Government (Access to Information) Act 1985 List of Background Papers: None
Contact Officer: Lucy Brant, Scrutiny Manager Telephone: 020 7983 5727 Email: [email protected]
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Page 64 Appendix 1 Health Committee meeting Offender and ex-offender mental health
Throughout its 2016/17 work programme, the London Assembly Health Committee has been examining mental health inequalities in London. Previous work has focused on the LGBT+ and Deaf and disabled communities, and suicide prevention. This is the final proposed meeting on this specific work stream. A report, bringing together these various strands will then be produced during the summer, which ties the findings of the committee to the Mayor’s work on the Health Inequalities Strategy and his mental health roadmap.
Purpose The purpose of this meeting is to determine What are the key mental health challenges facing prisoners, those on release on probation, and ex-offenders who have served their sentence? How the Mayor and the GLA can support better mental health for offenders and ex- offenders in London.
Background In recent years there has been a growing awareness that people in contact with the criminal justice system face significant health inequalities, including multiple and complex health and social care needs. Poor individual health and social inequalities are interlinked with an increased risk of offending.
According to Public Health England, addressing inequalities, including health inequalities, as well as directly addressing offending behaviour can improve public safety, prevent offending and reoffending, and reduce crime. Furthermore, meeting the health and social care needs and reducing the inequalities that those in contact with the criminal justice system will also provide a community dividend, i.e., will help to improve outcomes for other people, including those not in contact with the criminal justice system.
Of the approximate 88,500 people sentenced to immediate custody in 2015/16, roughly half will have been released from prison in less than 12 months. Since 1993 the prison population in England and Wales has increased by more than 41,000 people, a 92% rise.
Within London, more than one million residents live with mental health needs – a higher prevalence than in other parts of the country. The demands on the MPS with regards to mental health are increasing: between April 2013 and March 2015 London as a whole has seen increases in the number of criminal incidents involving mental health aspects (64 per cent increase) and the number of vulnerability reports recorded (31 per cent increase).
There are several data points which indicate a worsening picture for mental health provision for this cohort, including
Page 65 Appendix 1 Health Committee meeting Offender and ex-offender mental health
In the 12 months to December 2015 there were just over 32,000 selfharm incidents. This was an increase of just under 26% compared to 2005 and an increase of 25% compared to 2014. Over 100 people killed themselves in prisons in England and Wales in 2016, the highest death toll in a calendar year since recording practices began in 1978. While prisoners have a mortality rate about 50% higher than the population, released prisoners and offenders in the community, such as probationers, have over two to over three times the population mortality rate.
The graph below indicates that, across a range of severe mental health issues, prisoners and ex- offenders have substantially higher incidences
The role of the Mayor and the GLA The Mayor’s draft Police and Crime Plan recognises the need for better mental health provision in the criminal justice system, both to reduce the overall incidence of re-offending, but also address structural inequalities in terms of race and disadvantage for those in contact with the system. Potential actions by the Mayor included within the draft Plan include • Working with NHS England to ensure liaison and diversion services are delivering effective outcomes for offenders with mental health problems. • Working with the voluntary, community and social enterprise sector to develop their engagement in delivering health interventions to reduce offending/reoffending. • Integrated co-commissioning to address victim and offender health within communities, to address health inequality and with a view to developing a joint commissioning strategy and governance structure from 2017/18 onwards • Developing better pathways out of crime for offenders by working with the GLA, London Councils and wider partners to expand access to services that work with families of offenders
Page 66 Appendix 1 Health Committee meeting Offender and ex-offender mental health
and by working with businesses to provide greater employment opportunities and training to those leaving custody.
This session would provide an opportunity to hear from MOPAC about how it plans to encourage better mental health care for offenders and victims of crime, and particularly, how the ongoing devolution might provide new opportunities for the Mayor to directly intervene.
Aims of the review This meeting is intended to focus largely on mental health provision for both prisoners, and those released to the probation services. It will also focus primarily on those with short to medium term sentencing (ie a prison sentence of between one and five years) – the needs of those on longer prison terms, and those who will likely be out in the community within a few months to a few years, are very different.
To achieve this, the meeting will look at the pathway of care that prisoners receive, including Assessment on arrival at prisons, and how care is managed within the prison service How prisoners are assessed coming up to release, and what individual plans are put in place to ensure that mental health support is available, and How probation services execute these plans, and the barriers that ex-offenders face in maintaining good mental health while back in the community.
Suggested approach The committee will hold one meeting with invited guests to discuss this topic. Potential guests may include: NACRO Liaison and Diversion Prison Governor’s Association Centre for Mental Health
Potential site visit There is also a potential for a site visit to meet with ex-offenders who face barriers to accessing mental health services. The committee could use its links to voluntary sector organisations to identify an organisation who could help set-up a focus group, or to visit a probation hostel and observe the activities and speak to those working on the front line with this cohort.
Page 67 Appendix 1 Health Committee meeting Offender and ex-offender mental health
Key questions The committee will examine the following key questions:
What are the challenges in providing mental health services within prisons? How are these currently being addressed? How are prisoners assessed for mental health needs before release? What measures are in place to ensure a continuity of care for mental health provision once a prisoner is released into the community? How are ex-offenders monitored to ensure they receive the proper care on release from prison? What are the challenges that this group faces in interacting with health, mental health and probation services? Which groups are most poorly served within the current system? Have the reforms made to the prison and probation services addressed historical issues with providing care to this cohort? What more can be done by the Mayor to support better provision of mental health to prisoners and ex-offenders.
Output This meeting will provide material for the health committee’s report on mental health inequalities in London.
Page 68 Agenda Item 6
Subject: Deaf and Disabled Londoners Access to Mental Health Services
Report to: Health Committee
Report of: Executive Director of Secretariat Date: 19 April 2017
This report will be considered in public
1. Summary
1.1 The Committee is asked to formally agree its report Mental Health – Disabled and Deaf people.
2. Recommendation
2.1 That the Committee agrees its report Mental Health – Disabled and Deaf people, as attached at Appendix 1 to this report.
3. Background
3.1 On 12 January 2017, the Health Committee held a meeting to discuss the challenges that Deaf and Disabled Londoners face in accessing mental health services. This is part of the Health Committee’s wider review of access to mental health services in marginalised communities. The aim of the review is to recommend ways that the Mayor, and other stakeholders, can improve access to, and the quality of, mental health support in London.
3.2 In addition to its January meeting, the Committee invited views from stakeholders and members of the public through a written call for evidence. On 29 March 2017, Members of the Health Committee also visited the National Deaf Service at Springfield University Hospital, which provides specialised mental health support to both adults and children for the south of England. The findings from the investigation formed the basis of a final report Mental Health – Disabled and Deaf people.
4. Issues for Consideration
4.1 The Committee is recommended to formally agree its report Mental Health – Disabled and Deaf people, as attached at Appendix 1.
City Hall, The Queen’s Walk, London SE1 2AA Enquiries: 020 7983 4100 minicom: 020 7983 4458 www.london.gov.uk
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4.2 After informal agreement from the Chair, and in consultation with the Deputy Chairman, the report was published on 12 April 2017 as a draft.
4.3 The report makes the following recommendations:
Recommendation 1 In developing the mental health roadmap, the Mayor and the London Health Board should: Set out how they will work with local authorities and disability organisations to explore how to more accurately capture data on physical and sensory impairment across London at a borough level; Ensure that the intersectional nature of mental health experience is recognised; Encourage London’s mental health trusts to work with local organisations such as Healthwatch to audit how well their services meet the needs of disabled people; and Set out how the development of the mental health roadmap could support third sector organisations to link up and share best practice in this field.
Recommendation 2 In delivering the mental health road map, the Mayor and London Health Board should: Ensure that plain English, BSL and audio formats of the Mayor’s mental health programmes are made available free of charge to disabled people; Set out how they will promote activities and programmes which are disability and Deaf inclusive and promote mental wellbeing; Acknowledge and champion the importance of disability and Deaf equality training for mental health professionals to improve awareness; Use their convening powers and influence to develop pan-London commissioning arrangements for communications support for Deaf Londoners and those with learning disabilities; Set out how they will work with health and care partners to help ‘physical’ and ‘mental’ health services link up which each other more effectively at local levels.
Recommendation 3 The Mayor and London Health Board should align existing GLA group programmes with the mental health roadmap by: Setting out how they will work with employers to encourage more businesses to employ disabled and Deaf people, and how they will work with employers to ensure greater support to help disabled and Deaf people who are in work to retain employment; Setting out how the Mayor’s community cohesion and volunteering work streams could help support further opportunities to expand the network of peer support available across London; Setting out how they will work with disability and homeless organisations to assess the risk of homelessness for disabled and Deaf Londoners and take steps to address this through the Mayor’s housing strategy;
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Ensuring that MOPAC works with London’s DeafHope service to ensure his Violence Against Women and Girls strategy and Police and Crime Plan support disabled and Deaf people in London; Ensuring that TfL works proactively with local authorities and providers to assess the impact of any changes to the distribution of healthcare services across the capital, to ensure that transport is considered as early as possible in these plans; Proactively engaging disabled and Deaf Londoners on the Healthy Streets Programme to ensure changes to the public realm do not have an adverse impact and increase social isolation
Recommendation 4 To ensure that the mental health roadmap reflects the needs of disabled and Deaf people across London, the Mayor and London Health Board should: Set out how they will increase opportunities for disabled and Deaf people to contribute their views to help inform their policy work on mental health and on the wider determinants of mental health such as housing, transport and employment; Set out how they will identify and share best practice on engagement with health and care partners to enable a more proactive approach to seeking the views of disabled and Deaf service users; Host an annual mental health summit to report on progress in the development of the mental health roadmap, with specific inclusion of disabled and Deaf Londoners.
5. Legal Implications
5.1 The Mayor of London’s statutory responsibilities in relation to health matters, as set out in the Greater London Authority (GLA) Act 1999, are to develop a strategy which sets out “proposals and policies for promoting the reduction of health inequalities between persons living in Greater London”. The GLA Act 1999 defines health inequalities as inequalities between persons living in Greater London “in respect of life expectancy or general state of health which are wholly or partly a result of differences in respect of general health determinants” and also goes on to define “health determinants”. The Mayor of London has no statutory role in the commissioning of any health services or health service provision.
5.2 The Committee has the power to do what is recommended in the report.
5.3 Officers confirm that the report and its recommendations fall within the terms of reference.
6. Financial Implications
6.1 There are no financial implications arising from this report.
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List of appendices to this report: Appendix 1: Mental Health – Disabled and Deaf people.
Local Government (Access to Information) Act 1985 List of Background Papers: None
Contact Officer: Lucy Brant, Scrutiny Manager Telephone: 020 7983 5727 Email: [email protected]
Page 72 Appendix 1 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
The London Health Board, chaired by the Mayor, is developing a mental Key findings health roadmap. This aims to shine a spotlight on mental health and Disabled and Deaf people are more likely to experience poor mental galvanise action to improve mental health support for all Londoners. health than the wider population. As life expectancy rises, we can expect to see more people living with impairments in the future. Disabled and Deaf people face additional barriers to accessing Page 73 Page appropriate support at every stage of the mental health pathway, from prevention to crisis. Mental health services are not always good at dealing with the physical needs of service users, while disability services often overlook psychological needs. This is not good news for those who have both. Supporting independent living is a critical component of enabling good mental wellbeing for disabled and Deaf people.
Joined up policy is needed to tackle issues such as housing, transport, Members of the Health Committee meet staff and service users at Springfield Hospital’s employment and crime. These contribute to a disabling society that mental health services for deaf people damages mental health. The London Assembly Health Committee held an investigation Only by including the voices of disabled and Deaf people will we be into mental health support for disabled and Deaf Londoners. We spoke able to create services that meet their needs. to a range of service users and providers to gather views on how the The Mayor has significant opportunities to improve mental wellbeing Mayor could support better mental health for these groups. This report for these groups through his policies and programmes. sets out our key findings and makes recommendations to the Mayor and the London Health Board on potential areas for action.
London Assembly Health Committee I 1 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Recognising the scale of the issue There is little incentive for local authorities to actively seek out and identify disabled and Deaf residents who may be eligible for additional More than one in ten adult Londoners are classified as having some statutory assistance from the council. As a result, disabled and Deaf form of impairment.1 Types of impairment include physical and mobility people may not be accessing the support they need. However, this may impairments, sensory impairments (sight and hearing loss), learning be storing up mental health issues for the future. We urge the Mayor to disabilities, cognitive impairment, and long‐term mental ill health. Many work with local authorities and disability organisations to explore how disabled people have more than one impairment. to more accurately capture data on physical and sensory impairment
across London, at a borough level. There are no definitive figures for how many people in London have a Page 74 Page degree of sight or hearing loss, as registration with local services is voluntary. The latest available data estimates that in London there are: The committee supports the social model of disability. This model says that disability is caused by the way society is organised, rather than over a million people with hearing loss, including over 80,000 by a person’s impairment or difference. It looks at ways of removing profoundly or severely Deaf people, in London2 barriers that restrict life choices for disabled people so they can be 175,000 people living with sight loss in London3 independent and equal in society, with choice and control over their own lives. Additionally, there are estimated to be around 469,000 Londoners with a degree of mobility impairment.4 Disabled people developed the social model of disability because the traditional medical model did not explain their personal experience of The lack of clear data makes it difficult for local authorities to accurately disability, and viewed it as a ‘problem’ to be ‘fixed’. identify need within their local population. However, we heard that some disabled people are reluctant to register with their local Many Deaf people who use British Sign Language (BSL) reject the idea authorities due to fear of discrimination. For example, although there that they are disabled or impaired. But they share, with disabled are over two million people with sight eloss in th UK, only 360,000 are people, many challenges in accessing mental health services which registered with their local authority.5 support their specific needs.
An impairment is defined as long‐term limitation of a person’s physical,
mental or sensory function. London Assembly Health Committee I 2 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Disabled and Deaf people are more likely to An association between depression and disability in late life
is intuitively understood by many people: “Of course she’s experience poor mental health than the wider depressed; she’s old; she’s alone; she’s disabled.” population
Studies have shown that disabled and Deaf people are more likely to Eight out of 10 people with a physical impairment were not born with experience common mental health problems, especially anxiety and it.9 The vast majority become impaired through injury, accident, or depression. Around one in three people with chronic physical Page 75 Page illnesses such as stroke. The prevalence of disability therefore rises with impairment experience a mental health problem, compared to one in age. This means that mental health services need to know how to four in the wider population.6 Deaf people are twice as likely to suffer support people who become disabled later in life, as well as those who from depression as hearing people,7 and around 40 per cent of people are born with impairments. who lose their sight develop depression.8 But there is little data available at a regional level to determine how prevalent mental ill health There is likely to be an increase in the number of people living with is among disabled and Deaf people in London. impairment in the future. Rises in the rate of long‐term conditions that
can lead to disability, such as diabetes, coupled with rises in life The links between physical and sensory impairment and mental health expectancy, mean that people will be living for longer with disability. For are complex. But depression and anxiety are not the inevitable example, diabetes‐related sight loss is the leading cause of vision consequences of being, or becoming, a disabled person. Disability rights impairment in working age adults in the UK. And the number of people campaigners have raised concerns that many, including some health with diabetes has risen by 60 per cent in the UK in the last decade.10 professionals, believe that depression and physical/sensory impairment The incidence of mental ill health in disabled and Deaf Londoners is go together unavoidably, especially when the impairment is acquired likely to increase unless more is done to support good mental health in later in life. This has led to a lack of focus on the mental health needs of this population group. disabled and Deaf people and on the prevention of avoidable mental health problems.
London Assembly Health Committee I 3 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Disabled and Deaf people face additional The issue can be further compounded by the lack of a shared mental barriers to accessing appropriate support at health vocabulary between health professionals and disabled or Deaf every stage of the mental health pathway service users. Contributors to our investigation told us that it can be difficult for some disabled and Deaf people to recognise the symptoms
of depression or anxiety and to articulate them to people who could Prevention and health promotion offer support. So it is vital that information on how to recognise mental Having information about how to manage your own mental health is an ill health is made more widely available. important 76 Page part of prevention. But information on how to protect and promote positive mental wellbeing is not always accessible to disabled Prevention and resilience should be at the heart of the Mayor’s mental and Deaf people. We heard that, other than some mental health health strategies. It is therefore critical that resources and information services offering information in large print, there is little more offered to are delivered in accessible ways to enable disabled and Deaf people to accommodate the needs of blind and partially sighted people. Services benefit. We would welcome confirmation from the London Health are often advertised in inaccessible formats, such as posters and leaflets Board that plain English, BSL and audio formats of the Mayor’s mental in clinics. Similarly, blind and partially sighted people often experience health programmes will be made available free of charge to disabled problems receiving information in their preferred format, such as in and Deaf people. audio or braille. Much of the emphasis in mental health promotion is around staying Deaf users of British Sign Language (BSL) also report that even basic physically active and maintaining supportive social networks. Ensuring information is not routinely available to them in a format that they can that activities and programmes which are disability and Deaf inclusive understand. For example, Action on Hearing Loss told us that the NHS are more widely promoted by the Mayor would be a welcome step website contains over 900 health videos, but only 1 per cent of these forward for disabled and Deaf Londoners. are in BSL.11 And the increasing reliance on online and digital health promotion resources means that the one in four disabled adults in the UK who have never used the internet are at risk of missing out on key information around mental health support.12
London Assembly Health Committee I 4 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Diagnosis “the practical side of accessing a mental health service such GPs are the gateway to most mental health services. It is thought that as having to find a touch pad to gain access to the building, 90 per cent of people with mental health problems are seen just within then having to navigate around a new building and find the 13 primary care. We have previously investigated the difficulties faced by right person to speak to can cause a lot of stress and anxiety” Londoners in accessing GP services, which are increasingly over‐ stretched. Specific additional challenges disabled people face include booking appointments and physical access to GP premises (including accessible transport links). Communication barriers between service Looking at the whole person users 77 Page and GPs can make it harder to diagnose mental illness, or can lead A major barrier to the effective diagnosis of mental ill health identified to misdiagnosis. For example, Deaf people told us that their frustration by disabled people is that some healthcare professionals cannot see at communication barriers is sometimes mistaken for aggression by past their impairment and that “curiosity and fear” can get in the way of healthcare professionals. normal professional practice. The mental health charity MIND has stressed the importance of recognising that physical impairment and disability may not be the only or the most important aspect of Disabled and Deaf people told us someone’s experience that influences their mental health support They said this patient doesn’t that access issues often begin needs, or how they are treated by mental health support services.14 need an interpreter, they’re a before they even reach the GP’s
good lip reader – so I just shout office. We heard examples of Race, gender and sexuality, social and economic circumstances, and at them appointments being refused childhood experiences are likely to be part of the whole experience of because people couldn’t confirm mental health and it may be difficult for both professionals and them by phone, lengthy delays in individual disabled people to separate out such factors. We encourage getting appointments due to a lack of interpreting services, and a lack of the Mayor and the London Health Board to reflect this intersectional disability and Deaf awareness in frontline staff. We also heard that the nature of mental health experience in developing their work in this physical layout of some services could increase anxiety and act as a area. barrier.
London Assembly Health Committee I 5 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Treatment community and voluntary sector to provide a more cohesive system of Once a diagnosis has been made, there remain additional challenges for communication support across London and help to achieve economies disabled people in accessing treatment. London’s mental health services of scale. It could also help to reduce variation in access to support across are stretched, with long waiting lists for many services such as talking the capital. This is an area in which the Mayor should use his convening therapies. Private therapy is available, but is not affordable for many powers and influence to develop pan‐London commissioning disabled people. And there are particular challenges for people who arrangements for communication support. require communication support. Crisis Page 78 Page Research shows that recovery rates Service users report that mental health inpatient care is not always for Deaf people who have access to accessible to disabled and Deaf people. For example, facilities may not People are being left a therapist who can sign fluently incorporate adaptations to support people with mobility impairments, floundering for weeks and are significantly higher than for or have staff available to assist with activities such as washing or getting weeks without support those that use an interpreter. dressed. Medication required for physical conditions is sometimes SignHealth’s BSL Healthy Minds withdrawn on admission to mental health inpatient services, which can programme, which provides signing increase pain and distress. Medication for mental health can also therapists for Deaf people, exacerbate some physical impairments, but service users have reported used to be block funded to provide this service, but changes to that this is not always explained to them fully. And crisis support is often commissioning structures mean that Deaf people now need to make an telephone based, making it inaccessible to Deaf people. Simple individual funding request to their CCG. This is also the case for adaptations such as providing a mobile number to text could help open accessing psychological therapies through the National NHS Deaf up these services. The Mayor and London Health Board should Service. This can add a significant burden of anxiety and uncertainty at a encourage London’s mental health trusts to work with local time when people’s mental health is already suffering. organisations such as Healthwatch to audit how well their services meet the needs of disabled people. Reviewing needs and service availability at a London‐wide level would highlight opportunities for local authorities to work together with the
London Assembly Health Committee I 6 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Mainstream mental health services don’t …so the loss of specialist services and support always support people with physical or sensory is felt particularly keenly impairment effectively… Funding pressures across health and social care have led to the loss of specialist support for disabled people within community settings. This in A common theme identified throughout our investigation was the need turn leads to a lack of in‐depth knowledge and experience of how to for a more joined up approach between mental and physical health support the additional needs of disabled people. The loss of specialist services. We heard that the historical separation of these services support is compounded by cuts to training budgets which would enable meant that mental health professionals had comparatively little Page 79 Page mainstream services to support disabled people more effectively. This experience of working with and supporting disabled people. The presents a real and unacceptable risk that in future services will not be resulting lack of awareness means that disabled and Deaf people may able to handle service users with complex needs and they will simply fall be more likely to receive poorer quality of care. though the net.
Community and voluntary The Mayor and London Health Board should acknowledge and Some days she did not eat her organisations play a vital role in champion the importance of disability and Deaf equality training for food, because it was just left filling the gaps in statutory mental health professionals, to improve awareness and ensure that services there. The staff assumed it health provision. But there are few can meet complex needs. They should also strongly urge was part of her mental health with experience of supporting commissioners to ensure that funding for this training is protected. condition…but she was not disabled and Deaf people with their Reducing funding for this type of training risks not only worse mental aware of the food being left mental health needs, although health outcomes for disabled people, but increased costs to the health more are now recognising the need service down the line. to do so.
If you don’t have specialist provision in place and cut training that The Mayor and London Health Board should consider how the enables mainstream services to support diversity, people will not development of the mental health roadmap could support third sector access early intervention and will only access hospital care‐ and that organisations to link up and share best practice in this field. is more expensive
London Assembly Health Committee I 7 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
‘Physical health’ services often overlook Campaigners are calling for more emotional and peer support to be made available to help people who become disabled adapt to their new emotional and psychological need circumstances. For example, the Thomas Pocklington Trust reports that The prevalence of disability rises with age. It is important to recognise 92 per cent of people surveyed had received no emotional support at that everyone will respond differently to becoming impaired and won’t the time of diagnosis.17 necessarily develop mental ill health as a result. But there are a number of potential issues around becoming disabled which can contribute to Physical health services need to be more aware of potential raised anxiety and mental health problems. These include: psychological impacts of losing mobility, sight and/or hearing. Including
80 Page discussions around mental health during physiotherapy and at eye and concerns about loss of independent living hearing screenings could help identify people at risk and help signpost grief/trauma reactions to change in circumstances people to appropriate early support before mental health problems anxiety over retaining employment or managing childcare develop. Mental health service providers could liaise with local physical stress due to increased cost of living – on average, disabled rehabilitation services, sight loss centres, hearing clinics, and charities people spend £550 extra a month on living costs15 across London to raise awareness and begin to deliver mental health services to their users and in their venues. The London Health Board The pan‐disability charity Disability Rights UK highlights a lack of should look at ways it can work with health and care partners to help capacity in physical services to provide support to build and maintain ‘physical’ and ‘mental’ health services link up which each other more emotional resilience.16 So people who become disabled may also effectively at local levels. develop a mental health problem within the first few months after diagnosis. There are a number of voluntary sector organisations that Peer support and advocacy are recognised as successful interventions, aim to fill this gap, but these are struggling to meet demand. In addition, providing a network with shared experience and practical advice which they rely on people being aware of the available services and able to can reduce social isolation and help people adjust to their changed navigate the system. circumstances. The Mayor should consider how his community cohesion and volunteering work streams could help support further opportunities to expand the network of disabled and Deaf peer support available across London.
London Assembly Health Committee I 8 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Overcoming stigma and tackling discrimination Improving self‐esteem and reducing incidences of discrimination are key to improving mental wellbeing. Like everyone else, disabled and Deaf against disabled people will help support people experience better mental health when they are respected and better mental health valued by wider society. Stigma and discrimination towards disabled people is a double burden – So improving the visibility and inclusion of disabled and Deaf people it contributes to poor mental health and prevents people from accessing should be a key priority for the Mayor. support early. As mental illness is itself stigmatised, disabled and deaf Increasing opportunities for frontline workers to interact with disabled people 81 Page with mental health problems may experience additional people can help to overcome negative attitudes. We are encouraged to prejudice. The Mayor should lead pan‐London efforts to tackle hear that Transport for London has been working with Inclusion London discrimination against disabled and Deaf people in London. to roll out disability equality training delivered by disabled people Being a victim of discrimination is damaging to mental health. Research themselves. This training gives staff the chance to interact with disabled by the disability charity Scope in 2014 found that two thirds (67 per people and understand their needs, but also helps to highlight how cent) of the British public say they feel uncomfortable talking to disabled people unconsciously discriminate through use of language or because people. And over four fifths (85 per cent) of the British public believe of misunderstandings about disability. that disabled people face prejudice.18 They also found that 56 per cent of disabled people said they had experienced hostility, aggression or We urge the Mayor to promote this approach to local authorities and violence from a stranger because of their condition or impairment.19 health and care providers to enable greater awareness and understanding of how to best support disabled and Deaf people. These factors contribute to social isolation for disabled and Deaf people. Feeling lonely can have a negative impact on mental health. Research by disability charity Sense found that 23 per cent of disabled people feel I went to my local alcohol Giving people the space to ask the lonely most days, rising to 38 per cent for young disabled people. Some team but they told me questions they are uncomfortable 29 per cent reported only being able to meet up with friends once a they don’t work with to ask…so they feel confident and 20 month or less, while 6 per cent said they had no friends at all. Deaf people comfortable engaging
London Assembly Health Committee I 9 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Supporting independent living is a critical councils mean that eligibility criteria for accessing support have been redrawn, resulting in reduction or loss of support for many severely component of enabling good mental wellbeing impaired people. As services come under increasing strain, there are for disabled and Deaf people fewer resources available to support each individual. We heard evidence of people essentially trapped in their homes and unable to perform The ability to live independently and to exercise choice and control is a tasks such as washing, feeding themselves or going to the toilet. fundamental component of mental wellbeing. Pressures on social care are increasingly seen by disabled people to be having a negative impact The focus is to support people to be self‐reliant, on their mental health. Page 82 Page and I think there is a risk of some people with
disabilities falling through the net Social care Pressure on social care services has resulted in uneven quality of This lack of support also contributes to increased social isolation. And it support. Recent research by the disability charity Scope found that over is not just disabled service users who are struggling to cope. Families half of disabled people surveyed couldn’t get the support they needed and carers can also feel the strain. The Association of Directors of Adult to live independently.21 And disabled people report that the processes Social Services reports that staff within social care settings are also involved in accessing support can significantly increase anxiety and being placed under increasing levels of stress, to the potential detriment stress. of their own mental health.22
People with physical impairments, while experiencing general social We welcome recent Government announcements to boost short term pressures to deny the extent of physical dependency, find that in funding in social care. We share concerns that wider reforms are order to obtain assistance to go about their daily life they have to needed. But the prospect of yet more changes to the system may result stress weakness, lack of ability and failure to cope in further and continuing uncertainty for disabled people, with knock‐on effects for their mental health and wellbeing. As health and care in In particular, the closure of the Independent Living Fund and the London moves towards closer integration, the Mayor should assure transfer of this funding to local authorities has been viewed by himself that the social care needs of disabled and Deaf Londoners are campaigners as a retrograde step. They argue that financial pressures on being fully considered in planning for the future.
London Assembly Health Committee I 10 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
We need a joined up approach to tackling the researchers to increase hardship and have profoundly negative and severely detrimental impacts on mental health. wider determinants of mental ill health The Mayor can do much more to support mental health in London than Reassessment is proving very stressful for disabled people…because of urging health and care partners towards best practice. There are a the lack of ongoing emotional support, because there is not a system number of policy areas under his control where focused action to that supports people through that process, many people’s mental support disabled and Deaf Londoners could bring significant benefits. health and wellbeing worsens considerably
Employment 83 Page The Mayor is due to take responsibility for a devolved London Work and The positive role of meaningful employment in supporting and Health programme in 2017. It is imperative that he consults widely and protecting people’s mental health is well established. However, less repeatedly with disabled and Deaf people in the development and than 50 per cent of disabled people are in employment, compared to delivery of this programme. In response to this report, the Mayor almost 80 per cent of non‐disabled people.23 Disabled and Deaf people should set out how he plans to do this. also report frustration at being turned down for jobs because of assumptions about their ability to take on roles, which can damage self‐ Negative perceptions from employers can act as a barrier to disabled esteem and increase anxiety.24 People who become disabled often find people finding work. Recent research by Scope shows that 85 per cent it difficult to stay in employment: one in six people do not retain their of disabled people feel employer attitudes haven’t improved over the 26 job for a year after becoming disabled and one in three do not retain it last four years. for two years. 25 The Mayor should set out how he plans to engage with London’s Changes to the benefits and welfare system aimed at closing the employers to encourage more businesses to employ disabled and Deaf disability employment gap have also been linked with an increase in people, and how he will work with employers to ensure greater mental health problems for disabled people. In particular, work support to help disabled and Deaf people who are in work to retain capability assessments and the use of sanctions has been found by their employment.
London Assembly Health Committee I 11 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Housing that developers and providers needed greater incentives to provide and There is a shortage of housing that is specifically designed to meet maintain specialist and supported housing. Developers and supported disabled people’s physical needs. Being able to live independently is a housing providers are putting plans to develop new supported housing key factor in mental health, so this lack of specialist housing can have a on hold until there is agreement on how these places will be funded by profound impact on the wellbeing of disabled and Deaf people. housing benefit going forward, further affecting supply. According to a report by Leonard Cheshire Disability, 54 per cent of those with mobility impairments who have looked for accessible homes “I wanted to live with other High unemployment rates, and unsecure said they were difficult to find, only 4 per cent said they were easy to Deaf people but they said I housing tenure, mean that Disabled and Deaf find. 84 Page Disabled people also told us that some local authorities appeared had to be in a home with people may also be at increased risk of becoming reluctant to fund adaptations that would allow them to live hearing people. I get really homeless. Government figures indicate that independently. lonely and I can’t even ask from 2010 to 2016 the overall number of the staff for help.” households accepted as being homeless by local Supported housing improves individuals’ ability to stay in the authorities in England went up from 42,390 to community and has wide reaching mental health benefits by improving almost 60,000. The increase was the quality of life and enabling independent living. Providing supported disproportionately high for homeless households classed as vulnerable housing where disabled and Deaf people have access to peer support through mental illness, where homelessness went up 53 per cent, and can reduce social isolation. Housing services need to be more aware of for those classed as vulnerable through physical disability, by 49 per 27 the specific challenges faced by disabled and Deaf people when cent. assessing housing provision. The Mayor is responsible for a range of services for homeless people The Mayor supports the development of specialist housing for disabled and has recently announced an additional £50million funding in this people through his targeted Care and Support Specialised Housing Fund area. We would urge him to work with disability and homeless (MCSSHF), as well as through mainstream affordable homes organisations to assess how vulnerable disabled and Deaf Londoners programmes. A report by the London Assembly Housing Committee are to homelessness, and what could be done to improve support. found that this money was not always being targeted effectively and
London Assembly Health Committee I 12 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Crime Transport Being a victim of crime, including hate crime, is damaging to mental Inaccessible transport continues to have a detrimental impact on the health. Disabled people are significantly more likely to be victims of mental wellbeing of disabled and Deaf Londoners. The experience of crime than non‐disabled people.28 A new London‐wide reporting travelling alone can be extremely stressful, frustrating or frightening for scheme saw the number of disability hate crimes recorded by police some disabled people unsure if they will be left stranded on their increase by 500 per cent within weeks of its launch.29 However, journey. The cumulative effect of these negative experiences can in time disability hate crime recording has been historically low. Campaigners lead some disabled people to avoid independent travel altogether and have suggested that this may be due to a lack of support in reporting, increase the risk of social isolation. Page 85 Page and a continued view that disability hate crime is low priority for the police. Deaf people have highlighted specific difficulties in contacting Changes to the configuration of health and care services across London the police and reporting crime. could make it harder for disabled and deaf people to get access to the services they need. The Mayor and Transport for London should work Domestic abuse is a significant issue for disabled and Deaf people. Deaf proactively with local authorities and providers to assess the impact of women are twice as likely to be victims of domestic abuse than hearing any changes to the distribution of healthcare services across the women.30 Some disabled people may be more physically vulnerable capital and ensure that transport is considered as early as possible in than able‐bodied people and may be less able to escape or protect these plans. themselves from violent attacks. Some disabled people may also be more socially isolated as a result of their physical dependence on their Disabled people told us that they had particular concerns about changes partner, or less able to leave an abusive partner if they are concerned to the public realm that made it harder for them to navigate their local about whether they will be able to live independently. areas. The Mayor should ensure that his Healthy Streets Programme specifically addresses the concerns of disabled and Deaf people. We urge the Mayor to work with London’s DeafHope service and with organisations such as Refuge to ensure his Violence Against Women If a disabled person has travel delays, and Girls strategy, and the wider Police and Crime Plan, better they may not be able to make their acknowledge and support disabled and Deaf people in London. appointment, and have to wait long periods to get another one.
London Assembly Health Committee I 13 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Disabled and Deaf people need to be involved them to adopt a more proactive approach to seeking the views of disabled and Deaf service users. in shaping services that meet their needs In doing so, the Mayor and partners should recognise that traditional “Nothing about us, without us” forms of public consultation and engagement are not always fully Our investigation has highlighted that more can and should be done to accessible to disabled people. Our discussions with Healthwatch ensure that disabled and Deaf people have a voice in shaping services organisations have highlighted some of these challenges, including that meet their needs. The Mayor has acknowledged the important role access to suitable premises for face‐to‐face engagement, disseminating of 86 Page service users in sharing their experiences with service providers to accessible information to people who do not use the internet, and deliver improvements. securing interpretation services for BSL users. We urge the Mayor to work with London’s pan‐disability charities, and with smaller, user‐led Real improvements only come from listening to and respecting organisations, to ensure the diverse experiences of disabled and Deaf those suffering from mental health problems and from the people are captured. experts – those who have been in crisis and experienced the service Learning disabilities Our investigation has focused primarily on the needs of people with Disabled people and Deaf people told us they would value more visible physical and sensory impairments. However, we are aware that people engagement with, and access to, the Mayor to facilitate this. Previous with learning disabilities experience many similar issues accessing Mayors have appointed specific disability advisors to champion these appropriate mental health support. This includes increased risk of issues with policy makers. The Mayor and the London Health Board misdiagnosis, barriers to communication and a lack of awareness from should consider how to increase opportunities for disabled and Deaf health care professionals. They are also vulnerable to the same people to contribute their views to help inform their policy work on elements of a disabling society – unemployment, poverty, discrimination mental health and on the wider determinants of mental health such as and social isolation – as other disabled and Deaf people. We hope to housing, transport and employment. They should also take steps to look further into the specific health challenges and inequalities faced by develop and share best practice with health and care partners to enable people with learning disabilities in London at a later stage.
London Assembly Health Committee I 14 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
The Mayor is uniquely placed to provide To demonstrate his commitment to mental health, we are calling on the Mayor to hold an annual summit with service users, providers and the leadership on this issue third sector to measure the progress of this mental health roadmap We hope that the Mayor’s mental health roadmap will be a positive step and to examine further opportunities for action. forward. But it is important that action for better mental health is The Mayor and the London Health Board have taken an encouraging delivered, not just considered. And it is important that the roadmap approach to developing a pan‐London strategic response to mental marks the beginning of the process and not the end. health and wellbeing. At a time of significant financial and operational
The 87 Page continued inequality faced by disabled and Deaf Londoners is a challenge for health services across the city, we urge him to use his considerable risk to the mental health of these groups. It is vital that influence to ensure that the needs of disabled and Deaf Londoners are their voices are heard directly by policy makers and by health service not overlooked. providers. If the Mayor is serious about improving mental health for all Londoners, he will need to find ways of delivering targeted responses to Next steps people who are currently excluded from existing support. We are We would like to thank everyone who took part in this therefore calling on the Mayor to set out how he will ensure more investigation. In the coming months the committee will: regular engagement with deaf and disabled Londoners. The Mayor can do a great deal to raise the profile of mental health scrutinise the development of the mental health roadmap issues in London, tackle stigma and discrimination and increase press the Mayor for greater inclusion of disabled and Deaf awareness. Many of the interventions that would improve mental people in the development of his policies health also have wider community dividends, with increased review the Mayor’s health Inequalities Strategy to ensure the employment, better transport for all, reduced crime, and more experiences of disabled and Deaf Londoners are reflected community cohesion. So it is timely for the Mayor to adopt a ‘mental health in all policies’ approach to his work.
London Assembly Health Committee I 15 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Recommendations 2. 2. In delivering the mental health roadmap, the Mayor and the London Health Board should: 1. In developing the mental health roadmap, the Mayor and the London Health Board should: ensure that plain English, BSL and audio formats of the Mayor’s set out how they will work with local authorities and disability mental health programmes are made available free of charge to organisations to explore how to more accurately capture data on disabled people Page 88 Page physical and sensory impairment across London at a borough level set out how they will promote activities and programmes which are disability and Deaf inclusive and promote mental wellbeing ensure that the intersectional nature of mental health experience is recognised acknowledge and champion the importance of disability and Deaf equality training for mental health professionals to improve awareness encourage London’s mental health trusts to work with local organisations such as Healthwatch to audit how well their use their convening powers and influence to develop pan‐ services meet the needs of disabled people. London commissioning arrangements for communications support for Deaf Londoners and those with learning disabilities. set out how the development of the mental health roadmap could support third sector organisations to link up and share best set out how they will work with health and care partners to help practice in this field. ‘physical’ and ‘mental’ health services link up which each other more effectively at local levels. 1.
London Assembly Health Committee I 16 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
3. The Mayor and London Health Board should align of healthcare services across the capital, to ensure that transport existing GLA group programmes with the mental health is considered as early as possible in these plans roadmap by: proactively engaging disabled and Deaf Londoners on the Healthy Streets Programme to ensure changes to the public setting out how they will work with employers to encourage realm do not have an adverse impact and increase social more businesses to employ disabled and Deaf people, and how isolation they will work with employers to ensure greater support to help Page 89 Page disabled and Deaf people who are in work to retain employment 4. To ensure that the mental health roadmap reflects the
setting out how the Mayor’s community cohesion and needs of disabled and Deaf people across London, the volunteering work streams could help support further Mayor and London Health Board should: opportunities to expand the network of peer support available across London set out how they will increase opportunities for disabled and Deaf people to contribute their views to help inform their policy setting out how they will work with disability and homeless work on mental health and on the wider determinants of mental organisations to assess the risk of homelessness for disabled and health such as housing, transport and employment Deaf Londoners and take steps to address this through the Mayor’s housing strategy set out how they will identify and share best practice on engagement with health and care partners to enable a more ensuring that MOPAC works with London’s DeafHope service to proactive approach to seeking the views of disabled and Deaf ensure his Violence Against Women and Girls strategy and Police service users and Crime Plan support disabled and Deaf people in London host an annual mental health summit to report on progress in ensuring that TfL works proactively with local authorities and the development of the mental health roadmap, with specific providers to assess the impact of any changes to the distribution inclusion of disabled and Deaf Londoners
London Assembly Health Committee I 17 Holding the Mayor to account and investigating issues that Health Committee matter to Londoners Mental Health – Disabled and Deaf people April 2017
Endnotes 22 ADASS at London Assembly Health Committee meeting 12 January 2017 23 https://www.gov.uk/government/consultations/work-health-and-disability- 1http://www.papworthtrust.org.uk/sites/default/files/Disability%20Facts%20and%20Figures%20 improving-lives/work-health-and-disability-green-paper-improving-lives 2016.pdf 24 British Society for Mental health and Deafness submission 2 https://www.london.gov.uk/sites/default/files/london_assembly_health_committee_‐ 25http://www.papworthtrust.org.uk/sites/default/files/Disability%20Facts%20and%20 _access_to_health_services_for_deaf_people_‐_june_2015_‐_updated.pdf 3 Figures%202016.pdf https://www.london.gov.uk/sites/default/files/leading_the_way_march_2016.pdf 26 4 https://www.scope.org.uk/press-releases/more-disabled-people-in-work https://data.london.gov.uk/dataset/disability‐and‐mobility‐london 27 5 https://www.theguardian.com/society/2016/dec/23/families-and-disabled-people- http://www.rnib.org.uk/knowledge‐and‐research‐hub/key‐information‐and‐statistics hit-worse-by-rising-homelessness 6 https://www.mentalhealth.org.uk/sites/default/files/fundamental‐facts‐15.pdf 28 7 90 Page http://www.papworthtrust.org.uk/sites/default/files/Disability%20Facts%20and%20Figures%2 https://www.signhealth.org.uk › About Deafness 02016.pdf 8 Thomas Pocklington Trust submission 29 http://www.disabilitynewsservice.com/hate-crime-initiative-sees-police-reports-leap- 9 https://www.leonardcheshire.org/about‐us/disability‐facts‐and‐figures by-500-per-cent/ 10 https://www.diabetes.org.uk/About_us/News/diabetes‐up‐60‐per‐cent‐in‐last‐decade‐/ 30 SignHealth submission 11 Action on Hearing Loss submission 12https://www.ons.gov.uk/businessindustryandtrade/itandinternetindustry/bulletins/i nternetusers/2016 13 http://www.mind.org.uk/news‐campaigns/news/gps‐and‐practice‐nurses‐aren‐t‐ getting‐enough‐mental‐health‐training/#.WNElnG_yjcs 14 MIND submission 15 https://www.scope.org.uk/campaigns/extra‐costs 16 Disability Rights UK submission 17 Thomas Pocklington Trust submission 18 http://www.scope.org.uk/Scope/media/Images/Publication%20Directory/Current‐ attitudes‐towards‐disabled‐people.pdf 19 https://www.scope.org.uk/About‐Us/Media/Press‐releases/May‐ 2011/Deteriorating‐attitudes‐towards‐disabled‐people 20 https://www.sense.org.uk/content/disabled‐people‐face‐being‐cut‐society‐warns‐ national‐charity 21https://www.scope.org.uk/Scope/media/Documents/Publication%20Directory/Disable d-people-s-experiences-of-social-care.pdf?ext=.pdf
London Assembly Health Committee I 18 Agenda Item 7
Subject: Health Committee Work Programme
Report to: Health Committee
Report of: Executive Director of Secretariat Date: 19 April 2017
This report will be considered in public.
1. Summary
1.1 This is the last scheduled committee meeting of the current Assembly year, and this report provides an overview of the work undertaken during 2016/17. The report also provides information on proposed work and the schedule of meetings for 2017/18. The Committee has a rolling work programme so work may continue beyond each Assembly year.
2. Recommendations
2.1 That the Committee notes the topics covered during 2016/17;
2.2 That the Committee agrees its priority topics for 2017/18;
2.3 That the Committee delegates authority to the Chair, in consultation with the Deputy Chair, to agree:
(a) The terms of reference and scope of the proposed review of the Mayor’s Health Inequalities Strategy;
(b) Any further outputs relating to the Committee’s investigations into mental health inequalities and Sustainability and Transformation Plans.
(c) Arrangements for any site visits, informal meetings or engagement activities before the Committee’s next formal meeting.
3. Background
3.1 The Committee receives a report monitoring the progress of its work programme at each meeting.
City Hall, The Queen’s Walk, London SE1 2AA Enquiries: 020 7983 4100 minicom: 020 7983 4458 www.london.gov.uk Page 91
4. Issues for Consideration
4.1 The Health Committee is tasked with reviewing health and wellbeing across London, including reviewing progress against the Mayor’s health inequalities strategies.
2016/17 Work Programme 4.2 Over the past year the Health Committee has held six formal committee meetings. The programme of meetings is set out below:
15 June 2016 HIV Prevention 19 October 2016 Transport for London’s role in promoting health in London 29 November 2016 Suicide Prevention 12 January 2017 Mental health for disabled people and Deaf people 15 March 2017 Sustainability and Transformation Plans: implications for London 19 April 2017 Mental health for offenders and ex-offenders
4.3 The Committee also hosted a half-day seminar on LGBT+ Mental Health on 25 October 2016, and attended a site visit to the South West London and St George’s Mental Health NHS Trust specialist mental health service for Deaf people on 29 March 2017.
4.3 The Committee has also published a number of written outputs:
A letter and recommendations to the Mayor on improving HIV prevention efforts in London; A letter and recommendations to the Mayor on how to strengthen TfL’s role in supporting better health across London; A report summarising the findings from the LGBT+ mental health seminar; A letter and recommendations to the Mayor on how to bolster suicide prevention efforts in London; and A report summarising the findings of the investigation into mental health for disabled and Deaf people.
4.4 Further written outputs on offender mental health, mental health inequalities for marginalised groups in London, and a summary of findings from the March meeting on Sustainability and Transformation Plans will be completed and published in the forthcoming Assembly year.
Future topics and the schedule of meetings for 2015/16 4.5 The Chair and Deputy Chair met informally to consider and prioritise topics for the Committee’s 2017/18 work programme. The following priority topics were identified for consideration:
Page 92
Formal review of the Mayor’s forthcoming Health Inequalities Strategy; Avoidable sight loss in London; Healthy Early Years; Access to Dental care in London; Making work healthy; and Mitigating winter pressures.
4.6 A more detailed work programme will be reported to the Committee’s next meeting for formal agreement.
4.7 The schedule of all 2017/18 meetings, subject to decisions to be made at the Assembly’s Annual Meeting on 3 May 2017, is set out below.
26 June 2017 11 October 2017 28 November 2017 11 January 2018 21 February 2018 14 March 2018
5. Legal Implications
5.1 The Committee has the power to do what is recommended in the report.
5.2 The Mayor of London’s limited role in public health in London is defined at Part 5A of the GLA Act 1999 (as amended), which refers to his responsibility to produce a “health inequalities strategy”, where the GLA Act 1999 defines health inequalities as inequalities between persons living in Greater London “in respect of life expectancy or general state of health which are wholly or partly a result of differences in respect of general health determinants”.1 The Mayor of London currently has no role in the commissioning of any health services or health service provision.
6. Financial Implications
6.1 There are no financial implications arising from this report.
List of appendices to this report: None
Local Government (Access to Information) Act 1985 List of Background Papers: None.
Contact Officer: Lucy Brant Telephone: 020 7983 5727 Email: [email protected]
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