Waltham Forest CCG Estates Strategy 2016-2026

Document control version:

Issue Date Version Issued to Amendments

1 31.12.15 A NHSE

B.1 24.03.16 Bv1 FM/TP

B.2 01.04.16 Bv2 FM

C 26.04.16 C Public Various changes from engagement

D 29.04.16 D Commissioning Typos and updated Team information

Table of contents 1. Introduction and national context ...... 7 2. Local context ...... 7 2.1. Primary care commissioning strategy ...... 8 2.2. Financial challenges ...... 9 2.3. Population growth ...... 9 2.4. Disparate nature of estates ‘management’ ...... 12 2.5. Digital and IT strategies...... 12 2.6. Workforce ...... 13 2.7. Overview of existing estate ...... 14 2.8. Responses to national drivers for change ...... 15 2.9. Estates gap analysis ...... 16 3. Delivering the strategy ...... 16 3.1. WFCCG response to the estates challenge...... 17 4. Waltham Forest local overview ...... 18 4.1 The local borough ...... 18 4.2 Factors contributing to poor health ...... 19 5 Our vision ...... 20 5.1 Estates assumptions for primary care ...... 20 6 The current estate ...... 22 6.1 Overview and demand modelling ...... 23 6.2 Occupation and utilisation ...... 24 6.3 GP premises estate ...... 25 6.4 Current challenges and opportunities – acute sector ...... 26 7 Regeneration overview ...... 26 7.1 Blackhorse Lane area (including Sutherland Road) ...... 26 7.2 Leyton/Lea Bridge ...... 27 7.3 Walthamstow regeneration ...... 27 7.4 Wood Street Regeneration ...... 28 8 Possible income streams for capital spend ...... 28 8.1 Section 106 ...... 28 8.2 CIL (Community Infrastructure Levy) contributions ...... 29 8.3 Primary Care Transformation Fund (PCTF) schemes ...... 29

8.4 PCTF schemes 2016 onwards ...... 29 9 Gap analysis ...... 30 10 Estates options for change ...... 31 10.1 Overview ...... 31 10.2 Overview of Chingford locality ...... 31 10.3 Overview of Walthamstow locality ...... 34 10.4 Overview of Leytonstone/Leyton locality ...... 39 11 Possible hub map ...... 42 12 Provider property owner estates strategies ...... 43 12.1 Community Health Partnerships (CHP) ...... 43 12.2 NHS Property Services (NHS PS) ...... 43 12.3 North East London NHS Foundation Trust ...... 43 12.4 Evaluation process and criteria ...... 45 13 Delivering the strategy ...... 45 13.1 Financial impact ...... 45 13.2 Outline implementation plan ...... 46 a. Programme plan and milestones ...... 46 b. Resources ...... 47 c. Enablers of change and managing constraints ...... 47 d. Consultation plan ...... 48 e. Risks and mitigations ...... 48

Appendix A Summary of Community Estate Appendix B Summary of GP Premises Appendix C Summary of GP Premises 6 Facet Surveys Appendix D Waltham Forest JSNA Summary of key issues& Waltham Forest CCG Primary Care Strategy Summary of areas of focus Appendix E Summary of Digital Strategy Appendix F Capital revenue cost implications Appendix G Summary of Voids WFCCG Appendix H Children and family centres proposed sites map Appendix I Estates Strategy comms engagement plan

Please note, all appendices are available by request from: [email protected]

Glossary of key terms

Term Acronym General Practitioner GP Waltham Forest Clinical Commissioning Group WFCCG Estates Working Group EWG Transforming Services Together TST National Health Service; England NHSE Integrated Care Model ICM Clinical Commissioning Group CCG Primary Care Infrastructure Funding (funding PCIF via NHSE to premises development) Improvement Grant (funding via NHSE to IG premises development) Primary Care Transformation Fund (funding via PCTF NHSE to premises development) Waltham Forest, East London commissioning WEL groups North East London Foundation Trust NELFT NHS Property Services NHSPS Bart’s Health NHS Trust BH London Borough of Waltham Forest or Local LBWF or LA Authority Accident and Emergency Department A&E

Executive Summary

The Estates Strategy responds to and supports the delivery of the key outcomes of the Primary Care Strategy.

This document is for consultation with key stakeholders. Over the coming three months to the end of June 2016 it will be shared and discussed with a variety of key partners to test assumptions, check priorities and align strategic intentions. As such it will be subject to testing ideas and developing implementation plans to meet estates challenges. Some initial feedback has already been received and incorporated.

Primary care is where the majority of contact with patients takes place in the NHS in Waltham Forest and should meet the majority of people’s health needs. However, there are a number of challenges which face the borough and there is a need to define and implement efficient use of estates;  Increasing population in certain wards of the borough, with specific residential and commercial building solutions currently planned or in development  An aging local population and increasing volumes of long term conditions  Increasing costs of estates, with potential void space costs rising  Potentially less General Practitioners (GPs) operating and a dependence on the traditional GP model  Increased costs in attracting workforce to the borough due to high cost of living within the area  Increasing usage and costs of implementing effective information technology solutions for healthcare

In response to the challenge Waltham Forest CCG (WFCCG) has established a multi- organisational Estates Working Group (EWG) to develop an approach and a set of agreed documents to address the problems and improve our estate to support sustainable and effective healthcare. The EWG is a decision making body which includes key partners such as the London Borough of Waltham Forest, NHS England (NHSE) representatives and local landlords.

For Waltham Forest CCG to address the estate challenge, it means:-

 Developing and nurturing existing and new networks, and as opportunities arise developing new health networks and ‘hubs’, and new models of care aligned to the NHSE 5 year forward view.  As a result of the above pressures, likely organic reduction in the number of GP practices to achieve more sustainable, at scale, services, with the expectation of a minimum 10,000 patient list size.  Improving the quality and use of the existing primary care and community estate and establishing access to a wider range of community services to enable the implementation of the Primary Care Strategy.  The ideal estate would also include at least one larger facility per locality ( a GP Hub plus) hosting, on-site or locally, a number of out of hospital services including minor surgery units, sexual health clinics, enhanced diagnostic services and community services. Within the ideal model, back-office functions will be shared so that more funding can be available for clinical services. The CCG will work towards this aspiration, noting that, currently, a single site for such at-scale services does not exist in each locality and that a network or partnership approach may be a more appropriate local solution.  Enabling Digital Technology to support improving healthcare.

 Enabling increased use of local pharmacy and self-care solutions for healthcare.  Reducing estate where it is no longer fit for purpose or surplus to patient need.

Strategy objectives:

1. Estate that will support the development of a new primary care model which is in line with our regional planning (Transforming Services Together i.e. establishing sustainable larger GP practices, supporting multidisciplinary working, hub and spoke, networks).

2. Working towards achieving fit for purpose health centres (i.e. less converted houses) that meet the needs of patients.

3. Estate to meet growing population/changing population demographics (Premises number aligned to population growth).

4. Support practices to improve premises where facet scores are very low or/and immediate changes can be made. Remedial plans for every C and D scored facility.

5. Ensuring the best utilisation of estate and addressing voids.

The Estates Strategy will be a live and developing document that will consider the key opportunities and constraints that it is faced with.

The Estates Strategy considers:

1. The Waltham Forest Primary Care Strategy. 2. Current estate and best use of space. 3. Changes in demand in population both in terms of size and demographics. 4. NHSE Primary Care infrastructure/ Transformation Fund bids devolved to the CCG. 5. Other relevant strategies e.g. The Five Year Forward View, Digital/IT strategy key points/vision, integrated care and TST. 6. Quality in primary care and achieving good levels of patient experience. 7. NHS structure and decision making (especially relating to estates). 8. Potential estate models and locations to support our Integrated Care Model (ICM) and primary/community care model/vision with a focus on health and wellbeing and whole systems/the patient. 9. Capital and revenue affordability. 10. Engagement and consultation with partners, stakeholders, and patients.

This environment will support new models of care, where multidisciplinary teams from across health and social care organisations work together. Within this context the ‘reality constraint’ for development of the strategic intent will be the actual estate and the changing financial envelope. In addition to this, engagement with local people and GP partners will help to drive the strategic direction.

1. Introduction and national context

In October 2014, the NHS published the Five Year Forward View, which detailed new models of care to integrate acute and out of hospital services. The core principles contained within the view were:

. Give GP-led clinical commissioning groups (CCGs) more influence over the wider NHS budget, enabling a shift in investment from acute to primary and community services. . Expand funding to upgrade primary care infrastructure and scope of services. . Provide new funding through schemes such as the Primary Care Transformation Fund (PCTF) to support new ways of working and improved access to services. . Work with CCGs and others to design new incentives to encourage new GPs and practices to provide care in under-doctored areas to tackle health inequalities. . Build the public’s understanding that pharmacies and on-line resources can help them deal with coughs, colds and other minor ailments without the need for a GP appointment or A&E visit.

In addition to emerging GP federations, networks and super partnerships across London, the NHS Five Year Forward View identifies four further models which may be applied. The most directly relevant to out of hospital services have been described as Multispecialty Community Providers (MCPs) and Primary and Acute Care Systems (PACs). Whilst this is very high level, and considered aspirational within the context of Waltham Forest CCG. Therefore, this strategy takes the key points and looks to develop a roadmap for implementing the strategic aims of the CCG within the framework of the model.

High level modelling from NHS England (NHSE) suggests that in order to deliver a modern, high quality service for all, £310 – £810 million will need to be invested in primary and community services in London annually. This is expected to begin with a gradual shift in total health spend of 0.40% – 1.07% each year over five years, which has the potential to deliver a significant increase in primary and community care capacity in the medium term. To support the national and local development, additional funding is being provided nationally in the form of:

 Minimum growth in primary care budgets of 4% per annum over the next three years  Prime Minister's Challenge funding (a further £100m nationally for 2015/16)  Primary Care Transformation fund of £250m recurrent for four years (2015-19)  Additional transformation budget of £200m for new ‘vanguard’ sites

Within this context there is a strong rationale for re-balancing the NHS investment profile towards out of hospital services and infrastructure and is forming the basis of a number of national and regional policies, and local commissioning intentions/CCG five year strategic plans and funding streams are being identified to enable these changes.

2. Local context

Waltham Forest Clinical Commissioning Group (CCG) has been granted full delegation for the commissioning and performance management of primary medical services to meet the objectives set by NHSE’s five year forward view. To support this the primary

care infrastructure in Waltham Forest faces a number of challenges and must work within the frameworks set out within the following areas. 2.1. Primary Care Commissioning Strategy

The Clinical Commissioning Group (CCG) produced its Primary Care Strategy in 2015 and, as a delegated lead for commissioning primary care GP services, it is in the forefront of delivering improvements in primary care. The objectives of the strategy are: 1. To improve primary care services to deliver better health outcomes for our local population 2. Improve patient access to, and experience of, primary care services 3. To ensure effective community engagement to help support the delivery of patient centred care 4. To maximise clinical engagement, ensuring strong leadership across all primary care services 5. To embrace technology and ensure that the primary care infrastructure is fit for purpose and supports patients to self-manage. 6. Practices working collaboratively with other agencies to support the delivery of integrated care

The jointly produced ‘Transforming Services, Changing Lives Case for Change’ (Case for Change) for the Waltham Forest, East London (WEL) commissioning groups addresses the following factors: • Population projections and future demand on services • Variations in access and quality to primary care medical services • Financial sustainability • Developing a workforce that can meet the challenges of the changing NHS landscape and to support the delivery of better health comes for the local population.

The WFCCG Primary Care Strategy, builds upon the London Primary Care Framework by highlighting three improvement areas; proactive, accessible and coordinated care. Improvements in primary care will only be achieved if critical infrastructure activities are delivered to support change. By this we mean ensuring we have the best workforce, information technology and access to health services and information, as well as premises which are fit for purpose. This will involve better use of space, versatile clinical rooms and access in locations where the communities can be best served.

The WFCCG Primary Care strategy identified that there are 45 GP practices, 59 pharmacies, 44 dental surgeries and 25 opticians within the borough. The strategy also highlighted inconsistent quality of care as a key driver to the CCG strategic direction. A review of 150,000 A&E and urgent care visits showed that approximately one fifth were discharged with no investigations or significant treatment, suggesting that treatment could have been provided elsewhere.

It was also highlighted that GPs face increased demand as well as the challenge of bridging the gap between patient expectations and what can actually be delivered. The introduction of a GP federated network, including increased opening hours and weekend working is being piloted to support development in these three locations; Chingford – Parkside Medical Centre; Walthamstow – The St James Practice, and Leyton/ Leytonstone – Harrow Road Practice (The Triangle).

2.2. Financial challenges

In response to the national context, and to support the delivery of the NHSE five year forward view, WFCCG is working in partnership with the London Borough of Waltham Forest, and Newham and Tower Hamlets CCGs to deliver significant change through the economies of working together across both the primary and secondary acute care commissioning and provider landscape. This is being supported through the TST programme.

Within this local context some key impacts for financial consideration include;  The response to the North East London Foundation Trust (NELFT) strategy and its impact on WFCCG voids costs as this provider rationalises its estates usage across the borough.  Local Authority regeneration plans for high population growth areas must be matched by increase in health care provision.  NHS Property Services (NHSPS) strategy and move to charge market rent, which is likely to increase baseline costs for the CCG from 2016 onwards.  6-Facet surveys of estates, and associated costs for improvement to meet minimum standards.  The utilisation of estate; how to maximise the usage of NHS monies through various schemes, such as the Primary Care Transformation Fund (PCTF), and managing voids in health centres and GP practices.  The potential additional costs of newer and larger premises which may increase the cost pressure on the CCG.  Increasing patient demand and patient expectations influence capacity, location, size and quality of premises.  Increasing costs for the CCG to monitor and manage estates change and development which was previously budgeted.

There is also a need for provider organisations to make general efficiencies as required by Monitor (of at least 2%). We believe providers could, through their own savings initiatives and TST initiatives, reduce average length of stay and thereby contain the expected growth in demand for beds utilising the existing estate/bed base.

Currently the cost of voids for the borough is approximately £391,500 and will rise as local providers rationalise their own usage of estates, with the resultant cost pushed to the CCG.

2.3. Population growth

The overall population of Waltham Forest is forecast to grow by approximately 11% within the next ten years. Individual wards such as Higham Hill, will increase by almost 20% with that time frame. The following table and map highlight the potential growth areas (note that the London Borough of Waltham Forest is working to develop the population growth forecasts for April 2016 and details below are not finalised). Source; GLA capped SHLAA 2013 dataset (provided by the TST programme)

As a result of planned residential development of key strategic sites across Waltham Forest, this growth will not be distributed equally but focused in a small number of wards; Higham Hill, Larkswood, William Morris, Markhouse, Lea Bridge, High Street and Leyton seeing the most significant rises (as shown in the diagram below).

2.4. Disparate nature of estates ‘management’

Since the dissolution of the Primary Care Trusts in 2013 the ownership of primary care estate was broken up to a number of different receivers. This has meant some lack of strategic direction in considering borough wide issues as opposed to silo strategies.

In response to the identified requirements to create efficiencies related to estates across the borough, in 2014, WFCCG established an EWG bringing together all property owners, providers, NHSE, the CCG, nominated GP representatives and the London Borough of Waltham Forest to work together to share and seek joint opportunities to deliver a high quality estate in the right place throughout Waltham Forest. This group and its associated governance is the key enabler for the delivery of a co-ordinated estates strategy in the borough. This strategy proposes system- wide transformation and partnership working. WFCCG is working with the full range of partner organisations.

The key estates partners identified are;  Bart’s Health NHS Trust (BH)  London Borough Waltham Forest (LBWF)  North East London NHS Foundation Trust (NELFT)

Supported by;  Community Health Partnerships (CHP)  NHS Property Services Ltd (NHSPS)  NHS England (NHSE)  Neighbouring CCGs & London Boroughs - in particular Newham, Tower Hamlets, City and Hackney, Barking and Dagenham, Havering and Redbridge.  Transforming Services Together (TST)  Homerton University Hospital NHS Trust  NEL Commissioning Support Unit (CSU)

In addition, our partners are linked into the One Public Estate (OPE) programme which brings public sector bodies in a locality together to develop a joined up approach to managing their land and property. The programme supports local government to work with central government and public sector partners to release assets and share land and property information. Councils on the OPE programme are supported by the Local Government Association and Government Property Unit (GPU) who provide:

 Advice and expertise in building partnerships with public sector bodies  Knowledge and best practice from local and central government  Access to senior Whitehall and LGA officials helping to lift barriers and;  GPU funding to help deliver the programme

2.5. Digital and IT strategies

The CCG is delivering its Digital Strategy in three phases, starting with primary care digital services and then extending these to other providers, finally providing a single patient portal to support self-care. A summary is attached in appendix E.

In 2016-17 the CCG will be developing its digital capability and supporting the local population to become confident in using the digital option.

Key actions for the strategy include;  Developing a common, GP-led, approach to digital services  Support people in accessing their own care records: This will help people manage their health better from home or through digital devices, such as smart-phones and other applications.  Develop a shared electronic health record between health and social care providers, with patients consent: This will be mainly based on connecting existing systems up so that those caring for patients have access to vital information. This could include information on medication or care plans, recent discharge letters or details of recent emergency department attendances.  Developing virtual or digital General Practices through web development  Using an ‘Agile’ project-based approach to delivery

All of the above will have implications on the usage of estates, the way care is delivered and the access required for patients. The development of GP Hubs and Hub Pluses will be impacted by these changes, and we will continue to develop plans according to the results of the pilot projects. A key consideration for estates will be IT accessibility such as bandwidth, contracting arrangements for facilities with landlords/ providers for IT, and joint-working on development of consistent approaches to web-based technology to ensure equality of health care provision across the different localities of the borough.

2.6. Workforce

The CCG primary care strategy identified mapping out future workforce requirements as a key piece of work to be undertaken. The information was used to create a baseline for the current workforce, map it against future workforce requirements and identify areas which could be targeted for intervention and support. The GP recruitment and retention challenge needs to be overcome. In the audit of Waltham Forest practices a total of 166 GP’s (of all types) responded to the question regarding whether they intended to retire within the next 5 years. Of the 166 responders 25 (15%) stated that they wished to retire within the next 5 years.

Some highlighted areas for development are; GPs  166 GPs in Waltham Forest. 68 (41%) are over 50 years of age, with 25 planning to leave within 5 years. There are 11 trainee GPs (7%) and 16 long term locums (10%). 52% of local GPs are male, 48% female. Nurses  There are 68 nurses of which 46% are over 50 years of age and 13% planning to retire within 5 years. There are 17 nurse prescribers in the borough.

Health Care Assistants  There are 19 HCAs, of which 4 (21%) are over 50 years of age with only 1 planning to retire in the next 5 years. There are 22 practices who do not have a HCA.

The Waltham Forest Community Provider Education Network (CEPN) has been developing an approach to these issues and is currently identifying the skills and training gaps which the CCG needs to support. There are currently (December 2015) 14 training practices with 26 GP trainers across the borough. CEPN are reviewing the opportunity to create a more holistic approach to employee training which matches the future need for the CCG. The estates strategy will support CEPN by providing locations, new development and potentially information technology solutions (via the PCTF) which maximise the effectiveness of any training across the borough.

Key findings include the need for;  New workforce models  Training and development  Recruitment and retention

Given the growing population and skills-gap challenge, a sustainable workforce model needs to be developed. Currently in London, GPs work with fewer practice staff than elsewhere in the country. New ways of working will need to be introduced and encouraged. Specialists who currently spend most of their time working in hospitals are likely to spend more time working in the community. Health coaches and care navigators may become fundamental members of multi-disciplinary health and social care teams that operate out of shared facilities. The working environment will need to be designed to enable this multi-disciplinary team working.

The workforce strategy used to implement these improvements will impact on estates across the borough and will form a central part of the future strategic direction. It is our intention to facilitate usage of networks/sites which support list sizes of 10,000 or more patients with the likelihood of fewer practices, better use of local pharmacies and better use of IT systems to support health care needs. All of which will allow us to maximise the workforce capacity in a more efficient manner.

2.7. Overview of existing estate

There is a vast array and diversity of Estate that is currently utilised for the delivery of primary and out of hospital care in Waltham Forest with property owned or leased by CHP, NHSPS and NELFT as well as leased and owned GP Practice premises.

GP premises are in a varying condition across the Estate with 63.6% of premises being in a reasonable condition, but 35.4% are in a very poor condition requiring significant works or complete replacement. In a recent 6-Facet Survey of GP premises the potential cost to bring all facilities to standard was approximately £9 million, with the approximate cost of updating all buildings rated as unsatisfactory (scored C & D in accordance with the NHS Estate Codes National Standards) being £5.26 Million. A list of 6-facet ratings by building is included in Appendix C.

A review of utilisation has been undertaken, in which initial indications are that approximately 18% of space used by the CCG in local health centres (excluding GP premises which are currently being reviewed) is empty.

Changes due to the implementation of partner/ other organisation estates strategies across Waltham Forest will see a potential increase in voids to as much as 34% by the end of 2017, without immediate action. Further analysis has been completed in quarter three of 2015 and actions included in this strategy. The details of health centre voids is attached in Appendix G. Potential under-utilisation within GP sites remains a work in progress item and details will be included once developed in 2016. 14

2.8. Responses to national drivers for change

The Waltham Forest CCG primary care strategy is to work with the overall GP provider community to exploit opportunities to ensure greater joint-working/partnership/ collaborative working and therefore a potential overall reduction in the number of GP practices over the next few years, moving towards a minimum practice list size of 10,000.

The current practice list size is shown below;

Through this strategy, and the partnership working approach envisaged via the EWG, Waltham Forest CCG has outlined a road map for the future of estates across the borough which is aligned to our partner organisations, responds to changing models of care, is linked to population growth, maximises (where possible) the current estate and achieves the strategic aims identified above.

Demand for services across the entire health and social care system will increase during the coming years. The strategy calls for more services to be provided safely and sustainably in the community, closer to home. This will mean there will continue to be a shift of care away from being treated in traditional hospital settings to be cared for in community based services. The TST Case for Change showed that there are significant opportunities to make patients’ experience of care safer and quicker. This is especially true in services such as outpatients, clinical support services (tests and medicines management), but is also true in other services across the health and social care system.

The strategic direction of WFCCG seeks to address the health challenges in the borough. The Joint Strategic Needs Assessment highlights the needs of the Borough and key areas are and details are included in Appendix D:-

1. Population and population projections 2. Deprivation 3. Areas where Waltham Forest compares poorly or well against England 4. Issues affecting children and families 5. Adults: Smoking, substance misuse, alcohol misuse and obesity 6. Infectious Disease and Long Term Conditions 7. Life Expectancy

The Waltham Forest CCG Primary Care Strategy highlights the following key areas of focus. The impact of the strategic direction within these areas on the estate is outlined in Appendix D.

1. Maternity, children and young people 2. Urgent and Emergency Care 3. Planned Care 4. Integrated Care 5. Long term Conditions 6. Mental Health 7. Last Years of Life

2.9. Estates gap analysis

WFCCG have sourced and commissioned various work to ensure a good data-set of estates related information, which has supported the development of this Estates Strategy, and principle details are included in this Strategy and at Appendix A, B, C, D & G.

WFCCG has completed the Void Assessment programme for health centres and now has a good understanding of voids and costs arising. Work is now progressing to assess how such spaces can be used linking directly into CCG commissioning programmes and informing the Estates Strategy.

Areas where further work is required;  Undertaking of void assessment work of GP premises not in health centres where GP hubs may develop to, collaboratively, maximise usage of space.  Further understanding of estates costs and charging arrangements.  Feasibility Study for two localities of high population growth to assess best estates usage and opportunities.  Using the programme of engagement and consultation to test and inform the draft Estates Strategy and identify opportunities.

Some of this work therefore will be on-going, but the CCG is working to close this gap significantly and will continue to use the EWG as the conduit through which to test data, analyse information and support strategic decision making.

3. Delivering the Strategy

WFCCG has identified the following as critical factors to developing and delivering a successful estates strategy:-

 Establishment of the Estate Working Group (EWG) as the facilitator to the delivery of the estates strategy  Information gaps to be filled  2 year implementation priorities  Longer-term work programme aligned to partnership working  Identifying and maximising estates usage based on the Primary Care strategy, digital strategy, planned and unplanned care strategies and partner organisations estates strategies

 Identifying resource and using funding streams effectively, including any options to cease use of surplus estate and where possible realise property sale proceeds to support new schemes.

3.1. WFCCG response to the estates challenge

The CCG needs a fit for purpose estate in the right place for the benefit of patients and providers. The CCG is working with all of its partners in an effort to design the most efficient estates footprint for the people of the borough, with key feedback from the engagement being that patients want speedier access to local services, the opportunity to see the same GP where possible and responsive, safe service. A general concern has been that larger sites does not always mean better quality of service and that any planning related to GPs working more closely must be bottom-up and not top-down in its approach.

A ‘hub’ may not be an individual building or site as it has been traditionally viewed. A ‘hub’ will make use of technology and location to give patients the quickest and most convenient access to care that meets their needs. As such WFCCG is working with GPs throughout the course of the next ten years to define and develop working relationships, collaborations/ partnerships and (potentially) mergers which foster improved access to services for local people. Within this strategy we identify what this may mean for each locality and begin to outline potential areas in which we believe ‘hubs’ may be required based on the parameters set out in the details above.

What hubs may look like in ten years:

 GP Practices – Initially the current GP Practices but supporting the organic development of list sizes of 10,000+ as recommended by NHS England to ensure sustainability, supporting integrated care for patients, and long term delivery of a wider range of services. Working towards either developing existing or relocating merged/consolidated GP Practices to Primary Care GP Hubs.

 Primary Care GP Hub – Merged GP practices or GP Practices working closely & strongly together either based at the same site or across a number of sites with a total list size of at least 10-20,000 patients (estimated 1500m2), with the aim of long term consolidating if and when an appropriate opportunity arises. There would be access to care with less reliance on each individual GP and a hub and spoke/ networking model which maximises patient accessibility.

 Primary Care GP Hub Plus - Merged GP practices or GP Practices working closely & strongly together either based at the same site or across a number of sites with a total list size of at least 12-20,000 patients (estimated 1500- 2500m2). These could house additional “office based” specialties such as dermatology, rheumatology, neurology, additional Obstetrics OPD services or integrated social care. There would be improved access to integrated care within each locality. A virtual solution could be the provision of these enhanced services making use of resource/space available within a building, but with all Practices in the Ward using these services.

 Community Asset/Primary Care Hub or wide Multispecialty Community Provider (MCP) – (estimated 2500m2 +). Mixed use centre housing Local

Authority services (e.g. social work teams, library, drop in centre), and primary care GP hub (or GP hub plus) involving extended community health services and access to more out of hospital services.

An example of this for Waltham Forest could be the Whipps Cross Hospital site.

Therefore within the proposed primary care hub model above a patient may contact one telephone number, or one web-site, to make appointments or request information, but their point of delivery may be across a network of sites within a Primary Care hub. Examples could be;

 GP Practice: A patient contacts their GP practice for an appointment. The GP has a list size of 10,000 and operates from one site. An appointment is made at the next most convenient time. This GP practice wishes to remain as a single practice and operates effectively for its patient list.  Primary Care GP hub: A patient contacts their GP practice for an appointment. The GP practice is one of three sites who operate collaboratively as one partnership with shared functions and a list size of 14,000 patients. An appointment is offered at the most convenient time and location for the patient, and could be delivered at one of the three locations. If the patient wishes to see their ‘usual’ GP they may have less choice than if they choose the next most convenient time and location of an appointment. Over time the CCG work with the Primary Care GP hub to maximise usage of the facilities they use and include other local services which have transferred from hospital into the community within the ‘hub’. Where facilities are not fit for purpose or not utilised effectively a joint decision is made on the local approach.  Primary Care GP hub plus: A patient contacts their GP to make an appointment and is served as above in a Primary Care GP hub. The main difference for a hub plus is that there is likely to be one large site which can cater for a larger local patient population and has access to a variety of out of hospital or other community services. A patient may, for example, be discharged from hospital and attend orthopaedic clinics within the same building as their usual GP surgery.

The overall aim of the estate strategy is to empower the patient by allowing them to access services closer to home, more efficiently and with the GP of their choice.

4. Waltham Forest local overview

4.1 The local borough

North East London is often the area where high numbers of new immigrants move to first and then move on, meaning the people and the ethnic mix of the population are constantly changing. This can mean difficulties in providing continuity of care (particularly in general practice) and health conditions remaining undiagnosed for long periods. It is also now the area where lots of young people come and live on a temporary basis - that causes issues for urgent care services because many young people don’t register with GP’s.

The average life expectancy in England is 79.5 years for men and 83 years for women. Life expectancy is worse in Waltham Forest than the national average. Men in Waltham Forest can expect to live to around 76 years of age, and females to 81 years of age. Life expectancy varies further still between wards; by 12 years for males and 5 years for women in Waltham Forest.

‘Healthy life expectancy’ is the number of years from birth that a person can expect to remain in ‘good’ or ‘very good’ health. Healthy life expectancy is worse than the England average in Waltham Forest. We need to work hard to ensure we design our services around these particular needs of some of our population if we are to reduce inequalities.

Over the next 15 years, the population of Newham, Waltham Forest and Tower Hamlets will probably grow by 270,000 – the size of a new London borough. With population growth, we anticipate more births and need to plan for the increased demand on our services. As people live longer, so their health and social care needs will also increase. Our hospitals and emergency departments already face unprecedented demand for services and patient expectations are increasing.

There is a high level of population movement into and out of east London boroughs. For example, Waltham Forest has the 8th highest rate of population turnover in London, with 281 people moving each year per 1,000 population. This causes difficulty in providing continuity of care. At some A&E departments as many as 30% of those attending are not registered with a GP. We need to fix our urgent care system ensuring patients are seen in the right care setting for their needs. 17,000 patients registered with Waltham Forest GP Practices do not live in the Borough.

Life expectancy is worse than the rest of England, but that is more to do with environmental factors and deprivation in the area than a reflection on the quality of healthcare. However the TST showed that preventing ill health; better management of conditions by care providers before they become severe (and providing support for patients to self-care); and treating people holistically by looking at their physical and mental health needs together is essential to the long term future of healthcare.

The demographic profile of Waltham Forest will change considerably over the next thirty years. Based on GLA estimations, the population of the borough will increase by 35% (100,000 people) between 2015 and 2041.

As a result of planned residential development of key strategic sites across Waltham Forest, this growth will not be distributed equally but focused in a small number of wards; with Higham Hill, Larkswood, William Morris, Markhouse Lea Bridge, and High Street wards seeing the most significant rises.

This growth will require additional provision of general medical services across Waltham Forest, as well as other out of hospital care.

4.2 Factors contributing to poor health

Deprivation: there are high levels of deprivation in parts of Waltham Forest. In some areas, the levels are amongst the highest in the country.

The higher level of deprivation in Waltham Forest increases demand for GP services based on weighted average of 5.3 appointments per person/year in Waltham Forest

Ethnicity and language: many people in Waltham Forest do not speak English as a first language. This adds to the complexity of providing healthcare services. For example, interpreters are sometimes required and consultations can take longer.

Population mobility: North East London is often the area where new immigrants move to first and then move on, meaning the people and the ethnic mix of the population are constantly changing. This can mean difficulties in providing continuity of care (particularly in general practice) and health conditions remaining undiagnosed for long periods. It is also now the area where lots of young people come and live on a temporary basis - that causes issues for urgent care services because many young people don’t register with GP’s.

5 Our vision

5.1 Estates assumptions for primary care

The CCG primary care strategy, the TST strategy and the estates strategy make the following assumptions for future models of care;  Recommended minimum GP list size of 10,000  Higher level of deprivation in Waltham Forest increases demand for GP services based on weighted average of 5.3 appointments per person/year in Waltham Forest  Distance based accessibility to practices – 20 minutes walking/1.3-1.6 km  An average of 72 GP appointments per thousand population per annum.

The primary care hub model puts the patient at the centre (as illustrated in the diagram below) with the GP as the chief coordinator of the patient’s care provision.

In turn these hubs may be part of a wider Multispecialty Community Provider (MCP) with additional services such as secondary care specialists, social care, mental health and community services teams, community pharmacy.

In addition, the TST programme out of the hospital strategy has shown an additional need of 14 clinical and treatment rooms, which require an additional 10 GPs in the next 5 years; and 24 clinical and treatment rooms, which require an additional 16 GPs in the next 10 years.

(source: DoH and NHSE GP list size of 1,811 per GP and space need per GP 130m2)

The borough of Waltham Forest, and partners, working together as part of the TST programme

30,000+ patient list size

10,000+ patient list size

There is the desire to flex provision within each hub to meet local need and to suit local premises availability, maximising space, reducing void costs and ensuring suitable access for patients.

The provision can be as a virtual hub rather than everyone in the same physical building, with one service contract for each facility.

6 The current estate

The organisation of primary care practices across Waltham Forest is shown below.

6.1 Overview and demand modelling

Within the borough the key facts pertaining to estates are; Waltham Forest profile • 48 sites on NHS England Asset Register • 45 GP practices including a number of small single hander GP owned sites Population • Population density 6,897 persons per sq km (Greater London average is 4,523 persons) • 10.2% of population over 65 List size • Total (known) list size across borough of 297,758 (July 2015) • Average list size in 2015 of 6,767

The TST Programme has undertaken significant clinical and population modelling. The following table shows the additional infrastructure requirements in 2021 based on a 5% transfer (15,825 appointments) of Bart’s Health outpatient appointments (318,791 appointments) across Waltham Forest and increase in population:

Total Primary Care Total Consulting Treatment Estimated appointments baseline Appointments Rooms Rooms GIA required 1,039,940 2021 Required Required (m2) Total increase in Outpatient Appointments 15,825 2 1 265 (TST Shift) Total increase in GP appointments based on 62,502 9 2 971 Growth Total Appointments in 78,327 11 3 1,236 Primary Care

The following table shows the additional infrastructure in 2026 based on 5% transfer (16,619 appointments) of Bart’s Health outpatients (318,791 appointments across Waltham Forest and increase in population.

Total Primary Care Total Consulting Treatment Estimated appointments baseline Appointments Rooms Rooms GIA 1,039,940 2026 Required Required required (m2) Total increase in Outpatient Appointments (TST Shift) 16,619 2 1 265

Total increase in GP appointments based on 121,090 17 4 1,854 Growth Total Appointments in 137,709 19 5 2,119 Primary Care

The planned CCG clinical community procurements (as at December 2015) are likely to generate the following needs (note that MSK is a shift of activity from Acute based contracting to a community provider and therefore the detail below does not reflect ‘new’ activity and therefore not a ‘new’ need):-

In addition to the above the TST modelling suggests that 1 treatment will room will be required. The single room capacity could be a variety of sessions in different locations across the borough, as opposed to an individual room to which patients would need to travel. In the first instance the voids project will inform the estates strategy. Further work will develop the TST models and planned/ unplanned care requirements to define locations and clinical room requirements. In light of current voids and planned developments it is likely that there will be sufficient provisions for these clinical services via new procurements, which will become more defined as they develop in 2016-17.

Important note regarding clinical modelling:

By the very nature of modelling of delivering something new, assumptions need to be made and these have been made based upon best estimates and data available. As the work progresses to commission new services and move work out of the acute sector, the modelling will improve and predictions will become more accurate as they are actually tested.

6.2 Occupation and utilisation

There is a vast array and diversity of estate that is currently utilised for the delivery of primary care in Waltham Forest. One of the key issues facing the NHS is the disparate nature of the ownership of the estate and the fact that there is now a split between commissioning and provision of estate.

Unlike predecessor commissioning organisations, CCGs do not own any estate and are therefore reliant on working with separate organisations such as the two property companies and Provider organisations to effect change and the provision of the right estate in the right place.

The schedule of community healthcare premises (excluding mental health but including the community service of IAPT) in the London Borough of Waltham Forest is included at Appendix A.

The schedule of GP Practice premises in the London Borough of Waltham Forest is included at Appendix B.

6.3 GP premises estate

As with all estates providers, there is a wide spread in the condition of the GP premises. Waltham Forest CCG commissioned Ingleton Wood LLP to undertake six facet condition surveys of all GP premises and these surveys were undertaken in summer 2015.

Six facet surveys are a standard NHS Toolkit Survey Method to enable appraisal with regard to fitness for purpose for health care buildings in terms of use, condition and compliance. The six facets are:-

1. Physical condition 2. Functional suitability 3. Space utilisation 4. Quality 5. Fire, health and safety requirements 6. Environmental management

Each element of the building is assessed and ranked and the assessment criteria are:-

A As new (that is built within the past two years) and can be expected to perform adequately over its expected shelf life; B Sound, operationally safe and exhibits only minor deteriorations; C Operational but major repair or replacement will be needed soon, that is, within three years for building elements and one year for engineering elements D Runs a serious risk of imminent breakdown. X Supplementary rating added to C or D to indicate that nothing but a total rebuild or relocation will suffice (that is improvements are either impractical or too expensive to be tenable.

The overall result of the Six Facet Surveys for each GP premises in Waltham Forest are included in the Schedule of GP premises in Section 5.2 above and the detailed results Summary spreadsheet is included at Appendix B & C.

A summary of the results is as below:-

Percentage Number of Premises of Premises

A 1 2.1% B 30 62.5%

C 16 33.3%

D 1 2.1%

This is reasonably concurrent with other London boroughs, but is actually slightly above average.

The total costs to bring all the GP premises up to Condition B and retain in B is £9,015,351.

The total costs to bring the GP premises categorised as C&D up to Condition B is in excess of £5 Million, excluding sites with a separate re-provision plan and those not expected to be supported in five years, the requirement is £2,974,850.

By the nature of the surveys the actual cost of the works may be significantly higher as other works are deemed necessary or consider the best option to undertake at the time with the detailed planning of the works.

6.4 Current challenges and opportunities – acute sector

As a result of the TST Case for Change and the work completed since, the following initiatives have been identified for further consideration over the coming months:

 Whipps Cross Hospital: Working with Bart’s Health NHS Trust, development of a long term strategy through a Strategic Outline Case is currently underway as part of the CCG’s Transforming Services Together (TST) programme. This may yield opportunities for the development of community led services on this site.  Consideration of the benefit of a GP primary care led unscheduled care facility at Whipps Cross Hospital.

7 Regeneration overview

The following sites have been identified as major redevelopment opportunities by the London Borough of Waltham Forest. Borough wide, a proposal to develop a Mini Holland programme to improve the public realm, cycling facilities, and reduced reliance on the car across the borough is also under way, with the health and pharmacy elements of this to be developed.

All regeneration projects can be viewed on the Waltham Forest website. https://www.walthamforest.gov.uk/content/regeneration-projects

There is also a separate web page for the Mini Holland scheme which can be found at www.enjoywalthamforest.co.uk

7.1 Blackhorse Lane area (including Sutherland Road)

The Blackhorse Lane area has great potential for improvement. It has a unique location right on the edge of the Lea Valley Park, a strong small business base and a young population. Blackhorse Road Station also offers good rail and tube connections. By making the most of these assets Blackhorse Lane will become a thriving, more attractive place for both residents and businesses.

The Blackhorse Lane area is a key regeneration site for the borough, with the potential to provide over 2,500 new homes in the next five years (predominantly 1, 2 and 3 bedroom and circa 500 student units) and 1,000 new jobs over the next ten years as part of the comprehensive regeneration of the local area including new parks, roads, schools, community facilities and links to the Walthamstow Wetlands.

7.2 Leyton/Lea Bridge

This area, on the northern fringe of the Olympic Park, has potential for at least 2,500 new homes. Lea Bridge Station, which is on the Lea Bridge Road at its junction with Argall Way and Orient Way, was closed in 1985 when the train line serving it was rerouted. From 2016 it will run two trains an hour, and it will cater for up to 352,000 passengers per year by 2031. The new station will be a catalyst to the area east of the Leyton Marshes, which is without an on-the-doorstep rail service into central London. This new station is taking the majority of S.106 funding, but is a key enabler for regeneration of this area.

Lea Bridge Station area – Lea Bridge Station will kick-start new developments in the area. 97 Lea Bridge Road is a prominent site nearby providing opportunity for mixed use, employment, residential and social infrastructure development.

Bywaters – This 5.22 hectare site remains a significant landmark opportunity for development for mixed use, residential and employment opportunities which along with the Score Centre site (Coronation Square) and other smaller adjoining sites could contribute up to 1,500 homes. It is less than ten minutes from both Leyton tube station, the new Lea Bridge Station and close to the revitalised Leyton town centre.

Leyton Mills/Asda site – The 7.81 hectare site lies within Leyton District Centre and the main pedestrian entrance is opposite Leyton tube station. The mixed use site continues to present a considerable opportunity for intensification, including retail, residential and social infrastructure uses to incorporate a pedestrian and cycle bridge link to Eton Manor on the Queen Elizabeth Olympic Park to be delivered over the next ten years with potential for up to 2,000 homes.

Lea Bridge gas holders – This 2.49 hectare National Grid owned site borders Leyton Jubilee Park and is close to the Lee Valley Regional Park. The site provides opportunity for mixed use, employment and residential redevelopment in the event of de-commissioning.

The London Borough of Waltham Forest is also planning a significant regeneration and housing development scheme on land opposite Oliver Road Polyclinic currently occupied by a car park and the Score Centre, and various adjoining under-used land. This may be an opportunity for the CCG to re-provide enhanced facilities.

The Council has also identified a number of smaller sites along Church Road which could contribute up to a few hundred units in total.

Overall in the area, a master-plan is being prepared which will guide how much development is possible across this area, but it is envisaged that as a minimum upwards of 2,500 homes and growth in business base is likely over the next five to ten years.

7.3 Walthamstow regeneration

Significant public and private investment is being made in Walthamstow. The Local Authority area action plan identifies opportunity for 2,000 new homes by 2025 through redevelopment and expansion of the Mall Shopping Centre development around

Walthamstow Central Station and creation of a new neighbourhood at South Grove/ St James Street, including re-provision of the St James Health centre.

7.4 Wood Street Regeneration

Wood Street has benefited from funding from both Transport for London and the Mayor's Outer London Fund. This funding has enabled Public Realm improvements to be made to the length of Wood Street and the Plaza.

Investment in the shop fronts and windows of local businesses, local business support and training, art interventions, rejuvenation of the Wood Street Indoor Market and lighting features.

In addition to these immediate changes Wood Street is also an Area Action Plan area, with potential for 1,000 new homes. This includes the redevelopment of the Marlowe Road Estate, which will start in 2016.

The Local Authority is also reviewing the options to improve access to health and social care via children and family hubs across the borough. In early 2016 these sites are identified, yet ongoing conversations and planning for development is at an early stage. The CCG will work closely with both the LA and NELFT to understand whether there are any joint commissioning arrangements which could facilitate improved health and social care via these hubs and maximise the usage of public estate. The current map of proposed facilities is attached in appendix H.

8 Possible Income Streams for capital spend 8.1 Section 106

Planning obligations, in the form of S.106 Agreements with developers, Unilateral Undertakings, or S.278 Highway Agreements, are legally enforceable obligations that are entered into for the purpose of mitigating the impacts of a development proposal. The National Planning Policy Framework (2012) requires that all planning obligations must be necessary, directly related to the development, and fairly and reasonably related in scale and kind to the development.

Examples of planning obligations range from the provision of affordable homes and new open space to funding of school places, employment training schemes, or new healthcare schemes. The developer may either be required to comply with an obligation (non-financial obligations) or make payments to the council (financial contributions).

The WFCCG is working closely with the Council and other health partners to understand where new development and regeneration will likely occur, and to understand the likely impact on current healthcare provision, and in understanding potential future needs. Joint working will assist in identifying potential development sites, to inform discussions with developers about on-site provisions, and to inform negotiations of S.106 Agreements to meet identified demand and service needs.

The Council has already secured a number of obligations related to health facilities through S.106, such as the development expansion at Handsworth Medical Centre which is due to be completed by NHS PS by December 2016. The Council has additional S.106 funds set aside for other health facilities and proposals, and the Health and Wellbeing Board will work in partnership with the WFCCG to allocate these funds.

8.2 CIL (Community Infrastructure Levy) contributions

The Community Infrastructure Levy (CIL) is a planning charge, introduced by the Planning Act 2008 as a tool for local authorities in England and Wales to raise funds to assist in the provision of infrastructure to support the development of an area

Most new development which creates net additional floor space of 100 square metres or more, or creates a new dwelling, is liable for the levy. Unlike planning obligations (S.106 Agreements etc.), CIL is a non-negotiable levy set at a per sqm rate depending on the type and location of the development within the borough.

The monies collected through CIL are to assist in funding infrastructure to support development, and must be spent in accordance with the infrastructure types defined within the Regulations, and specified on the Councils Regulation 123 list

Currently the Council is committed to priority funding a local contribution towards the cost of re-opening Lea Bridge Station through CIL, and the funds available for other infrastructure items will accordingly be limited in the short-term

8.3 Estate Technology Transformation Fund (ETTF)

The Estate Technology Transformation Fund (formally the Primary Care Transformation fund and Primary Care Infrastructure fund) is a four year £1billion investment programme to help general practice make improvements, including in premises and technology. It is part of the additional NHS funding, announced by the Government in December 2014, to enable the direction of travel set out in the NHS Five Year Forward View.

The CCG strategy is to work with Practices to access funding through PCTF and assist with delivering the significant opportunity that this Investment Fund presents.

8.4 ETTF Schemes 2016 onwards

In November 2015, it was announced that from 2016/17 CCGs will take the lead on the assessment of PCTF schemes which will need to be determined by CCG estates strategies, and our financial assessment, included later, identifies key capital priorities against this.

CCGs will submit proposals to NHS England by end of June 2016. Proposals should be in line with broader CCG plans for delivering joined up out of hospital services for patients in their local communities and must meet one or more of the criteria set out below:

 Increased capacity for primary care services out of hospital;  Commitment to a wider range of services as set out in your commissioning intentions to reduce unplanned admissions to hospital;  Improving seven day access to effective care;  Increased training capacity.

CCGs should also produce phased funding plans (limited to 31 March 2019) for recommended developments, which take into account their long-term affordability. This is a key proviso and will pose a material factor in a challenging financial environment.

WFCCG has considered and will continue to assess schemes to ensure investment in the right long term premises. It may be that some short life short-term investments may be required pending longer term new-build/relocation options becoming available. In whichever choices are made the CCG will ensure that decisions fit the strategic objectives outlined earlier within this document. The CCG will also, as a matter of course, utilise the forum provided through the EWG to discuss estates related considerations with partners. The CCG is keen to see reinvestment within the borough as a result of any asset sales related to the estate strategy.

9 Gap analysis

Over the last few months, WFCCG have sourced and commissioned various work to ensure a good data set of information, which have supported the development of this Estates Strategy and principle details are included in this Strategy and at Appendix A & B.

Key information obtained is as follows:-

 Six facet condition surveys of all GP premises in Waltham Forest commissioned by Waltham Forest CCG and undertaken by Ingleton Wood LLP in summer 2015.  Six facet condition surveys of Health Centres in Waltham Forest commissioned by NHSPS and undertaken by Ingleton Wood LLP in early 2014.  Voids charging information.  NELFT estates strategy.  Various information on developments and opportunities provided by the London Borough of Waltham Forest.  Void assessment analysis for health centres.

Waltham Forest CCG will use the EWG as the facilitation panel and driver of the estates strategy for local activity. Areas where further work is required;

 Undertaking of void assessment work of GP Practice premises not in health centres.  Further understanding of GP premises estates costs and charging arrangements.  Further understanding of planned care procurements and service changes together with the estates and workforce implications.  Further exploring of opportunities with London Borough of Waltham Forest.  Further exploring and assessment of opportunities with NELFT.

 Work with TST and Bart’s NHS Trust on the potential opportunity for the Whipps Cross Hospital site.  Conversations with providers to explore opportunities to develop, improve or consolidate premises.  Feasibility Study for two localities of high population growth to assess best estates usage and opportunities.  Using the programme of engagement and consultation to test and inform the draft Estates Strategy and identify opportunities.

Some of this work will by its nature be on-going, but the CCG is working to close this gap significantly and this initial strategy seeks to identify key priorities for the next five to ten years.

10 Estates options for change

10.1 Overview

Whilst there are a number of challenges with the current Estate, particularly around the condition and capacity of the GP Premises estate, Waltham Forest has a number of exciting opportunities and developments which present opportunities for estates solutions to resolve some of the issues in key areas:-

 Poor quality in terms of condition and compliance of current premises  Lack of capacity of some current premises  Population growth  Activity completed in acute that could be delivered in the community  Changing demographics  Deprivation and health inequality

We discuss below the overall Borough wide opportunities and then the opportunities and possible solutions for each of the three localities of:-

 Chingford  Walthamstow  Leyton/Leytonstone

This will be informed and developed by the engagement and consultation programme.

10.2 Overview of Chingford locality

The Chingford locality includes 8 practices with an additional two branches where GPs operate. The Valley ward houses41% of the total patient list for Chingford and 50% of GP practices. Population growth is highest (8%) in Larkswood over the next ten years. Handsworth Medical Practice is currently undergoing development work through Section 106 funding, creating an additional 2 clinical rooms. Two practices (Old Church and Ridgeway) are looking to co-locate at the Silverthorn site in Larkswood, which currently houses out of hospital services for Rheumatology, MSK, paediatric eye and Maternity clinics amongst others. Close to this site is the Ainsley Rehabilitation unit, which is provided by NELFT and offers community services. This

makes the area around this site a good example of a working ‘hub’ for local people. NELFT services are also proposing to develop a community based clinic at an existing site at Hawkswell Court which is close to the Silverthorn Health centre. Dates to be confirmed.

There are no local authority schemes to redevelop land or housing within Chingford at present, however there are plans for a proposed children and family centre ‘hub’ close to Larkshall Medical Centre. In addition there is an empty NHS facility close to the Silverthorn site which could be divested by the CCG.

The distribution of practices, as of December 2015, is shown on the map below.

Therefore within Chingford the CCG is engaging with patients and practices to understand whether the following four locations for ‘hubs’ (marked A, B, C, D below) may be viable for the future. Within these ‘hubs’ the definitions remain loose and are based on the descriptors on page 16, noting that a hub is an approach to patient access to services and may not necessarily be one physical site.

Using the TST ideal of 1.6km maximum travel for patients to access services from their GP shows that ‘hub’ coverage meets the majority of patient’s access. Following feedback the CCG has refined this to a twenty minute walk from the centre of any hub location, which is shown below.

This shows that the CCG has to consider patient access for the area in the North of the borough. The CCG is beginning a review of the facilities and options in the Valley ward to understand what the best future arrangements for patients may be across this location (shown as C on the map above). Further engagement with local people and GPs is to run from April to June 2016.

Key priorities in Chingford

 Year 1 o CCG to complete a feasibility study for the Valley ward to support decision on GP hub locations and numbers. This will be jointly reviewed with current services to ensure full engagement. o CCG to engage with GPs to review potential for future working models which support the strategic objectives of the estates strategy o Complete the ETTF/IG work across practices which has been agreed in 2015-16. o Complete the development of the Silverthorn consolidation and gain learning from the project to inform further strategic direction on hubs. o To confirm a decision on the Higham’s Court site, potentially divesting the site via NHSPS o To work closely with NELFT as they develop Hawkswell Court as a local hub, working together to ensure best placement of effective patient care and support o To work closely with the Local Authority they develop their family and children’s centre hub in the locality o Implementation of C & D priorities from six facet survey where practicable and supported funding is available

o Review of clinical room size in practices to meet NHSE standard recommendation

 Year 3 – 5 o To have implemented the primary care strategic intent to, where possible, move services out of hospital and into community settings o To have engaged with GP practices and patients and delivered some partnership working/ collaborative approaches which create the hubs across the locality o To have agreed and implemented at least one new GP hub and one GP hub plus in the locality o To have an excellent, and effective, working relationship with key partners, such as the local authority, Bart’s Health and NELFT, which maximises the utilisation of public estates o To have reduced voids to a maximum of 10% across estates

 Longer term o To have implemented the required GP hubs within the locality o To have clearer access points for healthcare for patients, moving care closer to home where possible o To have effective joint-planning with partner organisations with regard to effective estate usage

10.3 Overview of Walthamstow locality

Walthamstow has the highest density of practises in the borough (20), and is also projected to be the population growth hotspot of the next ten years, with Higham Hill being the largest at 20%. There are also advanced discussions with the local authority for a potential new build health centre close to the St James practice which offers the opportunity to be a GP hub plus in the future (shown as I in the picture below. There is no GP practice in Hale End & Higham’s Park ward. Patients use Handsworth Medical practice or The Forest Surgery or locate out of the borough for services.

NELFT are also restructuring estates across the borough to fit into the hub at Thorpe Coombe (in Walthamstow), divesting locations where they pay rent. NELFT are looking into the potential to have a GP surgery within this hub. The local authority are also currently reviewing a development at site M, which is adjacent to the new Lea Bridge railway station. The CCG is conversations with the LA regarding opportunities for future health hubs within this area, although no specific schemes are, as yet, identified. As noted on page 10 this area will be a high population growth area in the next ten years.

Overlaying the potential ‘hub’ locations the majority of the locality is covered by the maximum 1.6km travel distance, however areas of potential need are seen within Wood Street ward (Hales End and Higham Park have good coverage from Handsworth Medical practice which is currently expanding its capacity).

In reviewing the 20 minute walk criteria for Walthamstow it becomes clear that the Wood Street area appears to be an area the CCG and GPs need to review to ensure sufficient accessibility for patients in the future (noting that the north of Hales End

and Highams Park are currently within walking distance of Handsworth Medical practice.

The Walthamstow area will see the highest pockets of population growth in the borough over the coming years, with central Walthamstow ear-marked for some major infrastructure change by the LA. The CCG is working closely with the LA to consider jointly planned health and social care estates locations which align to planning and population growth forecasts. Schemes at Sutherland Road and St James/ South Grove are in advanced talks and NHSE has recently (March 2016) agreed a funding request to increase capacity at The Claremont Medical Centre (Higham Hill ward) and Forest Surgery (Chapel End ward). In addition the CCG is working closely with Public Health to ensure that service locations are co-located where possible as contracts come up for re-commissioning.

The areas of Wood Street and High Street will require further review by the CCG to ensure access to health services as some areas are outside the proposed 20 minute walk. As part of the engagement process in 2016 the CCG will discuss options with local people and factor these into any future planning. In addition, further discussions

with GP practices regarding the potential to work more closely together to deliver both GP services and out of hospital services will be maintained as the CCG continues to align its Estates Strategy to the Primary Care Strategy. In Walthamstow there are ten practices with a list size of below 5,000 patients. Factoring population growth and currently identified developments there is scope for practices to begin the journey of working together. The CCG will continue to engage with GPs over the coming years as opportunities become available to either co-locate or merge services.

There remains an issue with the underutilised Forest Road site in William Morris ward which is currently 45% void. Options are being reviewed at present as the void space relates to the first and second floors of the building, with a busy GP practice on the ground floor. The CCG must consider consolidation of current estate before considering new builds.

The CCG is exploring potential developments at the Whipps Cross site via the TST programme for a potential major MCP development. Further analysis of the development at Lea Bridge (which, whilst in the CCG Leyton locality) is being undertaken with regard to opportunities related to provision of a health centre within new LA regeneration of the area. There may be economies of scale for GP Hubs or GP Hub Plus development which reduces the overall estates requirements and which may support GPs to develop partnership or merger opportunities. As many of the opportunities for Walthamstow are potentially three to five years away the CCG and its health partners are in an ideal position to have detailed conversations regarding the best utilisation of estates to support local people with both GP and out of hospital services.

Key priorities in Walthamstow

 Year 1 o CCG to complete a feasibility study for highest population growth areas to support decision on GP hubs locations and numbers across the locality. o Complete Utilisation studies (Claremont, St James, Forest Road) o CCG to engage with GPs to review potential for future working models which support the strategic objectives of the estates strategy o Complete the ETTF/IG work across practices which has been agreed in 2015-16 which includes development at Claremont Medical Centre and Forest Surgery o Complete further analysis of utilisation at the Forest Road site (William Morris ward) to maximise unused space and reduce voids to below 15% o Discuss options at Thorpe Coombe site with NELFT to understand any opportunities. o Review of clinical room size in practices to meet NHSE standard recommendation

 Year 3 – 5 o To have implemented the primary care strategic intent to, where possible, move services out of hospital and into community settings o To have engaged and delivered some consolidation for practices across the locality

o To have completed a feasibility study and worked with partner organisations to identify locations and costs for joint-working and delivery of new health facility sites within Walthamstow o To have agreed and implemented at least one GP hub in the locality o To have agreed the development of services, and joint working arrangements, for the Whipps Cross Hospital site o To have reduced voids to a maximum of 10% across estates

10.4 Overview of Leytonstone/Leyton locality

The Leyton/ Leytonstone locality currently contains 17 GP practices. As shown on page 10 there is potential population growth through the Leyton and Cathall wards across the next five to ten years which will place increased demand on the services offered across these locations. There is less GP coverage in the higher growth areas of Lea Bridge and Leyton than Cathall or Cann Hall where population growth is lower, and out of hospital services are underdeveloped within this locality compared to others in Waltham Forest. The LA have a potential planned development in Leyton, close to the Orient practice location, and Public Health services for Sexual Health are moving from the Orient facility in 2016 which will free space and give opportunities for further discussions with GPs regarding future consolidation in this high population growth area. As mentioned above the development of Lea Bridge railway station may also impact the need for services within the locality and will continue to be discussed with local partners. The Harrow Road Surgery has a number of vacant rooms and is currently providing some out of hospital services for the CCG. Further discussions should continue to consider options within this area as there are several practices who operate in close proximity. The ongoing discussions with regard to which Primary Care services should be developed in conjunction with Whipps Cross hospital will continue to drive some of the strategic decisions of the CCG, and engagement with GPs and the public will continue as the strategy emerges.

The CCG has been approached regarding opportunities for Waltham Forest GPs and patients to use the Sir Ludwig Gutteman Health & Wellbeing Centre site (SLG) in Stratford in the borough of Newham. Further discussed should continue to understand what the opportunities may be. 39

Overlaying the 20 minute walking diagram to the locality shows that the vast majority of the locality is covered by this criteria.

Key priorities in Leyton/ Leytonstone

 Year 1 o CCG to complete a feasibility study for highest population growth area of Lea Bridge to support decision on future service locations and numbers across the locality. o Complete utilisation studies (Allum Practice and Oliver Road) o Engage with local GPs to review potential future opportunities for working more closely to deliver primary care and community services. o Review utilisation of the SLG building and its potential for a GP Hub o Review of clinical room size in practices to meet NHSE standard recommendation o Maximise use of space at Harrow Road practice.

 Year 3 – 5 o To have implemented the primary care strategic intent to, where possible, move services out of hospital and into community settings o To have completed a feasibility study and worked with partner organisations to identify whether the SLG site is a viable option for residents of Waltham Forest o To have agreed and implemented at least one GP hub in the locality

o To have agreed the development of services, and joint working arrangements, for the Whipps Cross Hospital site o To have agreed and planned for opportunities which present themselves for joint working with all partners

11 Possible hub map Hub: Chingford Emerging possible hub locations are as follows:- Green?

Hub: GP/Community Silverthorne & NELFT at Hawkwell Court?

Hub: Valley area?

New Hub: Higham Hill area?

Central Community Services Thorpe Coombe?

Hub? Whipps Cross New Hub: GP/Community Hospital St James?

New Hub: Hub? Lea Bridge GP/Community Station Area? Harrow Rd HC TBC and/or The Allum Hub: Oliver Rd Polyclinic? Hub? Sir Ludwig Guttmann Shared with Newham/ Tower Hamlets?

12 Provider Property Owner Estates Strategies

Each Provider Property Owner has its own Estates Strategy and one of the key drivers of CCGs developing Estates Strategies is to ensure that these align and that opportunities for coordinated work can occur

12.1 Community Health Partnerships (CHP)

CHP have a strategy to maximise the occupancy of premises and ensure that they are flexible enough to meet the commissioning needs of commissioners, such as bookable clinical rooms rather than dedicated space. Wood Street Health Centre and Comely Bank (both in Walthamstow) are almost fully occupied with few void spaces.

12.2 NHS Property Services (NHS PS)

NHS Property Services inherited estate from the former Primary Care Trust (PCT) owners. A number of such sites have suffered from lack of investment over the years, through lack of funding, future planning blight (where replacement has always been the plan), and a different approach to estate management.

NHSPS have also inherited a number of long leases held with Curtis Medical Ltd all of which expire in approximately eight years and either replacement or lease renewal strategies will need to be in place for each of these buildings.

NHS PS have a strategy to support commissioners in the delivery of fit for purpose buildings whilst minimising the retention of poor quality buildings and surplus sites which can be disposed of.

NHS PS also have a strategy called ‘Laying the foundations’ which is about ensuring all occupiers of premises are on proper formal leases and a further impact of this is the planned charging of market rents for all space occupied which will put pressure on current occupiers/clinical providers which in turn will put pressure on the local health commissioning budgets, i.e. in Waltham Forest CCG.

Through the EWG the CCG is working closely to ensure there is joint-working and planning in relation to maximising the efficient use of current estates, including maximising utilisation of void space. The impacts of changes, in both organisations strategies, is being reviewed regularly and will support informed decision making.

12.3 North East London NHS Foundation Trust

NELFT have developed a strong estates strategy with regards to buildings owned by NHS PS and CHP and with regards to the community estate that they inherited from PCTs. The NELFT Estates Strategy is built on two main themes:-

1. Maximised usage of their freehold buildings and less utilisation of leasehold estate. 2. Co-location and hub in each locality. Developing Agile working, but are working on what this actually means in practice to support their clinicians.

This Estates Strategy was signed-off by the NELFT Board in 2014. The main impact on Waltham Forest is as follows:-

Site Strategy

Thorpe Coombe Site Establish a Hub in the middle of the Waltham Forest Borough and maximise the delivery of services delivered from here and also provision of office bases. Target date for the delivery of this new Hub is July 2018.

Ainslee Rehab Units No plans to vacate in the next 5 years. Indeed, NELFT are working on a joint mental health and community strategy.

Chingway Health Centre NELFT only occupy an IT Training Room and they plan to vacate this by the end of 2015.

Forest Road Health Centre Some vacation already with 1st Floor offices relocating to Hurst Rd Offices. Aim is to relocate remaining clinical services to Thorpe Coombe Hub in July 2018. This will leave the 1st Floor vacant.

Hurst Road Offices Strategy is to relocate all the Offices from this site to the new Thorpe Coombe Hub in July 2018. This is likely to leave the Hurst Road Office site vacant.

Oliver Road Polyclinic Strategy is to move the Borough wide Sexual Health Service to the new Thorpe Coombe Hub in July 2018. This will leave the Upper Ground Floor at Oliver Road Polyclinic vacant.

Silverthorne Health Centre Plan is to move all of the NELFT clinical services and offices to Hawkwell Court around May 2016 leaving this building almost entirely vacant.

St James Health Centre NELFT only run limited clinics at St James now and these are Smoking Cessation and Dieticians. NELFT are working on a plan to relocate these services to an alternative site and this happened in November 2015.

Leyton Green Health Centre School Nurses & District Nurses are based here. There is limited options for re-provision of these and Baby Clinics in this area, and so for now this site needs to be retained.

Hawkwell Court IAPT is growing and NELFT can accommodate growth at Hawkwell Court along with the Silverthorne services that they plan to relocate to there.

Naseberry Court NELFT plan to dispose of this form 1,503sqm two story in- patient unit.

The delivery of the NELFT strategy has some repercussions on the volume and location of void space for the CCG estates. These areas are being reviewed, alongside NHSPS, to ensure that all parties are making associated plans to maximise efficiency or removal of estates where appropriate. These actions are being fed into the local forum (the EWG) on a monthly basis to ensure details are managed effectively. Further developments in 2016-17 will tighten this process as it has clear impacts across the health economy.

12.4 Evaluation process and criteria

Waltham Forest CCG will need to develop an evaluation process and criteria for assessment of options and development opportunities to ensure the right estate is delivered in the right place and given that funds are not unlimited. Any scheme will also need to meet the NHS England criteria and will need to be very carefully considered, with full revenue consequences of the scheme understood due to the fact that increasingly these costs are having to be borne by the CCG rather than NHS England.

Waltham Forest CCG have established an Estates Working group which meets regularly (currently monthly) and comprises of the following attendees:-

 Finance Director (Chair)  Deputy Director Strategic Commissioning  Senior Commissioning Manager (Primary Care)  GP Governing Body representation  Three GP locality representatives  Community Health Partnerships and NHS Property Services Ltd  London Borough of Waltham Forest  NELFT and Bart’s Health NHS Trust

All schemes including s.106 & CLI schemes will be considered by the Estates Working Group and then depending on scope and value. Agreed schemes for development will be subject to any, or all, of the following internal panels/ Committees:-

 Waltham Forest CCG Finance & Performance Committee  Waltham Forest CCG Primary Care Committee  Waltham Forest CCG Governing Body  London Borough of Waltham Forest health & Wellbeing Board

13 Delivering the strategy 13.1 Financial impact Any recommended developments will need to take into account their long-term affordability. This is a key proviso for approval of any scheme by NHS England and will pose a material factor in a challenging financial environment. The full details of the financial impact are attached within Appendix F.

13.2 Outline implementation plan a. Programme plan and milestones

The following is timescale for the work undertaken to date, the strategy work currently being undertaken, and a possible aspirational timeline for delivery of schemes.

Any timeline will naturally depend on the nature and scope of the schemes being delivered. The very disparate nature of property ownership and the numerous interdependencies for the approvals process and delivery mean that timescales are purely indicative at this stage.

2018 & on to Dates 2015 2016 2017 2025 Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 Activities

Regular Joint Estates Strategy Meetings

Facet surveys of GP Premises

Space Utilisation Surveys

Develop Estates Strategy

Continuous development of Estates Strategy

Delivery of 2015/16 ETTF Schemes

Consider & agree 2016/17

ETTF schemes

Feasibility work for Phase One schemes

Develop business cases for

Phase One schemes Delivery of Phase One schemes

Develop business cases for Phase Two schemes Delivery of Phase Two

schemes

Phase Three schemes?

b. Resources

For projects to be a success require good project management and therefore resources to assess and explore opportunities, and work with interested parties to progress the scheme.

Any recommended developments will need to take into account their long-term affordability. This is a key proviso for approval of any scheme by NHS England and will pose a material factor in a challenging financial environment.

Negotiating an extensive design and build primary care project can be a complicated and time-consuming process. Most GPs and practice managers will lack the particular expertise, confidence or resources to manage the project on their own, and so will need professional assistance from the start of the project. For larger projects it is essential to appoint a project manager with experience of the building process and consultation techniques. This could be an internal member of staff if they have the required knowledge and experience, or an external person could be appointed.

The emerging need for resource is:- 1. GPs and practice managers will not have the technical knowledge and are very unlikely to have experienced a significant premises development opportunity – often such developments for a practice are ‘once in a lifetime’ opportunities. 2. GPs and practice managers are busy with their ‘day job’. 3. If the scheme is bringing more than one GP Practice together and other community provider organisations together, the need for an impartial project manager to steer the different organisations through the process and provide support concerns and differences is essential. 4. Without project management, there can be project creep where months can be lost for no real reason as the organisations will not always have the focus or skills to progress.

Waltham Forest CCG see resource put into schemes, even if they are only potential schemes at an early stage, are a key to the successful inception and progression of a scheme. Resources will need to be identified for this key area of work. Without this resource there will be a direct impact on the ability to deliver.

c. Enablers of change and managing constraints

Any enablers of change are often estates and a new premises, but the driver for change is the Primary Care Strategy and the need to have fit for purpose buildings in the right place to deliver primary care and community health services. The solution is not just building or refurbishing a building. Managing service delivery change and improvement is critical. For example, a scheme elsewhere in London delivered an excellent new fit for purpose building, but simply relocated a number of GP Practices and community services from four existing buildings into it. The CCG and CHP are now investing in some strategic management to develop a better sense of working together for the GP practices and community services some 18 months after the building was completed. Waltham Forest CCG are keen to see a faster pace of change and better approach to such developments where service change and working together goes hand in hand with any new premises development. A faster pace will be achieved through added investment/resources and collaboration with stakeholders and commissioners.

d. Engagement plan

An engagement document has been developed for the Estates Strategy. A copy is included at Appendix I.

The engagement will be with patients, providers, GPs, and other allied agencies and will take the form of workshops, events, and taking the strategy to key decision making meetings and authorities.

e. Risks and mitigations

All projects undertaken by Waltham Forest CCG and possible schemes identified have been risk rated. Key risks identified at this stage are:-

Risk Risk Risk identified Mitigation Ref rating

S Solution: The purpose of an Estates Strategy & good The right scheme is not delivered in S.1 management of the delivery process will minimise Green the right place. this risk. Ensure adequate resources are available to assist GP practices not willing to S.2 with change management. Ensure sufficient Amber participate/work together. consultation time. Changes in clinical delivery/ working Ensure adequate resources are available to assist S.3 Amber arrangements. with change management. S.4 Engagement Ensure effective engagement at each stage. Amber Current providers do not participate in Work with current Providers to ensure joint aims are S.5 Amber development of Hubs. achieved. GP networks do not participate in Work with GP Networks to ensure joint aims are S.6 Amber development of Hubs. achieved. Provider’s estate plans do not The purpose of an estates strategy & good S.7 complement commissioner’s estates management of the delivery process will minimise Green strategy this risk.

D Delivery Changing NHS processes mean Develop the best possible assessment of D.1 project delivery programmes are processes. React to changes as they are arise Amber affected. efficiently. Ensure good quality project management is in Construction process may be delayed D.2 place. Ensure effective contracts are in place. Amber for a whole variety of reasons. Ensure contingency allowance. Numerous interdependencies Ensure robust project management is in place. including IT, workforce, D.3 Ensure effective engagement and coordination of all Amber communications, planned & primary resources and strategies. care commissioning, etc. Identify need for resource and budget. Scope D.4 Resources & skills for management. Amber services and source provider. Population growth is predicated on GLA SHS data from 2013. Growth Working with local authority infrastructure team to D.5 models may under-predict required Amber understand growth scenarios in February 2016 need and distribution for health services

C Commissioning:

Ensure robust clinical procurement and then Commissioning does not deliver the C.1 subsequent management of clinical contracts. Amber required clinical service change. Ensure the right resources are there to enable this. The provider landscape is not Ensure effective procurement. Consider the need to C.2 sufficiently diverse to deliver new procure rather than just work with the existing Amber procurements. Provider. Work closely with GP practices to understand their GP practices choose not to locate priorities & concerns. C.3 Amber services in identified hubs. Consider mandating locations for the delivery of clinical services in any new procurements. Work closely with providers to understand their Providers choose not to relocate to priorities and concerns. C.4 Amber identified hubs. Consider mandating locations for the delivery of clinical services in any new procurements. Commissioning landscape/roles & Scan the commissioning horizon. Ensure flexibility C.5 Green responsibilities change. in contracts where possible.

F Financial: Identify revenue costs at an early stage. Work with NHS organisations to identify solutions. Ensure F.1 Lack of capital funding. Amber solutions are not over-designed to ensure revenue costs are kept affordable. Work with NHS England to access PCT and make F.2 ETTF funding may be limited Amber comprehensive and effective cases when bidding. Ensure good quality project management is in Construction process may be delayed F.3 place. Ensure effective contracts are in place. Amber for a whole variety of reasons. Ensure contingency allowance. Identify revenue costs at an early stage. Work with Lack of revenue funding to support NHS organisations to identify solutions. Ensure F.4 ongoing costs of new/expanded Red solutions are not over-designed to ensure revenue footprint occupier. costs are kept affordable. Lack of funding to support move of clinical services from the acute to the Deep dive into current costs. Work closely with F.5 Red community due to inability to extract existing providers. costs from the acute sector.