new south east london commissioning strategy programme · 2015. 3. 26. · south east london...

South East London Commissioning Strategy Programme Office

South East London Commissioning Strategy Programme

Case for Change

(DRAFT)

28 February 2014

DOCUMENT CONTROL

Version Date Author Comments

V0.14 15/01/2014 Programme Team

First draft for review with South East London Clinical Executive Group


Further refinement of first draft incorporating feedback from South East London Implementation Executive Group and Clinical Executive Group.


Updated to incorporate Partnership Group feedback for baseline


Draft for Engagement

South East London Commissioning Strategy Programme – Case for Change – DRAFT FOR ENGAGEMENT

SEL_CSP_CfC_v1.0_DRAFT - use for updating engagement summaries

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CONTENTS 1 Introduction ..................................................................................................................... 3

2 The health of south east London’s population has improved significantly but there is more to do ............................................................................................................................. 7

3 The national and London context is changing the way that health and integrated care services are planned and delivered ..................................................................................... 23

4 Significant developments and opportunities within south east London help us to make a strong and innovative response to the national and London context ................................... 32

5 Our health services have many strengths but quality is variable and we have tolerated unacceptable and unwarranted variation in quality for too long ........................................... 37

6 Patient satisfaction is low compared to national benchmarks – and there are common themes regarding how patients would like to see services improved ................................... 47

7 The financial position for commissioners is challenging ................................................. 50

8 Our partners face a similar and interrelated set of challenges ....................................... 53

9 Significant progress has been made to date .................................................................. 58

10 The South East London Commissioning Strategy will set out how we work with partners over the next five years to build on existing progress to address these challenges and deliver best possible outcomes and services within our resources ................................................. 64

Annex A – Joint Strategic Needs Assessments (JSNAs) for south east London boroughs .. 66



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1 Introduction

1.1 A vision for healthcare in south east London Our health outcomes in south east London are not as good as they should be:

Too many people live with preventable ill health or die too early

The outcomes from care in our health services vary significantly and high quality care is not available all the time

We don’t treat people early enough to have the best results

People’s experience of care is very variable and can be much better

Patients tell us that their care is not joined up between different services

The money to pay for the NHS is limited and need is continually increasing

It is taxpayers’ money and we have a responsibility to spend it well The longer we leave these problems, the worse they will get; we all need to change what we do and how we do it In south east London we spend £2.3billion in the NHS. Over the next five years we aim to achieve much better outcomes than we do now by:

Supporting people to be more in control of their health and have a greater say in their own care

Helping people to live independently and know what to do when things go wrong

Making sure primary care services are consistently excellent and with an increased focus on prevention

Reducing variation in healthcare outcomes by raising the standards in our health services to match the best

Developing joined up care so that people receive the support they need when they need it

Delivering services that meet the same high quality standards whenever and wherever care is provided

Spending our money wisely, to deliver better outcomes and avoid waste

1.2 NHS Services in south east London The South East London Strategic Planning Group (SPG) covers the six boroughs of Lambeth, Southwark, Lewisham, Bexley, Bromley and Greenwich. The combined population is circa 1.67m and is expected to grow to circa 1.87m by 20211. NHS services for the population of south east London are commissioned by Lambeth, Southwark, Lewisham, Greenwich, Bexley and Bromley Clinical Commissioning Groups (CCGs) and by NHS England. Each CCG is coterminous with its local borough. Spend on NHS services in south east London is circa £3bn, approximately half of which is focused on acute hospital-based services.

1 GLA 2012 Round Demographic Projections, 2013



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These commissioners plan and purchase NHS services from a number of healthcare organisations. NHS services are provided by:

Primary care 261 general practices, employing over 1,100 General practitioners and 650 practice nurses

242 dental practices

360 community pharmacies

Out-of-hours care provided by the GP co-operatives Grabadoc Healthcare Society, South East London doctors Co-operative (SELDOC) and EMDOC Bromley doctors On Call.

Community services

Four community service providers across the six boroughs: o For Southwark and Lambeth: Guy’s and St Thomas’ NHS Foundation

Trust o For Greenwich and Bexley: Oxleas NHS Foundation Trust o For Lewisham: Lewisham and Greenwich NHS Trust o For Bromley: predominantly by Bromley Healthcare, a Community

Interest Company.

Mental Health services

Two mental health NHS Foundation Trusts across the six boroughs: o For Lambeth, Southwark and Lewisham: predominantly South

London and Maudsley NHS Foundation Trust o For Bexley, Bromley and Greenwich: predominantly Oxleas NHS

Foundation Trust.

Acute services Dartford and Gravesham NHS Trust, operating from Darent Valley Hospital and Queen Mary’s Hospital Sidcup

Lewisham and Greenwich NHS Trust, an integrated healthcare trust operating from University Hospitals Lewisham and Queen Elizabeth Hospital Greenwich; with some services also provided at Queen Mary’s Hospital Sidcup

Guy’s and St Thomas’ NHS Foundation Trust, operating from two main sites at St Thomas’ Hospital (including the Evelina Children’s Hospital) and Guy’s Hospital; with some services also provided at Queen Mary’s Hospital Sidcup

King’s College Hospital NHS Foundation Trust, operating from Denmark Hill and from Princess Royal University Hospital in Bromley; with some services also provided at Queen Mary’s Hospital Sidcup.

Ambulance Services

London Ambulance Service NHS Trust responds to emergency calls and provides non-emergency patient transport services across all six boroughs.

The outline of acute service providers above reflects the organisational transactions that took place as part of the Trust Special Administrator (TSA) programme. The TSA programme was in place for South London Healthcare NHS Trust from August 2012. This programme ceased when the Trust was dissolved on 30 September 2013 and its services were transferred to other local NHS providers. The TSA had also made recommendations in relation to some service changes. All work on these recommendations ceased when they were successfully challenged through Judicial Review. The NHS in south east London helps to fund four hospices and a number of other local charitable and voluntary sector organisations via commissioned services. The four hospice organisations are Greenwich and Bexley Community Hospice, Harris Hospice Care, St Christopher’s Hospice and Trinity Hospice. The providers of NHS services work in partnership with the voluntary sector and social services, which are provided for their residents by local authorities, to ensure that the needs of patients and service users are met in an integrated fashion.



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South east London has one of the country’s six Academic Health Science Centres (AHSCs), King’s Health partners. The AHSC is a strategic partnership that brings together King’s College London with three NHS Foundation Trusts – Guy’s and St Thomas’, King’s College Hospital and South London and Maudsley to improve the health of the patients and population of south east London. South London also has one of only thirteen Academic Health Science Networks, the South London Health Innovation Network (HIN), a membership organisation focused on driving lasting improvements in health and wellbeing across south London by sharing innovations across the health system and capitalising on teaching and research strengths.

1.3 The purpose of this document The purpose of this document is to outline an overarching Case for Change for the south east London Commissioning Strategy. In doing so:

it will support further engagement with the stakeholders of the programme

it will enable south east London commissioners and their partners to set the priorities and associated level of ambition that will drive the five year commissioning strategy

the priority objectives identified will form the basis for design and development work through the programme’s Clinical Leadership Groups.

The Case for Change provides a south east London level synthesis of the issues and challenges facing our boroughs. It is therefore not intended to be a substitute for borough level Joint Strategic Needs Assessments (JSNAs), local commissioning plans, and Health and Wellbeing Strategies which will focus on borough-specific issues and challenges and will identify these is much greater detail. The document follows and expands on the structure of the Case for Change narrative that has been developed with programme partners and stakeholders. In doing so it covers the following sections and themes:

The health of south east London’s population has improved significantly but there is more to do: summarises population demographics and health needs

The national and London context is changing the way that health and integrated care services are planned and delivered: sets out the strategic context for the Case for Change and Commissioning Strategy

Significant developments and opportunities within south east London help us to make a strong and innovative response to the national and London context: sets out the local strategic context for the Case for Change and Commissioning Strategy and seeks to emphasise the opportunities to compliment information in the other sections on the challenges

Our health services have many strengths but quality is variable and we have tolerated unacceptable and unwarranted variation in quality for too long: describes the key issues in relation to quality, safety and performance, recognising that variation exists within and between organisations



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Patient satisfaction is low compared to national benchmarks – and there are common themes regarding how patients would like to see services improved: sets out what patients and public in south east London have told us

The financial position for commissioners is challenging: sets out the high level scale of the financial challenge across CCG commissioned services, primary care

Our partners face a similar and interrelated set of challenges: summarises the key issues and drivers affecting our provider partners

Significant progress has been made to date: describes the significant work to date on strategies and change programmes transforming the local health system

The South East London Commissioning Strategy will set out how we work with partners over the next five years to build on existing progress and address these challenges: describes the approach to the Strategy and next steps.

The Case for Change is intended to bring together issues and challenges for the existing health and social care system in south east London and identify with supporting evidence where there are opportunities to improve. In developing this draft we have worked closely with our partners and key stakeholders and to date the work has been enhanced through input from a number of groups including:

Public health colleagues

NHS provider organisation colleagues

Local authority colleagues

Senior clinicians from commissioners and NHS provider organisations

Patients and local people from the CCGs' representative groups and Lay Members of CCGs.

The Case for Change will continue to be developed in response to comments received from engagement activities in March 2014 and throughout the development of the strategy through to submission of the Final Strategy to be submitted in June 2014.



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2 The health of south east London’s population has improved significantly but there is more to do

Chapter summary and key messages

South east London has extremes of deprivation and wealth. A high proportion of the 1.67m population live in areas that are amongst the most deprived fifth (quintile) in England, while a smaller proportion live in the most affluent fifth (quintile) in England. The population of south east London is highly mobile. In Southwark and Lambeth, the equivalent of roughly half the current population has moved in and out over a five year period. Even in Bexley, the borough which has the most settled population, the equivalent of roughly a quarter of the current population has moved in and out over a five year period. Premature mortality and differences in life expectancy are both significant issues. There is a difference in life expectancy between the most and least deprived wards of 8.7 years for women and 9.3 years for men. About 11,000 people died prematurely across south east London over the period 2009 to 2011, with four boroughs being classified in the “worst” category for premature mortality outcomes in England. There are large and growing numbers of children living in south east London. Child poverty and obesity are significant challenges.

South east London population aged zero to fourteen is set to increase from 310,000 in 2011; to 356,000 in 2021. This is an increase of 1.39% per annum compared with 1.21% across London and 1.27% across England

Four out of six boroughs are bottom quartile for percentage of children in poverty, with an area average of 27.8% versus national median of 17.1%. The average for CCGs in the top quartile is 10.5%

Childhood obesity levels in south east London (for year 6 – 10/11 year old pupils) are consistently higher than the London average and significantly above the England average, with levels ranging from 17.3% to 26%. Five out of six boroughs are in the bottom quartile

Nationally 1 in 10 children and young people aged 5 - 16 suffer from a diagnosable mental health disorder - that is around three children in every class.

Helping our children to get the best start in life (through early access to maternity services, high quality parental support, early help, ante and post natal support) is critical to our children thriving in childhood and into adult life, especially those from disadvantaged backgrounds.

There are higher proportions of older people living in outer boroughs of south east London. Inner south east London has also experienced an increase in conditions associated with older people through increased life expectancy.

Bexley (with 6.6% of males and 9.3% of females aged over 75) and Bromley (6.9% of males and 9.7% of females aged over 75) have relatively high proportions of older people compared with other boroughs

Inner south east London boroughs have also experienced an increase in burden of conditions associated with older people, as a result of increased life expectancy (for example in Lambeth, men now live 5 years longer than in 1995 and women 2.7 years).



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The biggest causes of premature mortality are cardiovascular diseases, cancers and respiratory diseases. Mortality rates for these diseases have decreased significantly over recent years, but rates continue to be considerably above London average

Cardiovascular disease: Under 75 deaths from CVD in south east London have declined steeply and are now in line with the London average though still slightly above the national average. This masks significant variation between the boroughs, with Greenwich having the highest directly standardised rate at 70 per 100,000 in 2012 compared to Bromley with the lowest at 43

Cancer: Whilst there have been some improvements across the six boroughs prevalence is still above London average. If the number of premature mortalities for Cancer in Southwark, Lambeth and Greenwich is reduced to the south east London average this would lead to a reduction of 64 mortalities per year by 2019

Respiratory diseases: Deaths from chronic obstructive pulmonary disorder across south east London are significantly higher than the national average, driven by high instances in the inner London boroughs, Reducing to the national average level would result in reduction of deaths attributable to chronic obstructive pulmonary disorder across south east London by 88 per year.

Mental health continues to place the highest burden of morbidity in this part of London.

A 2011 study identified that in south east London all mental health disorders were associated with substantially lower life expectancy compared to National statistics for general population: between 8.0 and 14.6 years lost for men and between 9.8 to 17.5 years lost for women, depending on the specific disorder.

Nationally:

Three in four people with common mental health problems receive no treatment, and even for psychotic disorders this figure is nearly 1 in 3

People with severe mental illness are in some cases 3 or 4 times more likely to die prematurely from the ‘big killer’ diseases, when compared to the population as a whole. Improving mental health also makes obvious economic sense

The costs to the NHS of co-morbid mental health problems run into billions. A number of other health issues have been identified as a ‘high burden’ of ill health across south east London where the trend or outlook is worsening.

Alcohol-related diseases: there are above average admission rates for alcohol attributable diseases, and an increase in mortality rates. Reducing to the national average in those boroughs that exceed the national average for alcohol specific mortality would lead to a reduction of 17 deaths a year

Sexual health: there are the highest levels of HIV and STIs in the country in inner south east London, with a concentration amongst gay men and black African populations for HIV

Older People: there is a continuing rise in the numbers of people with dementia in south east London, and only about half of the predicted number of current patients are diagnosed and included on GP dementia registers. Older people tend to have multi-morbidities. National estimates are that 12% of people over 65 will have three or more long term conditions, 34% two or more and 67% one long term condition; 2% of patients with chronic disease account for 30% of unplanned hospital admissions, 80% of GP consultations and 70-80% spend is on people with long term conditions

Diabetes: there in an increasing burden of ill health from diabetes, with rates increasing in parallel with the increase in London and England as a whole. It is estimated that about one in four people with diabetes are undiagnosed.



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The outlook is improving across south East London for a number of other health issues identified as ‘high burden’ of ill health, but these remain significant challenges.

Smoking: nearly one in five adults in south east London still smokes. Smoking still remains the biggest current direct cause of preventable mortality and morbidity. If the three boroughs above the south east London average were to reach the average levels this would further reduce smoking prevalence by a total of 9,500

Teenage conceptions: rates are still significantly above national and London averages in inner south east London. The borough with the highest rate was Southwark with 42.7 per 1000 conceptions to under 18 year old young women.

This section is intended to provide a high level synthesis of, and therefore not to be a substitute for, the detailed Joint Strategic Needs Assessments (JSNAs) available for each borough. These will provide further detail of specific issues and challenges affecting the populations of individual boroughs (see Annex A for full details). South east London comprises six local authority boroughs. It is a highly varied sub-region of London, and includes four boroughs with inner London characteristics (Lambeth, Southwark, Lewisham and Greenwich), and two with outer London characteristics (Bexley and Bromley). For many health outcomes, there is a clear divide between the inner boroughs (Lambeth, Southwark, Lewisham and Greenwich) and the outer boroughs (Bexley and Bromley), with the inner boroughs experiencing significantly poorer outcomes across a range of mental and physical health outcomes linked to their higher levels of deprivation and greater ethnic diversity. All boroughs experience health inequalities within their boundaries, including Bexley and Bromley which, despite being generally less deprived than the other south east London boroughs, still have pockets of deprivation whose populations experience significantly poorer health. Over the last decade, the population has increased significantly, due to a combination of increasing life expectancy and new housing developments, which has been especially marked along the stretch of south east London adjoining the Thames.

2.1 South east London has a diverse and mobile population with extremes of deprivation and wealth

A high proportion of the 1.67m population live in areas that are amongst the most deprived fifth (quintile) in England, while a smaller proportion live in the most affluent fifth (quintile) in England. Four of the six boroughs (Lambeth, Southwark, Lewisham and Greenwich) rank amongst the 15% most deprived local authority areas in the country2. The other two boroughs (Bexley and Bromley) are significantly less deprived but have pockets of deprivation in particular geographical areas. The population is very ethnically mixed; ranging from 15.7% of the population of Bromley being from black and minority ethic groups to 46.5% in Lewisham3. Figure 1 shows the estimated numbers of people from different ethnic backgrounds living in South East London in 2014, and the estimated numbers that will be resident in 2024. This

2 IMD 2010, http://data.gov.uk/dataset/index-of-multiple-deprivation

3 Census 2011, Black and Minority Ethnic (BME) Population, http://www.localhealth.org.uk

http://data.gov.uk/dataset/index-of-multiple-deprivation

http://www.localhealth.org.uk/



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shows an increase in numbers predicted across all ethnic groups, but with a higher proportional increase amongst Black, Asian and Minority Ethnic (BAME) groups. The graphs show the proportions of the population from different ethnic groups in 2014 and 2024. This shows a similar picture with the proportion from white backgrounds predicted to fall by 5% and the proportions from BAME groups increasing. Figure 1 - Ethnic population 2014 & 2024 (numbers and percentages)

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The age profile of the population includes a relatively high proportion of younger people, especially 0-9 years, and a slowly increasing older population, with more females than males living into older age. Figure 2 below shows the current (2014) age profile for South East London and the predicted change to this profile in 10 years time (2024). This shows a predicted relative decrease in the proportion of the population in the young (<30) age range, and an increase in the proportion of the population in the older (55+) age range. This increasing number of older people, including those surviving into very old age, will continue to require an increase in services to meet their health and social care needs. Figure 2 - Age structure in South East London, 2014 and 2014

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4 Source: GLA ethnic group projections 2012 round, SHLAA-based, November 2013



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The local population is highly mobile. In Southwark and Lambeth, the equivalent of roughly 9% and 10% respectively of the current population moved in and out over a 12 month period mid 2011 to mid 2012. Even in Bexley, the borough which has the most settled population, the equivalent figure was around 5%, compared with approximately 3% in London as a whole5. Looking only at migration into the area, there is a stark difference between boroughs. Figure 3 shows, for example, that 12.5% of the population of Lambeth in 2011 had moved into the borough within the previous 12 months. In Bexley, only 4.5% of the population had moved into the borough during the previous year. Figure 3 -: Population mobility based on Census 2011

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2.1.1 Meeting Equalities Act (2010) Requirements

The six CCGs in south east London each undertake an annual assessment of how effectively the services they commission engage with and meet the needs of 9 protected groups outlined in the Equality Act 2010. The protected groups are: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex (gender) and sexual orientation. Each CCG uses the framework of the NHS Equality Delivery System to identify a rolling programme of equality objectives, which set out the improvement priorities for the CCG for the year ahead. The following are some examples of improvement priorities that have been worked on recently in south east London to address equalities issues:

Improve access to primary care for older people and people with long term conditions (Lewisham CCG)

Improve the physical health of people known to have mental health problems especially people with severe mental illness (SMI) (Lambeth CCG)

Integrating equality and human rights into commissioned contracts; ensuring contracts have equality and human rights specifications and demonstrable compliance outcomes for Southwark people (Southwark CCG)

Devise a social media strategy to promote healthcare for younger people via media such as Facebook and Twitter (Greenwich CCG)

Develop a comprehensive improvement plan based on the Learning Disability Health Self Assessment Framework (Bexley CCG)

5 ONS Migration Indicators Tool, Mid 2012 data, http://www.ons.gov.uk/ons/publications/re-reference-

tables.html?edition=tcm%3A77-320124 6 Source: Census 2011

http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-320124

http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-320124



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Improving the health and well being of older people, particularly those with Dementia (Bromley CCG).

2.2 Premature mortality and differences in life expectancy are both issues There is a difference in life expectancy between the most and least deprived wards of 8.7 years for women and 9.3 years for men. In Woolwich Riverside men live to 74.7 years on average and women to 79.9; whilst in Petts Wood and Knoll men live to 83.4 years on average and women to 89.2 years. South east London population aged zero to fourteen is set to increase from 310,000 in 2011; to 356,000 in 2021. This is an increase of 1.39% per annum compared with 1.21% across London and 1.27% across England. Four out of six boroughs are bottom quartile for percentage of children in poverty, with an area average of 27.8% versus national median of 17.1%. The average for CCGs in the top quartile is 10.5%. Bexley (with 6.6% of males and 9.3% of females aged over 75) and Bromley (6.9% of males and 9.7% of females aged over 75) have relatively high proportions of older people compared with other boroughs and with south east London as a whole (4.1% of males and 5.8% of females respectively). Inner south east London boroughs have also experienced an increase in burden of conditions associated with older people, as a result of increased life expectancy (for example in Lambeth, men now live 5 years longer than in 1995 and women 2.7 years). About 11,000 people died prematurely across south east London over the period 2009 to 2011, with four out of six boroughs being classified in the “worst” category for premature mortality outcomes in England.

2.3 The biggest causes of premature mortality continue to be cardiovascular diseases, cancers and respiratory diseases

The biggest causes of premature mortality in south east London continue to be cardiovascular diseases, cancers and respiratory diseases. Whilst mortality is generally declining from these diseases there is still considerable headroom for further improvements. Mental health continues to place the highest burden on morbidity in this part of London. The following have been identified as important issues for south east London:

2.4 A number of health issues have been identified as a ‘high burden’ of ill health across south east London where the trend or outlook is worsening

Obesity: there are very high levels of childhood obesity. Figure 4 below shows that childhood obesity levels in south east London (for year 6 – 10/11 year old pupils) are consistently higher than the London average and significantly above the England average. The borough level data show a wide variation between CCGs, with Southwark having the highest levels at 26% versus Bromley with the lowest at 17.3% The overall childhood obesity levels are more than 5% higher than national average at year 6.The number of obese 10/11 year olds are predicted to rise to 4170 by 2018/19. Just reducing to the national average level would lead to 780 less obese children in south east London by 2019.



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Figure 4 Childhood Obesity Rates 2012/137

Mental ill health: there is a high burden of common and serious mental illness especially in inner south east London; and associated with this the link to lower life expectancy of those with serious mental illness. People with severe mental illness (SMI) die prematurely from the same causes of death that affect the general population, e.g. heart disease, diabetes, cancer, stroke, and pulmonary disease, but at a more frequent rate. Specifically, adults with psychotic disorders die, on average, 11 years earlier than adults with no mental disorder, most often from these co-morbid conditions. The modifiable risk factors that contribute to early mortality - smoking, obesity, hypertension, metabolic disorder, substance misuse, low physical activity, poor fitness and diet - are also more common in people with SMI, and their onset is often earlier. Two-thirds or more of adults with SMI smoke; over 40% are obese (60% for women); and metabolic syndrome is highly prevalent, especially in women. Iatrogenic effects of psychiatric medications, which may include weight gain and metabolic disorder, further adversely affect the health of people with SMI, often with rapid onset. A 2011 study8 identified that in south east London all mental health disorders were associated with substantially lower life expectancy compared to National statistics for general population: 8.0 to 14.6 life years lost for men and 9.8 to 17.5 life years lost for women. The highest reductions were found for men with schizophrenia (14.6 years lost) and women with schizoaffective disorders (17.5 years lost). In June 2013 the Minister for Care Services, Norman Lamb MP, articulated his concern regarding the way in which people with mental health problems receive inadequate care for their mental and physical health needs, resulting in poorer physical health than the general population and premature mortality9, including:

Three in four people with common mental health problems receive no treatment, and even for psychotic disorders this figure is nearly 1 in 3

7 Source: HSCIC, National Child Measurement Programme

8 Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary

Mental Health Care Case Register in London, Chang et al, 2011, http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0019590 9 ‘Achieving Parity of Esteem between Mental and Physical Health’ Norman Lamb MP, Care Services Minister,

June 19th 2013 - https://www.gov.uk/government/speeches/achieving-parity-of-esteem-between-mental-and-physical-health

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0019590

https://www.gov.uk/government/speeches/achieving-parity-of-esteem-between-mental-and-physical-health

https://www.gov.uk/government/speeches/achieving-parity-of-esteem-between-mental-and-physical-health



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People with severe mental illness are in some cases 3 or 4 times more likely to die prematurely from the ‘big killer’ diseases, when compared to the population as a whole. Improving mental health also makes obvious economic sense

The costs to the NHS of co-morbid mental health problems run into billions. The costs of mental illness to the economy and society are higher still. And yet there are effective treatments out there, like IAPT (Improving Access to Psychological Therapies), like RAID (Rapid Access Interface and Discharge), which save money as well as improving lives.

Given the high levels of mental health needs especially amongst specific groups within south east London (including some black and minority ethnic groups, some groups of young people, such as those looked after in local authority care, prisoners, those experiencing domestic violence etc), it is critical that the mental and physical health of people with mental illnesses are addressed fully. Alcohol related diseases: there are above average admission rates for alcohol attributable diseases, and an increase in mortality rates. Figures 2 and 3 below show that alcohol specific mortality is lower in south east London than in London and England for males and lower than in England but higher than London for females. Figure 5 Alcohol Mortality (Males 2004-2010)

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Average alcohol specific mortality for men in south east London is already lower than the England average, but this is largely driven by comparatively low rates in the outer London boroughs (Bexley and Bromley).The four inner London Boroughs (Lewisham, Greenwich, Lambeth and Southwark) all remain above the national average. Just reducing to the national average in these four boroughs would lead to a reduction of 10 mortalities a year (3, 3, 2 and 2 respectively) due to male alcohol specific mortality in south east London.

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Source: PHE, Local Alcohol Profiles for England



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Figure 6 Alcohol Mortality (Females 2004-2010)11

Average alcohol specific mortality for women in south east London is already significantly lower than the England average, with only Lambeth in excess. This is good news, but we can still improve. If female alcohol specific mortality in Lambeth and Southwark is brought down to the average for south east London, this would lead to a reduction of 7 mortalities per year by 2019 (5 and 2 respectively). Sexual health: there are the highest levels of HIV and STIs in the country in inner south east London, with a concentration amongst gay men and black African populations for HIV. Figure 4 below shows continuing high levels of in STIs in SE London, with an increasing rate for Chlamydia and gonorrhoea. Figure 7 STI Diagnoses in SE London 2009 - 2012

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Figure 5 shows that HIV prevalence in south east London continues to be high, and is continuing to increase marginally over time. The rate varies significantly between boroughs with Lambeth and Southwark having very high rates, far in excess of the London average. Bexley and Bromley have relatively low rates; Greenwich is in line with the London average with Lewisham rates slightly higher.

11

Source: PHE, Local Alcohol Profiles for England 12

Source: HPA



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Figure 8 HIV Prevalence across South East London 201212

Conditions related to older people: three is an increasing burden of conditions related to the ageing population; especially high numbers of older people in outer south east London; and significant increases in line with improved life expectancy in parts of inner south east London. Figure 6 shows the predicted ongoing rise in the numbers of people with dementia in south east London, and that only about half of the predicted number of current patients with dementia are diagnosed and included on GP Quality Outcomes Framework (QOF) dementia registers. Figure 9 Dementia Projections (2012-2020) and QOF Registration Data

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Older people tend to have multi-morbidities. 12% of people over 65 will have three or more long term conditions, 34% two or more and 67% one long term condition14. A Department of Health consultation on the Information Revolution showed that the 2% of patients with chronic disease account for 30% of unplanned hospital admissions, 80% of GP consultations and 70-80% spend is on people with long term conditions. Diabetes: diagnoses of diabetes are trending upwards across south east London. Figure 7 shows a high and increasing burden of ill health in south east London from diabetes, with rates increasing in parallel with the increase in London and England as a whole. These figures represent an underestimate of the true numbers of people with diabetes as it is estimated that about one in four people with diabetes are undiagnosed.

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Source: POPPI 2014 / Dementia Prevalence Calculator 14

(HSE 1997)



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Figure 10 Diabetes Prevalence in SE London (QOF data 2011-2013)15

2.5 At the same time the outlook is improving across south East London for a number of other health issues identified as ‘high burden’ of ill health

Cancer: Whilst there have been some improvements across the six boroughs prevalence is still above London average. Figure 8 shows a steady decline in cancer mortality in south east London as well as London and England as a whole. There is considerable variation between the boroughs with the directly standardised rate (DSR) per 100,000 in Southwark being the highest at 114 in 2012, compared to 90 in Bromley. Figure 11 Cancer Mortality (1993 – 2012)

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Premature mortality from cancer in south east London is already lower than the England average, but there is significant variation between the boroughs with Southwark, Lambeth and Greenwich all over the national average. If the number of premature mortalities for Cancer in Southwark, Lambeth and Greenwich is reduced to the south east London average this would lead to a reduction of 64 mortalities per year by 2019 (31, 23 and 10 respectively). Smoking: smoking prevalence is now below national average, but nearly one in five adults still smoke. Figure 9 below shows that smoking rates in south east London are declining quickly, faster than the London and national averages. Nevertheless, smoking still remains the biggest current direct cause of preventable mortality and morbidity and as such continues to be a major priority for improving health and addressing health inequalities. Smoking rates are far higher amongst lower socio-economic groups, amongst men, and

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Source: HSCIC / Diabetes Prevalence Model, APHO 16

Source: HSCIC Indicator Portal



18

certain ethnic groups (such as white, Irish, eastern European), and are a major contributory factor to health inequalities. Figure 12 Smoking Prevalence 2009-2012

17

Average smoking prevalence in south east London is already lower than the England average, but if the three boroughs above the south east London average were to reach the average levels this would further reduce smoking prevalence by a total of 9,50018. Cardiovascular disease: premature deaths from CVD continue to decline, though stroke and heart failure are above London average. Figure 10 below shows that under 75 deaths from CVD in south east London have declined steeply and are now in line with the London average though still slightly above the national average. This masks significant variation between the boroughs, with Greenwich having the highest DSR at 70 per 100,000 in 2012 compared to Bromley with the lowest at 43. Figure 13 Premature deaths from cardiovascular diseases 1993 - 2012

19

Respiratory disease: despite some improvements, rates are still above London average. Figure 11 below shows that deaths from COPD have been falling steadily over the last two decades, but remain well above the London and national averages. There are some signs that the gap is closing. There is considerable variation between the boroughs, with respiratory deaths in Greenwich being the highest in 2012 with a directly standardised

17

Source: Public Health England 18

Reductions by borough: Lewisham: 4,350, Lambeth: 4,650 and Southwark: 500. 19 Source: HSCIC Indicator Portal



19

mortality rate (DSR) of 40.4 compared to Bromley having the lowest rate with a DSR of 22.85. Figure 14 Deaths from Chronic Obstructive Pulmonary Disorder (COPD) 1993-2012

20

Deaths from chronic obstructive pulmonary disorder across south east London are significantly higher than the national average, driven by high instances in the inner London boroughs, Just reducing to the national average level would result in reduction of deaths attributable to chronic obstructive pulmonary disorder across south east London by 88 per year21. Teenage conceptions: significant decline in recent years, but rates still significantly above national and London averages in inner south east London. The estimated number of conceptions to women aged under 18 in England and Wales in 2011 was the lowest since records began in 1969. This was also reflected locally in south east London. Table 1 below shows, in 2011, Bromley was the only borough with an under 18-conception rate lower than the London average at 26.3 per 1000 (compared to the London average of 28.7). The borough with the highest rate was Southwark with 42.7 per 1000 conceptions to under 18 year old young women.

Table 1 Under 18 conception rates per 1000 (2011)22

Area Conception rate (per 1000)

Bromley 26.3

Bexley 28.4

Lambeth 34.8

Greenwich 38.1

Lewisham 39.9

Southwark 42.7

SE London average 35.0

20 Source: HSCIC Indicator Portal 21

Reduction from 31.61 deaths per 100,000 population to 26.56 deaths per 100,000 population 22

Source: ONS



20

Area Conception rate (per 1000)

London average 28.7

England average 30.7

2.6 The health and well-being of children and young people In addition to the issues outlined above of importance to the younger population, such as obesity, teenage conceptions and sexual health, there are a number of other health concerns of importance to children and young people.

2.6.1 Mental health and well-being23

The mental health and well-being of children and young people is critically important to enabling them to have happy, productive and successful childhoods. Good mental health enables children to thrive socially, to do well at school and to develop the resilience and coping skills needed to navigate adolescence and move successfully into adult life. Poor mental health can impair this success. In the UK:

1 in 10 children and young people aged 5 - 16 suffer from a diagnosable mental health disorder - that is around three children in every class.

Between 1 in every 12 and 1 in 15 children and young people deliberately self-harm There has been a big increase in the number of young people being admitted to hospital

because of self harm. Over the last ten years this figure has increased by 68% More than half of all adults with mental health problems were diagnosed in childhood.

Less than half were treated appropriately at the time Nearly 80,000 children and young people suffer from severe depression Over 8,000 children aged under 10 years old suffer from severe depression 72% of children in care have behavioural or emotional problems - these are some of the

most vulnerable people in our society 95% of imprisoned young offenders have a mental health disorder. Many of them are

struggling with more than one disorder The number of young people aged 15-16 with depression nearly doubled between the

1980s and the 2000s The proportion of young people aged 15-16 with a conduct disorder more than doubled

between 1974 and 1999

There is a higher prevalence of mental health problems amongst young people living in more deprived communities, so these kinds of poor mental health behaviours and outcomes are likely to be higher amongst children and young people in inner SE London.

2.6.2 Best start in life

Supporting children to have the best start in life, especially during the first 1000 days of life, is critical to long health outcomes and to social and educational success in childhood and adult life. Factors supporting the best start in life which continue to be important for our populations include: High quality ante-natal care, including early booking for pregnant women, good access to

ante-natal and newborn screening programmes, and support to reduce domestic violence, smoking, drug and alcohol abuse during pregnancy

Access to high quality parenting advice and support, especially for the most vulnerable children and families, for example through the effective deployment of the Family Nurse

23

Source: http://www.youngminds.org.uk/training_services/policy/mental_health_statistics

http://www.youngminds.org.uk/training_services/policy/mental_health_statistics



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Partnership approach complementing universal health visiting provision; and support to prevent and tackle post-natal depression

High quality advice and support to promote breastfeeding, promote good child and maternal nutrition and ensure high uptake of childhood immunisations

Early help for struggling families, to improve outcomes and reduce the need for social care interventions such as care proceedings

2.6.3 Smoking

Whilst rates of smoking amongst young people are showing some signs of decline, there is a growing concern about the uptake amongst young people of ‘fashion’-related tobacco and nicotine related products. There is evidence of young people from all social backgrounds experimenting with smoking using Shisha pipes, through social events such as parties, and of there being a low recognition of the high tobacco content inhaled through the use of Shisha. E-cigarettes are growing in popularity at great pace, and there is significant concern that they will prove a gateway product for young people into smoking ‘real’ cigarettes. They are promoted as a less dangerous route to managing nicotine cravings for people trying to quit smoking, but are marketed aggressively as fashion items and there is evidence that a significant proportion of people who use them were not previous cigarette smokers; hence the development of a new addition to nicotine. It will be important for our public health, children’s services and enforcement colleagues to be vigilant and to work together through effective information sharing and joint action to reduce the risks posed by these newer entrants to the smoking and tobacco world to our young people’s health in SE London.

2.7 Some conditions disproportionately affect particular groups Due to the nature of the population in south east London, there are a number of additional health conditions and outcomes that affect smaller numbers of groups within the population disproportionately. These challenges are described in more detail in individual borough JSNAs – however some of the key themes are summarised below. These include for example tuberculosis (TB), which is especially prevalent amongst areas with higher numbers of people from the Indian sub-continent (including India, Pakistan and Nepal) and particular African countries such as Somalia and Nigeria. Homeless people also experience proportionately higher levels of TB disease; there are higher numbers of homeless people in inner SEL boroughs than outer. Relatively high numbers of people also experience Malaria in south east London, especially those returning to the UK from visits to a country of origin with a high prevalence of malaria (especially West African and Asian countries) having not taken precautions to protect themselves against infection during their visit. Female genital mutilation (FGM) is a serious health-related practice that affects women from minority groups in SE London. In the UK, FGM tends to be practised in areas of the country with higher concentrations of people from countries where this cultural ritual practice is common, such as sub-Saharan and North African countries and to a lesser extent Asia and the Middle East. Often, first-generation immigrants, refugees and asylum seekers from these communities will continue to practice FGM in the UK despite the fact that it is illegal in this country. Given the profile of the population in SE London, this practice continues be an issue for us.



22

There are pockets of Gypsy and Traveller communities across SE London, for example in Sidcup in Bexley, Orpington in Bromley and Abbey Wood in Greenwich. Despite a lack of robust national data on the health status of Gypsies and Travellers, studies have revealed their health outcomes to be much poorer than the general population and also poorer than others in socially deprived areas. Gypsies and Travellers have the lowest life expectancy of any group in the UK and experience an infant mortality rate that is three times higher than the national average. Access to routine health services, including primary care, is often lower amongst this group within the population. This can lead, for example, to low levels of childhood immunisation and adult screening uptake, and delays in the diagnosing of health conditions such as diabetes, cardio-vascular and respiratory diseases and cancers. Outbreaks of diseases such as measles are more common amongst these groups than the general population.



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3 The national and London context is changing the way that health and integrated care services are planned and delivered

Chapter summary and key messages The way in which health and integrated care services are planned and delivered is changing. NHS England London has told us that:

London has growing and ageing population and a rise in long-term conditions (both single and multiple conditions) will require better primary care and more integrated care

People in control of their own health and patients in control of their own care is essential

The way hospitals are organised is unsustainable and does not support the provision of high quality care

Research, education, new technologies and a better understanding of diseases will help us transform the health service.

As part of a Call to Action, NHS England has identified six transformational service models that will define the characteristics of the NHS in five years:

A completely new approach to ensuring that citizens are fully included in all aspects of service design and change and that patients are fully empowered in their own care

Wider primary care, provided at scale

A modern model of integrated care

Access to the highest quality urgent and emergency care

A step-change in the productivity of elective care

Specialised services concentrated in centres of excellence. There needs to be wider primary care, provided at scale.

Population growth and patients’ health complexity is placing unprecedented demand and pressure on GPs. Primary care services are struggling to respond

Despite some practices achieving excellent clinical outcomes and patient satisfaction, there is significant variation in performance and London practices lag behind the rest of the country in measures of quality and patient satisfaction

London needs a primary care service that has the capacity and capability to provide the best care possible, in a modern environment that enables multidisciplinary working and training

Plans to change hospital services usually depend on boosting capacity in primary care. If we do not improve access to primary care London’s hospitals will be increasingly unsustainable

It is predicted there will be a £4 billion funding gap in London by 2020 and financial pressures are forcing some GP practices to close. If we do not address this in a planned way we will see a steady erosion of the quality of care and patients will suffer.

A modern model of integrated care is required.

Integrated care services must ensure tailored care for vulnerable and older people

Services must be integrated around the patient

Plans must take account of the £3.8 billion Better Care Fund that comes into operation in 2015/16 and is aimed at supporting the integration of health and social care.



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Our workforce needs to enable modern models of primary and integrated care Patients should be able to easily access and navigate high quality urgent and emergency care.

Many people are struggling to navigate and access urgent care services provided outside of hospital. A high rate of 999 calls is being experienced for both emergency and urgent care needs; and patients are defaulting to A&E. At the same time there are significant differences in the types and levels of service provided in A&E departments

The report on the first phase Urgent and Emergency Care review suggests that the quality of urgent and emergency care would be enhanced if patients were treated as close to home as possible and if networks were established, with major specialised services offered in between 40 and 70 major emergency centres, supported by other emergency centres and urgent care facilities.

Patients should be able to access high quality specialised services concentrated in centres of excellence. Specialised services for less common disorders need to be concentrated in centres of excellence where the highest quality can be delivered. This enables the best possible quality of services to be delivered at volume and in a sustainable way, whilst connecting actively to research and teaching. Quality and safety must be at the heart of commissioning and delivery of local services Ensuring high quality care requires providers, commissioners and individual professionals to work together and consider the different facets of quality to enable the system to:

Systematically drive continuous improvements linked to the overarching outcomes or domains set out in the NHS Outcomes Framework

Ensure essential standards of quality and safety are maintained (including the London Clinical Standards).

3.1 The way in which health and integrated care services are planned and

delivered is changing Everyone Counts: Planning for Patients 2014/15 - 2018/1924 sets out the outcomes and ambitions that will deliver the vision of ‘high quality care for all, now and for future generations’; as well as the approach to strategy and planning for health and integrated care services over the next five years.

3.1.1 Vision, outcomes and ambition

‘High quality care for all, now and for future generations’ is underpinned by the following elements: The NHS Outcomes Framework and its five domains

24

Everyone Counts: Planning for Patients 2014/15 - 2018/19, NHS England, http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid.pdf




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1. We want to prevent people from dying prematurely, with an increase in life expectancy for all sections of society

2. We want to make sure that those people with long-term conditions, including those with mental illnesses, get the best possible quality of life

3. We want to ensure patients are able to recover quickly and successfully from episodes of ill-health or following an injury

4. We want to ensure patients have a great experience of all their care 5. We want to ensure that patients in our care are kept safe and protected from all

avoidable harm.

Seven measurable ambitions that will be used as indicators of success 1. Securing additional years of life for the people of England with treatable mental and

physical health conditions 2. Improving the health related quality of life of the 15 million+ people with one or more

long-term condition, including mental health conditions 3. Reducing the amount of time people spend avoidably in hospital through better and more

integrated care in the community, outside of hospital 4. Increasing the proportion of older people living independently at home following

discharge from hospital 5. Increasing the number of people with mental and physical health conditions having a

positive experience of hospital care 6. Increasing the number of people with mental and physical health condition having a

positive experience of care outside hospital, in general practice and in the community 7. Making significant progress towards eliminating avoidable deaths in our hospitals caused

by problems in care. The further measures on which rapid focus and significant improvement is needed:

improving health, which must have as much focus as treating illness

in improving health, there must be particular emphasis on reducing inequalities

commitment to moving towards parity of esteem between physical and mental health.

In July 2013, NHS England along with national partners launched ‘A Call to Action’, setting out the challenges and opportunities faced by the health and care systems across the country over the next five to ten years. The review set out the need to find ways to raise the quality of care for all in our communities to the best international standards while closing a potential funding gap of around £30 billion by 2020/21. In the London-wide consultation on ‘A Call to Action’ the following factors were being considered in the development of a sustainable health service for the capital:

A growing and ageing population and a rise in long-term conditions (both single and multiple conditions) will require better primary care and more integrated care

People in control of their own health and patients in control of their own care is essential

The way hospitals are organised is unsustainable and does not support the provision of high quality care

Research, education, new technologies and a better understanding of diseases will help us transform the health service.

Based on the responses to ‘A Call to Action’ NHS England has identified six transformational service models that will define the characteristics of the NHS in five years: 1. A completely new approach to ensuring that citizens are fully included in all aspects of

service design and change and that patients are fully empowered in their own care



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2. Wider primary care, provided at scale 3. A modern model of integrated care 4. Access to the highest quality urgent and emergency care 5. A step-change in the productivity of elective care 6. Specialised services concentrated in centres of excellence. Underpinning each of these models are the four essential elements of quality, access, innovation and value for money.

3.1.2 Purpose of this strategic context section

The remainder of this section steps selectively through some of the key strategic considerations raised for the development the five year South East London Commissioning Strategy, by the planning guidance and by other key strategies and programmes. The intention is not to exhaustively cover all elements included in the planning guidance, which can be viewed in full here25, but to surface the points most pertinent to the strategy.

3.2 Public and patients must be fully included in all aspects of service design and change and patients fully empowered in their own care

This means ensuring that that public, patient and carer voices are at the centre of healthcare services from planning to delivery; and empowering patients through digital technology and through transparency and sharing of data. NHS commissioners have a duty to support better patient and public participation, through ensuring:

Individual Participation: patients and carers are able to participate in planning, managing and making decisions about their own care and treatment

Public participation: effective participation of the public in the commissioning process itself, so that services reflect the needs of local people.

The duties of CCGs as commissioners are set out in Transforming Participation in Health and Care26. The importance of strong user voice in services will be further strengthened by the rollout of Personal Health Budgets during 2014 and related approaches to personalisation of care.

3.3 There needs to be wider primary care, provided at scale NHS England is responsible for commissioning primary care through local area teams. CCGs share a joint responsibility with NHS England for transforming and driving up quality in primary care, and CCGs themselves play a key role in the clinical leadership of primary care to deliver high quality services. 90% of patient contact with the NHS takes place in general practice, amounting to more than 300 million consultations every year. GPs play a key role not only in providing services themselves, but also helping their patients to navigate the system and access the care they need in other settings.

25 Everyone Counts: Planning for Patients 2014/15 - 2018/19, NHS England, http://www.england.nhs.uk/wp-

content/uploads/2013/12/5yr-strat-plann-guid.pdf 26

Transforming Participation In Health And Care, NHS England September 2013, http://www.england.nhs.uk/wp-content/uploads/2013/09/trans-part-hc-guid1.pdf



http://www.england.nhs.uk/wp-content/uploads/2013/09/trans-part-hc-guid1.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/09/trans-part-hc-guid1.pdf



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One of NHS England’s key aims as commissioner of primary care is that general practice, community pharmacy and other primary care services should be enabled to play a key role at the heart of integrated community services. This includes a strengthened role in integrated care for vulnerable and older people as agreed in the new GMS contract (outlined further in Section 3.4). There is currently an unprecedented strain on general practice services in London. The pressures include:

Population growth and patients’ health complexity is placing unprecedented demand and pressure on GPs. Primary care services are struggling to respond

Despite some practices achieving excellent clinical outcomes and patient satisfaction, there is significant variation in performance and London practices lag behind the rest of the country in measures of quality and patient satisfaction

London needs a primary care service that has the capacity and capability to provide the best care possible, in a modern environment that enables multidisciplinary working and training

Plans to change hospital services usually depend on boosting capacity in primary care. If we do not improve access to primary care London’s hospitals will be increasingly unsustainable

It is predicted there will be a £4 billion funding gap in London by 2020 and financial pressures are forcing some GP practices to close. If we do not address this in a planned way we will see a steady erosion of the quality of care and patients will suffer.

NHS England has published a Case for Change about London’s primary care27. This sets out the challenges facing general practice today and the priorities that doctors and patients believe are important to address. A consultation is taking place on the Case for Change during the first quarter of 2014. The emerging Commissioning Strategy for south east London will need to reflect the resulting outcomes and transformational approaches developed from the consultation; as well as the parallel consultation on the role of community pharmacy.

3.4 A modern model of integrated care is required Everyone Counts sets out a vision for integrated care with a senior clinician taking responsibility (through a personal relationship) for active coordination of the full range of support from lifestyle help to acute care. Some of the key aspects are as follows: Ensuring tailored care for vulnerable and older people. This includes:

the current governmental focus on patients aged over 75 and those with complex needs

arrangements in the new GP contract for patients aged over 75 to have an accountable GP and for those who need it to have a comprehensive and co-ordinated package of care

the transfer of £5 per head from CCGs to fund practice plans to transform care for the over 75s and reduce avoidable admissions.

Care integrated around the patient. Integrated care around the patient can encompass a range of different service models, but each is likely to include the following features:

senior clinicians (within a team) taking full responsibility for people with multiple long-term conditions

27

Transforming Primary Care in London: General Practice A Call to Action, NHS England November 2013,

http://www.england.nhs.uk/london/wp-content/uploads/sites/8/2013/12/london-call-to-action.pdf

http://www.england.nhs.uk/london/wp-content/uploads/sites/8/2013/12/london-call-to-action.pdf



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full responsibility lasting from presentation to episodic care, including personalised care planning for those who would benefit

co-ordination of care including lifestyle support and advice, social care, general practice care and hospital episode co-management.

The Better Care Fund. The £3.8 billion Better Care Fund that comes into operation in 2015/16 is aimed at supporting the integration of health and social care. Commissioners must include in their plans their vision for how health and social care services work together to provide better support at home and earlier treatment in the community to prevent people needing emergency care in hospital or care homes. All CCGs are setting our plans for how they will take in 2014/15 to create the funding required to make the Better Care Fund affordable when it is introduced in 2015/16 in order to fulfil their duty to commission sustainable services for patients.

3.5 Our workforce needs to enable modern models of primary and integrated care

To deliver high quality care, we need staff in the right numbers, with the right skills, values and behaviours. Over and above this, the following need to be in place to enable population based healthcare:

Every healthcare worker has the knowledge, skills and ability to carry out their role for

which they are valued; every patient and carer feels able to play a full part in determining

the care they need and to obtain it in a timely way

Every member of the workforce thinks proactively about how they can support their

patient to improve or maintain their own health and wellbeing, prevent illness, and move

towards recovery, and identify how and when they need to access health and social care

services

Staff need to be trained to help communities mobilise and work together to improve their

health

Staff will support patients to feel in control of their own health and wellbeing

Staff are equipped with excellent skills in communication, team working, and the ability to

navigate professional and organisational boundaries to get the best for their patients

Structures, systems and processes are important elements of working in a preventative, community-focused approach but the key contribution is the response of each individual staff member. Having been trained largely in addressing illness, staff will need to shift their way of thinking to ‘wellness’. In addition to the expectation of ‘curing illness’, staff will need to adjust to empowering patients, families and communities to maintain their own wellbeing, by prioritising interventions such as, for example, rehabilitation. This will require not only new skills and ways of working but the evolution of new roles and career pathways. We need to ensure that the training and education of our workforce, whether initial undergraduate training or via CPPD, reflects the way healthcare delivery is moving and contributes to the requirements of the Education Outcomes Framework13. As with simulation-based learning, the closer education and training is to ‘real life’ working experiences the better prepared the individual. Therefore, we need to increase opportunities for multidisciplinary and inter-professional learning and train students, trainees and staff in settings most similar to where they work (or, for students, will work). This will enhance the learning experience of different workforce groups by more accurately reflecting the environments they work within.



29

3.6 Patients should be able to easily access and navigate high quality urgent and emergency care

Many people are struggling to navigate and access urgent care services provided outside of hospital. A high rate of 999 calls is being experienced for both emergency and urgent care needs; and patients are defaulting to A&E. At the same time there are significant differences in the types and levels of service provided in A&E departments. Three major elements set the context for the strategic development of urgent and emergency care services. The Urgent and Emergency Care Review28. The report on the first phase Urgent and Emergency Care review suggests that the quality of urgent and emergency care would be enhanced if patients were treated as close to home as possible and if networks were established, with major specialised services offered in between 40 and 70 major emergency centres, supported by other emergency centres and urgent care facilities. NHS 111. NHS 111 services will be a key component of the urgent care service. NHS 111 services will be rolled out to cover the whole of England. In addition, NHS England and CCGs will produce a new service specification for 111 to support the future commissioning of a comprehensive and high quality service. Urgent Care Working Groups. Urgent Care Working Groups (UCWGs) will lead local resilience planning, including acting as the vehicle for reaching agreement on the investment plans to be funded by the retained 70 per cent from the application of the marginal rate rule.

3.7 Patients should be able to access high quality specialised services concentrated in centres of excellence

Specialised services for less common disorders need to be concentrated in centres of excellence where the highest quality can be delivered. This enables not only the best possible quality of services to be delivered at volume and in a sustainable way, whilst connecting actively to research and teaching.

In some cases specialised services are currently being delivered out of too many sites, with

too much variety in quality and at too high a cost in some places29. Since April 2013, prescribed specialised services have been a core responsibility of NHS England. The Specialised Commissioning Team (SCT) for the London Region of NHS England incorporates both the area and regional structure in one team and is supporting NHS England’s A Call to Action. A national five year strategy for Specialised Commissioning will be published in April 2014 will address the service specific objectives for the next 5 years, overarching strategic objectives for the provision of a system of specialised healthcare as a whole and the impact of co-dependency between service areas. The strategic commissioning approach has the following 6 strands:

28

Phase 1 Report of the National review of Urgent and Emergency Care, NHS England November 2013, http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.FV.pdf. 29 Everyone Counts: Planning for Patients 2014/15 - 2018/19, NHS England, http://www.england.nhs.uk/wp-

content/uploads/2013/12/5yr-strat-plann-guid.pdf

http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.FV.pdf





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Figure 15 Strategic commissioning approach for specialised services

3.8 Quality and safety must be at the heart of commissioning and delivery of local services

The quality of patient care and patient safety should come before all other considerations in local NHS services. Ensuring high quality care requires providers, commissioners and individual professionals to work together and consider the different facets of quality to enable the system to:

Systematically drive continuous improvements linked to the overarching outcomes or domains set out in the NHS Outcomes Framework

Ensure essential standards of quality and safety are maintained (including the London Clinical Standards).

Figure 16 The quality curve showing the different facets of quality

30

30

Adapted from: Quality in the new health system-maintaining and improving quality, National Quality Board January 2013



31

To effectively improve and sustain high quality care and patient safety there is a need to ensure:

An open and honest culture exists across the system

Continual learning and improvement

Patients are proactively engaged, empowered and involved

That robust, relevant and timely information available at every level of the system

There are agreed quality and patient safety metrics (qualitative and quantitative) that are routinely and effectively measured

Effective use of comparative quality indicators

Development and implementation of innovative approaches to delivering healthcare. There are a number of high profile reports that demonstrate the need to prioritise and monitor quality and safety across the system:

The Francis Report into the systemic failings at the Mid Staffordshire NHS Foundation Trust31 sets out a series of recommendations to ensure best possible care for patients in the NHS. Responses to the Francis Report by the Government32 and the National Quality Board33 will drive approaches to improving nursing, midwifery and care staffing to ensure best possible care for patients in the NHS.

Transforming Care: A national response to Winterbourne View Hospital34 sets out the basis on which CCGs, Local Authorities and specialised commissioners should work together to implement the core specification, the document setting out the principles that must be present in all education, health and social care services for children, young people, adults and older people with learning disabilities and/or autism who either display, or are at risk of displaying, behaviour that challenges

The Berwick review into patient safety35 has significant implications for how CCGs take an active part in their local patient safety improvement collaborative and support local improvement setting out a number of recommendations. The key messages were a “promise to learn and a commitment to act”

Also key to the quality agenda are the findings of the NHS Services, Seven Days a Week Forum36. The Forum has reported to NHS England on how NHS services can be improved to provide a more responsive and patient centred service across the seven day week, with an initial focus on urgent and emergency care. The review found significant variation in outcomes for patients admitted to hospital at the weekend, seen in mortality rates, patient experience, length of stay and re-admission rates.

31

http://www.midstaffspublicinquiry.com 32

Hard Truths, Department of Health January 2014, https://www.gov.uk/government/publications/mid-staffordshire-nhs-ft-public-inquiry-government-response 33

How to ensure the right people, with the right skills, are in the right place at the right time, National Quality Board November 2013, http://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-how-to-guid.pdf 34

Department of Health December 2012, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213215/final-report.pdf 35

A promise to learn – a commitment to act: Improving the Safety of Patients in England, National Advisory Group on the Safety of Patients in England, August 2013 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf 36

NHS England December 2013, http://www.england.nhs.uk/ourwork/qual-clin-lead/7-day-week/

http://www.midstaffspublicinquiry.com/

https://www.gov.uk/government/publications/mid-staffordshire-nhs-ft-public-inquiry-government-response

https://www.gov.uk/government/publications/mid-staffordshire-nhs-ft-public-inquiry-government-response

http://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-how-to-guid.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213215/final-report.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf

http://www.england.nhs.uk/ourwork/qual-clin-lead/7-day-week/



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4 Significant developments and opportunities within south east London help us to make a strong and innovative response to the national and London context

Chapter summary and key messages Our CCGs are playing a key role in providing clinical leadership for their local health systems. In practice this includes:

Maintaining a constant clinical focus on improving quality and health outcomes and reducing health inequalities

Engaging and providing leadership to their member practices in the improvement of local services

Ensuring that public and patient voice is at the heart of commissioning decisions

Working with local Health and Wellbeing Boards and local partnership arrangements to deliver local Health and Wellbeing Strategies; and now to develop and deliver plans in relation to the Better Care Fund.

We have a longstanding history of joint working across the six boroughs, including:

Integrated governance, joint working arrangements for working across the six boroughs

A history of working across the six boroughs on strategic and transformational work – including A Picture of Health for South East London, and more recently the TSA Implementation Programme at South London Healthcare Trust.

The South East London Community Based Care (CBC) Strategy is starting to transform community based care through three delivery programmes:

Primary and Community Care: Providing easy access to high quality, responsive primary and community care as the first point of call for people in order to provide a universal service for the whole population and to proactively support people in staying healthy

Integrated Care: Ensuring there is high quality integrated care for high-risk groups (such as those with long term conditions, the frail elderly and people with long term mental health problems) and that providers (health and social care) are working together, with the patient at the centre. This will enable people to remain active, well and supported in their own homes wherever possible

Planned Care: For episodes where people require it, they should receive simple, timely, convenient and effective planned care with seamless transitions across primary and secondary care, supported by a set of consistent protocols and guidelines for referrals and the use of diagnostics.

Delivering the organisational changes associated with the dissolution of South London Healthcare Trust has created a pattern of NHS organisations which provides a good foundation for the future. South east London has one of the country’s six Academic Health Science Centres (AHSCs), King’s Health Partners. The work of the AHSC includes:

Working through Clinical Academic Groups which bring together subject matter experts into operational units focused on ensuring that learnings from research are used quickly, consistently and systematically to improve clinical services

Four key delivery programmes, which include locally: o Southwark and Lambeth Integrated Care – a programme which aims to organise



33

local systems of health and social care more effectively and to provide care in a more integrated way so that patients in south east London get the best service possible

o Integrated Cancer Centre - a major collaboration across our Trusts and university to combine ground breaking cancer research with first-class clinical care for cancer patients.

South London Health Innovation Network is responsible for sharing innovations across the health system, capitalising on teaching and research strengths to drive lasting improvements in health and wellbeing across South London. Programmes being taken forward locally include diabetes, alcohol, musculoskeletal, dementia and cancer.

4.1 Our CCGs are playing a key role in providing clinical leadership on behalf

of their members and local populations South East London’s CCGs are the autonomous statutory decision making bodies responsible alongside NHS England Direct Commissioning, for the commissioning of NHS services across the local health system. Our CCGs have a key role in providing clinical leadership within their boroughs. In practice this includes:

Understanding the health needs and priorities of their local population to ensure the right services are commissioned and delivered

Ensuring that patient and public voice is at the heart of commissioning

Ensuring patients are proactively engaged in treatment decisions

Maintaining a continual clinical focus on improving quality, safety, patient experience and health outcomes as well as reducing health inequalities

Engaging and providing leadership to their member practices in the improvement of local services

Working with local Health and Wellbeing Boards and local partnership arrangements to deliver local Health and Wellbeing Strategies; and now to develop and deliver plans in relation to the Better Care Fund.

Working with all partner organisations including research and health sciences to develop and implement innovative approaches to commissioning and delivering healthcare.

We have a longstanding history of joint working across the six boroughs, including:

integrated governance and joint working arrangements for working across the six boroughs

well established collaborative and lead commissioning relationships with local providers

a history of working across the six boroughs on strategic and transformational work – including A Picture of Health for South East London, and more recently the TSA Implementation Programme at South London Healthcare Trust.

4.2 The Better Care Fund is an opportunity to integrate and transform services

The Better Care Fund, which comes into effect from 2014/15, is a £3.8bn fund which is being created as a ‘single pooled budget for health and social care services to work more closely together in local areas, based on a plan agreed between the NHS and local authorities.37 It

37

Local Government Association and NHS England 2013, http://www.england.nhs.uk/2013/08/09/hlth-soc-care/

http://www.england.nhs.uk/2013/08/09/hlth-soc-care/



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offers a substantial opportunity both to address the immediate pressures on local services and to transform and provide the basis for a more integrated health and care system38. CCGs in south east London are working with their Local Authorities and other partners to develop local visions and plans for use of the fund. These are being agreed with local Health and Wellbeing Boards in early 2014. The plans will be a key part of two year operating plans and five year strategies. Plans must include detail of how the following will be provided:

Protection for social care services

Seven-day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends

Better data sharing between health and social care, based on the NHS number

A joint approach to assessments and care planning and, where funding is used for integrated packages of care, an accountable professional

Agreement on the consequential impact of changes in the acute sector, with an analysis, provider-by-provider, of what the impact will be in their local area alongside public and patient and service user engagement in this planning, and plans for political buy-in.

4.3 The South East London Community Based Care (CBC) Strategy is starting to transform community based care through three delivery programmes

The South East London Community Based Care (CBC) Strategy was approved in 2012 by the six CCGs in south east London. The strategy sets out aspirations for community based care which all south east London CCGs have committed to deliver. Each CCG started from a different point and through their operating plans set out plans for year one delivery. These were then embedded into contracts with providers or developed into specific work programmes such as service redesign and other change programmes to be implemented throughout the year. There are three delivery programmes:

Primary and Community Care: Providing easy access to high quality, responsive primary and community care as the first point of call for people in order to provide a universal service for the whole population and to proactively support people in staying healthy.

Integrated Care: Ensuring there is high quality integrated care for high risk groups (such as those with long term conditions, the frail elderly and people with long term mental health problems) and that providers (health and social care) are working together, with the patient at the centre. This will enable people to remain active, well and supported in their own homes wherever possible.

Planned Care: For episodes where people require it, they should receive simple, timely, convenient and effective planned care with seamless transitions across primary and secondary care, supported by a set of consistent protocols and guidelines for referrals and the use of diagnostics.

These delivery work programmes are supported by five enabling programmes: Communications, Self-management, IM&T, Workforce and Contract Levers.

38

Making best use of the Better Care Fund, Kings Fund 2014, http://www.kingsfund.org.uk/publications/making-best-use-better-care-fund

http://www.kingsfund.org.uk/publications/making-best-use-better-care-fund

http://www.kingsfund.org.uk/publications/making-best-use-better-care-fund



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All boroughs are taking forward innovative integrated care programmes in support of the CBC Strategy. Progress on these schemes is described further in Section 9. Some examples include:

Greenwich CCG and its partners have been awarded national pioneer status for a programme that will build upon the existing integrated care system for older people and people with physical disabilities, enabling health and social care partners to base integrated services within clusters of GP practices to further improve care for patients and contribute to delivering community based care across south east London

Southwark and Lambeth CCGs are taking an integrated approach across the two boroughs on the development of an Academic Integrated Care Organisation (AICO) including a home (virtual) ward and enhanced rapid response to manage service users in their own homes; and integrated care for service users with long term conditions and the frail elderly.

4.4 South east London has one of the country’s six Academic Health Science Centres, King’s Health Partners

King’s Health Partners39 is one of six Academic Health Science Centres (AHSCs) in England. It is a partnership that brings together King’s College London with three NHS Foundation Trusts – Guy’s and St Thomas’, King’s College Hospital and South London and Maudsley to improve the health of the patients and population of south east London. This powerful collaboration combines research, clinical care, education and training to ensure the broadest possible provision of services, including acute and mental healthcare, as well as enabling a closer dialogue between the academic and the clinician, speeding up the time it takes for discoveries in the laboratory to be translated into trials and, ultimately, treatments. The work of King’s Health Partners is focused through Clinical Academic Groups which bring together subject matter experts into operational units focused on ensuring that learning from research is used quickly, consistently and systematically to improve a wide range of clinical services, for example cancer care, dementia and diabetes, and a number of programmes that use the combined expertise of their staff to tackle challenging healthcare issues across London. Current programmes are:

Southwark and Lambeth Integrated Care – a programme which aims to organise local systems of health and social care more effectively and to provide care in a more integrated way so that patients in south east London get the best service possible

Integrated Cancer Centre – a major collaboration across member Trusts and university to combine ground breaking cancer research with first-class clinical care for cancer patients

King's Centre for Global Health – a programme to co-ordinate all Global Health activities across all schools within King's College London and the NHS organisations across Kings Health Partners. Work involves establishing close partnerships with countries to offer a range of support to their health institutions and improve standards of care

King's Improvement Science – an initiative that aims to improve people's health by improving health services.

39

http://www.kingshealthpartners.org/info/about-us

http://www.kingshealthpartners.org/info/about-us



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4.5 South London’s Health Innovation Network is driving lasting improvements in health and wellbeing across south London

The South London Health Innovation Network (HIN)40 is one of thirteen Academic Health Science Networks (AHSNs) across the country. It is a membership organisation that includes Local Authorities, Acute, Mental Health and other Trusts, Commissioners, Primary Care Providers, Higher Education Institutions, Third Sector, Patient and Charity Organisations, Industry and Commercial Partners. The HIN is driving lasting improvements in health and wellbeing across south London by sharing innovations across the health system and capitalising on teaching and research strengths. It is focussed on health priorities for local communities across a number of clinical areas and cross-cutting innovation themes, to deliver service improvement and sustainable change. Work of the HIN is focused on a combination of:

Clinical areas, consisting of: diabetes, alcohol, musculoskeletal, dementia and cancer. For example the Diabetes Clinical Programme is working in partnership with local stakeholders to develop and implement innovative ways of improving health outcomes for people with diabetes, working to share best practice across the network.

Innovation themes, consisting of: patient experience, information, wealth creation, education and training, and research. For example in relation to Patient Experience, South London HIN is working to accelerate feedback–service improvement cycles, focusing on diabetes and dementia pathways. A major project is underway, working with dementia patients and carers as well as the people who provide health services, to co-create experience metrics for dementia patients and carers. This work will shape the way care is delivered in the future.

40

http://www.hin-southlondon.org/about

http://www.hin-southlondon.org/about



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5 Our health services have many strengths but quality is variable and we have tolerated unacceptable and unwarranted variation in quality for too long

Chapter summary and key messages No Trust in south east London fully meets the London standards for safety and quality in emergency care and maternity services.

Compliance with London Adult Emergency Standards varies. There were five standards across medicine and surgery which all hospitals across south east London failed to meet

Across south east London there was broad variation amongst hospitals with no individual hospital either meeting or not meeting all of the key national standards for Critical Care, Emergency Department, Fractured Neck of Femur, Maternity and Paediatrics standards. There were two standards which all hospitals in south east London failed to meet.

There is significant variation in the performance of acute Trusts, both within and between organisations. Based on analysis prior to the dissolution of South London Healthcare Trust:

All Trusts in south east London were in the fourth (bottom) quartile for median time in Accident and Emergency from arrival to treatment

Patients reported bottom quartile experience of care in three of four Trusts – South London Healthcare, Kings College Hospital and Lewisham Healthcare Trust

Patients diagnosed with cancer were experiencing higher than average over 31 day waits for their first treatment in the majority of trusts with Guys and St Thomas’ being in the fourth (bottom) quartile

Only Kings College Hospital was above average for number of two week referral to first outpatient appointment for breast symptoms with Guys and St Thomas’ and University Hospital Lewisham in the fourth (bottom) quartile

All Trusts showed better than average performance in terms of emergency readmissions within 28 days of discharge

Three out of four Trusts were in the first (top) quartile for the summary indicator on low hospital mortality, although South London Healthcare Trust was in the third quartile for this measure.

In primary care, many patients find it hard to get an appointment with their GP. The services available are inconsistent and quality and outcomes variable, with lower patient satisfaction scores compared to other parts of England.

Patients report 4th (bottom) quartile experience of care in four of the six CCGs in south east London with the remaining two CCGs, Lambeth and Lewisham, in the 3rd quartile

All south east London CCGs have lower than average GP access, with Bexley, Lewisham and Southwark in the fourth quartile nationally; and remaining CCGs in the third quartile

There is significant variation in achievement of GP outcomes, both within and between boroughs. Best performance against GP outcomes across south east London was Bromley where 54% of practices are ‘achieving’ or ‘higher achieving’ practices; the worst performance was in Lambeth where this figure is only 12%. The equivalent England average is 62%

All south east London CCGs have lower than average (1st quartile) primary care spend



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compared to the rest of England. Within south east London there are specific challenges to ensure that maternity services provision meets the highest standards of care and quality and health outcomes.

Failure to meet a number of national standards and key performance indicators for example, screening and first antenatal appointment

Employment and retention of the highly skilled workforce required to deliver a service across all health settings, linking to performance against the London Quality Standards set out elsewhere

Current capacity issues, which results in maternity services being suspended at hospitals, and women being diverted away from their hospital of choice. Between April 2011 and November 2012, providers of maternity services across SEL suspended services on 37 occasions

The recent CQC Patients Survey highlighted areas for improvement in each of the SEL maternity service providers including staff attitude in postnatal wards, pain relief and breastfeeding information and advice.

As a system we have need to improve quality and to drive consistency and productivity in community and mental health services. For Mental Health services:

Services deliver top quartile performance on only one out of eleven observed outcomes, namely CPA review in the past 12 months

Three out of six CCGs had high (bottom quartile) incidents of serious harm in MH care (Lambeth, Lewisham, and Southwark) whilst the remanding 3 are in the 3rd quartile

Three of six CCGs have low employment for adults with MH conditions (Bexley, Bromley, Greenwich).

For Community services:

Immunisation of children is bottom quartile for Greenwich, Lambeth, Lewisham, Southwark and 3rd quartile for the rest

All CCGs struggle with patient safety in the community with 5 of 6 CCGs in the bottom quartile for pressure ulcer prevention (all boroughs except Lambeth), and 3 in bottom quartile for falls in the community (Lambeth, Southwark and Lewisham)

All of the SEL CCGs are in 3rd quartile on delayed transfer of care. Note – further detail on quality and performance for specialised services to be incorporated once information available.

5.1 There is significant variation in the performance of acute Trusts, both

within and between organisations

Acute Trusts in south east London are currently balancing increased volumes and complexity of care, more stringent quality standards and a challenging financial environment, as summarised in Section 7 below. Figure 15 below provides a summary of regional analysis compiled for the 2014/15 planning process on key effectiveness measures in acute care. Please note this is based on analysis prior to the dissolution of South London Healthcare Trust in September 2013. The analysis indicates the following themes:



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All four Trusts in south east London are in the fourth (bottom) quartile for median time in Accident and Emergency from arrival to treatment, with South London Healthcare Trust also in the fourth (bottom) quartile for Accident and Emergency waits over four hours.

Patients report fourth (bottom) quartile experience of care in three of four Trusts in south east London, with only Guys and St Thomas’ in the first (top) quartile

The majority of Trusts in south east London are below average for Cancelled operations not rebooked within 28 days, with South London Healthcare Trust in the fourth (bottom) quartile

Patients diagnosed with cancer are experiencing higher than average incidents over 31 day waits for their first treatment in the majority of trusts with Guys and St Thomas’ being in the fourth (bottom) quartile

Only Kings College Hospital is above average for number two week referral to first outpatient appointment for breast symptoms with Guys and St Thomas’ and University Hospital Lewisham in the fourth (bottom) quartile

All Trusts perform show better than average performance in terms of emergency readmissions within 28 days of discharge

Three out of four Trusts are in the first (top) quartile for the summary hospital mortality indicator, although South London Healthcare Trust was in the third quartile for this measure.

Figure 17 Summary of acute care effectiveness in south east London

41

41

South east London Strategic Planning Group Data Pack – NHS England November 2013



40

5.2 No Trust in south east London fully meets the London standards for safety and quality in emergency care and maternity services

Please note this section will be updated with results of the 2012/13 self-assessment exercise once these are available, expected early March 2014. Improving the quality and safety of acute emergency (adult and paediatric) and maternity services was identified as one of the NHS in London’s key priorities in 2012/13. The Quality and Safety Programme was established in 2012 with this purpose, and resulted in a set of quality standards to be met within London’s acute emergency and maternity services across all seven days of the week42. These were signed off by the Clinical Senate and published in February 2013. All CCGs in south east London are committed to commissioning services to these standards and have provided formal agreement through their governing bodies. The following analysis summarises the position of south east London hospitals against clinical standards based on audits and self-assessments conducted during July to September 2012. Hospitals were examined against the London adult emergency standards, plus national standards for critical care, emergency departments, fractured neck of femur, maternity and paediatrics. It should be noted that in most cases the London standards subsequently developed are more stringent than the associated national standards. The audit findings represent a point in time view, and do not reflect any actions taken by providers since September 2012. Providers in south east London have performed a new self-assessment against the London clinical standards during 2013, the results of which are awaited at the time of writing. This section of the Case for Change will be updated to reflect the findings of the 2013 assessment once these are available. The headline findings of the 2012 audit and self-assessment for south east London acute providers are set out in 4.1.1 and 4.1.2 below.

5.2.1 Compliance with London Adult Emergency Standards varies

There were five standards across medicine and surgery which all hospitals across south east London failed to meet: • Standard 2: A clear multi-disciplinary assessment to be undertaken within 12 hours and

a treatment or management plan to be in place within 24 hours • Standard 3b: Consultant involvement is required for patients who reach trigger criteria.

Consultant involvement for patients considered high risk to be within one hour • Standard 6: All patients on acute medical and surgical units to be seen and reviewed by

a consultant during twice daily ward rounds, including all acutely ill patients directly transferred, or others who deteriorate

• Standard 20: Consultant-led communication and information to be provided to patients • Standard 23: Prompt screening of all complex needs inpatients to take place by a multi-

professional team which has access to pharmacy and therapy services, including physiotherapy and occupational therapy, seven days a week with an overnight rota for respiratory physiotherapy.

Kings College Hospital and University Hospital Lewisham had robust plans in place to achieve compliance with standard 20 in surgery during 2012/13.

42

For further detail please see: http://www.londonhp.nhs.uk/services/quality-and-safety-programme/.

http://www.londonhp.nhs.uk/services/quality-and-safety-programme/



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Figure 18 Level of compliance with London adult emergency standards across south east London acute providers, July to September 2012

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5.2.2 Compliance with National Standards for Critical Care, Emergency

Department, Fractured Neck of Femur, Maternity and Paediatrics standards is

better but with room for improvement

Across south east London there was broad variation amongst hospitals with no individual hospital either meeting or not meeting all of the key national standards considered. King’s College Hospital, St Thomas’ and University Hospital Lewisham were notable for achieving compliance with the majority of the standards considered. There were two standards which all hospitals in south east London failed to meet, these were: • Paediatrics standard 2(a): All emergency admissions to be seen and assessed by the

responsible consultant within 12 hours of admission or within 14 hours of time of arrival at the hospital

• Paediatrics standard 2(b): Where children with surgical problems are admitted to a non-specialist surgical unit, they should be jointly managed and reviewed by both surgical and paediatric senior teams within 12 hours of admission.

5.3 In primary care, many patients find it hard to get an appointment with their GP and the services available are inconsistent, with lower patient satisfaction scores compared to other parts of England.

There is currently an unprecedented strain on general practice services in London, as summarised in Section 3.3 above. Figure 17 provides a summary of regional analysis compiled for the 2014/15 planning process on key spend and effectiveness measures in primary care.

43 South east London Strategic Planning Group Data Pack – NHS England November 2013



42

Figure 19 Summary of primary care spend and effectiveness in south east London44

The analysis and other key sources of data on quality and performance in local primary care indicate the following themes:

Patients report 4th (bottom) quartile experience of care in four of the six CCGs in south east London with the remaining two CCGs, Lambeth and Lewisham, in the 3rd quartile

All south east London CCGs have lower than average GP access, with Bexley, Lewisham and Southwark in the fourth quartile nationally; and remaining CCGs in the third quartile

The percentage of GPs with a review planned due to breaches of GP Outcome Standards is variable, as further indicated in Figure 18 below. Best performance across south east London was Bromley where 54% of practices are ‘achieving’ or ‘higher achieving’ practices; the worst performance was in Lambeth where this figure is only 12%. The equivalent England average is 62%

There is also significant variation in achievement of GP outcomes within individual boroughs, comparing performance of practices against each outcome indicator. There are notable successes – for example in the last quarter all GP practices across south East London were within 1 standard deviation of the mean for achievement of outcomes for end of life and early detection of cancer. However there were high levels of variation across all boroughs in relation to achievement of outcomes for serious mental illness, smoking cessation advice, and identification of asthma

All south east London CCGs have lower than average (1st quartile) primary care spend compared to the rest of England.

The condition of local premises and infrastructure also impact on how effectively local GP services can respond to pressures through achievement of scale and better integration:

Work on the London-wide Case for Change for Primary Care indicates that across the capital only a small percentage of practices are utilising their current digital capacity to access records (circa 3% of practices); cancel or book appointments on line (circa 40% of practices); or order repeat prescriptions on lines (again circa 40% of practices)

A thorough diagnostic of one London region found 30% of practices to be operating from substandard premises – the proportion elsewhere is likely to be similar.




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Figure 20 Proportion of practices in each London CCG by GP outcome achievement45

5.4 As a system we need to respond to the need to improve quality and to drive consistency and productivity in community and mental health services.

Mental health and learning disabilities services Performance on Mental Health (MH) and Learning Disabilities (LD) services is variable across south east London. Figure 19 sets out regional analysis compiled for the 2014/15 planning process, which indicates that:

Services deliver top quartile performance on one out of eleven observed outcomes, namely CPA review in the past 12 months

Three out of six CCGs had high (bottom quartile) incidents of serious harm in MH care (Lambeth, Lewisham, and Southwark) whilst the remanding 3 are in the 3rd quartile

Three of six CCGs have low employment for adults with MH conditions (Bexley, Bromley, Greenwich)

MH spend is in the highest quartile for 4 CCGs (Greenwich, Lambeth, Lewisham, Southwark) and lowest quartile for Bexley and Bromley

LD spend is in the 3rd quartile for Greenwich and Lambeth and lowest spend quartile for the rest

A number of CCGs have noted a poor (but improving) interface between primary care and mental health services, resulting in slow response times, lack of clarity on link staff, and variation in GPs’ knowledge about mental health and primary care access to specialist interventions and expertise.




44

A number of CCGs also have priorities in relation to improving IAPT services and improving CAMHS services to focus on prevention and early help. Figure 21 Enhancing quality of life for people with mental illness and learning disabilities

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Community Services Performance on Community Services is also variable. Figure 20 below sets out regional analysis compiled for the 2014/15 planning process, which indicates that:

Performance of ambulatory care sensitive (ACS) admissions from selected community sources varies from top quartile (Lambeth, Southwark) to bottom quartile (Bromley), with remaining CCGs in the 3rd quartile

Immunisation of children is bottom quartile for Greenwich, Lambeth, Lewisham, Southwark and 3rd quartile for the rest

All CCGs struggle with patient safety in the community with 5 of 6 CCGs in the bottom quartile for pressure ulcer prevention (all boroughs except Lambeth), and 3 in bottom quartile for falls in the community (Lambeth, Southwark and Lewisham)

All of the SEL CCGs are in 3rd quartile on delayed transfer of care

Spend is variable across the CCGs with Southwark in the lowest (1st) quartile on community spend and Bexley, Lambeth and Lewisham in the 3rd quartile.

Workforce recruitment and retention of district nurses and health visitors in inner city London is a challenge affecting a number of CCGs.




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Figure 22 Enhancing quality of life in the Community47

5.5 Within south east London there are specific challenges to ensure that

maternity services provision meets the highest standards of care and quality and health outcomes

As well as an increasing population and consequent demand for maternity services, south

east London contains an increasing number of women with more complicated health and

social care needs who require more support. Locally the acute provider landscape has been

through considerable change in the last year. Whilst not immediately impacting on the

current provision of maternity services it has not resolved either the financial issues or the

existing capacity (both physical and workforce) issues in local maternity services.

Some of the particular challenges facing maternity services in south east London include:

Failure to meet a number of national standards and key performance indicators for example, screening and first antenatal appointment. Performance against assorted national measures for maternity services is set out in the figure below for each south east London borough

Employment and retention of the highly skilled workforce required to deliver a service across all health settings. All SEL Trusts are signed up to achieving the London Health Programme Standards in relation to midwifery and obstetrician staffing, however a recent audit across all Trusts in London showed very few maternity services currently achieving these

Current capacity issues, which results in maternity services being suspended at hospitals, and women being diverted away from their hospital of choice. Between April 2011 and November 2012, providers of maternity services across SEL suspended services on 37 occasions. On 26 of those occasions suspension was necessary because of lack of beds. The other reasons were shortage of medical or midwifery staff

Although service users are broadly satisfied with their care in SEL, the recent CQC Patients Survey highlighted areas for improvement in each of the SEL maternity service




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providers. These included staff attitude in postnatal wards, pain relief and breastfeeding information and advice.

Table 2 Performance of south east London CCGs against an assortment of national maternity measures

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Measure Bromley Bexley Greenwich Lambeth Southwark Lewisham London (where available)

% Low Birth Weight 6.9 6.6 7.3 7.6 8.5 8.3 8

Infant Mortality 2.6 3.7 4.3 6.5 4.6 4.8 4.4

% All C-section 26 28 27 25 27 27 28

% elective C-section

11 11.7 8.8 8.8 8.5 9.4

% Breastfeeding initiation

83 71 79 92 89 85 87

Smoking at time of delivery (SATOD)

6.1 10.2 9.1 4.6 4.4 7.5

% deliveries to teenage mothers

3.3 4.6 4.4 3.8 3.6 4

5.6 Access, quality and performance for specialised services across south east London

Drafting Note – A national service compliance exercise for specialised services in NHS England London Region (including equity and access review) is nearing completion, and will be used to update this section once available.

48 ChiMat website - http://atlas.chimat.org.uk/IAS/

http://atlas.chimat.org.uk/IAS/



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6 Patient satisfaction is low compared to national benchmarks – and there are common themes regarding how patients would like to see services improved

Chapter Summary Patient satisfaction is low compared to national benchmarks.

Bexley, Bromley, Greenwich and Southwark are in the bottom quartile nationally for patient experience of primary care. Bexley, Bromley, Greenwich and Lambeth are in the bottom quartile nationally for patient experience of hospital care.

In 2013 three of the four acute trusts in south east London (Kings College Hospital NHS Foundation Trust, Lewisham Healthcare NHS Trust, and South London Healthcare NHS Trust) scored in the bottom quartile nationally for the friends and family test.

There is rich local feedback regarding how patients would like to see services improved. Themes identified which are common across boroughs include:

Primary care is valued highly

There is a need for better and consistent access to services at local level – and at times convenient to the patient

There is support for community hubs and access to services in community based centres

Local public and patients would like more and better information about various aspects of services and commissioning

There is support for services being more joined up.

Note - this section will be further expanded and developed as part of developing the Strategy and further engagement on the Case for Change.

6.1 Patient satisfaction is low compared to national benchmarks Patient satisfaction across south east London is generally low compared to national benchmarks. Bexley Bromley, Greenwich and Southwark are in the bottom quartile nationally for patient experience of primary care. Bexley, Bromley, Greenwich and Lambeth are in the bottom quartile nationally for patient experience of hospital care. At the same time in 2013 three of the four acute trusts in south east London49 (Kings College Hospital NHS Foundation Trust, Lewisham Healthcare NHS Trust, and South London Healthcare NHS Trust) scored in the bottom quartile nationally for the friends and family test, testing whether patients would recommend the trust to friends and family. The area average was 66.7% versus national median of 72.5% and an average for top quartile providers of 82.7%.

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Prior to the dissolution of South London Healthcare NHS Trust



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Figure 23 Results of patients experience surveys for primary care and hospital care across south east London boroughs; and of friends and family test for local hospital trusts

6.2 There is rich local feedback regarding how patients would like to see services improved

Public and patients have also fed back to commissioners on their concerns and what they value in relation to health services locally. What patients and people in south east London have told us so far:

They really like having services close to home from their GPs, pharmacists, opticians and dentists.

They believe GPs should not have to send people to hospital if there are ways to care for them at home.

They would like more services in their local communities rather than in hospitals.

They would like more services to help people be looked after at home rather than going into hospital.

They believe not all illnesses mean people need to go to or stay in hospitals.

They believe that older people often do not need to go to A&E, but go because they can’t easily get a visit from their GP.

They would like more GPs to offer on line booking for appointments, telephone consultations and some walk-in sessions.

They would like GPs to open for longer and be open at weekends.

They believe that people need to be able to use their local health services more easily and at different times of the day and night.

They want to know more about what services are out there for them and what other services are in the pipeline.

They would like their services to more "joined up" - health, social care and local voluntary services.

They believe that hospitals with senior doctors on duty all the time are much better places to go to in an emergency (even if it takes longer to get there) than a hospital that only has a senior doctor on duty some of the time.

They believe we should have different grades of emergency units, with special ones for heart and stroke and other serious problems.

They believe that after-hours treatment and being able to see the most senior doctors in hospitals 24x7 is something that is vital for very ill people.

They believe that treatment and tests at weekends by an expert would be a great improvement.

They think we need to look closely at children's health from birth onwards and how women are looked after when they are expecting and having babies.



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They believe that children with mental health problems need to be able to get into adult services more easily as they grow up.

They would like more prevention and self care advice to keep up health improvements and prevent ill-health.

They think older people's care and end of life care need to be looked at closely. Throughout the development of this Case for Change and the associated 5 Year Strategy for south east London we will continue to build on this valuable feedback with further targeted engagement exercises.



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7 The financial position for commissioners is challenging

Chapter Summary The financial position for commissioners is challenging. For CCGs:

Analysis by NHS England shows that if we continue with the current model of care and expected funding levels, there could be a national funding gap of £30bn between 2013/14 and 2020/21 - this is on top of efficiency savings already being met

Financial modelling carried out prior to the final national allocation settlement indicates that the scale of financial challenge for south east London CCGs increases from circa £60m in 13-14 to £74m, in 2014/15. This represents around 5% of budgets in each CCG

For 2014/15 the assumption is that there will be a net impact from the transfer of funds to local authorities to create the Better Care Fund. Proposals for these funds are being developed in collaboration with Local Authority colleagues and are being taken for approval through Health and Wellbeing boards by March 2014.

For Primary Care:

The new allocation policy agreed in December 2013 results in London area teams being over target by 2.8% and therefore receiving a base level of funding increase in 2014/15 of 1.60% against a national average of 2.14%. This further impacts in 15/16 with a resource increase of 1.29%

National agreements on inflation uplifts through the Doctors’ and Dentists’ Remuneration Body are yet to be agreed but together with ONS population growth set a minimum uplift of circa 2.0% in 2014/15. This presents a minimum funding gap of 0.4%. Changes in the business rules regarding non-recurrent reserves put further pressure on available recurrent resources

Primary Care across London has achieved a £28m financial savings agenda in 13/14 but has a carried forward requirement of £22m in advance of the 14/15 settlement.

For Specialised Commissioning:

The challenges faced follow the work done in 2013-14 to arrive at a baseline allocation for specialised services across London

There has been a significant loss of resources to other regions, and it is recognised that further allocation adjustments between NHS England and CCGs will be necessary at the end of quarter one 2014-15. Until then allocations are based on the outcome of the work done by the London technical group, which was agreed in December 2013

These services face a reduction of approximately 6-7% in 2014-15, and further cutbacks in later years.



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7.1 The financial challenge for CCGs The allocations that have been received cover the next two financial years, with an outline of the expected increases for later years.

The NHSE Board agreed increases after considering a range of options at its December meeting.

The option agreed gives all CCGs a minimum level of increase in 2014-15 of 2.14% and 1.9% in 2015-16.

Most CCGs in south east London are under their capitation target funding level. The NHSE agreed to have a pace of change attached to the new formula, so that after all CCGs getting the same level of increase at 2.3% in 2013-14, they will get a range from the minimum 2.14%, up to over 4% in some cases. This will move all CCGs close to their target allocation by March 2016, so that increases of only 1.7-1.8% are predicted for later years. Analysis by NHS England shows that if we continue with the current model of care and expected funding levels, there could be a national funding gap of £30bn between 2013/14 and 2020/21. This is on top of efficiency savings already being met. This means that CCGs in South East London will need to achieve significant financial savings as part of delivering improvements in quality, innovation, productivity and prevention. Table 3 Financial modelling of the scale of the financial challenge for south east London CCGs after Better Care Fund transfer

Table 3 above shows financial modelling on the scale of financial challenge, carried out as part of their first submission Financial Plans in February, for south east London CCGs. This represents an increase from around £60m in 2013/14 to £74m in 2014/15. This represents 5% of budgets in each CCG. In addition the CCGs are assuring the Trust’s own CIP plans, for their impact on quality and patient safety. CCGs and Trusts are working together to identify how this challenge can be met including discussing new ways of contracting and risk sharing. This work is based around the definition of south east London joint collaborative commissioning intentions overlaid with local individual CCG service requirements. For 2015/16 the assumption is that there will be a net impact from the transfer of funds to local authorities to create the Better Care Fund. Proposals for these funds are being taken for approval through Health and Wellbeing boards in March 2014 and CCGs are currently working with Local Authority colleagues to develop these plans.

CCG 2014/15 2015/16 2016/17 2017/18 2018/19 Total

Bexley 13 8 5 6 6 38

Bromley 12 12 8 5 5 42

Greenwich 9 7 4 6 6 32

Lambeth 15 20 18 15 13 81

Lewisham 9 14 14 12 12 61

Southwark 16 13 15 12 12 68

Total 74 74 64 56 54 322



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7.2 The financial challenge for primary care commissioning The initial allocation of resources to NHS England for primary care services was based on existing commitments transferred from former PCTs. The allocation policy agreed by the NHS England Board in December 2013 moved to a weighted capitation model for primary medical services using the Carr-Hill formula adjusted for deprivation. This change results in London area teams being considered over target by 2.8% and therefore receiving a base level of funding increase in 2014/15 of 1.60% against a national average of 2.14%. This further impacts in 15/16 with a resource increase of 1.29%. These funding levels reduce the primary care target position to being over by 1.2% in 2015/16. National agreements on inflation uplifts through the Doctors’ and Dentists’ Remuneration Body (DDRB) are yet to be agreed but together with ONS population growth set a minimum uplift of circa 2.0% in 2014/15. This therefore presents a minimum funding gap of 0.4%. Primary Care across London as achieved a £28m financial saving agenda in 13/14 but has a carried forward requirement of £22m in advance of the 14/15 settlement.

7.3 The financial challenge for specialised commissioning As stated the challenge set by NHS England is to save almost 6-7% of the current expenditure on specialised services. This is particularly difficult when many are relatively small volume, high cost in nature. The local Trusts are very dependent on this income to maintain their workload – for example NHS England is now the largest commissioner for Guy’s and St Thomas’ NHS Foundation Trust and Kings College Hospital Foundation NHS Foundation Trust. The CCGs are working in partnership with NHS England to ensure appropriate contracts are in place for all services. There remains a risk that when the further baseline work is complete, there could be a financial impact on the CCG’s allocations in 2014-15.



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8 Our partners face a similar and interrelated set of challenges

Chapter Summary South east London’s acute, community and mental health providers face a similar and interrelated set of challenges and drivers to commissioners Key issues and drivers for providers in south east London include:

A constrained financial environment

The implications of regulatory changes and recent key recommendations in relation to safety, quality and patient care (including the Francis Report, the Berwick Report, recommendations as a result of Winterbourne View, the Urgent and Emergency Care review, and the Future Hospitals Commission)

Uncertainty in the system about the long term provider landscape and future patient flows

Local service integration including primary care and integrated community care

Emergency centre designation

Specialist service consolidation / designation in line with the national strategic direction

New workforce models in response to the need for ambulatory upskilling and staff shortages within the existing workforce

Information Management and Technology, which will be a key enabler of change for providers, but will also demand time and investment.

London’s ambulance service is facing increasing and changing needs for care Some of the key factors affecting the service include:

Increasing demand, whereby over the last three years there have been significant changes in the health needs and expectations of Londoners, with a total increase in incidents of 5% between 2011 and 2013.

Changing profile of demand by illness, including an 11% increase in alcohol related calls between 2011 and 2013; a 19% increase in chest pain related calls between 2011 and 2013; and an 11% increase in dyspnoea calls between 2011 and 2013

Diversion between demand growth and level of funding

Changing patient needs including those on an ageing population, high and increasing diversity of population, increasing issues as a result of population not registered with a GP, and the need to address the symptoms of mental illness

Utilisation of staff significantly above the rest of the country. The challenge for adult social care Many Local Authorities face unprecedented pressures on their resources and in some instances are looking to save over 30% of their current expenditure over the next 3-4 years. Adult Social Care provision forms a large percentage of any local authority budget and faces the challenge therefore of reducing expenditure and finding more cost effective ways of working whilst maintaining services that are safe and of high quality. Demand in services is growing in some areas with increasing numbers of older residents, residents living much longer with complex care and health needs, increased mental health service demand alongside the continued need to support those with lifelong health and care needs to live as independently and as full a life as possible.



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8.1 South east London’s acute, community and mental health providers face a similar and interrelated set of challenges and drivers to commissioners

A number of drivers and issues are shaping the strategic context for provider organisations. Constrained financial environment: Commissioners will not be able to afford current levels of activity across all providers. Growth is likely to be contained within available financial envelopes. At the same time the shift of resource to social care funding through the Better Care Fund is likely to impact commissioners’ available spend on existing services. Providers will need to continue to focus on reducing their cost base, improving productivity and where appropriate on diversification of their income base. This is relevant both for CCG commissioned services and those specialised services commissioned by NHSE. Recent tendering and Any Qualified Provider (AQP) activity locally is an example of CCG commissioned change which is looking to drive down and shift cost risk, particularly for elective services, and community services contracts continue to be pressurised at a time when the system is looking to move more services into out of hospital settings. There is a national process for assessing specialised services against core standards and then subsequent designation or derogation. This creates risks and opportunities for south east London providers from changes within London and more widely within south east England. Requirements of quality, safety and patient care: The implications of regulatory changes and recent key recommendations in relation to safety and quality of services continue to have an impact. These include the Francis, Berwick, Winterbourne View reports mentioned in Section 3; as well as other work such as the Urgent and Emergency Care Review (see above in this section) and the Royal College of Physicians Future Hospitals Commission50. These are leading to new and increasingly stringent requirements in relation to delivering the fundamentals of care and measuring achievement against clear quality, safety and efficiency standards. In addition there is a continued focus on measuring and capturing patient and public feedback about their experiences and involving carers, the public and patients in planning services and service changes. . Uncertainty in the system about the long term provider landscape and future patient flows: It is likely that current pressures will lead to viability issues for some trusts, potentially resulting in consolidation of providers. Trusts therefore need to consider alliance and partnering arrangements with other NHS, third sector and industry partners and to work with commissioners to plan for future patient flows at a service line level. AQP tendering and specialised services changes add to the uncertainty. There is also a requirement to think about south east London in a south London context for some services and providers need to be mindful of flows to and from south west London and indeed into Kent, Surrey and Sussex, particularly for specialised services. Local service integration: Considerations in relation to integration of local services include:

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Royal College of Physicians Future Hospitals Report http://www.rcplondon.ac.uk/sites/default/files/future-hospital-commission-report.pdf

http://www.rcplondon.ac.uk/sites/default/files/future-hospital-commission-report.pdf

http://www.rcplondon.ac.uk/sites/default/files/future-hospital-commission-report.pdf



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Local confederations of GP practices forming in order to establish appropriate scale and implications particularly for community providers in terms of ‘ wrapping services’ around locality facilities

The development of Community Based Care strategies locally including initiatives such as Lambeth and Southwark Integrated Care, Greenwich Integrated Care Pioneer, Lewisham and Greenwich which look to integrate across all health providers and with social care

The future of current community contracts and a tension between integration initiatives with current providers and a policy of ‘testing the market’.

More services being commissioned in the community and other non-hospital settings, with corresponding implications for hospital bed capacity and ambulatory up-skilling of the workforce.

Emergency centre designation: There is likely to be a designation process for major emergency departments nationally with changes happening over a five-to-ten year period. This is likely to have implications for patient flows and acute providers will need to decide what changes and investment are needed to achieve designation. Specialist service consolidation / designation: There are likely to be fewer hospitals offering specialised services with a consolidation of providers serving wider geographical areas. Discussions nationally are signalling a reduction to between 30 and 15 providers and arguably London will be expected to make significant changes given perceived over provision. This will be combined with a continued downward pressure on costs and greater required standards in relation to quality, safety and patient experience. Academic Health Sciences: There is likely to be a greater role for AHSCs and AHSNs as drivers of integration and innovation and south east London has Kings’ Health Partners, one of three AHSC’s in London, and the Health Innovation Network which covers all of South London. The interface between service and academic agendas will be critical to ensure the rapid translation of new treatment and techniques ‘from the bench to the bedside’. The recognition of and importance of integrating physical and mental health services is a particular focus locally. Partnership working: Patient and public involvement are critical and need to be at the heart of planning for local services; as well as being key to driving greater self-management and personalisation of local services. As mentioned above there is also a need for all providers to work in multiple partnerships over a range of geographies in order to meet their strategic ambitions to improve care and experiences for patients. New workforce models: Changes in the clinical workforce link to a number of the factors mentioned above:

New types of roles are likely to be needed and in new care settings, particularly in the community but also in relation to the treatment of patients with multiple morbidities and across the emergency care pathways.

At the same time there are known staff shortages in parts of the health workforce – for example: emergency care doctors, NICU nurses, health visitors, medical physics staff, and perfusionists. This will require co-ordination with commissioners of education for health staff as well as innovative solutions and the development of new roles.

Providers need to work through the impact of the move toward 24/7 and 7-day working on their workforce, as well as regulatory changes

Significant changes will be needed to the commissioning of education for key professional groups.



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Drafting note – Information from the latest staff surveys to be included when available in March Information Management and Technology: Information and technology will be a key enabler of change for providers, but will also demand time and investment. Areas of focus include:

Sharing of patient information between providers to ensure joined up care – in particular between hospitals and primary care and between health providers and social care

Personalised care plans and use of telehealth and telecare to support those with long term conditions, remote consultations etc

Enabling patients to be able to access their own health information electronically

Join up of clinical data sets through care.data

8.2 London’s ambulance service is facing increasing and changing needs for care

The London Ambulance Service is the busiest ambulance service in the world, responding to over 1.7 million calls a year, with demand increasing year on year. The developing strategy Right Response; Right Care: A strategy for the London Ambulance service towards 2020 aims to address London’s increasing and changing needs for care. Some of the key factors affecting the service include: Increasing demand Over the last three years there have been significant changes in the health needs and expectations of Londoners.

% Change Year-On-Year 2013 Vs 2011 2013 vs 2012

999 Calls (Inc MPS) 10.2% 0.03%

Cat A Incidents 22.6% 6.87%

Total Incidents 5.0% 1.48%

Within south east London Lambeth is the borough with fourth highest number of 999 requests across London. Lambeth and Southwark boroughs respectively have the second and third highest total incidents and calls across London. Changing profile of demand by illness Considering the changing needs of callers over the last three years we find that:

Alcohol related calls have increased by 11% between 2011 and 2013

Chest pain calls have increased by 19% between 2011 and 2013

Dyspnoea calls have increased by 11% between 2011 and 2013 Diversion between demand growth and funding During much of this time, the London Ambulance Service did not see financial growth and therefore increased demand had to be absorbed. This has meant that financial investment in the London Ambulance Service has not matched demand. Changing patient needs As well as demand growth increasing, the needs of our patients are changing:

Ageing population – the characteristics and growth of south east London’s ageing population are set our in Section 3 of this document. Many of south east London’s frail elderly residents live alone and are often isolated, and this often results in the London Ambulance Service taking them to hospital, even if their presenting medical condition



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can be managed, as they do not have the necessary support in place to keep them at home

Growing diversity of population – London’s growing population diversity results in over 100 languages being spoken in London and 1.7m people not having English as their first language

Level of GP registration - many London residents are not registered with a GP which results in their choice of urgent and emergency care being either the London Ambulance Service or Hospital Accident & Emergency departments. London’s churn means that long term campaigns to educate people on London’s health services may not achieve the desired success as people have moved on

Mental illness - NHS England statistics show that around 800,000 people are now living with dementia and that this is expected to rise to one million by 2021. In any given year, an estimated 1 in 4 individuals will experience a diagnosable mental health condition, and that many people will experience two or more conditions at once. The London Ambulance Service is seeing a growing number of people with mental health conditions using our services.

Utilisation of staff London Ambulance crews are utilised for over 85% of their time. In other parts of the country this is more likely to be 65%. This constant pressure contributes significantly to staff turnover rates.

8.3 The challenge for adult social care Many Local Authorities face unprecedented pressures on their resources and in some instances are looking to save over 30% of their current expenditure over the next 3-4 years. Adult Social Care provision forms a large percentage of any local authority budget and faces the challenge therefore of reducing expenditure and finding more cost effective ways of working whilst maintaining services that are safe and of high quality. Demand in services is growing in some areas with increasing numbers of older residents, residents living much longer with complex care and health needs, increased mental health service demand alongside the continued need to support those with lifelong health and care needs to live as independently and as full a life as possible. The Better Care Fund 2015/16 has been established in recognition of the challenge to social care and recognition that this challenge can only be effectively met by redesigning adult social care and health provision together. There is a need for joining care and health services more effectively and where and when they are most needed. Earlier identification of need, supporting residents to be able to help themselves where possible and providing care in a planned way are essential to effective social care services. The challenge is to use this fund and other related expenditure to achieve joint care services that improve peoples’ health and care provision rather than cost shunting expenditure from one partner organisation to another. The overall principles of social care are more challenging to deliver in the current climate but remain as important and have to be addressed in any reconfiguration of services. Our service users tell us they want:

Care that is co-ordinated and joins up around them

Personalised care that gives access to information, knowledge and the resources to be able to develop their own care and health more effectively

To remain at home and live independently for as long and as well as possible



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9 Significant progress has been made to date

Chapter Summary The South East London Community Based Care Strategy has delivered significant progress across primary and community care, planned care and integrated care delivery programmes: For Primary and Community Care this has included:

Development of primary care quality improvement plans to understand and address variation in outcomes now

Development and delivery of significant change management programmes in each borough focused on organisational development within primary care to address issues of scale and capacity, supporting the adoption of new models of ‘at scale’ delivery

A pioneer programme has been developed across the six boroughs which will support those groups of providers that wish to move further, faster in testing and implementing new models with a commitment to share and disseminate best practice / learning to the wider general practice community.

For Planned Care this has included:

Bexley CCG is undertaking a number of Prime Contracting procurements using COBIC (Commissioning for Outcome-Based Incentivised Contracts)

Bromley CCG has Community Gynaecology and MSK services in place

The Greenwich Referral Management and Booking Service (RMBS) has been rolled out incrementally since September 2011 with all Greenwich practices participating since February 2013

Lewisham CCG has transformed its diabetes pathway. For Integrated Care this has included:

The National ‘Pioneer Project’ will enable Greenwich Health and Social Care partners to rebase integrated services within clusters of GP practices to further improve care for patients and contribute to delivering community based care across south east London

Building on the existing Southwark and Lambeth Integrated Care (SLIC) partnership, Southwark and Lambeth are taking an integrated approach on the development of an Academic Integrated Care Organisation (AICO) which will include: a home (virtual) ward and enhanced rapid response to manage service users in their own homes; and integrated care for service users with long term conditions and the frail elderly

Lewisham’s population-based programme is building on work to integrate services in a number of areas including district nursing, reablement, multidisciplinary teaming in primary care, risk profiling, and a virtual patient record

Bexley will take a case-management approach to identifying patients with complex needs and deliver integrated care services for older people across health and social care

In Bromley a locality pilot is underway with a core team including community provider and GP practices identifying complex patients requiring case management.

London-wide programmes have transformed local services across a number of specialities. Recent significant London-wide programmes have transformed outcomes for local people:

As a result of the London-wide programme to create the London stroke system, four



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times as many patients are treated with clot-busting drugs, reducing disability, there is less variation in death rates around the capital and patients spend less time in hospital

The London trauma system has transformed the treatment of people who suffer a serious injury or major trauma and need high quality, specialist care to give them the best chances of survival and recovery. At the end of the first year alone it was estimated that 58 Londoners were alive who were expected to die of their injuries when their chances of survival were compared to data on similar patients nationally

Significant transformation programmes are underway across the capital in relation to cancer, mental health and urgent and emergency care. The Commissioning Strategy Programme will work closely with these programmes to ensure that work and strategic direction are closely aligned.

9.1 The South East London Community Based Care Strategy has delivered significant progress across primary and community care, planned care and integrated care delivery programmes

The delivery programmes supporting the South East London’s Community Based Care Strategy are at varying levels of development and progress. Progress against each of the three delivery programmes (primary and community care, integrated care and planned care) is summarised in the sections below.

9.1.1 Primary and Community Care

The primary and community care workstream draws clinicians and commissioning leads from each CCG and NHS England to develop and implement a shared programme of work at pace and scale. The workstream has agreed a common framework of delivery across each of the six boroughs focused upon three key areas:

Development of primary care quality improvement plans to understand and address variation in outcomes

Establishment of Primary and Community care strategies across each borough that seek to respond to the emerging London Case for Change and give focus to improved quality, outcomes and effectiveness through population focused commissioning and a locality approach to commissioning across all six boroughs

Development and delivery of significant change management programmes in each borough focused on organisational development within primary care to address issues of scale and capacity, supporting the adoption of new models of ‘at scale’ delivery

The workstream has recognised the local context within which each CCG operates and the different starting points that each borough has in embarking upon this work. Working together the CCGs have developed a common approach to major issues in order to drive and co-ordinate action across south east London. This has resulted in:

A single and agreed approach to assessing variation and outlying practices with the NHS England Primary Care Contracting team which will result in individual and locality quality improvement plans across south east London. The process has been road tested in each borough over the third quarter and will go live in January 2014

Based on their Primary and Community care strategies, CCGs will launch commissioning approaches that provide a consistent population focus based upon localities of delivery via networks of Primary and Community care

The delivery of significant and funded organisational development plans in each borough for the development of primary care delivery through new models of care at scale



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A pioneer programme has been developed across the six boroughs that will support those groups of providers that wish to move further, faster in testing and implementing new models with a commitment to share and disseminate best practice / learning to the wider general practice community

Agreed non-recurrent investment in supporting the delivery of commissioning strategies and organisational development activities over the full period of the CBC strategy.

Collaboration between the boroughs has provided a common voice and involvement in wider development work across London. The programme is now represented on the London Primary Care Programme Board and Clinical board at Chief Officer and Governing Body clinical lead levels and will contribute to and shape pan London approaches to this area. The workstream has been instrumental in identifying and disseminating best practice through a regular digest to boroughs and through hosting key learning events.

9.1.2 Planned care

A range of planned care schemes are underway at an individual CCG level. Lessons learned and challenges from these projects have been, and will continue to be, co-ordinated and shared across the south east London CCGs through the CBC Planned Care Workstream Group. Some example schemes include: • Bexley CCG is undertaking a number of Prime Contracting procurements using COBIC

(Commissioning for Outcome-Based Incentivised Contracts). Contracts will offer the best possible outcomes for patients and CCG. Pathways include MSK, cardiology and diabetes. These programmes will go live late in 2013/14

• Bromley CCG has Community Gynaecology and MSK services in place and has been able to share key lessons learnt with the other CCGs

• The Greenwich Referral Management and Booking Service (RMBS) has been rolled out incrementally since September 2011 with all Greenwich practices participating since February 2013. Reporting is indicating a downward trend in bookings to secondary care and an increase in community bookings. Mental health referrals are now being routed through the RMBS at the request of GPs to improve navigation for patients. Greenwich now achieves 98% for use of Choose & Book

• Lewisham CCG has transformed its diabetes pathway utilising various mechanisms to enhance diagnosis across Primary Care, including ‘Peer2Peer support’ which involves a dedicated clinical lead supporting practices by providing hands on in-practice advice and guidance. This has helped strengthen and improve the number of patients taken through the 3Rs process (Register, Recall, Review) and 9 Care Processes (NICE standard)

• Lambeth CCG is working with the ‘Transforming outcomes through the imaging group’ set up by the GSTT charity to review a number of diagnostic pathways

• Southwark Community Dermatology Service now offers a single point of referral for GPs to send routine dermatology referrals alongside a newly developed advice and guidance function for practices. This will help strengthen the education component of the service whilst continuing to offer treatment, including minor surgery, for a range of dermatology conditions.

In addition to the individual CCG schemes currently underway, CCGs are agreeing pan south east London opportunities for delivery in 2014/15. Areas being analysed include: • Diagnostics • Referral management and booking processes • Pre and post -operative assessments and care.



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9.1.3 Integrated care

All boroughs are driving forward integrated care programmes: Greenwich: The National ‘Pioneer Project’ will build upon the existing integrated care system which is delivering coordinated services for older people and people with physical disabilities in Greenwich. It will enable Greenwich Health and Social Care partners to rebase integrated services within clusters of GP practices to further improve care for patients and contribute to delivering community based care across south east London. The service provides:

A core multi disciplinary team of: GPs; district nurses; community matrons; continence, podiatry, and memory services; social care; Improving Access to Psychological Therapies; domiciliary care; physiotherapists; occupational therapists and community psychiatric nurses supported by telecare / telehealth as appropriate

A service focussed on prevention, early identification and co-ordinated care for people at high risk of ill health and hospitalisation, with integral support for carers

Clear pathways to secondary acute and mental health services and other related services such as housing.

Lambeth and Southwark: Southwark and Lambeth Integrated Care (SLIC) is well established partnership between local GPs, King’s College Hospital, Guy’s and St Thomas’ Hospitals, the South London and Maudsley Mental Health trust, social care in both local councils, and Lambeth and CCGs. To date, the partnership has focused on care for older people and people with long term conditions, redesigning and improving care for these groups by bringing together local people and their carers with the professionals who care for them, to plan changes and monitor how they are working. Building on this work Southwark and Lambeth are taking an integrated approach across the two boroughs on the development of an Academic Integrated Care Organisation (AICO) to ensure integrated delivery to the target population. Benefits to service users include:

A home (virtual) ward and enhanced rapid response to manage service users in their own homes

Integrated care for service users with long term conditions and the frail elderly. Lewisham: Lewisham’s population-based programme builds on work to integrate services in a number of areas:

Bringing district nurses into the Advice and Information Team

Integrating Local Authority reablement and provider intermediate care team to create a single service to avoid unnecessary hospital admissions/readmissions and reduce need for high level health & social care services

Creating integrated Multi Disciplinary Teams working with primary care

Undertaking risk profiling of GP adult population

Including community development to support and improve health and wellbeing

Introducing a virtual patient record across the system. Bexley: A case management approach is being taken forward to identify patients with complex needs, in combination with integrated care services for older people across health and social care. Benefits to services users include: • Keeping care managed in a community setting, supporting them to remain healthy • Reducing the likelihood of admission to hospital or long-term care. Bromley: Locality pilot underway with a core team including community provider and GP practices identifying complex patients requiring case management. Benefits to service users include:



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• Holistic approach using generic assessment forms • Proactive assessment and support of service users in a community setting • All information about individuals’ care in one place.

9.1.4 Outcomes of community-based care – a case example

The Strategy is already starting to have an effect in changing the local health system. For example some of the outcomes of the Phase 1 Integrated Care System project upon which Greenwich partners are building with their national pioneer integrated care project include51:

Work so far has seen a decrease in emergency admissions for people with conditions that could be treated in the community. Greenwich is now ranked the 15th best performing borough nationally

Over the last 2 years, there has been an 8% reduction each year in the number of people supported with a social care package

Between 11/12 and 12/13, there was a 7% reduction in the number of people supported in long-term care placements throughout the year

There has been an increase in the number of people aged 65+ to remain at home following discharge from hospital through a reablement intervention and who are at home 91 days later. During 12/13, 89% were still at home at 91 days, up from 79% in 11/12

During 11/12, the number of people re-admitted to hospital within 14 days reduced. Greenwich’s performance remains better than national and peer group figures

From the end of 10/11, the number of bed days spent in hospital has reduced and fallen below national and peer group comparison.

9.2 London-wide programmes have transformed local services across a number of specialities

London wide programmes have delivered significant improvement in outcomes for key specialties. Two programmes that have significantly transformed the service landscape in recent years relate to the centralisation of stroke and major trauma services based on networks that link local services with specialist centres. Details of these changes are set out below. Significant transformation programmes are already underway across the capital in relation to cancer, mental health and urgent and emergency care. The Commissioning Strategy Programme will work closely with these programmes to ensure that work and strategic direction are closely aligned.

9.2.1 Stroke services have been transformed with improved outcomes

The London Stroke Strategy was responsible for transforming the provision of stroke services across the capital from a fragmented system where stroke care was delivered in all 31 acute hospitals in the capital, to a dedicated network of eight hyper-acute stroke units operate across London, supported by 24 stroke units. In south east London the hyper-acute stroke units are located at Kings College Hospital in Denmark Hill and at Princess Royal University Hospital in Orpington.

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Greenwich Coordinated Care - Expression of interest for health and social care Pioneer pilot, http://www.icase.org.uk/pg/cv_content/content/view/88639/network?cindex=16

http://www.icase.org.uk/pg/cv_content/content/view/88639/network?cindex=16



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Each hyper-acute unit is staffed works on a 24/7 basis to assess, diagnose and treat stroke patients within 30 minutes of arrival and to provide immediate care for the first 72 hours or until the patient has stabilised. This includes immediate access to a brain scan and clot-busting drugs. The eight units are supported by 24 stroke units across London to provide ongoing care once a patient is stabilised, including multi-therapy rehabilitation. As a result of the changes, four times as many patients are treated with clot-busting drugs, reducing disability, there is less variation in death rates around the capital and patients spend less time in hospital. The average journey time in London for a patient being taken to the new units is 14 minutes.

9.2.2 The London trauma system has transformed outcomes for those who have

suffered a serious injury or major trauma

The London trauma system has transformed the treatment of people who suffer a serious injury or major trauma and need high quality, specialist care to give them the best chances of survival and recovery. The trauma system is made up of four trauma networks. Each has a major trauma centre, linked in with a number of local trauma units for treating those people with less serious injury. The most seriously injured patients, such as those with multiple injuries including head injury, life-threatening wounds and multiple fractures, are treated at trauma centres where teams of specialists including trauma surgeons, orthopaedic surgeons and neurosurgeons are on hand. Patients with less serious injuries are treated by their local A&E trauma centres. Each local trauma service is linked to a specialist centre as part of a network designed to share expertise and resources.

At the end of the first year alone it was estimated that 58 Londoners were alive who were expected to die of their injuries when their chances of survival were compared to data on similar patients nationally52. In south east London the major trauma centre is located at King’s College Hospital (Denmark Hill).

52

London Trauma Office Annual Report April 2010 – March 2011, http://www.londontraumaoffice.nhs.uk/silo/files/lto-annual-report-2010-to-2011.pdf

http://www.londontraumaoffice.nhs.uk/silo/files/lto-annual-report-2010-to-2011.pdf



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10 The South East London Commissioning Strategy will set out how we work with partners over the next five years to build on existing progress to address these challenges and deliver best possible outcomes and services within our resources

Since the start of September 2013, south east London commissioners have been working together to form a new commissioner-led, clinically-driven programme to address the challenges faced across the south east London health system in partnership with providers and the local authorities. The South East London Commissioning Strategy Programme will encompass the south east London response to NHS England’s requirement to produce a five year strategy and is currently in an initiation phase, defining its overall scope and delivery approach. The approach will have a strong focus on engagement, aiming to co-design with partners, including patients and local people. Initial thinking will be developed and amended through the engagement process. Key principles for the approach, which are being developed with partners, include:

Being based on local needs and aspirations, listening to local voices and building on work at borough level, whilst taking into account national and London policies.

Focusing on improving health outcomes and reducing inequalities.

Employing a strong partnership approach, led by NHS commissioners and involving closely a wide range of local partners, including patients and communities, local authorities and NHS partners, to build agreement on priorities, strategic goals and outcomes.

Creating solid foundations by ensuring all stakeholders have a common understanding of the scale of the challenge and then a shared vision and ambition for the next five years.

Being open and transparent throughout the process, from identification of need, to implementation of the strategy.

Engaging broadly, building on existing borough-level work with wider engagement activity to complement this as appropriate.

Working with the Health and Wellbeing Board in each borough. Following these principles, the South East London Commissioning Strategy will build on the six individual CCG-level strategies developed locally with partners. CCGs will work collaboratively on the elements of the strategy that cannot be addressed at CCG level alone, or where there is common agreement that there is added value in working collectively. Engagement will be undertaken throughout the process, primarily through existing borough-level engagement, but on a wider basis where this is helpful and as advised by the South East London CCG Stakeholder Reference Group. Initial engagement will include developing the case for change, scope and vision, the ambition of the programme and will move onto priorities and models of care as the programme develops. (The draft strategy was initiated before the conclusion of the NHS ‘Call to Action’ consultation. The work will be reviewed at the completion of this consultation to check alignment). Specific engagement will take place to take into account equalities aspects and impacts on the nine statutorily protected groups, plus the needs of socially and economically deprived populations and of carers in south east London.



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Annex A – Joint Strategic Needs Assessments (JSNAs) for south east London boroughs

Borough

JSNA available at the following location

Bexley http://www.bexley.gov.uk/index.aspx?articleid=2344&mode=1

Bromley http://bromley.mylifeportal.co.uk/uploadedFiles/Bromley/Bromley_Homepage/Document_Library/Public_Health/BROMLEY%20JSNA%202012%20%20no%202.pdf

Greenwich http://www.royalgreenwich.gov.uk/info/200088/statistics_and_census_information/1239/joint_strategic_needs_assessment

Lambeth http://www.lambeth.gov.uk/planning-and-building-control/joint-strategic-needs-assessment-jsna

Lewisham http://www.lewishamjsna.org.uk/home/lewishams-joint-strategic-needs-assessment

Southwark http://www.southwarkjsna.com/