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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 V0.15 24/01/2014 Programme Team Further refinement of first draft incorporating feedback from South East London Implementation Executive Group and Clinical Executive Group. V0.16 25/02/2014 Programme Team Updated to incorporate Partnership Group feedback for baseline V1.0 28/02/2014 Programme Team Draft for Engagement

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  • 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

    V0.15 24/01/2014 Programme Team

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

    V0.16 25/02/2014 Programme Team

    Updated to incorporate Partnership Group feedback for baseline

    V1.0 28/02/2014 Programme Team

    Draft for Engagement

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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-deprivationhttp://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)

    4

    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 (

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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

    6

    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%3A77-320124http://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.0019590https://www.gov.uk/government/speeches/achieving-parity-of-esteem-between-mental-and-physical-healthhttps://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)

    10

    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.

    10

    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

    12

    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

    13

    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.

    13

    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)

    16

    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

    15

    Source: HSCIC / Diabetes Prevalence Model, APHO 16

    Source: HSCIC Indicator Portal

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    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

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    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

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    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.

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    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

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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/2013/12/5yr-strat-plann-guid.pdfhttp://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid.pdfhttp://www.england.nhs.uk/wp-content/uploads/2013/09/trans-part-hc-guid1.pdfhttp://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.

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

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

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    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.

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    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-responsehttps://www.gov.uk/government/publications/mid-staffordshire-nhs-ft-public-inquiry-government-responsehttp://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-how-to-guid.pdfhttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213215/final-report.pdfhttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdfhttp://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

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    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 th