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NHS North West London

Shaping a Healthier Future

Pre-Consultation Business Case

Volume 1

Chapters 1 to 6

Edition: 1

20 June 2012

Foreword by NW London CCG Chairs

As clinical leaders in NW London, our aim is to deliver the best possible healthcare to our patients. But people‟s health needs are changing, and under the current structure of the NHS, we aren‟t able to deliver care to the standards we would like. We believe we need to change our model of healthcare delivery now, so we can be in a position to provide high-quality care in the long term. This need for change in the NHS is a response to ongoing changes in the population. NW London is growing, people are living longer, and more people are developing conditions such as diabetes and obesity. This is putting pressure on our health services. To fully meet people‟s needs, we need a system where we can deliver the right kind of healthcare, in the right setting. In many cases, the best setting isn‟t in hospitals. We believe that increasing the amount of care delivered closer to the patient‟s home will enable better co-ordination of their care, and improve the quality of that care and its value for money. When people do need hospital care, we believe that centralising key services will ensure that patients always have access to the best possible care. As the Chairs of the eight Clinical Commissioning Groups for NW London, and the leaders of the programme to deliver this change, we have made four key commitments which underpin our vision for how services should work in the future. The first is a commitment to help people take better care of themselves, understand where and when they can get treatment, and understand different treatment options. Secondly, when patients have an urgent healthcare problem, we are committed to ensuring they can easily access a primary care clinician 24 hours a day, seven days a week by telephone, email and face-to-face consultations. Our third commitment is that if patients need to see a specialist or receive support from community or social care services, this will be organised in a timely way and GPs will be responsible for co-ordinating the delivery of their healthcare. Finally, if patients need to be admitted to hospital, we are committed to ensuring this will be to a properly maintained and up-to-date facility where they receive care delivered by highly trained specialists at all times. With these specialist clinicians working together in larger teams, building on each other‟s expertise, patients can be assured of receiving the best possible treatment. We see these commitments as obvious aspirations for any world-class healthcare organisation. Achieving them does require us to make significant changes, and some difficult decisions, but we believe these are essential. The changes may be substantial, but the rewards of getting it right will be too, with better healthcare, better support, more lives saved, and a sustainable, efficient system. Dr Ethie Kong – Brent CCG Chair Dr Ruth O’Hare – Central London (Westminster) CCG Chair Dr Mark Sweeney – West London (Kensington, Chelsea, Queen’s Park and Paddington) CCG Chair Dr Mohini Parmar – NHS Ealing CCG Chair Dr Tim Spicer – NHS Hammersmith & Fulham CCG Chair Dr Amol Kelshiker – NHS Harrow CCG Chair Dr Ian Goodman – NHS Hillingdon CCG Chair Dr Nicola Burbidge – NHS Hounslow CCG Chair

Foreword by Programme Medical Directors

Shaping a Healthier Future is a programme of change for how we run the NHS in NW London. This pre-consultation business case sets out the background to the programme, why change is necessary, and what changes we are proposing. The NHS serves almost two million people in NW London. This population is growing and becoming older, which means that we have to manage an increase in the number of people living with chronic conditions. Treatments for other diseases are improving, so there are also many more people surviving following treatment of cancer and living with other illnesses. Meanwhile, illnesses related to modern lifestyles – such as obesity – are adding to the disease burden. We know that many people are unhappy with the care they currently receive. Access to GPs can be frustrating, and people often aren‟t given enough support with managing long-term conditions. Some end up in hospital unnecessarily. Within hospitals, we know that quality of care is inconsistent, with people admitted at weekends having poorer outcomes because of staff shortages. We also know that medical technology is advancing rapidly, and we‟re getting better at providing world class care in specialist centres. Clinicians themselves are becoming more specialised. It makes sense for these specialist clinicians to work together in larger teams, so they can build on each other‟s expertise and patients can be assured of access to specialised care at all times. Taken together, these factors present a compelling case for change in how we deliver healthcare. Our clinicians have stated a vision of the quality of care that the NHS in NW London should provide, and proposals for how we can achieve it against measurable quality standards. Our proposals are based on developing “Out of Hospital” care, so that patients can more easily access a broad range of good quality, localised care services with their GP practice co-ordinating services. Alongside this, we are proposing to centralise emergency care and other specialist services on fewer sites, so we can ensure that those who do need to attend hospital can always access the best quality care. These changes will involve restructuring our hospital sites under a new model, with each site fitting into one of four hospital types. We‟re still maintaining most services on most sites, but by centralising particular services and developing out of hospital care, we believe we can deliver the highest quality care to the greatest number of people. Clinical outcomes will improve, patient and staff experiences will improve, and our services will become more financially sustainable, making the NHS fit to serve NW London for many years to come. Mark Spencer Susan LaBrooy Tim Spicer Mike Anderson Programme Medical Directors for Shaping a healthier future

Foreword by Senior Responsible Owner

NW London is a large, diverse area with almost two million people of all ages, backgrounds and income levels. As the senior responsible owner and Chief Executive of NHS NW London, my role is to ensure that everyone here has access to the same high quality, safe, and effective care, delivered consistently and in the right setting. Everyone who deals with our health system – patients, their carers and staff – should have a positive experience. Currently, the way we deliver services in NW London doesn‟t deliver on all of these objectives. Change is needed, and that change will require a considerable effort from the different organisations that make up the NHS, as well as from support and partner organisations. This process of change is actually already underway. We‟ve taken a new approach to how we deliver services to stroke patients, for instance. Our new centralised stroke units, backed up with a network of support units, have already prevented an estimated 300 deaths a year in NW London. We want to build on that success and make further, substantial changes to how we deliver care. To make this happen, Clinical Commissioning Groups in every borough have looked at the health needs of their communities, and how best to meet them. Their main proposal is to transform the care provided in local communities. More care should be delivered closer to home. And by also centralising some specialist hospital-based services, the NHS can ensure that people can benefit from receiving treatment at centres of best practice and excellence. This isn‟t about cutting corners or getting by with the bare minimum. We want to change the way we deliver care so that outcomes are improved, both in terms of clinical outcomes and patient/staff experiences. We‟ve used robust clinical evidence to set targets, and clinicians have set out the standards by which we can measure our performance against them. In this pre-consultation business case, we summarise the changes that clinicians have proposed in both primary and secondary care. It describes our plan to develop out of hospital care and to reconfigure hospital services. It also sets out the benefits that these changes will deliver and an overview of how the changes will be made. I am pleased to recommend this pre-consultation business case to the JCPCT and NHS London with the full support of the Shaping a healthier future Programme Board, Clinical Board and the NW London Clinical Commissioning Groups.

Anne Rainsberry Senior Responsible Owner and Chief Executive for NHS NW London

Table of Contents

Page

1 Executive Summary Volume 1 5

2 Introduction to the NHS in NW London Volume 1 9

3 Introduction to the Shaping a healthier future programme Volume 1 18

4 Stakeholder Engagement Volume 1 24

5 Clinical Case for Change Volume 1 43

6 Financial Base Case Volume 1 55

7 Our vision for how to improve significantly the health of people in NW London

Volume 2 3

8 Delivering better care out of hospital and in hospital Volume 2 39

9 Benefits of implementing the vision Volume 2 61

10 Quality assurance of the vision Volume 2 78

11 Determining the number of major hospitals needed Volume 3 3

12 Determining options for five major hospitals Volume 3 11

13 Developing criteria to evaluate options for major hospital sites Volume 3 25

14 Appraisal of options for locating major hospital sites Volume 3 34

15 Confirmation of options for consultation Volume 3 70

16 Proposals common to all consultation options Volume 4 3

17 Preferred option for consultation Volume 4 28

18 Other options for consultation Volume 4 38

19 Implementation plans Volume 5 3

20 Plans for consultation Volume 5 15

21 Approval process Volume 5 22

22 Next steps Volume 5 24

App A A1) Programme Governance and A2) Programme Governance: Terms of Reference for Programme bodies

Volume 6

App B Further information on stakeholder engagement Volume 7

App C Consolidated finance pack from F&BP modelling Volume 8

App D D1 to D8) 8 CCG Strategy documents Volumes 9 - 16

App E Out of Hospital Standards Volume 17

App F Methodology for impact on workforce Volume 17

App G Additional information on assurance Volume 17

App H Further information on travel analysis Volume 17

App I Evidence on impact of quality of estates Volume 17

App J Further information on estates analysis Volume 17

App K Western Eye Hospital proposed relocation Volume 17

App L Estimated impact of reconfiguration options on activity Volume 18

1. Executive Summary

Forewords In the forewords, the Chairs of each of the eight CCGs in NW London, supported by the Shaping a healthier future Medical Directors and the Chief Executive of NHS NW London, outline the challenge to provide better quality care in the face of an ageing population, advances in technology, and other issues. In response to this the Chairs have developed proposals on how health services in NW London should be changed in the future. 1. Executive Summary 2. Introduction to the NHS in NW London This chapter describes the shape and structure of the NHS in NW London and how the local commissioners ensure that the two million people who live there receive the community, acute, mental health and specialist services they need. 3. Introduction to the Shaping a healthier future programme This chapter describes the work that preceded the programme and how the programme was established. The underlying principles of the programme are supported by the programme‟s governance. The programme has worked with clinicians, the public, patients and other stakeholders over the last eight months on proposals to transform the health system in NW London and develop a set of options for consultation. 4. Stakeholder Engagement This chapter describes how there has been engagement with a wide range of stakeholders. Through a series of three major stakeholder events, meetings, newsletters and other channels, we have tested our thinking with clinicians, patient groups, the public, provider organisations, local authorities, and MPs, to gather feedback and act on it as proposals have been developed. This has enabled effort to be focused on the areas that are most important to each stakeholder group and ensures there is a solid foundation of engagement before the proposals are put to public consultation. 5. Clinical Case for Change This chapter describes why change is necessary and why it must start now. Clinicians looked at the current and future demands on the NHS in NW London and how the current configuration of services is not always delivering the best clinical outcomes and positive patient experiences. The case for change shows that services need to be reconfigured to improve quality and to build a sustainable health economy. 6. Financial Base Case This chapter describes the financial imperative for change. Commissioners must save £243 million to make the system sustainable and to provide enough money for the necessary investment in out of hospital care. This provides the base case against which any proposed option can be assessed. This is in addition to the cost improvement plans of hospitals themselves, designed to respond to the planned decrease in tariff over the next three years.

7. Our vision for how to improve significantly the health of people in NW London This chapter describes how patients will be treated in the future to ensure they receive the highest standards of care. Services will be provided locally where possible and centralised where necessary. Services will also be integrated across organisational boundaries to provide a seamless experience of care in range of care settings. It includes the vision for improving services delivered outside hospital settings and how this will be delivered. The new CCGs have developed borough-level visions and strategies, tailored to the needs of their local populations, and based on a common set of quality standards. The visions focus on easy access and rapid response to community services using planned pathways integrated across organisations. The visions are illustrated by case studies on initiatives that have already begun. It also includes our vision and how services will be delivered within hospital settings. Clinicians have developed visions for emergency surgery and A&E, maternity and paediatric services. Clinicians have developed a set of clinical standards for these three areas to underpin quality within any future configuration of acute services. Patient stories illustrate how care will be delivered in the future for a range of conditions. 8. Delivering better care out of hospital and in hospital This chapter describes the range of service models that clinicians are proposing, from care at home to specialist, tertiary care. CCGs have developed a set of service models to deliver better out of hospital care in every borough. The models describe how patients can receive care at home, at their GP practice, at a clinic, in a local hub or a local hospital, with transfer to acute and more specialist care if necessary. Clinicians have agreed plans to invest up to £120 million over the next three years to make this a reality. The local hospital will be the centre for earlier intervention and better coordinated care. Over 75% of the activity that is currently delivered on acute hospital sites will continue to be delivered there after the proposed changes. The local hospital will act as a centre for urgent care and as the hub of a network. Finally, using the acute clinical standards and the clinical dependencies between services, clinicians developed the service delivery models for hospitals in NW London that form the building blocks for future configurations. Local clinicians developed three further models for hospital care – major hospitals (with 24/7 A&Es), elective hospitals (for planned care) and specialist hospitals (providing tertiary care). 9. Benefits of implementing the vision This chapter describes the benefits that are expected following the implementation of the vision. Clinicians have developed a framework covering improved outcomes for patients with better clinical experiences, and carers and staff working in a multi-disciplinary, financially sustainable environment 10. Quality assurance of the vision This chapter describes the external assurance and scrutiny that the programme has undergone. The clinical proposals have been assured by the National Clinical Advisory Team and an External Clinical Panel has provided additional scrutiny and guidance. The whole process and engagement undertaken by the programme has been assured by an Office of Government Commerce Gateway review. The programme believes it has met the four tests for reconfiguration set out by the Secretary of State and has submitted its evidence to NHS London. 11. Determining the number of major hospitals needed This chapter describes the process for determining how many „major‟ hospitals there should be in NW London. A set of hurdle criteria, developed by clinicians, were used to establish the

optimal number and, based on this, clinicians believe NW London needs five major hospitals. Having fewer would be too expensive and take too long to deliver, although it would be clinically safe if implemented. If there were more than five, then clinical quality would fall as clinicians would not see enough patients and there would not be enough staff for sustainable clinical rotas. 12. Determining options for five major hospitals This chapter describes the process for developing a smaller list of options for where the five major hospitals should be located. By applying further hurdle criteria, clinicians developed a set of eight options for further consideration. The eight options were based on eight of the current A&E sites as Central Middlesex is proposed to be designated as an elective hospital. In all cases, Hillingdon and Northwick Park are proposed to be designated as major hospitals with the remaining three major hospitals at – Charing Cross or Chelsea and Westminster; Ealing or West Middlesex and Hammersmith or St Mary‟s. 13. Developing criteria to evaluate options for major hospital sites This chapter describes the evaluation criteria that were used for determining where the major hospitals should be located. The criteria were developed by clinicians and tested with wider groups and the public. The criteria are focused on quality of care, access to services, value for money, deliverability and the impact on research & education. 14. Appraisal of options for locating major hospital sites This chapter describes the process for evaluating the list of eight options for locating major hospital sites. By applying the evaluation criteria, each of the eight options were evaluated across a range of factors. The evaluation showed that three options were rated better than the others and should be considered further. In all these three options St Mary‟s would be designated as a major hospital and Hammersmith would remain as a specialist hospital. Option 5 (Hillingdon, Northwick Park, St Mary‟s, West Middlesex and Chelsea and Westminster) emerged as the strongest, preferred option. Across the remaining two options for major hospitals there is still a choice between Ealing and West Middlesex, and between Charing Cross and Chelsea and Westminster. 15. Confirmation of options for consultation This chapter describes the sensitivity analysis that was carried out on the remaining three options to ascertain how robust they are and whether any should not be proposed to be part of the consultation. The sensitivity analysis showed that option 5 remained the preferred option and that all three options are recommended to go forward to public consultation. 16. Proposals common to all consultation options This chapter describes the proposals that are proposed to go forward to consultation that are common to the three consultation options. It brings together the proposals for changes to out of hospital care and the Central Middlesex, Hammersmith, Hillingdon and Northwick Park sites. It also outlines proposals for local hospitals and proposals to move the Western Eye Hospital and the Hyper-Acute Stoke Unit to the St Mary‟s site. 17. Preferred option for consultation This chapter describes Option 5, our proposed preferred option to put to public consultation. This option has major hospital sites at Hillingdon, Northwick Park, St Mary‟s, West Middlesex and Chelsea and Westminster. The chapter outlines what the option means for each site and

the high-level implications for activity, estates and workforce. It describes how this option meets the case for change and why it is preferred. 18. Other options for consultation This chapter describes a further two options that are proposed to be put to public consultation. The options are Option 6 (Hillingdon, Northwick Park, St Mary‟s, West Middlesex and Charing Cross) and Option 7 (Hillingdon, Northwick Park, St Mary‟s, Ealing and Chelsea and Westminster). The chapter outlines what each option means for each site and the high-level implications for activity, estates and workforce. 19. Implementation plans This chapter describes how, dependent on the outcome of consultation, the chosen option would be implemented. CCGs have carried out extensive work on how they might implement their out of hospital strategies. Out of hospital transformation will happen first and then changes to hospital services will be completed by 2016. 20. Plans for consultation This chapter describes the work carried out to prepare for consultation and the plans for conducting the consultation. As agreed with the Joint Health Oversight & Scrutiny Committee, the consultation will run for 14 weeks from 2 July 2012, during which a series of events will be held with the public and staff to describe the consultation proposals and to get feedback to inform any future decision. 21. Approval process This chapter describes the approval process for the work of the programme and the PCBC prior to going to the Joint Committee of Primary Care Trusts for approval. 22. Next steps Following consultation, all the responses will be collated and taken into consideration. The business case will be refreshed, the proposals may be refined and further examination of the impact of the proposals on some clinical pathways. There will also be an independent report compiled on the consultation responses. A final set of proposals will be given to the Joint Committee of Primary Care Trusts, with an aim for a final decision on service change in early 2013.

2. Introduction to the NHS in NW London

This chapter describes the shape and structure of the NHS in NW London and how the local commissioners ensure that the two million people who live there receive the community, acute, mental health and specialist services they need. This chapter sets out:

Commissioning arrangements

Out of Hospital services provision

Acute hospital services provision. 2.1 Commissioning arrangements in NW London Primary Care Trusts (PCTs) are currently responsible for commissioning the majority of NHS services in England. PCTs in London are grouped into six clusters, one of which is the NW London (NW London) Cluster. Figure 2.1 shows the different NHS clusters in London. Figure 2.1: PCT Clusters in London

The scope of Shaping a healthier future covers the services provided in NW London which serves all residents of NW London and some residents of neighbouring boroughs and PCTs. The health economy of NW London currently comprises eight PCTs: Brent, Ealing, Hammersmith & Fulham, Harrow, Hillingdon, Hounslow, Kensington & Chelsea and Westminster, as shown in Figure 2.2.

Figure 2.2: PCTs in NW London

The eight PCTs are governed by the NHS NW London Joint Committee of PCTs (JCPCT), which is a meeting in common of all eight PCTs. In March 2012 the PCTs agreed to appoint a single group of Non-Executive Directors. From April 2013, PCTs will no longer exist. New bodies known as Clinical Commissioning Groups (CCGs) are being established to commission the majority of NHS services in their local areas. In NW London there will be eight CCGs, as shown in Figure 2.3.

Figure 2.3: Clinical Commissioning Groups in NW London as of June 2012.

The responsibility for commissioning health services in NW London is in the process of being transitioned from the NW London Cluster to the eight CCGs. All NW London CCGs have been established and are actively working within current Cluster arrangements to ensure a seamless transition of responsibilities from April 2013. This recognises that CCGs must support the proposals (to meet the requirement of support from GPs and commissioners as part of the Four Tests) and that they will be responsible for implementation of the proposals. It is critical that they have been equal partners in decision-making within Shaping a healthier future. 2.2 Out of Hospital service provision in NW London The term “Out of Hospital” is used to refer to all healthcare provision outside an acute setting. Within NW London there estimated to be over 11 million attendances at GP surgeries annually along with almost 3 million other community attendances1. Out of hospital settings include:

GP practices and health centres

Community health services

Dental practices

Pharmacies

Opticians

1 Reference costs 2009/10 - District Nursing, HV Post natal visits, specialist palliative care, GP

practice list size (QOF 2010/11) * natl average GP visits per person (Qresearch 2009), Reference costs 2009/10, other community activity (including Health Visitor activity other than post-natal visit)

Walk-in centres

Mental and community health services. NW London has four main community health providers that deliver community nursing and therapy services. These include:

Central London Community Healthcare Trust (CLCH), covering Hammersmith & Fulham, Kensington & Chelsea and Westminster

Hounslow and Richmond Community Healthcare (HRCH), covering Hounslow

Central and North West London NHS Foundation Trust, incorporating Hillingdon Community service provider, covering Hillingdon

Ealing Hospital Trust, incorporating Ealing Integrated Care Organisation, covering Brent, Ealing and Harrow.

There are two mental health trusts that provide Out of Hospital mental health services across NW London:

West London Mental Health NHS Trust, covering Ealing, Hammersmith & Fulham and Hounslow

Central and North West London NHS Foundation Trust, covering Brent, Kensington & Chelsea, Harrow, Hillingdon and Westminster.

There are also a number of hospices, rehabilitation centres and old people‟s homes. 2.3 Hospital services in NW London Within NW London there are nine acute trusts:

Chelsea and Westminster Hospital NHS Foundation Trust

Imperial College Healthcare NHS Trust. This includes Charing Cross Hospital, Hammersmith Hospital (including Queen Charlotte‟s Hospital), St Mary‟s Hospital and Western Eye Hospital

The Hillingdon Hospitals NHS Foundation Trust. This includes Hillingdon Hospital and Mount Vernon Hospital2

The North West London Hospitals NHS Trust. This includes Central Middlesex Hospital and Northwick Park Hospital

West Middlesex University Hospital NHS Trust

Ealing Hospital NHS Trust

The Royal Marsden NHS Foundation Trust

The Royal Brompton & Harefield NHS Foundation Trust. This includes Royal Brompton Hospital and Harefield Hospital

The Royal National Orthopaedic Hospital NHS Trust. In addition to commissioning services from these trusts, some services are commissioned from hospitals outside of NW London, often in central London.

2 Mount Vernon is the site for some services that are not part of the Hillingdon Hospitals NHS

Foundation Trust. These services are excluded from the scope of Shaping a healthier future. These services include:

- East and North Hertfordshire Trust (cancer services) - Lynda Jackson Macmillan Centre - The Royal Free (plastic surgery)

Figure 2.4 shows the position of the hospital sites in NW London and those in neighbouring areas. Figure 2.4: Hospital sites in NW London and surrounding areas

A wide range of services are provided at the hospital sites in NW London. There is a relatively high number of sites for the size of population and geographical area and the majority of the acute hospital sites (excluding the specialist trusts) provide very similar ranges of services. Figure 2.5 sets out the services provided by each of the acute trusts in NW London. These are grouped according to hospital service delivery models (local hospital, major hospital, elective centre and specialist centre), which have been defined by local clinicians. These models are explained further in Chapter 8.

Mount Vernon

Harefield

RNOH

Hillingdon

Northwick Park

Ealing

West Middlesex

Central Middlesex

Hammersmith

Charing Cross

St Mary‟s

Chelsea and

Westminster

Royal

Brompton

Royal Marsden

Imperial

NW London

Hospitals

WatfordBarnet

Royal Free

UCLH

St Thomas‟

St George‟s

Kingston

St Peter‟s

Wexham Park

Wycombe

Key

Sites that

form a merged

Trust

Trust name

Western Eye

St Charles

Figure 2.5: Current services provided at acute hospital sites in NW London

2.3.1 Acute hospital activity levels

Across the 11 acute hospital sites (this excludes the specialist hospitals of Royal Brompton, Royal Marsden and Royal National Orthopaedic Hospital) in NW London there are approximately 4,060 acute beds of which 3,450 are adult and 610 paediatric or maternity. A summary of activity in NW London hospitals is described in Figure 2.6. Figure 2.6: Summary of activity by site and type of service (number of spells/attendances in 2010/11)3

2.3.2 Acute hospital cross-border flows Some hospitals in NW London provide significant levels of activity for non-NW London patients, as demonstrated in Figure 2.7.

3 2010/11 HES; NW London Reconfiguration modelling. Critical care data is excluded as a line from

the table due to inconsistent reporting but included in totals, so that they can be reconciled with overall data. Excludes activity commissioned privately.

Figure 2.7: Activity provided by NW London providers for non-NW London patients (% of total acute activity)4

The majority of this cross-border activity is from neighbouring regions in South West London, North Central London as well as the surrounding Home Counties, as shown in Figure 2.7.

4 Notes from figure 2.7:

1. 2010/11 HES Inpatient spells 2. 2010/11 HES outpatient attendances (first and follow-up) 3. 2009/10 identified A&E and minor trauma attendances (only c.75% total activity is captured in

the HES data)

Figure 2.8: Top 10 non-NW London PCT regions referring to NW London acute trusts5 (total activity)

5 Notes from figure 2.8:

1. 2010/11 HES Inpatient spells 2. 2010/11 HES outpatient attendances (first and follow-up) 3. 2009/10 identified A&E and minor trauma attendances (only c.75% total activity is captured in the

HES data)

3. Introduction to the Shaping a healthier future programme

This chapter describes the work that preceded the programme and how the programme was established. The underlying principles of the programme are supported by the programme’s governance. The programme has worked with clinicians, the public, patients and other stakeholders over the last eight months on proposals to transform the health system in NW London and develop a set of options for consultation. This chapter sets out:

An overview of the Shaping a healthier future programme

An overview of the contents of the remainder of this document. 3.1 Overview of the Shaping a healthier future programme There has been a history of re-thinking the provision of hospital care in NW London for many years. For example, the Tomlinson report (in 1992) highlighted a need to rationalise hospital sites across London and NW London in particular. Many of the drivers that existed then still exist today. Shaping a healthier future builds on significant previous work undertaken in NW London, including work conducted by a series of Clinical Working Groups (CWGs) between 2009-11 to develop suitable models for clinical services, which culminated in some of the key elements of the 2011 Commissioning Strategy Plan; including:

The definition of a case for change for NW London

The definition of a detailed strategy to localise care close to patients‟ homes, to centralise specialist care and to integrate care for people with long term conditions and the elderly

New clinical quality standards for NW London

Proposals for the establishment of a service change programme. As a result, the Shaping a healthier future programme was established in November 2011 to develop proposals for service change across NW London, encompassing acute services and out of hospital care. There are a number of other planned activities to improve services as part of the Commissioning Strategic Plan (CSP), for example, the development of integrated care systems across NW London. These will support Shaping a healthier future in achieving its goals but are outside the direct scope of the programme.

3.1.1 Principles underpinning the programme’s approach

To enable the CCGs to identify the optimal design for the future services required in NW London, Shaping a healthier future has followed an approach based upon four core principles (which are underpinned by the Secretary of State‟s four tests for reconfigurations):

Clinically led and supported by GP commissioners – At all stages of the development of the proposals, local clinicians have led the work to ensure that any proposals lead to the improvement of the quality and safety of care and help to improve patient experience. The work is led by four Medical Directors – two representing primary care and two representing acute care. Together they have ensured that the development of options has been clinically-led and that the recommendations identified are clinically appropriate and viable. CCGs have been

involved directly in development of proposals and are part of the programme approval process. The Clinical Board (see Section 3.1.2) has been responsible for commissioning, reviewing and testing analysis that supports the recommendations that they have made to Programme Board. Further detail on those local clinicians involved in the programme can be found in Appendices A1 & A2. Additionally engagement has taken place with wider groups of local clinicians, such as at three public and clinical engagement events (further information in Chapter 4). Engagement with clinicians has always been led by the senior clinicians involved in the programme.

Informed by engagement with the public, patients and local authorities – engagement has taken place with local stakeholders at each stage of development to understand the potential impact of any proposals; including direct involvement of NW London‟s Patient and Public Advisory Group (PPAG) and engaging the Shadow Health and Wellbeing Boards. The four Medical Directors have been actively involved in a wide variety of engagement events across all the different stakeholder groups identified. Further information on stakeholder engagement undertaken can be found in Chapter 4. We will undertake formal public consultation, for 14 weeks, during which we will explain our proposals, and how they have been developed, to the wider public and listen to their views on the implications of those proposals. This will include specific work to understand the implication of proposals on different equalities groups, in particular traditionally under-represented groups. Further information on the public consultation can be found in Chapter 20.

Robust and transparent process underpinned by a sound clinical evidence base – our Case for Change and quality standards are already based on sound local and national clinical evidence. We have used a robust, evidence-based process for developing and appraising options for change that we have shared with stakeholders at each stage of its development; working in particular with senior local clinicians and external clinical advisors to ensure any options are clinically sound. This has also included testing the impact of proposals on patients and the public – for residents of each borough, for inequalities, for patients with specific healthcare needs and patient travel times – and considering impacts on activity, capacity at different sites, and financial and capital implications for providers and commissioners.

Consistency with current and prospective patient choice – the core principles of centralising, localising and integrating will impact on the way services are provided, and therefore on the choices available to the public. We believe this will have a positive impact, providing a choice of higher quality services for NW London. We continue to work with local clinicians, our PPAG and Overview and Scrutiny Committees to consider how any proposals for service change may affect other aspects of patient choice (i.e. choice of provider, setting and intervention) as described in the NHS Constitution.

We have sought views from patients, their representatives and other local stakeholders as this work has developed and will continue to do so during and after consultation.

3.1.2 Programme governance

Shaping a healthier future has a clear governance structure in which the JCPCT is the decision-making body for the programme. The JCPCT is constituted of the eight PCTs in NW London plus representatives from Camden, Richmond & Twickenham and Wandsworth PCTs. The NW London Cluster Board commissioned the programme, setting out the overall scope, aims and timescales but it is the JCPCT that will:

Take the decision on whether to proceed to consultation on the proposals set out in this document; and

Ultimately, take the final decision on whether to proceed with proposed service changes.

Figure 3.1 sets out the governance structure for Shaping a healthier future. Figure 3.1: Governance structure for Shaping a healthier future

The JCPCT is advised by a Programme Board, which oversees programme delivery, in particular managing cross-organisational issues, risks and dependencies. The Programme Board consists of:

NW London Cluster executive team

CEOs for all NW London (acute, mental health and community) providers

All eight NW London CCG Chairs

Representatives from NHS London, South West London PCT cluster, North Central London PCT cluster and the NW London PPAG.

The Clinical Board has responsibility for providing clinical leadership to the programme, ensuring the programme develops robust clinical proposals and making clinical recommendations to the Programme. The Clinical Board consists of:

The four Programme Medical Directors

Nominated clinical leads for all NW London providers (usually Medical Directors)

Nominated clinical leads for all NW London CCGs (usually CCG chairs)

NHS NW London Director of Nursing and nursing representatives

PPAG representative.

The Clinical Board has met fortnightly throughout the programme and has taken the lead in commissioning, reviewing and testing different analysis to support the development of the reconfiguration proposals. Local clinicians have asked for wider clinical expertise in certain areas, such as paediatrics, and have stayed in close contact with other clinical working groups, such as the London Health Programme, to ensure that they have the latest advice from those groups and that their proposals align with the latest developments and recommendations to deliver the highest levels of clinical quality and safety. The remaining work is managed through working groups each with commissioning, provider and PPAG representatives – the Out of Hospital Care Working Group, the Communications and Engagement Working Group and the Finance and Business Planning Working Group. Alongside this structure other external groups, such as the Expert Clinical Panel, have a role in reviewing the work of the programme and strengthening its recommendations through expert advice and challenge. During the programme timeline, there will be a number of changes in the local NHS including:

Transition of commissioning responsibilities from PCTs to CCGs

Establishment of the NHS Commissioning Board and governance structures established to carry out the Board‟s role in London

Changes to the role of LINKs

Establishment of Health & Wellbeing Boards and Clinical Senates. Shaping a healthier future has planned for and is responding to these changes as they take place; ensuring an appropriate fit with new arrangements as part of the NW London‟s overall response to the changes. Further detail of programme governance arrangements, including membership of the different Boards is provided in Appendices A1 & A2.

3.1.3 Wider engagement and involvement in developing the proposals

Clinicians have led the programme throughout, working with key stakeholders to:

Set out the case for service change in NW London

Develop the vision for NHS services in NW London, including standards for both primary and secondary care and a set of service delivery models

Identify options for change

Analyse and evaluate these options to identify proposals to take to public consultation.

Testing and refinement has taken place throughout the development of the proposals, starting from the setting out of the Case for Change. This has included reviews by NCAT and the Expert Clinical Panel, discussions with patient and public groups and their representatives. NHS NW London also pays due regard to the aims of the general equality duty and the public sector equality duty, and complies with both its general equality duty and its public sector duty when making decisions. We have endeavoured to understand the potential effect of our practices and policies on our staff and communities, particularly those from different protected groups under section 149 of the Equality Act 2010. Consideration and understanding of the potential effects of our proposals on different people has been an additional component of review and refinement.

Further information on stakeholder engagement undertaken through this process of developing our proposals can be found in Chapter 4.

3.1.4 Programme timeline The overall programme timeline is broken down into five phases as shown in Figure 3.2: Figure 3.2: Shaping a healthier future programme phases

At the time of issue of this pre consultation business case the programme has reached the end of the pre-consultation phase. It has completed the identification of options for change and is seeking the agreement of the JCPCT to consult with the public on these proposals.

3.2 Purpose and scope of the pre-consultation business case Public consultation is a statutory requirement where major service change is intended and the process of consultation and engagement on Shaping a healthier future is governed by Sections 242 and 244 of the National Health Act 2006. The framework set out in the legislation has been expanded in guidance, “Changing for the Better” and “High Quality for All – NHS Next Stage Review”, published by the Department of Health. The guidance mandates the need for a business case, and NHS London have provided further guidance in their Reconfiguration Guide on the detail that the business case should comprise to make a pre-consultation business case (PCBC).

The PCBC is a technical and analytical document that sets out the information necessary for the Joint Committee of Primary Care Trusts (JCPCT) to make a decision as to whether to proceed to consultation. It sets out in detail the process we have been through to identify our proposals for change, the final set of proposals and the implications of these proposals. It includes:

Our vision, supported by clinical standards and proposed clinical service models

The benefits we expect to realise

How we have considered the options available to us and evaluated them to move through a long list, medium list and short list to a recommended proposal

The proposals for service change we are recommending for consultation

What we believe the next steps are to enable the JCPCT to go to consultation and to support planning for implementation.

The PCBC will be published by NHS NW London but it is not intended to be the main mechanism through which we explain our proposals to the public. The consultation document is a public-facing document that sets out the proposals and their implications and asks specific questions to help us to test and refine these proposals (Further information on the consultation document can be found in Chapter 20).

Other programme documentation can be found on the Shaping a healthier future website at http://www.northwestlondon.nhs.uk/shapingahealthierfuture/

http://www.northwestlondon.nhs.uk/shapingahealthierfuture/

4. Stakeholder engagement

This chapter describes how there has been engagement with a wide range of stakeholders. Through a series of three major stakeholder events, meetings, newsletters and other channels, we have tested our thinking with clinicians, patient groups, the public, provider organisations, local authorities, and MPs, to gather feedback and act on it as proposals have been developed. This has enabled effort to be focused on the areas that are most important to each stakeholder group and ensures there is a solid foundation of engagement before the proposals are put to public consultation. This chapter sets out:

A summary of our stakeholder engagement strategy

Principles for stakeholder engagement

An overview of stakeholder engagement activities undertaken during pre-consultation, including clinical engagement, provider engagement, patient groups, public engagement and political stakeholder engagement

Key themes of feedback from these different groups and our responses. Further detail on stakeholder engagement can be found in Appendix B. 4.1 Summary of stakeholder engagement strategy

The Case for Change was published in February 2012. This set out the desire of local clinicians to transform the way care is delivered in NW London and outlined the basis for the Shaping a healthier future programme. The Case for Change set out the fundamental issues and challenges currently facing the healthcare system and it identified where improvements could be made, particularly to the consistency and quality of clinical outcomes and patient experiences. The Case for Change has provided a basis on which to build engagement with a wide variety of stakeholders across NW London, crucially with patients, the public and clinicians. This engagement has also been used to involve these groups in the development of our proposals. Shaping a healthier future has set out a clear stakeholder engagement strategy that is crucial to the successful delivery of our proposals. We understand that patients, staff and the wider public care deeply about what happens to their local NHS services and it is critical that they are part of the journey we undertake. Stakeholder engagement work started at the beginning of the Shaping a healthier future programme and built on similar work carried out with Clinical Working Groups and other stakeholders in previous years. The programme carried out a systematic and wide-ranging programme of engagement based on an agreed set of principles and an understanding of who our stakeholders are and how they should be engaged.

Figure 4.1: Summary of stakeholder engagement strategy

This chapter sets out a summary of our approach to stakeholder engagement and the activity that took place during the pre-consultation phase. Further information about the formal consultation phase and the work that will be carried out during consultation to process responses we receive can be found in Chapter 20 of this document. Full details of all stakeholder engagement that has taken place in this pre-consultation phase can be found in Appendix B of this document. This includes engagement event reports, newsletters and details of all meetings attended.

4.2 Stakeholder engagement principles

A set of stakeholder engagement principles to underpin our activity was developed. We committed to:

Plan and undertake appropriate engagement with relevant stakeholders at each stage of the programme

Deliver sufficient levels of awareness and understanding about proposed service changes across NW London among key identified stakeholder groups

Provide regular opportunities for stakeholders to engage with us before, throughout and post formal consultation to facilitate engagement and consultation through high quality, credible communications channels and messages

Baseline and monitor support among key stakeholder groups, before, throughout and after consultation

Meet statutory requirements to engage stakeholders

Ensure consistency of communications between commissioners and providers, as part of managing internal communications

Ensure consistent clinical engagement through regular dialogue between programme Medical Directors and provider/borough clinicians

Be proactive in identifying existing stakeholder events and meetings to tap into to increase programme awareness and relationship with stakeholders

Work collaboratively with the media to ensure access to accurate information for the public.

4.3 Identification of stakeholders

The programme conducted a robust identification and prioritisation process that identified a wide range of stakeholders who should be involved in the development of proposals to change the way NHS services are delivered. To identify all the stakeholders, we considered how we could capture the full range of opinions in the development process and how we could incorporate different experiences and learning from similar programmes. As part of the identification and prioritisation process, the programme developed:

Stakeholder groupings through an intensive stakeholder workshop

A stakeholder analysis showing key groups of stakeholders

A stakeholder prioritisation grid in which stakeholder groups were assessed with respect to specific concerns about the programme and prioritised to ensure those concerns are being discussed, understood and met

A stakeholder diary in which all external meetings with stakeholders were logged and communication tracked regularly

A meetings calendar in which all relevant stakeholder meetings were logged to ensure engagement with key stakeholders groups such that meetings were well attended and prepared for.

Figure 4.2 provides a summary of the different stakeholder groups that were identified and the table in Figure 4.3 shows the purpose of engagement with each of the six groups.

Figure 4.2: Summary of key stakeholder groups identified in the Shaping a healthier future programme

Figure 4.3: Purpose of engagement with each stakeholder group

Stakeholder Group

Individual Stakeholders Purpose of Engagement

Clinicians & Staff

CCGs

GPs

Royal Colleges

London Deanery

British Medical Association

Clinical input such that the options developed reflect the highest levels of clinical quality and benefit to the patient

Providers NW London acute trusts

NW London community services providers

NW London mental health trusts

London Ambulance Service

Providers along each care pathway are able to input into proposals by providing knowledge and understanding of their population and patients, such that this enables a better outcome for patients

Patient Groups Public and Patient Advisory Group (PPAG)

LINks

Ensure patient groups are aware of key messages around potential service changes, that these are visible and transparent, allowing patient involvement in shaping the proposals

Public Members of the public The public are aware of potential changes to the way their healthcare services are delivered, what is being considered and how the possible changes might affect them

Political Health Overview & Scrutiny Committees (HOSCs) and the Joint HOSC

MPs

Greater London Assembly Members

Health & Wellbeing Boards

Borough councillors

Borough cabinet members

Ensure that there is a clear understanding of the reasons for change amongst those who represent the public and that these reasons are challenged and scrutinised to enable the best decisions to be made for better healthcare delivery in the future

Full details of stakeholder mapping, prioritisation can be found in Appendix B. 4.4 Stakeholder engagement activities

Throughout the pre-consultation period we have ensured regular and continuous engagement with stakeholders. Progress against the plan was regularly discussed at Programme Executive and Programme Board meetings and the plan was refreshed based on feedback from these groups to ensure the appropriate focus was directed at each group. The programme has engaged extensively with clinicians, the public, patient representatives, providers and political stakeholders to develop a set of recommendations to put forward for consultation. Following the publication of the Case for Change, work focussed on detailed options development, testing and finalising options for consultation in the preparation for consultation. A range of methods have been used as part of our stakeholder engagement activities above and beyond meetings with individuals and groups. Different types of stakeholder engagement activities have included:

Newsletters being issued monthly to internal staff, patients, the public and GPs. The newsletters provided regular updates on programme progress as well as details of the options development process (internally and externally).

the Shaping a healthier future website which provides information on the programme to all online users, including key documentation from the programme and materials from stakeholder events, which can be downloaded

Social media mechanisms such as Twitter to deliver programme news

Three large open forum events to engage with public, patients and clinicians, allowing questions to be asked, input into the development of the proposals, and further information given to attendees. These were held on 15 February, 23 March

and 15 May 2012. Over 200 people attended each event, including around 80-100 clinicians at each one.

4.4.1 Three major stakeholder events

Three major stakeholder events have taken place during this pre-consultation phase. Figure 4.4 sets out a summary of the events. Figure 4.4: Summary of three major stakeholder events 15 February Lord’s Cricket Club

200+ attendees: - Representatives from all eight LINks patient groups from across

NW London - Representatives from all eight local authorities in NW London,

including elected councillors - Patient groups including Age UK, Mencap, MIND and the Patients

Association - GPs from across NW London including those from the new

Commissioning Consortia in each borough - Clinicians representing every NHS NW London service provider,

including hospitals and community health services Covered: - Case for change - Clinical standards (acute and OOH) - Evaluation criteria

23 March Lord’s Cricket Club

180+ attendees: - Representatives from all eight LINks groups - Representatives from patient groups such as MIND, Hammersmith

and Fulham Disability Forum, Age UK and Community Voice - Representatives from all eight Clinical Commissioning Groups in

NW London - Representatives from NW London Local Authorities - Representatives from eight provider trusts as well as NW London‟s

community and mental healthcare providers - GPs and CCG leads from across NW London Covered: - Long list to medium list process - Local vision and plans for out of hospital care - Evaluation criteria

15 May Satavis Pattidar Centre

180+ attendees: - representatives from six of the eight LINks groups - representatives from patient groups such as BME Health Forum,

Breathe Easy Brent, West London Citizens, Hanwell Neighbourly Care Scheme and Age UK

- Councillors and/or officers from six of the eight NW London councils

- representatives from the Clinical Commissioning Groups in NW London

- representatives from six acute provider trusts as well as NW London‟s community and mental healthcare providers

- GPs from across NW London Covered: - Programme update and timeline - Medium list to short list process

Patient pathways now and in the future - Consultation plans

4.4.2 Clinical engagement activities

Enabling widespread clinical engagement during the pre-consultation period was essential in developing options for reconfiguration. The Programme Medical Directors worked closely with the Clinical Board (which consisted of medical directors from each provider in NW London and clinical representatives from each CCG) to develop the main deliverables from the pre-consultation phase, including:

The Case for Change

Clinical Vision

Clinical standards

Service delivery models

Medium list of options

Shortlist of options

Recommended options. In addition, the Programme Medical Directors have been continuously committed to supporting stakeholder engagement by attending and presenting at meetings to enable the clinical messages to be given accurately to other clinicians and for audience feedback to be gathered and considered throughout the proposals development process. To ensure wider clinical engagement, direct engagement has been focused on two core groups; senior provider clinicians and local GP Practice staff. This has been delivered through a series of local clinical engagement events during March – May 2012. The first area of focus was on the quality standards, service models and influencing the options development process. The second area of focus has been on the NCAT review, refining the options for consultation and understanding the site-specific implications in more detail. Figure 4.5 is a summary of clinical events that the programme has been involved with during pre-consultation. Figure 4.5: Summary of clinical engagement meetings attended by programme representatives

Chelsea & Westminster Open forum event

17 Apr 12-1pm, Chelsea and Westminster - 12 - 1pm Hospital boardroom. All staff invited to attend (clinical and non-clinical) - Medical Directors open forum event. Around 50 attendees, clinicians and other staff

Harrow GP Forum

18 April, attended by over 60 GPs.

Royal Brompton and Harefield

20 Apr 9-10am, Harefield Hospital, Concert Hall, Harefield Site. Audit day - Medical Directors (20-25 consultants expected)

Royal Brompton and Harefield

20 Apr 11-12pm, Royal Brompton, Part of CHGD day - Medical Directors. Clinical audit days at both sites –Approx 40 attended at each. Mix of senior clinicians, nurses and other.

Ealing GP Event 24 Apr 8pm, Ealing, MS spoke with GPs regarding OOH strategies

Chelsea & Westminster Grand round

3 May, event well attended.

Royal Marsden Hospital

08 May 5.30pm, Royal Marsden Hospital, Slot medical advisory committee. Senior clinicians invited to a specific briefing.

4.4.3 Feedback from clinical engagement activities

From the different clinical engagement activities some key themes of concern were raised. Figure 4.6 summarises these themes and the responses made. Figure 4.6: Key themes of feedback received from clinical engagement activities

Event/group Key themes and messages How the programme has incorporated these messages into our proposals

Local clinical engagement events during March – May 2012.

The key areas discussed with this group were: o Consultation options. o National Clinical Advisory Team

(NCAT) review. o Need to explore protected

groups within Southall and Central Ealing population and how that will be serviced.

o Development of UCCs. o OOH will have to be functioning

prior to services moving. o Support for UCC/Emergency

Department (ED) Working Group.

o Provide evidence of CCG support for process.

o Providing clear narrative about patient flows and pathways, especially in Ealing.

o The first area of focus was on the quality standards, service models and influencing the options development process. Clinical input has driven the development of the standards and service models.

o The second area of focus has been on the NCAT review, refining the options for consultation and understanding the site-specific implications in more detail. A wide range of clinicians had input into the NCAT process. The NCAT review was broadly supportive of the programme.

o Programme has created CIGs to explore the development of UCCs.

o Programme undertaking detailed implementation planning, led by CIGs.

o Programme has sought letters of support from providers and

Ealing CCG 08 May 7.10pm, Trailfinders Sports Club, Ealing, 20 minutes presentation followed by questions. Ealing wide GPs to attend. This was a meeting of GPs in general with about 60 of them there to discuss practice issues.

North West London Hospitals

14 May 4.45-5.45pm, Room SR3, Medical Education Offices, HA1 3UJ, slot part of medical advisory committee. Medical staff committee meeting:

Approx 30 attended & mix of consultants

Video link to Central Middlesex from NPH

Case for change presentation + 30mins discussion.

Ealing Hospital NHS Trust

16 May 5.15pm-6.30pm, Board Room, Main Hospital, update on SAHF. 30 consultants present.

West Middlesex University Hospital

22 May 12-1pm, Education Centre, Twickenham Road, Isleworth, Middlesex TW7 6AF, Update on SaHF. Approximately 35 people attended, mix of nurses/admin/consultants.

West Middlesex University Hospital

23 May 5pm, Education Centre, Twickenham Road, Isleworth, Middlesex TW7 6AF, Update on SAHF. 15 people – majority consultants and several nurses.

CCGs. o Programme producing Borough

information packs for consultation describing the changes for specific Boroughs.

o Consultation materials written to provide a clear story.

GPs o Southall GPs sought assurances about access to services

o GPs in NW London received the Case for Change and each of the programme newsletters.

o They were also invited to each of the three pre-consultation stakeholder engagement events with strong representation at each one.

o Broad support for changes invested at NPH. Accident & Emergency (A&E) and intensive care surgeons planning extra activity which will be coming their way.

o Programme developed engagement plans for Southall GPs and public around what service configuration in and out of hospital would be required for this population.

4.4.4 Provider engagement activities

The programme has engaged with clinicians and managers across the providers in NW London, with the main focus on acute providers and community care providers. These have included:

Events focussed on a wider group of clinicians. The programme was aware whilst there was strong clinical engagement through the Clinical Board and regular Programme meetings, local clinicians wanted to support this through engagement with the wider clinical community. This was done by Programme Medical Directors using standing events such as regular consultant meetings and GP forums to present the progress of the programme and to answer questions. The record of engagement with these providers can be found in Appendix B

Clinicians representing every NW London service provider, including hospitals and community health services and GPs attended three stakeholder events where they were able to discuss and inform the programme‟s work on:

o The case for change o Rationale for options development o Out of Hospital visions and strategies o Consultation options o Plans for consultation.

Programme newsletters have been shared with all GPs. In addition to these activities, the programme ran a monthly Communications and Engagement working group. This consisted of programme communications staff and directors of communications from each of the providers. This enabled us to ensure alignment of activities between the programme and providers and gave the opportunity to share progress and gain feedback on considerations for the programme. It enabled us to disseminate material and messages and also for the provider teams to request tailored

material from the programme. Between each meeting we shared relevant materials including the development of options, post event reports and newsletters that provider communications leads have then been able to distribute to provider staff. This has resulted in wider stakeholder engagement.

4.4.5 Patient groups engagement activities

The main engagement activities to engage with patient groups have been the three stakeholder events, where half a day was given to discussing the work of the programme with patient and public representatives. At the first event on 15 February, the attendees demonstrated general acceptance of the Case for Change and strong acceptance of the clinical and quality standards that had been developed. Leads from each of the Clinical Commissioning Groups presented an outline of the work they were undertaking to set out the strategies for their local Out of Hospital care provision.

The second event, on 23 March followed a similar format. This event was heavily influenced by the first as it demonstrated to the audience how feedback had been interpreted, as well as how it had influenced the development of options and the methodologies that were to be used for evaluating options. The latest local Out of Hospital plans were presented (again by leads from the Clinical Commissioning Groups) as was the process used to refine the long list of possible options to a medium list. Attendees were asked to vote on whether they understood the process described and over 85% said that they had. A third major stakeholder event was held on 15 May, this time at a venue further out in NW London, at Wembley Park, and in the evening. Nearly 300 people attended, many of whom were deliberately invited from community and other groups who had not previously engaged with the programme. An update on the programme was given, and explanations about the medium list and further analysis of options provided, as well as an account of how consultation is proposed to be carried out. Throughout the development of the recommended proposals, meetings and briefings have also been held with the Patient Public Advisory Group (PPAG) and its members. This has allowed for the direct input of patient representatives into the programme. The programme has taken PPAG through all stages of the programme including the Case for Change and the options development process. These meetings have generally been monthly and a record of these meetings can be found in Appendix B. LINks members were present at the three major stakeholder engagement events. In addition, PPAG representatives have ensured LINks members are aware of programme objectives and progress. The programme has attended LINks meetings and further formal engagement with LINks will take place during consultation. A record of attendance at LINks meeting can be found in Appendix B.

4.4.6 Public engagement activities

The main focus of our engagement with the wider public has been through the three large stakeholder events, as described above in Section 4.4.1. In addition to these events and other regular meetings with patient groups, the programme has proactively sought opportunities to speak at open, public events to raise awareness of the work of the programme prior to the full public consultation. This has included:

A public meeting on 23 February 2012 in Ealing of around 200 people organised by the West London Citizens network, at which clinicians presented the Case for Change, early work on options development, and discussed specific questions relating to Ealing hospital and other local services. The event was well organised with some speakers subsequently attending the 23 March event held by the programme.

A meeting of the West London Voluntary Services event in Ealing on 29 March 2012, at which clinicians explained where the programme had progressed to and took questions.

A second meeting of the West London Citizens network held on 9 May 2012 again comprising around 200 people at which programme leaders including local GPs presented an update on the programme. The audience were very engaged and appreciative of the programme being open and transparent about latest progress.

As part of the wider consultation and engagement work for Shaping a healthier future, the communications and engagement team have undertaken work to engage and consult groups, communities that are seen as seldom heard and traditionally under represented. This includes groups such as refugee communities, the elderly, faith groups, BME communities and women from within these communities. This element of the work will ensure that these groups are aware of the possible changes to NHS services within their local area and how these may affect them as an individual or as a community. We have also sought to ensure that any concerns or views they have on the reconfiguration of services are captured and used to help determine the future provision of NHS services. Details of the meetings attended during pre-consultation can be found in Appendix B. Going forward, the focus of this work will be to link in with existing networks and forums within the eight boroughs. This will include work with local authority colleagues who support voluntary and community sector networks, voluntary sector organisations, including the CVS network, and small community organisations who work with the key target groups and meeting with faith groups who are able to access a large number of community members through the work they undertake. The work compliments the larger formal consultation taking place and also links in with equalities impact analysis which will form the basis of ensuring that the impact of changes to services does not have an adverse impact on potential groups.

4.4.7 Feedback from patient and public engagement activities

From the different patient and public engagement activities some key themes of concern were raised. Figure 4.7 summarises these themes and the responses made. Figure 4.7: Summary of key themes and responses from patient and public engagement activities


15 February event

Overall, the Case for Change was very well received and the need to address the issues it raises was widely recognised. Attendees also told us they were pleased to be involved in the discussions at this early stage in the programme. Key themes for OOH care included:

Clinical leaders have used the feedback from the event to inform: o The clinical standards –

particularly out-of-hospital care standards

o The ongoing development of visions and plans for out-of-hospital care in each borough


o Issues with continuity of care in the community

o Communication between settings, specialties and health and social care

o Improved coordination of care o Better information sharing

systems to facilitate joint working o Issues with access to care in the

community. Key themes for acute care included: o Clinical quality most important

criteria.

o The development of a medium list of options for change

o The identification of potential criteria to use to assess the medium list of options in order to establish a shortlist for public consultation in the summer

o The agenda for the next event on 23 March and our planning for other events in May and through public consultation

23 March event

Delegates voted to indicate how well they understood the options development process which described how the programme has moved from a long-list of options for change to a medium-list. 85% of patient and public representatives and clinicians voted positively to say they understood this. Key themes for OOH included: o Strategies well received. o Changes should reflect better

care not cost reduction. o Adequate resources to deliver

success o Integration of health and social

services o Information systems that support

care delivery across settings. Key themes about options for change: o Consider access more widely. o Focus on clinical case for change. o Consider population density and

neighbouring areas.

The programme‟s leaders built feedback from the event into their plans, specifically: o Working with local clinicians to

agree our shortlist of options for change.

o Working with local clinicians, local authorities and others across the eight NW London boroughs to refine the local visions for out-of-hospital Care.

o Programme undertook engagement events to give a wider body of local patient representatives and local clinicians the opportunity to hear about the programme and influence it.

o Undertaking detailed travel analysis, an equalities review to look at access, and convening a Travel advisory Group.

o Liaising with neighbouring PCTs and providers to ascertain the likely impacts of the NW London reconfiguration.

o OOH strategies consider IT systems and funding has been included in the modelling, ICP pilot demonstrated requirement for integrated IT systems.

o Programme engaging with H&WB Boards to explore links between health and social care.

15 May event

Key themes for developing options for change included: o Emphasising that this isn‟t cost

driven.

Following feedback from this event, programme leaders are: o Working with local clinicians to

further develop the three


o Clarifying the role of Urgent Care Centres (UCCs).

o Ensuring the programme addresses the equalities challenge.

Key themes for developing patient pathways included: o More detail about patient

pathways o Further consideration given to

mental health and the elderly o Improved capacity and capability

in the community o Better access to GPs o Improved communication.

recommended options for consultation

o Working with local clinicians, local authorities and others across the eight NW London boroughs to refine the local visions for out-of-hospital care

o Setting up CIGs which will work with primary and secondary care clinicians to clarify pathways including workforce, urgent care centres, etc.

o Holding ongoing discussions with local patient representatives on our Patient and PPAG - which has representatives on each of our working groups

o Running more engagement events to give a wider body of local patient representatives and local clinicians the opportunity to hear about the programme and influence it

o Further developing our consultation plans and refining this with the NW London Joint Health Overview and Scrutiny Committee (JHOSC) and PPAG.

LINks sessions

Some members of the relevant LINks expressed concerns that travel analysis based on information from Transport for London (TfL) was not robust.

In order to address these concerns, the programme is establishing a travel advisory group which will involve input from council transport leads, TfL and PPAG LINks representatives.

PPAG PPAG have provided input into the following: o Consultation document and

questions. o PCBC o Consultation plan Feedback received included: o Emphasising improvements to

access through the delivery of OOH strategies.

o Ensuring MH services are considered.

o Concerns about the impact of the financial position of some boroughs and the need for clear communication of key messages during the consultation period.

This feedback has been used as follows: o MH was included in OOH

strategies: o A meeting was offered with the

programme‟s finance lead to address the first concern and the PPAG will be involved in reviewing and informing the development of messages used in consultation materials.

o The programme has used input from PPAG to create revised drafts of the key consultation documents and Pre Consultation Business Case (PCBC).

o Ensuring OOH borough strategies


o Concerns re: integration with social services.

provide a coherent story for patients.

o Ensuring OOH strategies provide details of the integration between health and social care.

West London Citizens event

The key themes emerging from the event were: o Access was the main concern

among the residents of Ealing. o Programme will need to address

transport concerns. o Case for Change was well

received, especially the vision „Specialise, Localise, and Integrate‟.

o Reconfiguration programme made an offer to come back and have a more discursive event to hear about what else could be there.

o Ensure continued focus on engagement with Ealing.

o Detailed consideration of travel implications for Ealing residents.

4.4.8 Political stakeholder engagement activities

There has been significant engagement with political stakeholders throughout the pre-consultation period. This has included meetings with councillors, cabinet members and Health and Wellbeing Boards (H&WBs) in NW London. Greater London Assembly Members have been sent the newsletter. A record of meetings with these groups can be found in Appendix B.

4.4.8.1 Members of Parliament

Engagement with MPs began on 23 December 2011. We sent a letter introducing the programme to the 18 relevant NW London MPs, inviting them to meet with the programme. This was then followed up with phone calls and meetings with those MPs who asked to meet the programme. All NW London MPs have received the three newsletters. A list of meetings with MPs can be found in Appendix B.

4.4.8.2 Local councils and councillors

All NW London Council leaders, Cabinet Members and key officers received an introductory letter on 1 February 2012. They have also received the Case for Change and each issue of the Newsletter. All NW London local authorities have been invited to send representatives to all three stakeholder events. Representatives from all eight attended the first event. Representatives from six of the eight attended the other two. A list of all meetings with individual councils and councilors can be found in Appendix B.

4.4.8.3 Health Overview and Scrutiny Committees The Joint Health and Overview Scrutiny Committee (JHOSC) is formed by bringing together representatives of each Health Overview and Scrutiny Committee (HOSC) in the area and, if

necessary, in neighbouring boroughs. It has responsibility for scrutinising the programme and its proposals for service change and agreeing whether or not the proposals are considered substantial and whether, therefore, public consultation is necessary. Figure 4.8 summarises the engagement activity that has taken place with individual HOSCs and the JHOSC during pre-consultation. Figure 4.8: Summary of engagement activity with HOSC and JHOSC

Following the meeting on 29 February, HOSC members subsequently agreed to form the JHOSC in shadow form until formal meetings of the relevant councils could officially agree which councillors should be members of the full JHOSC. The first meeting of the shadow JHOSC took place on 4 April to discuss the latest work undertaken by the programme. Specifically, JHOSC members were taken through the presentation explaining how the evaluation of options for change had been based on clinical criteria and on patient and public feedback, and how this was now going to be used to develop the next set of recommendations for consultation. Engagement with individual HOSCs has been ongoing in parallel with individual borough HOSCs. There has been regular attendance by the programme at as many HOSC meetings as possible in every borough. A list of all meetings with individual HOSCs can be found in Appendix B.

4.4.8.4 Health and Wellbeing Boards

On 25 May a Health and Wellbeing Board (H&WB) event was held. Attendees from Ealing, Hammersmith & Fulham, Harrow, Hillingdon, Hounslow, Kensington & Chelsea and Westminster were at the event. Engagement with the H&WBs will be ongoing. Figure 4.9: Summary of engagement activity with H&WBs

6 December 2011 Anne Rainsberry wrote to the nearly 100 members of the various HOSCs in the eight relevant NW London boroughs so that their duties to form a JHOSC could be considered in good time.

16 January 2012 An informal briefing meeting was attended by scrutiny chairs, vice chairs, and/or officers from all eight relevant HOSCs.

29 February 2012 A second meeting of all relevant HOSC members was held to reinforce the need for them to form a JHOSC in April in order for the programme to proceed as planned.

4 April 2012 Full JHOSC meeting (in Shadow Form).

17 May 2012 Full JHOSC meeting (in Shadow Form).

12 June 2012 Full JHOSC meeting (in Shadow Form).

24 May 2012 Principal stakeholder attendees at this NW London H&WB engagement event included:

CCG chairs

H&WB chairs

Borough Directors

DPHs, and

Other shadow H&WB members.

4.4.8.5 Greater London Assembly Members

All Assembly Members, the Mayor and key Greater London Assembly (GLA) officers received an introductory letter on 23 December 2011 from the Senior Responsible Officer for Shaping a healthier future, introducing the programme. They have also received the Case for Change and each issue of the Newsletter. Briefings have also been provided ahead of Mayor‟s Question Time, People‟s Question Time and key meetings. A record of all meetings with individual GLA Members can be found in Appendix B.

4.4.9 Feedback from political stakeholder engagement activities From the different political stakeholder engagement activities some key themes of concern were raised. Figure 4.10 summarises these themes and the responses made. Figure 4.10: Summary of key themes and responses from political stakeholder engagement activities


HOSC o HOSC members agreed to form the JHOSC in shadow form until formal meetings of the relevant councils could officially agree which councillors should be members of the full JHOSC.

o Engagement with individual HOSCs has been ongoing in parallel with JHOSC engagement. There has been regular attendance by the programme at as many HOSC meetings as possible in every borough. Key feedback from HOSCs includes: o Welcomed the proposals to

have more integrated care and more care in a community setting.

o Sought reassurance that all patient groups would benefit

o Reassurance that GPs support the proposals

o That it would create a financially viable future for the NHS

o That carers would get support; workforce development

o The programme confirmed its commitment to continuing to engage with individual borough HOSCs as well as the JHOSC.

o The programme is also committed to providing responses to HOSCs and the JHOSC within 28 days and meeting monthly, 8 to 10 days prior to Programme Board meetings.

The programme has used this feedback in the following ways: o Undertaking an equalities review

to ensure groups are not disproportionally impacted.

o Sought written support from GPs. o Undertaken substantial travel

analysis and convened a travel advisory group (TAG).

o Used peak morning travel times for the analysis to present a worst case scenario.

o Create robust financial models to develop the consultation options and articulate how reconfiguration creates financial stability and sustainability for the NHS in NW

Covered a briefing on:

OOH strategy

Acute services reconfiguration and implications.

o That there would be no financial or service imbalance across NW London

o Parking/access and impact on blue badges and cross borough travel

o Need to emphasise what the different types of hospitals are.

o Need to look at travel/speak to local transport people.

o Need to do more about why things failing now and how they will improve.

o Maternity provision.

London. o The financial models looked at

sites and trusts to ascertain a micro and macro picture of the financial position as a result of various reconfiguration options.

o Developed clear service models for the different hospital types and the core and additional services provided at each type before and after reconfiguration, with patient stories giving the service models context.

o Developed a detailed narrative about what happens if the NHS „does nothing‟, i.e. the quality, clinical, patient experience, and financial implications.

o Developed maternity standards and used this to define the number and types of units post reconfiguration, convened the Clinical Implementation Groups (CIGs) to develop maternity services.

JHOSC (Shadow)

The full JHOSC has now met three times (in Shadow Form) and they have: o JHOSC has input into the PCBC

and the consultation document, including comments about the consultation questions and the narrative.

o Throughout the pre-consultation engagement period, the JHOSC and some individual HOSCs requested various pieces of information from the programme including detailed travel analysis and estates work, which has been provided where possible.

o Ealing OSC requested a presentation on local out-of-hospital providers which was subsequently provided by representatives of the Ealing CCG. Requested information on the technical aspects of the travel time data.

o The programme discussed the consultation timeline with the JHOSC and agreed a two week extension to the standard period to accommodate summer holidays and the Olympics (resulting in a 14 week consultation duration).

o The programme discussed the most appropriate day to commence consultation and agreed the 2 July.

o The programme followed up with the relevant transport official from the borough, the programme convened a Travel Advisory Group and this has representatives from the Boroughs.

o The programme has used the input from the JHOSC to develop both the PCBC and the consultation document.

o We undertook further detailed analysis on travel time analysis (12 June), also covering the equalities analysis and impact on protected groups.

H&WB Board

Shaping a healthier future/ OOH: o There were queries about

The Programme has woven the following key messages into the

(Shadow) schedules and some concern that strategies need to be more closely integrated.

o It was recognised that OOH & SaHF have very significant implications for Borough‟s JHWS for some years.

o H&WB roles and current development There was discussion about the H&WB‟s role in relation to OOH and the balance between it being regarded as a stakeholder verses a partner and the extent to which there was a real opportunity to shape the strategies.

o Engagement to date with OOH and reconfiguration

o It was noted that board away days had proved productive and suggested that boards should avoid overly full business agendas since they need time to explore system transition together.

Challenges and solutions: o It was recognised that the

question of the impact of plans on social care has been raised a number of times already and that whilst everyone recognises this issue nobody appears to have modelled the impact at a local level. This is an area where H&WBs need to assume leadership. NHS NW London might consider how it can support H&WBs to make progress in this area.

o It was noted that Children‟s services are given relatively little attention in OOH strategies and that this involves greater consideration to prevention services and wellbeing.

o It was suggested that H&WBs will not be able to achieve system transformation without working with other boroughs.

narrative of the PCBC: o The urgency of the challenge we

face o The inevitability of system failure if

we don‟t deliver a planned reconfiguration

o The programme has also considered the resources that can be made available to Boroughs to model health and social care impacts

The programme undertook the following in response to the H&WBB: o Consider how to address care for

the elderly and those with LTC, children‟s services, wider determinants, i.e. will a phased approach be adopted or look to advance each consecutively.

o Established the paediatric CIG which will work over the next 6 months to consider implementation issues in greater detail.

o Urgent and emergency care CIG will consider implementation issues in greater detail.

o In discussion with NHS NW London Delivery Support Unit (DSU) on how this fits with implementation support for OOH and engagement with social care.

o Programme exploring the requirement for a further engagement with the Accountable Officers.

NW London MPs

o Some MPs expressed concerns about the proposed closure of an A&E in their area.

o The programme offered follow up meeting to help address these concerns and provide additional information about the proposals.

Tri-Borough Leaders

o Challenge that NHS has not opted out of European Working Time

o Most of the questions here were answered in the session by

Directive (EWTD). o Need to avoid „winners and losers‟

and also be transparent. o Don‟t trust transport figures from

TFL and so you need to talk to H&F transport people.

o People understand what an A&E is but not a UCC.

o Parking and blue badge co-ordination will also be an issue.

o How will people know the best place to go if it is not the A&E?

o Need to do what stroke and care consultation did.

o Should you consult in Nov/Dec instead?

Programme Representative o Commitments were made to

follow up with H&F transport officials, including points on blue badge and parking.

o Programme has established a Travel Advisory Group which meets regularly to provide guidance and oversight of programme travel issues.

Local Councils

Some Councillors expressed concerns around the following issues: o Parking / access and impact on

blue badges holders. o Impact on transport and patient

travel across borough. o Explain the different types of

hospital proposed. o Current situation and why it needs

to improve.

o The programme offered follow up meeting to help address these concerns and provide additional information about the proposals.

o Programme has established a TAG which meets regularly to provide guidance and oversight of programme travel issues.

o The programme has ensured the PCBC contains adequate detail about the case for change and what would happen under „do nothing‟.

5. Clinical Case for Change

This chapter describes why change is necessary and why it must start now. Clinicians looked at the current and future demands on the NHS in NW London and how the current configuration of services is not always delivering the best clinical outcomes and positive patient experiences. The case for change shows that services need to be reconfigured to improve quality and to build a sustainable health economy. The Case for Change was developed by clinicians with involvement from providers, Clinical Commissioning Groups and representatives of patient groups and the public. It builds upon the case for change set out in the 2011 Commissioning Strategic Plan, but represents the specific case for service change in NW London. The key elements of the case for change are set out below. Further detail is available in our full case for change, which was approved by the Programme Board in January 2012 and published as a standalone document which is available on our website www.northwestlondon.nhs.uk/shapingahealthierfuture/6. 5.1 The demands on the NHS in NW London are changing The population of NW London is growing and life expectancy is improving. NW London is forecast to increase by approximately 113,000 people (5.9%) growing from 1.9 million to 2 million in the next 10 years. Ten years ago life expectancy in NW London was 76.8 years for men and 81.9 years for women, but it is now about three years longer: 80 years for men and 84.5 years for women7, particularly due to early diagnosis and improved treatments resulting in fewer people dying prematurely from diseases such as cancer, heart disease and strokes. For the NHS, this is hugely significant because older people are more likely to develop long-term conditions such as diabetes, heart disease and breathing difficulties and are more at risk of strokes, cancer and other health problems. Three out of every five people aged over 60 in England suffer from these kinds of conditions and as the population ages there will be more people with age-related diseases. In NW London some 300,000, nearly one in six, of people all ages have one of the following five long-term conditions: diabetes, asthma, coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), and cystic fibrosis disease (CFD)8. Fortunately, our ability to prevent, diagnose and treat medical conditions is constantly improving. Much of this advanced medical treatment depends on better technology and equipment, operated by more specialised clinicians. Surgeons now specialise in different conditions and different parts of the body: until recently cardiology did not even exist as a speciality, now it is a major clinical speciality with a number of sub-specialities. This in turn means the traditional ways of organising care in the NHS have had to change. A recent report by the King‟s Fund9 has underlined how advances in medicine and surgery have led clinical staff and equipment to become more specialised, leading to specialist teams brought together in fewer, larger hospital sites so that skills can be maximised and patient outcomes improved.

6 Some of the references included in this chapter have been truncated. For full references, please refer to the full

case for change. 7 GP registered population figures used to calculate population weightings of each NW London PCT. Life

expectancies associated with each NW London PCT then multiplied by weightings to produce “average” life expectancy for NW London 8 Source: QOF, Proportion of GP registered population in NW London who are on the CHD, COPD, CFD,

diabetes and asthma registers 9 Reconfiguring Hospital Services 2011

http://www.northwestlondon.nhs.uk/shapingahealthierfuture/

Medical advances also mean fewer hospital beds are needed. Most routine surgery is now done in just one day (“day surgery”) and 80% of all patients have stays in hospital of fewer than three days10. Not surprisingly therefore, the number of hospital beds in NW London has fallen by about 9% over the last five years11. As medicine and surgery continue to become more specialised, and new techniques allow people to go home even earlier, or avoid going to hospital at all, the number of hospital beds will reduce even more. The rise of the internet, mobile communications, and “telehealth12” all provide other ways for patients to access advice about their health and communicate with health and social care professionals. This creates more opportunities to support patients in their own homes and receive services, traditionally based in a hospital, through more local facilities such as GP surgeries. This results in services being moved closer to patients‟ own homes. In financial terms, analysis suggests that Government expenditure on health will only be increasing very slightly in real terms in the years up to 201513. Alongside this, the financial pressures caused by the changing demographic profile and maintaining pace of new technologies would lead to a need for budgets to rise by around 5% per year14, unless we change the way services are delivered. To prudently manage NHS resources, NHS NW London is committed to delivering unprecedented levels of efficiency savings of at least 4% per year. Services also need to be redesigned to be more affordable and ensure that we are spending money in the best way to deliver the best clinical outcomes for patients. 5.2 The NHS in NW London has also been changing The doctors, nurses, other clinicians, managers and staff of the NHS in NW London have been working hard to constantly improve healthcare delivery across hospital, primary care and in local communities. Critical services have started to be centralised where necessary to deliver high quality care:

Major Trauma: People who suffer a serious injury or major trauma need high quality, specialist care to give them the best chances of survival and recovery. From 2010, NW London patients have received new world-class trauma care through the London trauma system. This is made up of four trauma networks, each with a major trauma centre. During the first year the system has saved the lives of an estimated 58 people in London who would otherwise have been expected to die15. The network has prevented disability for many more.

Stroke Services: The provision of stroke services across London, including NW London, has dramatically improved. Only three years ago, stroke care was fragmented across the capital, being delivered in all of the 31 acute hospitals. Now there is a dedicated network of eight “hyper-acute” stroke units operate across London. This new approach is thought to have prevented an estimated 100 deaths per year in NW London16.

At the same time the NHS in NW London has improved the way services are delivered in the community so care is delivered as close as possible to where patients live and is integrated with local hospitals:

10

Hospital Episode Statistics 11

Department of Health 12

Using technology such as the internet to remotely monitor and care for people‟s conditions 13

Where next for NHS reforms? The case for integrated care, The King‟s Fund, 2011. 14

NHS NW London modelling 15

London Trauma Office 16

NHS press article: “Specialist stroke centres save lives across capital”

The STARRS scheme (Short Term Assessment, Rehabilitation and Reablement Service) in Brent has improved the transition for patients between acute hospital services and community services, reducing the need for patients to go to hospital and leading to a much better, more independent quality of life.

Integrated Care Pilot (ICP): The ICP – set up to focus on patients over 75 or with diabetes – overcomes the boundaries between hospitals, community care services, social care and local authorities to allow faster access, streamlined for patients and a stronger focus on their long-term needs. The GP practices involved have initially experienced a 6.6% reduction in non-elective admissions for diabetic and elderly patient groups, compared to 0.3% increase for non-involved GP practices17. This reduction is likely to increase as the pilot becomes fully operational.

5.3 But more change is still needed

To meet the clinical and financial challenges that the NHS faces in NW London, we need to support people to stay healthy and ensure that if they get ill the best community and hospital services are available to them. Significant further change is needed to deliver this to the people of NW London:

5.3.1 To prevent ill health in the first place

Many people in NW London are not as healthy as they could be. There is currently a difference of up to 17 years in life expectancy in different wards in NW London18; heavily correlated with deprivation it is caused by a number of factors: living conditions, diet, levels of smoking and drinking, access to sport and leisure activities, social and support networks, as well as barriers to healthcare, including seemingly obvious things like language and literacy. More needs to be done to promote health and stop people of NW London getting ill. Much can be done through successful promotion of public health information and campaigns that assist people to take personal responsibility for their own health. Also, more proactive primary care and better integrated working needs to happen so that the whole system – from schools, to GPs, from community nurses to hospital doctors – works seamlessly to support everyone to lead healthier lives.

5.3.2 To provide easy access to high quality GPs and their teams

If a basic level of access to GP care is not provided, it can result in more people resorting to using A&E services. These are more costly to deliver and are also “episodic” as they lack the continuity and historical knowledge that a GP practice can provide, resulting in poorer care for the patient. Despite many GP practices in NW London offering a good quality service, many patients still find it too hard to access good quality care. Patient satisfaction in primary care is low in all eight NW London boroughs when compared with national levels, as seen in the table below:

The majority (79%) of GP practices in NW London have below national average satisfaction scores. This could, in part, lead to the higher than average use of A&Es, particularly in outer NW London, for example, emergency admissions are much higher in Ealing and Hounslow compared to the national average

17

NW London Integrated Care Pilot preliminary performance assessment (presented at NW London JCPCT 10

th April 2012)

18 Greater London Authority (London.gov.uk)

Similarly, one in four patients in NW London do not feel that they are being treated by their GP with care and concern

In terms of communication and access (such as communications by the doctor, level of empathy, satisfaction with the out-of-hours service), five of the NW London boroughs rank in the bottom 10% nationally.

Figure 5.1: Primary care patient satisfaction scores for communication and access in NW London19 (percentages of patients reporting satisfaction during 2010/11)

The effectiveness of the delivery of GP services is highly variable and often below national averages. This variation means we are not consistently delivering the kind of high quality primary care we should be.

5.3.3 To support patients with long term conditions and to enable older

people to live more independently In NW London there are big differences in the level of care given to people with long term conditions and the specialist services available to them out of hospital, for example leading to significant variations in the specialist support given to diabetic patients and the level of amputation rates suffered by them20. Figures 5.2 and 5.3 show the variations in funding levels across the different PCTs in NW London for different settings of care and on long-term conditions.

19

GP Patient survey 2010/11 20

Total lower limb amputation rates per 1,000 adults with diabetes vary in NW London (Yorkshire & Humber Public Health Observatory)

Figure 5.2: Funding by PCTs for each setting of care21 (percentage of 2010/11 PCT programme budget spent on setting of care)

Figure 5.3: Spending on long-term conditions across NW London22

If people with long-term conditions are not cared for well enough in the community, they create a heavy burden for our hospitals. NW London currently estimates people living with such conditions account for 67% of all hospital bed days23. Some solutions, such as the Integrated Care Pilot, have been developed within NW London. Elsewhere, a pilot project in Ipswich has helped 107 patients to better manage their own

21

Source: 2010-11 Programme Budgeting Benchmarking Tool Version 1.0.14.12.11.xls 22

Source: Expenditure from 2009-10 programme budget. Number of patients with each LTC - QOF 2009-10 23

Based on Department of Health methodology

conditions with a resulting 75% reduction in GP visits and 75% reduction in bed days in hospital over a six-month period. Staff are being trained to become “health coaches” to their patients. For older people, receiving co-ordinated and effective support from social care, the NHS and the local community delivered together enables independent living. When this works well it can keep people out of hospital and healthier for longer. In hospital older people are at risk of developing further conditions such as delirium, malnutrition, pressure ulcers, venous thromboembolism, hospital acquired infection, incontinence, functional decline, depression, falls and dehydration. Currently, too many older people are admitted to hospital when, with appropriate out of hospital care, they could be treated in the community and looked after in their own home. Equally, at the end of people‟s lives, more want to die at home rather than in hospital, and more needs to be done to enable this. In NW London only 18% of people are dying at home versus a national average of 23% and in contrast to the wishes of 54% of patients24.

5.4 Hospitals also need to change to improve the quality of care While the NHS must focus on keeping people healthy and treating them, where possible, in the community or their own homes, there will always be the need to treat some patients in hospitals. In NW London, however, the NHS is struggling to deliver consistent, high quality hospital care:

Patient experience across NW London hospitals is rated in a lower percentile compared to other regions

Many staff would not be comfortable sending their own relatives to hospitals in NW London

There is marked variation in the quality of acute hospital services in NW London.

5.4.1 To improve patient and staff satisfaction

Patients are regularly surveyed on their experience of hospital services and in NW London these results are mixed. Only the three specialist hospital trusts in NW London have scores substantially higher than the national average when it comes to overall patient experience. Across the other five measures collected by the Care Quality Commission (CQC) non-specialist hospitals scored about the same or lower than the national average. Staff are also regularly surveyed and worryingly in some NW London hospitals a significant number of staff do not “agree” or “agree strongly” that they would recommend their hospital as a place to work or to be treated25.

5.4.2 To make high quality more consistent

In general, the clinical quality of hospitals in NW London compares well to the national average in terms of mortality rates. But there remain significant variations in mortality, for example, standardised mortality rates at Imperial are significantly lower than the other hospitals in NW London26.

24

www.londonhp.nhs.uk/services/end-of-life/case-for-change/ 25

National NHS Staff Survey 2010 26

AES Case for Change September 2011; Dr Foster Ltd

http://www.londonhp.nhs.uk/services/end-of-life/case-for-change/

Figure 5.4: Mortality rates across London Trusts27

A pan-London study in 2011 established that there is a greater than 10% higher mortality rate in London for emergency admissions at the weekend compared to weekdays. We believe this could be addressed by improved consultant cover and access to diagnostics at weekends. Data for London shows that patients admitted at the weekend are more likely to die from an emergency admission compared to a weekday. It is estimated that around 130 lives could be saved across NW London every year if mortality rates for admissions at the weekend were the same as during the week28. Other areas of care also demonstrate variations in quality, for example the proportion of patients who need to be readmitted after receiving a number of procedures varies considerably from one hospital to another. For example, readmissions for cholecystectomy (the surgical removal of the gallbladder) vary substantially. This can be due to multiple reasons, but one reason is differences in the way in which patients are cared for which results in complications after surgery. Figure 5.5: Readmissions for cholecystectomies, April to September 201129

27

Source: AES-Case-for-change-September-2011; Dr. Foster Ltd. 28

High Quality Hospital Provision in London – an Analysis: Quotes 520 lives could be saved across London, NW London estimated to account for 25% of these 29

NW London Performance team

5.4.3 By providing 24/7 access to specialist emergency care Clinical evidence compiled30 has highlighted that for emergency care services, early involvement of senior medical personnel in the assessment and subsequent management of many acutely ill patients improves outcomes, including fewer complications and lower mortality rates. A self-reported survey of London trusts undertaken in 2011 demonstrated that there is considerable variation in the availability of senior experienced staff to care for patients between hospitals and between the service provided on weekdays compared to that at weekends: Findings included:

Senior doctors availability in acute medicine and emergency general surgery at the weekends is more than halved at many sites compared to cover during the week;

Patients admitted on a Saturday have a 16% greater chance of dying than if admitted on a weekday, with a corresponding figure of 11% on a Sunday

This is a group that has the least access to senior clinicians and diagnostics when they most need it.

The diagram below shows the significant reduction in review of emergency surgery admissions by senior doctors at weekends compared to weekdays. Figure 5.6: Emergency general surgical admissions reviewed by a consultant within 12 hours (London)31

It is known that in NW London, four hospitals are not always meeting the best practice guidelines of emergency general surgery admissions seeing a consultant within 12 hours. The Royal Colleges have recommended increased consultant presence, in particular to cover emergency and maternity services. Achieving such increased coverage is a huge challenge nationally as well as in NW London:

30

National Confidential Enquiry into Patient Outcome and Death (2007); Emergency admissions: A step in the right direction, NCEPOD; Royal College of Surgeons (2011), Emergency Surgery, Acute Medical Care (2007) Royal College of Physicians; Report of the acute medicine task force, Royal College of Physicians. 31

Source: Survey of London acute trusts (2011)

Units need to serve a sufficiently large population so that they are busy enough out-of-hours for staff to maintain their skills in dealing with complications. This is a particular issue for senior staff who must also spend time fulfilling other responsibilities

Only larger units can afford to employ an increased number of senior staff, with many smaller units already being on the margins of economic viability due to junior doctors now working fewer hours

There is insufficient staff available to provide such increased cover across all units, even if it could be afforded and skills could be maintained.

Just as staff need to maintain their skills, so specialist teams gain skills because of the increased numbers they treat. It is well established that the more specialised doctors and other professional staff become, the better the results for patients32. For example, patients treated by a specialist surgeon are at a lower risk of death, are likely to have fewer complications and are likely to benefit from shorter stays in hospital33. Specialists become proficient by dealing with large numbers of similar cases. By being located in specialist centres and working as part of a network of specialist staff, specialists can access the best equipment and develop their skills by working alongside other specialists. There are some excellent specialist centres and networks already benefitting patients and carers in NW London. However there are other areas of clinical practice which would also benefit by being centralised in a few centres of excellence, such as specialist laparoscopic (keyhole) surgery34,35. Laparoscopic surgery is associated with faster recovery times and can improve patient outcomes, yet at Ealing hospital only a third of surgeons providing emergency care are able to perform laparoscopic surgery. However, other very specialist services, for example, cardiology, oncology (cancer), vascular surgery and neurosurgery, need to be delivered in larger centres of excellence with specialist staff, equipment and facilities. With increasing specialisation and guidelines setting standards for the degree of experience staff need to get to be sufficiently qualified, it is becoming increasingly difficult for the NHS in NW London to sustain the specialist surgical and other teams needed and ensure they see the volume of cases to enable specialists to maintain and develop new skills and sub-specialise across all our current sites. With NW London‟s growing population it is increasingly hard to provide a broad range of services around the clock at the existing nine acute hospital sites to the standards we believe our patients should expect. We have more A&E departments per head of population than other parts of the country and this makes it harder to ensure enough senior staff are available. Currently only one trust in NW London is currently providing the level of consultant cover recommended by the College of Emergency Medicine. Even with the current configuration of A&E services nationally, four NW London hospitals have a catchment population smaller than average, as shown in figure 5.7. In addition, all but one (Northwick Park) have a catchment population smaller than the Royal College of Surgeons preferred level.

32

Hall, Hsiao, Majercik, Hirbe, Hamilton, The impact of Surgeon Specialization on Patient Mortality; Annals of Surgery 2000 33

Chowdhury, Dagash, Pierro. A systematic review of the impact of volume of surgery and specialisation on patient outcome; British Journal of Surgery, 2007. 34

NHS London, Adult emergency services: acute medicine and emergency general surgery, 2011 35

Profile of health and services in South West London, Report of the Clinical Working Groups, July 2011

Figure 5.7: Catchment population of A&E provision in NW London36 (‘000 population per A&E)

Residents in NW London currently enjoy excellent access to acute services, with travel times between hospitals being relatively short in comparison to other areas of the UK. However, medical evidence clearly indicates that for life-threatening conditions, for example a heart attack, stroke or major trauma, the clinical outcome is far more dependent on getting to the right specialist service than it is on small differences in travel times. Indeed, NHS London has already implemented pathways of care that take patients with major trauma, acute heart attack or stroke to designated centres, even if that means going past another acute hospital. The clinical benefit, in terms of improved survival and reduced disability from the implementation of these pathways, has been proven. If high quality hospital care is to be delivered, there is a clear need to consolidate some services in NW London. 5.5 The NHS in NW London can face the challenge and use reconfiguration to change

the way our services are provided – across hospitals and in the community

In order to meet these challenges and improve the quality of care provided across NW London, we believe we need to “reconfigure” our services and change the way they are currently provided across our hospitals, GP practices and other community care sites. This will mean we will need to review the current pattern of hospitals in NW London. We need to ensure that people in NW London have access to the right care in the right places. Higher quality, more effective treatments for patients need to be provided more consistently where they are needed, within higher quality, more up-to-date, safer places. Care needs to be provided in a more integrated way, in partnership with social services and local government, so that it is clear to patients who is managing their care and that they can seamlessly transition between care settings.

36

Estates Return Information Collection, 2010/11; ONS. Assumes 200 A&Es in England; Includes small, medium, large, teaching and multi-service acute Trusts, excludes specialist Trusts; sites with over 10,000 admissions; Assumes Hammersmith catchment travels to St. Mary‟s; Estimated catchment populations for individual trusts in NW London; England populations ONS mid-2009 estimates;

More investment needs to be made in GP services and other local healthcare, so it is more consistent and of a higher standard, bringing better routine treatments closer to home and supporting more services outside hospitals, where they are needed. Alongside this, clinical teams need to be established so patients needing specialist treatment can be certain they will be seen by experienced specialist clinicians, who are familiar with, and who regularly treat, similar patients with their condition. This also implies more efficient use of NHS buildings and equipment and more targeted investment in both, as well as reduced management costs by planning care across a larger area and achieving savings on a larger scale. 5.6 Significant investment is required to improve NW London’s NHS hospital estate

as well as improving primary and community care facilities

NW London spends more on hospital buildings than the NHS does in other parts of the country and, as a result, spends less in the community. The amount of space per bed is approximately 50% larger than in the rest of the country, and consequently NW London has higher fixed costs and as well as having hospitals that are more expensive to run and maintain than average. Figure 5.8: Size and use of NHS acute estate in NW London37

The physical condition of much of the NHS estate in NW London is poor:

Three quarters of hospitals require significant investment and refurbishment to meet modern standards, at an estimated cost of approximately £150 million38 – we need to prioritise where we invest to maximum effect as capital funding is a scarce resource.

37

Source: Estates Return Information Collection, 2010/11; ONS (Includes small, medium, large, teaching and multi-service acute Trusts, excludes specialist Trusts; sites with over 10,000 admissions). Estimated catchment populations for individual trusts in NW London; England populations ONS mid-2009 estimates 38

ERIC Site-level data, HEFS, 2010/11

Catchment population1 per acute

hospital site

„000 population/site

Gross Internal m2 per 1000

population

259

211-19%

England

Average

NWL

363393

NWL England

Average

+8%

NW London has a smaller catchment NW London uses more space

In addition, primary and community care requires further investment – for example, GP practices in Ealing would require £6.5 million investment to meet statutory requirements and guidelines, at an average of £81,000 per practice39.

Ealing has 80 GP practices. As Figure 5.9 shows, only 4% of GP practices were meeting statutory requirements and guidance at the time of the last estates review. Figure 5.9: Evaluation of primary care estate against statutory requirements and guidance in Ealing (numbers of GP practices)40

5.7 Summary NW London needs to move from the current set-up of what services are provided, where they are located and how they are „balanced‟ between primary and secondary care providers. Therefore, in providing a recommendation for how services should be configured going forward this pre-consultation business case sets out how we will address the issues identified in the case for change. In particular:

Chapters 7 and 8 set out our vision for care in NW London, describing the clinical standards and clinical service models local clinicians have defined in order to address the issues raised in the case for change (this includes further analysis on specific areas such as maternity services and paediatrics in Sections 7.8.2 and 7.8.3).

Chapter 9 explains the benefits local clinicians, commissioners and providers hope to achieve as a result of the vision and shortlisted options.

Chapters 11 to 15 set out how we have considered the options available to us to address the case for change and implement that vision.

39

Ealing Facet Surveys 2008/09 summary findings, Ingleton Wood 40

Ealing Facet Surveys 2008/09 summary findings, Ingleton Wood

6. Financial base case

This chapter describes the financial imperative for change. Commissioners must save £243 million to make the system sustainable and to provide enough money for the necessary investment in out of hospital care. This provides the base case against which any proposed option can be assessed. This is in addition to the cost improvement plans of hospitals themselves, designed to respond to the planned decrease in tariff over the next three years. This chapter sets out:

The scale of the financial challenge across NW London

The approach to modelling

Savings identified by commissioners

The challenges facing acute trusts to implement QIPP

The bed capacity base case. All additional information supporting the financial analysis and modelling carried out during pre-consultation may be found in Appendix C. 6.1 Commissioners and providers face extreme financial pressures

Although the Government‟s pledge to protect health budgets meant they fared well compared to some other areas of public spending, expenditure will only be increasing very slightly in real terms in the years up to 2015. Against this, the financial pressures caused by the increasing age of the population, the increased burden of more ill health and the need to keep pace with new technology would need growth of 5% each year unless we change the way services are delivered. As a result, the 2010 Spending Review committed the NHS to finding £20bn in productivity improvements by 2015 to reinvest in services to meet increasing demand. This means the NHS is required to deliver efficiency savings of at least 4% a year – something which has never been delivered before. NHS NW London is one of the largest PCT Clusters in England. The total spend in the NW London health economy is £3.5 billion, which represents 24% of health expenditure in London. Based on current services, by 2014/15 an estimated additional £1 billion of funding would be needed above that which is likely to be available, in order to keep pace with expected increases in demand. This pressure would broadly fall one third for commissioners and two thirds across all the providers (acute and non-acute).

Figure 6.1: Projected funding gap for NHS NW London41

The projected funding gap shown in Figure 6.1 is based on modelling work undertaken before Shaping a healthier future. The North West London Reconfiguration modelling supersedes this earlier modelling. 6.2 Approach to modelling

A major part of any future configuration of health services in NW London is the degree to which it can help address the financial challenge and create a sustainable health economy. In order to assess any proposal for the configuration of services, we therefore need to assess it against a base case or “do nothing scenario” by carrying out financial modelling. The financial modelling has been overseen by the Finance & Business Planning Group. The group has as its members all NW London Financial Directors (PCTs, NHS Trusts and FTs), with the exception of the Royal Marsden. The data collection took place during January and February 2012, so the starting point for the financial forecasts is the 11/12 year-end projections based on the Trusts‟ forecasts at that time. All key assumptions have been agreed by the group. It is recognised that further work will be required to complete a „Generic Economic Model‟ (GEM) to support any capital business cases. The Strategic Health Authority recommends that this is undertaken before final decision-making. The objective of the analysis is to provide an assessment of the relative value of the potential reconfiguration options compared against each other and against the „do nothing‟ scenario (where no reconfiguration is undertaken). Therefore, the focus of the modelling work is on those factors that differentiate between the options. The objective is not to attempt to account for all of the potential drivers of future finances that would be needed to accurately forecast Trust and site level income and expenditure at a level required to produce a long term financial model (LTFM) for each provider that would meet Monitor

41

HfL, NHSL planning guidance, local planning assumptions

requirements. Subsequent Business Cases will be required to support specific investments in both Out of Hospital transformation and acute reconfiguration. The approach to the financial analysis includes:

Scope of the analysis

The commissioner view includes the budget and forecast spend for all CCGs in NW London

The acute reconfiguration analysis covers 9 acute sites in NW London: St. Mary‟s, Charing Cross, Hammersmith (including Queen Charlotte‟s), Chelsea & Westminster, West Middlesex, Ealing hospital (excluding community care services), Central Middlesex, Northwick Park & St. Mark‟s, Hillingdon hospital (does not include Mount Vernon). All other sites are excluded from the reconfiguration analysis

Community care providers and the community care part of Ealing CHS are not included in the analysis.

The initial phase of the modelling developed Trust I&E forecasts pre-reconfiguration, called the „do nothing‟ scenario. These forecasts are based on:

Activity and income changes due to commissioners‟ plans, and assumptions on tariff changes

Cost changes due to changes in activity, cost inflation and Trust productivity opportunities (informed by peer benchmarks, and agreed with Trust representatives on the F&BP group)

The forecasts are based on explicit assumptions on each variable up to 14/15, then income and cost assumed to be in steady state in subsequent years.

The second stage modelled the changes due to reconfiguration options:

Activity movements in line with the assumptions for how patient flows will change, developed and agreed by the Clinical Board

Capacity changes due to activity and bed movements

Capital requirements to build new capacity, move services between sites, build new Local Hospitals and dispose of existing assets. The estimates focus on the required capital programmes directly related to the reconfiguration options and are not intended as a comprehensive estimate of the total future capital spend

Cost changes due to changes in activity, consolidation savings and changes in fixed costs.

Each reconfiguration option was evaluated against five „value for money‟ (VfM) metrics to provide a comparative assessment of the options. The Finance & Business Planning Group reviewed all of the detailed findings and the summary evaluation scores when assessing the overall viability and relative strengths and weaknesses of each option. The findings from this F&BP group were then presented to the Programme Board for their assessment of the options. The third stage stress tested the initial assessments through a series of sensitivity tests on the main variables that determine the VfM evaluation. All of the options were tested against each sensitivity to determine changes in the relative ordering of the options against each other, and the relative value compared to the „do nothing‟ scenario.

Outputs of the second stage of modelling may be found in Chapter 14 and outputs of the third stage of modelling may be found in Chapter 15. The detailed assumptions to support all financial analysis undertaken, including the „base case‟ scenario modelling, may be found in Appendix C.

6.3 Savings identified by commissioners Commissioners in NW London will need recurrent savings of £243 million by 2014/15 which combines plans to deliver £381 million of gross savings and set aside £138 million for investment. This investment includes that required to support the transformation of care provided Out of Hospital. Figure 6.2 sets out the NW London commissioning budget, spend, QIPP savings and investment that will be required from 2011/12 to 2014/15. Figure 6.2: Summary of NW London commissioning budget and spend from 2011/12 to 2014/1542

As part of the QIPP plans, commissioners have determined where the savings of £381 million are planned to come from. This is set out in Figure 6.3. Around 60% of these savings are planned to come from the acute sector, which is in proportion to the current overall spend in this area.

42

NW London Commissioning Service Plan 1 Dec 2011; Revised QIPP figures 1 Feb 2012.

Figure 6.3: Summary of planned gross QIPP savings by service up to 2014/1543

With acute settings needing to deliver the majority of savings, the remainder of savings required are planned relatively evenly across the remaining settings of care. CCG plans have already identified £219 million of the £228 million acute savings needed. To achieve these savings will require an estimated investment of £84 million in out of hospital services. This is shown in Figure 6.4. If the same investment to saving ratio is assumed for the remaining 4% of acute savings needed, then a reinvestment of £87 million will be required to deliver the full £228 million acute savings.

43

NW London QIPP database 2011/12 (15th Dec 11) – revised 1 Feb 12.

Figure 6.4: Identification of planned acute savings44

Just under half of the QIPP savings to be realised in acute settings is in non-elective activity. A slightly lower amount, £84 million, is planned to be saved in outpatient activity. Smaller amounts, £13 million and £21 million are to be made in A&E services and elective services respectively. The proportion of investment to be made in Out of Hospital services mirrors the gross savings required, with the majority (around £73 million) to be invested into non-elective and outpatient services. Overall, commissioners will see a net saving of £135 million. The ratio of investment to savings required is 1:2.6 thus demonstrating significantly improved value for money. To check the „reasonableness‟ of the estimated savings set to come from the different types of activity within the acute setting, these figures were compared with the bottom up estimates that were developed by CCGs. CCGs have developed bottom up plans based on QIPP initiatives, and these planned savings closely match the initial estimates, with a small amount (£9 million) of further savings still needed. The full requirement for savings has been used to model the financial outlook for the acute sector before reconfiguration. 6.4 Acute Trusts face challenges to implement QIPP

Further financial modelling was carried out to determine where the acute savings would come from both in terms of the service areas and the Trusts. The QIPP savings of £228 million represent a 9-15% reduction in acute income prior to demand growth, mainly focused on outpatients and non-elective activity. The planned gross QIPP savings for NW London for each Trust are set out in Figure 6.5.

44

Commissioning Service Plan, 1st December 2011; QIPP plans 15th December 2011; QIPP revision; Healthcare for London; HES; CCG input and expert interviews; NHS DSU; CCG finance teams

Figure 6.5: Planned QIPP savings for each Trust according to type of service45

While Imperial will need to make the greatest amount of savings in monetary terms, £78 million, West Middlesex and North West London Hospitals need to save the largest proportion of their income, around 15%. Inflation, tariff rises and QIPP savings mean that the acute sector will struggle to be financially viable in the „base case‟ before reconfiguration, even with unprecedented productivity savings. Most relevant to analysis of any service reconfiguration will be the effect of these combined factors on each of the nine non-specialist hospital sites in NW London. This is shown in Figure 6.6.

45

Revised QIPP analysis Feb 2012.

£m, % From NWL commissionersFrom non-NWL1 commissionersPercent of 11/12 income

1 QIPP f rom outside NWL assumed to be proportional to income f rom outside NWL, except Imperial where no QIPP was assumed for non-London income

due to specialist nature of the work

Gross QIPP for NWL commissioners, by Trust and POD 12/13 to 14/15

13

Chelsea

& Westminster

West Middlesex

9

14

Imperial1 35

Hillingdon

11

13

North West

London Hospitals 22

Ealing

20

10

26

4

6

12

23

4

2

2

1

1

2

5

1

1

2

3

1

2

3

42

26

53

14

21

36

78

4

2

0

7

0

13

1

-9% 6%

-11% 6%

-15% 8%

-12% 8%

-15% 7%

-14% 7%

Total from NWL

commissioners only

96 84 11 14 22 228

Total acute

QIPP for NWL commissioners

ElectiveA&ENon-elective Outpatient TotalPercent of

11/12 incomeOther

Demand

growth (% of 11/12 income)

Other (incl.

Outside NWL

Figure 6.6: Financial ‘base case’ forecasts for hospital sites in NW London in 2014/15

Figure 6.6 shows that the forecasts indicate that NW London would face an overall deficit of £8 million in 2014/15. Four sites, West Middlesex, Central Middlesex, Northwick Park and Hillingdon, would all be in deficit by £1 - £10 million. Four sites would be „borderline‟, St Mary‟s, Hammersmith, Charing Cross and Ealing. Only one site, Chelsea & Westminster, is forecast to make a sufficient surplus that would ensure that it remains viable going forward. These forecasts are the result of a detailed financial analysis undertaken by the NHS NW London Finance & Business Planning group. At a high level, the main drivers of the differing financial positions are:

Cost inflation: +2.2%

Tariff deflator: -1.8%

Demand growth: 2.5-3.0%, varying by CCG

QIPP: approx. -4%, varying by CCG and area of activity (i.e. non-elective, outpatient, etc)

Productivity savings: 4.7-5.4%, varying by Trust. These forecasts provide the central case. There are potential circumstances which would result in a much larger overall deficit. These circumstances could include scenarios where Trusts do not deliver these unprecedented levels of productivity savings or where higher pay or non-pay cost inflation occurs. The financial downside case is shown in Figure 6.7.

Figure 6.7: Financial ‘downside to base case’ forecasts for hospital sites in NW London in 2014/1546

If circumstances led to the downside being realised, all the acute sites in NW London would be in deficit, with an overall deficit of £122 million. 6.5 The bed capacity base case

Alongside the impact of Commissioner QIPP, Trusts also need to deliver their Cost Improvement Programmes (CIPs). A significant component of the CIPs is the need to reduce the average length of stay. The effects of QIPP and the length of stay reductions means that number of beds needed in the future will be less than the requirement now. The effect of QIPP and CIP on the bed requirement is shown in Figure 6.8.

46

NW London Reconfiguration modelling

Figure 6.8: Summary of estimated surplus of bed capacity47

After commissioner changes and length of stay reductions, it is estimated that there are 1,005 adult acute beds of spare capacity in the sector. The net effect of changes due to demand and commissioner strategy leads to a reduction of 380 beds. In addition, reductions in the average lengths of stay leads to a further reduction of 418 beds. Taking account of these reductions and unused beds of 181, there is a total a reduction of 979 general beds. Having this number of beds without reducing the number of sites is an inefficient and expensive use of buildings. The reduction in the number of beds continues a trend that has seen the number of beds in the NHS decrease over the last 30 years as clinical practice changes. Figure 6.9: Average daily number of available beds, by sector – England – 1987/88 to 2008/9

47

Trust submissions 2012; “Base case” forecast model.

6.6 Conclusion

NHS NW London needs to address the financial challenge that it faces in the coming years. Commissioners have developed plans for how to make savings and reinvest these savings in out of hospital care. The programme has carried out analysis to assess the potential impact of doing nothing and this base line scenario shows a deficit across NW London providers of £8 million. If inflation is higher than expected and there is a shortfall in planned efficiency savings, this could be significantly greater.

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