developing a sustainability and transformation plan for north east London

Better health and care: developinga sustainability and transformationplan for north east LondonA summary of progress to date

Draft, subject to change Autumn 2016

Everyone living in north east London should liveindependent and healthier lives, and for this to happen, the National Health Service needs to improve and change.In order to achieve this, the NHS and councils are workingto develop a Sustainability and Transformation Plan (STP)for north east London.

The STP plan will turn the ambitions of the NHS Five YearForward View into reality. It is still being developed, andneeds the input of local people before it is finalised.

The Five Year Forward View

The NHS Five Year Forward View is astrategy for the NHS in England. Itsets out the gaps in health and socialcare, describing how the quality ofNHS care can be variable, preventableillness is widespread, and healthinequalities deep rooted.

People’s needs are changing, newtreatment options are emerging, andthere are challenges in areas such asmental health, cancer and support forfrail older patients. Pressure on NHSservices continue to increase.

The NHS Five Year Forward View setsout solutions for the future basedaround new models of care (changingthe way care is delivered) andhighlighting the importance of publichealth and ill health prevention,joining-up services across health andsocial care, empowering patients andcommunities, strengthening primarycare and making further efficienciesin the health service.

2

Our vision is to:

Measurably improve health andwellbeing outcomes for the peopleof north east London and ensuresustainable health and social careservices, built around the needs oflocal people

Develop new ways of working toachieve better outcomes for all,focused on the prevention of illhealth and out of hospital care

Work in partnership to plan,commission (buy), contract and deliverservices efficiently and safely.

Draft, subject to change


Clinical commissioning groups, local authoritiesand NHS provider trusts (hospitals, communityservices and mental health services) are workingtogether to drive genuine and sustainable change,putting the patient and their experience at theheart of quality improvement and achievingimproved health outcomes in the longer term bydeveloping the STP for north east London. Thisinvolves over 20 organisations:

Clinical commissioning groups (GP-led groupsresponsible for planning and buying NHS services):Barking and Dagenham, City and Hackney,Havering, Newham, Redbridge, Tower Hamlets andWaltham Forest.

Local authorities: Barking and Dagenham, City ofLondon Corporation, Hackney, Havering, Newham,Redbridge, Tower Hamlets and Waltham Forest.

Providers: Barking, Havering and RedbridgeUniversity Hospitals NHS Trust, Barts Health NHSTrust, East London NHS Foundation Trust,Homerton University Hospital NHS FoundationTrust, NELFT NHS Foundation Trust.

We are also working with GP provider groups,colleagues from NHS England, NHS Improvement,Health Education England and UCL Partners.

Working together to achieve change

3

It will only be possible to improve health and care in northeast London with support and input from local people. This document includes our early thinking, but we will beembarking on a wide ranging engagement programme todiscuss these plans with you. No plans will be implementedwithout the appropriate engagement and, where required,consultation with local people.


Our population is projected to grow at thefastest rate in London with an 18% growth over15 years (345,000 more people, the equivalentof a large borough).

There are high rates of people being admitted tohospital with conditions that could be cared forin the community.

A&E use is increasing in most boroughs.

There are highly deprived areas, with manyresidents challenged by poor physical and mentalhealth which is linked to factors such as lowincomes, poor housing and high rates of smoking.

There are generally high rates of physicallyinactive adults, which can lead to diabetes,dementia and obesity, all of which are morecommon in people living in poverty.

People are living longer, meaning that theyrequire more care and support later in life, andconditions linked to ageing such as dementia arebecoming more common. We have higher thanaverage rates of childhood obesity and belowaverage immunisation rates.

Two of our three hospital trusts are in specialmeasures, meaning there are concerns about thequality of care they provide.

More people than average find it hard to get anappointment with their GP.

There is a national shortage of GPs, and manylocal GPs are nearing retirement age.

The money we spend on health and care willincrease significantly over the next few years butthe money available to us will not.

Working together to address these challenges willgive us the best opportunity to make sure healthand care services in north east London aresustainable by 2021.

Why do we need a new plan for health and care?

4

Our challenges in north east London:

Benefits to patients andcommunities

You will be empowered to be independentand take responsibility for your health and wellbeing

You will live longer and healthier lives by reducing the chances of major healthrisks such as obesity, smoking and alcohol misuse

You will find it easier to use urgent andemergency care

Your care will be provided in modern, fitfor purpose buildings that are welcomingfor patients and staff

You will find it easier to use primary care,with some services operating from 8am –8pm, seven days a week.


1 Promoting prevention and self-care – to reduce the burden on health care services,we want to encourage more people to lookafter themselves and their health so that theystay well.

2 Improving primary care – to meet the risingdemand placed on our primary care services, we will transform primary care by workingtogether and using multi-disciplinary teamscomprised of community, social care andhealthcare professionals.

3 Reforming hospital services – most of ourhospital care does not currently meet therequired standards. We will change this byreforming hospital care through redesigningpatient pathways and working together more closely.

The STP is a plan for working together across northeast London where it makes sense to do so.Aligned to the STP are a number of local plans thathelp achieve our ambitions:

Hackney: devolution pilot, bringing health andsocial care providers together to deliver anintegrated, effective and financially sustainablesystem that covers the whole range of wellbeing. To find out more: www.cityandhackneyccg.nhs.uk

Barking and Dagenham, Havering andRedbridge (BHR): as a devolution pilot BHR isexploring bringing health and social care servicestogether to deliver better outcomes for residents,including the option of a single local accountablecare organisation. To find out more:www.bhrpartnership.org.uk

Newham, Tower Hamlets and Waltham Forest:a partnership between Newham, Tower Hamletsand Waltham Forest CCGs and Barts Health NHSTrust, involving many other organisations andstakeholders. It aims to deliver safe, sustainable,high-quality services to improve the local healthand social care economy in east London – in linewith the challenges of the NHS Five Year ForwardView and the established case for change.www.transformingservices.org.uk

In north east London there are also two ‘vanguard’programmes, aimed at supporting improvementand integration of services.

Each vanguard site has freedoms and flexibilitieswhich they would otherwise not have in order todeliver innovation at pace and share their learning.

These are:

Urgent and emergency care vanguard

Local GPs, hospitals, community services andcouncils are working across Barking andDagenham, Havering and Redbridge to transformurgent and emergency care services. This ishappening by changing the way people use urgentcare locally, creating a simplified, streamlinedurgent care system that delivers intelligent,responsive urgent care for local people. For moreinformation: www.bhrpartnership.org.uk

New models of care vanguard

In Tower Hamlets local health and care partners aredeveloping new ways of working to provideintegrated and person-centred care to local people,including looking at how to transform the waycare is provided to adults with complex needs andchildren and young people. With a focus onprevention and being able to use high qualityservices, the vanguard will improve physical, social,emotional and cognitive development and improvelife-long health and wellbeing. For moreinformation: www.towerhamletsccg.nhs.uk

Solving our challenges

5

Our top three ambitions are:

Draft, subject to change6

Our approach

1 Make sure we have the right healthand care services in the right placeto care for our growing population

Our growing population is putting pressure onour health and social care services. We need tofocus on preventing illness, improving primarycare (GP) services and making sure there arebeds in our hospitals for those who truly needthem. We can make this happen by:

Changing the way people use health services by focusing on prevention and self-care,equipping and empowering everyone to helpthemselves where possible

Making sure our urgent and emergency caresystem directs people to the right place firsttime, with proactive, easy to use primary care at its heart

Offering effective outpatient care, so hospitalbeds are only for those who really need to be admitted

Making sure our hospitals work together, and with community and social care to deliverseamless, patient-centred care

Making sure our buildings and our workforcecan support local people from cradle to grave.

We have identified six priorities to focus on across north east London:

Spotlight on… Maternity

Why things need to change: There isincreasing demand for maternity services,and more pregnant women requirespecialist support.

Our vision: Services that are centred onwomen and families that are caring,compassionate and offer the very bestexperiences of safe care, with kindnessand choice at the heart of this offer.

How we will achieve this:

We will focus on:

• Improving the experiences women who use our maternity services have

• Increasing opportunities to give birth in midwife-led settings

• Improving transitional care for motherswith babies in a neonatal intensive careunit (currently being piloted)

• Developing models of care that makecontinuity of care the norm for allwomen, not just those withstraightforward pregnancies

• Making the maternity system moreefficient and supportive of women’schoice and support maternity staff togrow and develop to bring about these changes

• Making sure there is universal access to the right mental health services forwomen before and after they give birth

• Supporting self-care / personal healthbudgets for women.

2 Transform the way care is provided:encourage self-care, offer care closeto home and make sure secondarycare is high quality

We will empower people to manage their ownhealth and wellbeing where possible, and makesure the care they receive is of a consistentlyhigh quality. We want to make this happen by:

Transforming primary care by addressing areas ofpoor quality/access, including offering care from8am to 8pm, seven days a week.

Making sure that people receive high quality carein the right setting, ideally close to their home.

Delivering coordinated care to support thehealth and wellbeing of people with complexhealth and social care needs.

Making sure that when people fall seriously ill orneed emergency care, hospitals provide strong,safe and high quality services.

Improving hospital services: delivering betterurgent and emergency care, coordinatingplanned care/surgery, offering more birthingoptions and encouraging hospital trusts to work together.

Changing the way and order that people aretreated (triage) in urgent and emergency care so that patients receive the right care at the right time according to their needs. Onlypatients who need more intensive care shouldbe admitted to hospital, reducing the demandfor costly hospital beds.

Developing outpatient care so it is provided inthe community where possible. Developingservices that provide planned, short termintensive help so people can stay independent,rather than have to go into hospital.

Draft, subject to change 7

3 Secure the future of our health andsocial care providers

Many of our health and care providers facechallenging financial circumstances, andalthough they have made significant progress inimproving services and making savings, moreneeds to be done to make sure we have betterquality, innovative services which deliver valuefor money. The challenge is to work together to develop a plan to support organisationsproviding local services. This will involve:

Changing the way services are provided sofewer people attend or are admitted tohospitals unnecessarily (and that those who are admitted can be treated and discharged more efficiently).

Driving greater efficiency and productivityinitiatives within and across organisationsproviding services (e.g. procurement, clinicalservices, back office and bank/agency staff).

Looking at ways to work together more formally.

Exploring opportunities for the NHS to workmore closely with councils through localdevolution pilots.


Spotlight on… Cancer

Why things need to change: In north eastLondon (NEL), cancer screening uptake isbelow the England average and emergencypresentation is 5% higher than the nationalaverage. There needs to be a step change indiagnosing cancers quicker and earlier,increasing uptake to screening, andreducing variation in how care is provided.

Our vision: Fewer people in NEL get cancer and those who do are diagnosedmore quickly. People with cancer have animproved chance of survival, with timelyaccess to high quality modern treatments sothat they live well after treatment and havea better experience throughout their care.


We will focus on:

• reducing emergency presentations,making sure more people with cancer will see a doctor and bediagnosed sooner

• reducing new primary cancers andrecurrence in people surviving withcancer

• improving one-year survival rates

• making sure all people with cancer are cared for by high quality patientcentred services, during and after their treatment

• supporting people living with cancer as a long term condition, making sure95% of patients have an agreed aftertreatment plan

• achieving world-class cancer outcomes,as set out in the National CancerTaskforce Report by 2020.

How things could work…. Virtual kidney clinics

Normally, if a GP thinks a patient needs more specialist care, they will be referred to a face-to-face outpatient clinic at a hospital. There the patient may undergo tests and be assessed by aconsultant to diagnose their condition and work out a treatment plan. Because of the rapidlyincreasing demand for healthcare services, sometimes people can wait two months or morefor an appointment.

This year a new service in east London was launched where patients with a risk of developingkidney problems are referred to a virtual clinic. This involves a specialist reviewing a patient’selectronic GP notes and any tests that have been done in primary care, often within five daysof a referral. The specialist then advises the GP and patient what should happen next –whether it’s advice about how to monitor and look after their condition, or to have furthertests or treatment.

All of this means that more people are provided with specialist advice, earlier and faster.Patients are also more able to look after themselves and help prevent their conditionworsening. It also means that only those that need one have a face-to-face outpatientappointment, reducing demand and waiting times for appointments.

We aim to roll out these pilots further across north east London, and share the learning withother areas.



4 Improve specialised care

Specialised services are expert services such assome treatment for rare cancers provided inrelatively few hospitals and used by smallnumbers of patients. Demand for these servicesis growing, and we need to work with otherNHS organisations in London to become a worldclass destination for specialised services. Theareas we’re looking at include specialised cancer,renal, cardiac, neonatal and paediatric care.

Spotlight on… Primary care

Why things need to change: Our population is growing and people are living longer, andin poor health with complex care needs. This means increased demand for primary careservices (29% population increase in some boroughs) and there is a variation in quality ofprimary care services.

Our vision: high quality, locally responsive primary care, making it easier and more convenientto use GP services, shifting the balance of work to proactive and planned care, with GPsproviding an ongoing relationship for care coordination for patients, seamless delegation tothe extended primary care team, and GPs freed up and enabled to spend time with patientswith complex conditions on person-centred, planned and preventative care.


We will focus on:

• More people being able to use pre-bookable primary care

• Making sure all practices are operating within routine opening hours and that flexibleappointment lengths are available for people’s different health needs

• Encouraging practices to improve patient participation and engagement

• Establishing social prescribing pilots

• Increasing uptake of Patient Online and the number of bookable slots available online

• Making it easier for patients to contact their GP practice and have same day contact with aclinician if they need it

• Providing a better service for patients with complex conditions who need care from morethan one health professional

• Empowering patients to look after themselves (self-care) and remain healthy


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LeisureEducation

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MaternityAcute physical and mental care

Emergency careSpecialised services

Promoting prevention and self-care

Improving primary care Reforming hospital services

WorkplaceHousing

Self-service care

Self-carePeer-led services

Voluntary sector servicesHome-based support

Mental health servicesChildren’s servicesSocial care services

Opticians/dentists/pharmaciesGPs

Integrated multi-disciplinary teamsSupport from volunteers

Benefits to patients and communities

Shorter waiting times

Health and care services will be more efficient and easier to use

You will be supported to be independent in your own home for as long as possible

Improved access to specialist services locally and within London, saving some patients long journeysto other locations elsewhere in England

Improved outcomes through faster access and earlier diagnosis

Greater opportunities for innovation

Our approach in summary

5 Work together to tackle challenges, identify solutions, make decisions and improve thehealth of local people

We need to change the way we work if we areto improve care and create models of care thatare truly people-centred and sustainable. Thiswill involve:

pooling health and social care budgets

joining previously separate services, wherepractical

close working between local authorities, theNHS and other voluntary and communityorganisations.

6 Use our buildings better

We want care to be provided in modernbuildings suitable for healthcare. We aredeveloping an estates strategy that looks at our buildings, what services are based in themand where there are opportunities to use themmore effectively, or if they should be sold. Wealso need to look at how we can better manageour private finance initiative (PFI) buildings,which place significant financial pressure onsome providers.

King George Hospital A&E

Through the STP, we want to change the way people use health services, including changing the way people are treated in urgent and emergency care so that they receive the right care atthe right time according to their needs. We want to make sure that only patients who needmore concentrated care are admitted to hospital, reducing the demand for hospital beds. Thedecision to make changes to A&E services at King George Hospital in Goodmayes has alreadybeen made and endorsed by the Secretary of State for Health.


Benefits to patients and communities

Focus on the whole person: mental health, physical health, social and spiritual circumstances

Improved physical health for people with mental health issues and vice versa

Greater choice of local settings for care

More services provided in one place together by health and social care

Improved access to 24/7 emergency care, with full acute hospital back-up, at Queen’s Hospital inRomford following reconfiguration of King George Hospital A&E into an urgent care centre.


Spotlight on… Mental health

Why things need to change: Locally, mental ill health is widespread, and north eastLondon has the highest levels of new cases of psychosis in England. Made worse by deprivation,this adds to pressure on health resources, with demand in some mental health services expectedto increase by about 20% by 2020.

Our vision: Improve people’s mental health and wellbeing, and provide sustainable and person-centred mental health services as part of a whole health and social care system, placing mentalhealth at the heart of new models of care.


We will focus on:

• Improving self-care and prevention, including the use of digital support

• Improving access to and quality of services including before and after birth (perinatal),psychological therapies, early intervention in psychosis, crisis and dementia care, meetingnational requirements

• Making sure we can have the capacity to meet the predicted demand for mental health services

• Putting mental health at the heart of our integrated care models, across primary andsecondary care and as close to home as possible

• Improving psychological support for people with long term conditions

• Improving the physical health of people with severe mental illness, in order to improve quality of life

• Improving access to psychological treatment for people with common mental disorders,including additional mental health support in primary care

• Improving psychosis support – productive pathways, crisis and accommodation

• Supporting system effectiveness through physical and mental health integration – bettersupport for people with long term conditions.

We are clear that things need to change. If wecarry on as we are in north east London, we willhave a shortfall of £578m by 2021. We haveidentified ways to help close this gap and findsavings, including through:

Individual CCGs’ and providers’ savingsprogrammes – to run the organisations moreefficiently and effectively.

Working together – using our transformationprogrammes such as Transforming ServicesTogether to achieve savings.

Standardising and combining back officefunctions - in many cases, back office functionssuch as HR, finance, facilities management andIT are duplicated across providers and cost andquality vary.

Consolidating services and sharing goodpractice can improve productivity and savemoney.

Using our buildings more efficiently – so we aremaking the best use of our spaces.

Capitalising on our collective buying power –where it is better value for money to do so, wewill procure contracts and spend at a north eastLondon level, for example buying medicines inbulk will save money and ensure consistency.

Working with local people to co-design newservices and identify opportunities forproductivity and efficiency improvements.

We can also receive funding from the nationalSustainability and Transformation Fund, but this isconditional on the quality of our STP.

Finances – how will we pay for this?


Spotlight on… Workforce

We cannot achieve any change without our staff – they are crucial to the success of theSTP. We will transform our workforce by:

Retaining staff - by making our organisations great places to work, offering career development,education and training so our staff have the skills needed to deliver amazing care, and keepingour staff happy and healthy.

Promoting north east London as a great place to live and work – in order to recruit staff/ talent,we need people to recognise this part of London is a great place to live and work. We mustcreate career and education opportunities for people so they want to live and work here.

make sure people live longer and healthier livesby reducing major health risks such as obesity,smoking and alcohol misuse.

develop new ways to deliver care, focusing onkeeping people well (prevention) and keepingthem out of hospital.

make sure all our hospitals provide care that issafe, compassionate, effective and efficient, everytime.

make sure all local health and social care servicesprovide high quality care that local people need,do it well, and are sustainable.

work together to make sure health and socialcare services are planned and deliveredinnovatively, efficiently and safely.

break down organisational barriers so care isprovided seamlessly between GPs and hospitals,between physical and mental health services, andbetween health and social care.

better support patients and unpaid carers, andfurther develop our work with voluntaryorganisations and local communities.

make sure we can afford to run a safe andsustainable NHS.

How our plans will make a difference to you

We will:


Tell us what you think

We’d like to know what you think about our STP so far. It’s still adraft, so the content can and will change. We’d like to hear from asmany people as possible about what you think so we can refine ourideas and further develop our STP, based on your comments.

As we’ve said before, it is only possible to improve health and carein north east London with the support and input from local peopleand communities. This document summarises our early thinking, butwe will be embarking on a wider ranging engagement programmeto discuss these plans with you. No changes will be made withoutthe appropriate engagement and, where required, consultationwith local people.

Please send us an email and tell us what you think:

[email protected]

To find out more about the STP or sign up to our newsletter visitour website: www.nelstp.org.uk


Draft plan in development

NORTH EAST LONDON SUSTAINABILITY & TRANSFORMATION PLAN

17/11/2016 2

Better health and care: our vision

The NHS Five Year Forward View

Sets out the vision for the future of

the NHS in England. It considers:

• Progress

• Challenges up to 2020/21

• Solutions.

The solutions are based around

changing the way care is delivered

e.g.:

public health and preventing ill

health prevention

joining-up services across

health and social care

empowering patients and

communities

strengthening primary care

making further efficiencies.

Everyone deserves the opportunity to live an independent and

healthy life. For this to happen, the health service needs to

improve.

The sustainability and transformation plan (STP) for north east

London will turn the ambitions of the NHS Five Year Forward

View into reality.

Our vision is to:

• Develop new ways of working to achieve better outcomes

for all. We will focus on preventing ill health and improving

out of hospital care

• Measurably improve health and wellbeing outcomes for

people in north east London and ensure sustainable health

and social care services, built around their needs

• Work in partnership to plan, commission (buy), contract and

deliver services efficiently and safely.

17/11/2016 3

Working together will achieve change

We are working together to drive genuine and sustainable change, putting the patient and

their experience at the heart of quality improvement and achieving improved health

outcomes.

The NEL STP involves 20 organisations across eight local authorities:

• Clinical commissioning groups (GP-led groups responsible for planning and

buying NHS services): Barking and Dagenham, City and Hackney, Havering,

Newham, Redbridge, Tower Hamlets and Waltham Forest.

• Local authorities: Barking and Dagenham, City of London Corporation, Hackney,

Havering, Newham, Redbridge, Tower Hamlets and Waltham Forest.

• Providers: Barking, Havering and Redbridge University Hospitals NHS Trust, Barts

Health NHS Trust, East London NHS Foundation Trust, Homerton University Hospital

NHS Foundation Trust, NELFT NHS Foundation Trust.

We are also working with colleagues from NHS England, NHS Improvement, Health

Education England and UCL Partners.

17/11/2016 4

The challenges we face together

Working together to address these challenges will give us the best opportunity to make sure health and

care services in north east London are sustainable by 2021.

Sustainability: using resources to meet the needs of people today without reducing the ability of future

generations to meet their own needs.

Our challenges:

• The fastest growing population in London – projected 18% growth in 15 years (345,000 more people).

• High rates of people admitted to hospital who could be cared for in the community. Increasing A&E use.

• Areas of high deprivation and high rates of physical inactivity, leading to poor physical/mental health

• Higher than average rates of childhood obesity and below average immunisation rates.

• People are living longer, meaning that they require more care and support later in life.

• Two of three hospital trusts in special measures, with concerns about the quality of care they provide.

• A national shortage of GPs, with many local GPs nearing retirement age and more people than average

finding it hard to get an appointment.

• Increased costs of health and care.

17/11/2016 5

Solving our challenges

We have developed a framework that is built around our commitment to person centred care

systems. Our top three ambitions are:

1. Promoting prevention and self-care: helping people stay well will also reduce the demand

on health care services.

2. Improving primary care: working together and using multi-disciplinary teams comprised of

community, social care and healthcare professionals to improve care will also reduce costs.

3. Reforming acute services: some of our hospital care does not meet the required standards.

We will improve care and reduce costs by redesigning patient pathways and working together.

17/11/2016 6

A people-centred system

17/11/2016 7

How does the STP relate to local initiatives?

Local plan: Hackney devolution pilot brings health and social care providers together to deliver an integrated, effective and financially sustainable

wellbeing system

Local plan: Barking and Dagenham, Havering and Redbridge (BHR) devolution pilot brings health and

social care together to deliver better outcomes for residents, including the option of a single local

accountable care organisation

Vanguard: BHR urgent and emergency care

Local plan: Newham, Tower Hamlets and Waltham Forest. The Transforming Services Together

programme aims to deliver safe, sustainable, high-quality services to improve the local health and social

care economy

Vanguard: Tower Hamlets new models of care is looking to provide integrated and person-centred care.

The STP proposes new initiatives to take

advantage of economies of scale and will

aid sharing of knowledge and best

practice.

The STP supports existing programmes of

work – helping them to be delivered and

adding value. For instance there are three

local plans and two ‘vanguard’

programmes, aimed at supporting

improvement and integration of services

(see opposite).

The STP supports improvement

programmes which aim to help Barts

Health NHS Trust and Barking, Havering

and Redbridge University Hospitals NHS

Trust out of special measures.

The STP encourages locally developed

initiatives and does not override locally

agreed plans and decisions.

17/11/2016 8

The six key priorities we need to address together

Joining

forces

Delivery

Model

Specialis

ed

services

Sustainable

health and

social care

providers

Estates

Demand

and

Capacity

Six key

priorities

1. The right services in the right place

• If we increase prevention, improve primary

care and ensure our acute model will provide

beds for those who need it most we can avoid

building a new hospital for the growing

population

2. Encourage self-care, offer care

close to home and make sure

secondary care is high quality

• Address areas of poor quality

and access in primary care

• Support hospitals to meet core

standards, including the urgent

and emergency care changes at

King George Hospital

• Collaborate on campaigns and

services e.g. 111

5. Improve the health of local

people

• Pooling health and social care

budgets

• Joining separate services where

practical

• Close working between local

authorities, the NHS, voluntary and

community organisations

6. Use our buildings better

• We will develop a strategy that considers our

buildings and the services they house, and

investigate opportunities to use our estate

more effectively, or sell parts

• Look at how we can better manage our private

finance initiative buildings, which place

significant financial pressure on some

providers

4. Improve specialised care

• Demand for specialised services is growing

and we need to work with other NHS

organisations in London to become a world

class destination for these services

3. Secure the future of our health and social

care providers. Many face challenging

financial circumstances

• Providers are evaluating options for formal

collaboration and shared learning

• Devolution pilots in BHR and City and

Hackney are actively exploring opportunities

with local authorities

Specialised

services

17/11/2016 9

Our workforce

We cannot achieve change without our staff – they are crucial to the success of the STP. We

will transform our workforce by:

• Retaining staff - by making our organisations great places to work, offering leadership,

career development, education and training so our staff have the skills needed to deliver

amazing care and the confidence to use them. We will also develop schemes to help staff

be happy and healthy, in and out of their working environment.

• Recruiting staff and talent – by promoting north east London as a great place to live and

work. We must create career and education opportunities for people so they want to live and

work here.

• Supporting new models of care – by developing our staff to support the delivery of models

of care, including creating new clinical roles and helping our staff to acquire the necessary

skills

17/11/2016 10

Finances – how will we pay for this?

If we do nothing to address NHS financial challenges we will have a shortfall of £578 million by 2021

as our increased income will not keep pace with expenditure. If we carry on with ‘business as usual’

efficiencies of 2% a year, we will have a shortfall of c£336 million by 2021.

In local authorities and the Corporation of London, if we consider adult social care, the Better Care

Fund, children’s services and public health, there will be a £238 million shortfall by 2021 if we take no

action to address the issues.

We will find savings and reduce these gaps by:

• Delivering individual organisations’ savings programmes – making them more efficient and effective

• Working together – using our local transformation programmes to achieve savings; combining back

office functions such as HR, finance, facilities management and IT to improve services and make

savings; consolidating services and sharing good practice, which can improve productivity and

save money; using our buildings more efficiently; using our collective buying power to secure better

value contracts, for example medicines

• Working with local people to co-design new services that better meet their needs, and identify

opportunities for productivity and efficiency improvements

• Accessing funding from the national Sustainability and Transformation Fund, but this is conditional

on the quality of our STP.

17/11/2016 11

Involving local people and stakeholders

Our plans and priorities must be developed with those who use, pay for or work for the NHS.

• During the summer we produced a summary of progress and shared the first draft STP on

our website. We met with a number of MPs; arranged for elected members from each

borough to meet the STP executive; engaged with Overview and Scrutiny Committees,

Health and Wellbeing Boards and the Local Government Association; involved local authority

staff; met with local patient and campaign groups; presented the plans to clinical groups and

staff; held events on particular topics and with key stakeholders and discussed the plans at

public board meetings of all NHS partners.

• On 21 October we submitted an updated narrative, eight delivery plans and a

communications and engagement plan to NHS England. We have now published these on

our website www.nelstp.org.uk

• Over the coming months we are encouraging staff and stakeholders including councils and

Health and Wellbeing Boards to make their views known. We will be working with local

Healthwatches to gauge the views of the public and local interest groups.

• We will take all views into account when preparing the STP in the New Year.

http://www.nelstp.org.uk/

17/11/2016 12

Governance and equality

A group (including health organisations, local authorities and Healthwatch) has been set up to

review and update the governance arrangements. It has developed a shadow governance

structure and initial terms of reference which strengthens existing forums such as the STP

Board and adds several new bodies, most notably:

• A Community Council – of residents, voluntary sector, councillors and other key

stakeholders

• An Assurance Group – an independent group of audit chairs to provide assurance and

scrutiny

• A Financial Strategy Group – to provide oversight and assurance of the consolidated

financial strategy

An equality screening is underway to consider the potential equality impacts of the proposals.

This will be published on our website shortly. The screening includes:

• An assessment of the level at which the analyses need to be conducted (London-wide,

regional, local area or borough level)

• A screening of the overarching Framework for better care and wellbeing

• Description of the actions to be taken

17/11/2016 13

Next steps

We welcome comments on any aspect of the draft STP. However key questions we are asking

are:

• What do you think about what we have chosen to focus on?

• Do you think we have the right priorities?

• Is there anything missing that you think we should include?

To find out about STP-related events, sign up to our newsletter or read a more detailed version of

the STP at: www.nelstp.org.uk

For more information please contact us on [email protected]


mailto:[email protected]

North east London:Sustainability and Transformation Plan

Transformation

underpinned by system

thinking and local action

DRAFT- POLICY IN DEVELOPMENT

21 October 2016

2Draft policy in development

No. Section Page

1 Executive Summary 3

2 NEL Care, Quality and Wellbeing Challenges 4

3 Better Care and Wellbeing 7

4 Specialised Services 22

5 Productivity 25

6 Enablers for Change 28

7 Five Year Affordability Challenge 31

8 Governance and System Leadership 36

9 System Reform 39

10 Making Progress 42

11 Our ‘Asks’ 43

11 Conclusion 44

12 Appendices 45

Contents

Guide to reading this document

• Acronyms used throughout the document are explained in the appendix, page 51.

• We assign specific symbols to each of our six key priorities, introduced on page 6. Where a

section addresses a key priority, the relevant symbol is shown in the top right corner of the page.

• Deliverables are outlined at the end of each chapter or section, where applicable, and detailed

deliverables are available in the appendix, pages 47-48.


We want people in north east London (NEL) to live happy

and healthy lives. To achieve this, we must make changes

to how local people live, access care, and how care is

delivered. During 2016, 20 organisations across NEL

have worked together to develop a sustainability and

transformation plan (STP). This builds on our positive

experiences of collaboration in NEL but also protects and

promotes autonomy for all of the organisations involved.

Each organisation faces common challenges including a

growing population, a rapid increase in demand for services

and scarce resources. We all recognise that we must work

together to address these challenges; this will give us the

best opportunity to make our health economy sustainable by

2021 and beyond.

We have adopted a joint vision:

1. To measurably improve health and wellbeing outcomes

for the people of NEL and ensure sustainable health

and social care services, built around the needs of local

people.

2. To develop new models of care to achieve better

outcomes for all, focused on prevention and out-of-

hospital care.

3. To work in partnership to commission, contract and

deliver services efficiently and safely.

NEL is an area with significant health and wellbeing

challenges. Our population is set to grow by 18% in the

next fifteen years, and five out of our eight boroughs are in

the lowest quintile for deprivation in the UK. Health

inequalities are high, with many residents challenged by

poor physical and mental health driven by factors such as

smoking and childhood obesity. People frequently move

around the patch and are highly dependent on secondary

care. This makes our challenges unique and places

significant pressure on local services.

We have developed a NEL level framework that will

ensure every patient receives the same level of high

quality care. Our primary ambition is to support local

people to manage their own health. On this basis we have

built a framework designed to deliver consistent primary

care across NEL, promote out-of-hospital services, ensure

good mental health, encourage preventative activities and

champion interventions which tackle the wider determinants

of health and wellbeing. This framework will be guided by

the principle of “system thinking and local action” to enable

system-wide change, while allowing for local flexibility.

We want our hospitals to provide care that is safe,

effective and efficient every time. The majority of our

hospitals have underperformed in recent inspections and

continue to fail to meet some of the expected standards

around waiting times. We want our hospitals to attain a

world class reputation for services, and plan to establish this

through developing ambulatory care, surgical hubs and

streamlined outpatient pathways. This will help us to tackle

operational challenges and provide safe and compassionate

secondary care.

Providers have a unique opportunity to increase their

productivity through collaboration. Cost improvement

programmes will no longer be enough to achieve the scale

of efficiency required to address our system-wide financial

challenge. The STP has given providers the impetus to co-

design new opportunities for productivity and service

efficiency improvements beyond traditional organisational

boundaries. This will give us the strongest opportunity to

achieve savings on the scale set out in the Carter Review.

Our vision for better care and wellbeing will be

supported by system reform including the development

of new and more collaborative commissioning and

provider models. Across NEL, we have already started to

develop innovative commissioning models (for example

capitated budgets in Waltham Forest and East London,

WEL) and work is ongoing to explore further opportunities

through our devolution pilots (Barking, Havering and

Redbridge, BHR and City and Hackney, CH). Our providers

are also working differently to ensure their organisational

governance and staffing models can support the shift to

integrated care and an emphasis on out-of-hospital

interventions.

As part of this transformation, we have identified

workforce, technology and infrastructure as key

enablers which will require investment and

development. Without this, we will not succeed in

implementing better care and wellbeing for people or a

sustainable system-wide position.

Our total financial challenge in a ‘do nothing’ scenario

would be £578m by 2021. Achieving ambitious ‘business

as usual’ cost improvements as we have done in the past

would still leave us with a funding gap of £336m by 2021.

Through the STP, we have identified a range of

opportunities and interventions to help reduce the gap

significantly. This will be aided by Sustainability and

Transformation Funding (STF) funding, specialised

commissioning savings and potential support for excess

Public Finance Initiative (PFI) costs. Significant work has

started to evaluate the savings opportunities, particularly on

specialised commissioning.

We have developed our governance structures to

support the next stages of planning and

implementation. Our robust governance structure allows

individual organisations to share responsibility while

balancing the need for autonomy, accountability and public

and patient involvement.

The NEL transformation journey has started. We are

committed to meeting all NHS core standards and delivering

progress in every priority. Together we will deliver a

sustainable health and wellbeing economy across NEL. It’s

a significant challenge, but one we welcome as it

provides opportunities to make a real and lasting

difference to the lives of local people.

1. Executive Summary

Executive Summary


There are a number of challenges NEL is facing from a health and wellbeing as well as a care and quality perspective which

are summarised below and on page 5. For a summary of the financial challenges see chapter 7.

2. NEL Care, Quality and Wellbeing Challenges

Demographics

• There is significant deprivation (five of the eight STP

boroughs are in the worst Index of Multiple

Deprivation quintile). Estimates suggest differentially

high growth in ethnic groups at increased risk of some

priority health conditions.

• There is a significant projected increase in population

of 6.1% in five years and 18% over 15 years. This

population is also highly mobile, with residents who

frequently move within and between boroughs.

• There are significant health inequalities across NEL and

within boroughs, in terms of life expectancy and years

of life lived with poor health.

Wellbeing

• NEL has higher rates of obesity among

children starting primary school than the

averages for England and London. All

boroughs have cited this as a priority

requiring system-wide change across the

NHS as well as local government.

• Health inequalities remain a significant

issue in NEL with diabetes, dementia and

obesity all disproportionately affecting

people in poverty.

• NEL has generally high rates of physically

inactive adults.

Long-term conditions

• There is an increased risk of mortality

among people with diabetes in NEL

and an increasing 'at risk' population.

The proportion of people with Type 1

and Type 2 diabetes who receive

NICE-recommended care processes is

variable. Primary care prescribing

costs are high for endocrine conditions

(which includes diabetes).

• Cancer screening uptake is below

the England average and emergency

presentation is 5% higher than the

national average.

Mental health

• With a rising older population, continuing work towards early

diagnosis of dementia and social management will remain a

priority. Two of seven CCGs are not hitting the dementia

diagnosis target. Right Care analysis identified that for NEL,

rates of admission for people aged over 65 with dementia are

poor.

• Most CCGs, but not all, are meeting Improving Access to

Psychological Therapies (IAPT) access targets.

• Parity of esteem has not yet been achieved across NEL.

• Acute mental health indicators in the Mental Health task force

report identify good performance, however concerns have been

identified with levels of new psychosis presentation. Further

work is required to quantify and respond to challenges such as

high first episode psychosis rates.

• There is a low employment rate for those with mental illness.

Health and wellbeing challenges

NEL Care, Quality and Wellbeing Challenges


• Two of three acute trusts failing A&E 4hr target waits.

• Two of three acute trusts failing to return monthly 18 week RTT pathway data.

• Two of three acute trusts (six out of seven hospital sites) in special measures after CQC inspections.

• All seven CCGs failing 75% Category A ambulance response times within eight minutes.

• Variation in emergency bed days and GP referral rates across all seven CCGs.

Core Standards

• Inconsistent consultant assessment for emergency admissions across specialities in NEL providers (standard two).

• Inconsistent consultant ward reviews across specialities in NEL providers (standard eight).

• A need to support patient activation and self-care.

7 Day Services / UEC reforms

• Further work is needed to improve the wider determinants of mental health.

• Inconsistent diagnosis rates of dementia in NEL GPs, with 2 CCGs failing to meet the standard

• National Standard began in April 2016 for 50% of people with first episode psychosis to begin evidence-based treatment within 2 weeks. All CCGs/providers are meeting this target.

• Submission made on 16 September, identified £2.2m of funding across 3 years for perinatal mental health across NEL.

Mental Health

• Do not currently meet National Service Model standards for patients with learning disabilities.

• Greater focus required on community and prevention services including dental care, type two diabetes, and breast screening.

• Workforce training required to equip staff with the skills and knowledge to support patients with learning disabilities and autism.

• Need to build capability and capacity within communities to support people with autism and avoid unnecessary hospital admissions.

Learning Disabilities

• CCGs below national average on Patient Survey for success in getting an appointment and ease of getting through on the phone.

• Demand for appointments is rising with GP consultation rates increasing.

• Highly mobile population and high practice list turnover generating further demand.

• Challenge in securing the primary care workforce with example of more than 25% of GPs being beyond retirement age in one borough.

Primary Care

• The increase in births presents a significant challenge to capacity for maternity services.

• There is currently under utilisation of midwifery led care pathways and birth settings.

• There is a lack of continuity of care across the maternity pathway and women’s experiences of care are often reported as being poor.

• Variation in benchmarked data of UK perinatal deaths for births across NEL providers.

• Many more women with complex health needs are now becoming pregnant.

Maternity

• Inconsistent patient experience results from Friends and Family Test for A&E, inpatients, maternity and outpatients.

• Inconsistent patient experience results from Friends and Family Test for mental health providers.

• In some areas, only 22-29% of patients are dying in their preferred place of residence.

Patient Experience

• The cancer treatment pathway is very fragmented with many challenges.

• Emergency cancer presentations are 21.1% in NEL (20.6% England average indicates worse survival rates at one year).

• Lower one year survival rate for all cancers across all seven CCGs compared to all survival rates across England.

Cancer

• In cluster comparison of Right Care data, cancer survival is a key area of improvement across NEL.

• Mental health, patient experience, prevention and new models of care are other key opportunity areas for NEL commissioners.

• Potential savings through primary care prescribing:

• £5-10m in endocrine

• £3m in respiratory

• £1-2m in each of CVD, GI and MSK.

Right Care

• Delivery of constitutional standards for RTT, 62 day wait for cancer.

• Resolution of local derogations for certain specialties for example chemotherapy, specialised neurology, NICU.

• Key strategic intervention in NEL is the joint work on neuro-rehabilitation.

• Service reviews for the transfer of cardiac services from UCLH, trauma, and cancer Services.

• NICU capacity.

Specialised

Commissioning

• Unable to maintain services; there is a need to recruit and retain to ensure we are able to maintain services in the face of an ageing workforce.

• Over-reliance on agency use.

• A need for the development of new roles/extended scope and skills.

• A need for multidisciplinary teams working to support new care models.

Workforce

There is a need across NEL to:

• Provide the infrastructure necessary to support new, connected, ways of working.

• Provide clinicians with a full view of the patient electronic health record in real time that is editable and supports bookings across services.

• Deliver population health through real time risk stratification scoring.

• Enable patients to view their own care records and to make bookings in to their primary care providers.

Technology

The care and quality challenges outlined below exist across NEL. They are present in some CCGs, but may not necessarily

be in all. We recognise there are some areas of excellent care and quality; nevertheless, the challenge remains substantial.

The rest of this document presents several solution and plans that will help reduce and ultimately resolve all of our challenges

across NEL.

Care and quality challenges



Our key priorities

Whilst each of our economies has a different starting point, on the basis of the NEL-wide challenges set out we have

identified six key priorities which need to be addressed collectively.

The right services in

the right place:

Matching demand

with appropriate

capacity in NEL

Our population is projected to grow at the fastest rate in London (18% over 15 years to reach

345,000 additional people) and this is putting pressure on all health and social care services.

Adding to this, people in NEL are highly diverse. They also tend to be mobile, moving frequently

between boroughs and are more dependent on A&E and acute services. If we do not make

changes, we will need to meet this demand through building another hospital. We need to find a

way to channel the demand for services through maximising prevention, supporting self-

care and innovating in the way we deliver services. It is important to note that even with

successful prevention, NEL’s high birth rate means that we may need to increase our

physical infrastructure.

Encourage self-care,

offer care close to

home and make sure

secondary care is

high quality

Transforming our delivery models is essential to empowering our residents to manage their own

health and wellbeing and tackling the variations in quality, access and outcomes that exist in

NEL. There are still pockets of poor primary care quality and delivery. We have a history of

innovation with two of the five devolution pilots in London, an Urgent and Emergency Care

(UEC) vanguard and a Multispecialty Community Provider (MCP) in development. However, we

realise that these separate delivery models in each health economy will not deliver the benefits

of transformative change. Crucially, we must drive a system vision that leverages community

assets and ensures that residents are proactive in managing their own physical and mental

health and receive coordinated, quality care in the right setting.

Secure the future of

our health and social

care providers. Many

face challenging

financial

circumstances

Many of our health and social care providers face challenging financial circumstances. Although

our hospitals have made significant progress in creating productivity and improvement

programmes, we recognise that medium term provider-led cost improvement plans cannot

succeed in isolation.

Our providers need to collaborate on improving the costs of workforce, support services and

diagnostics. Our challenge is to create a roadmap for viability that is supported at a whole

system level with NEL coordinated support, transparency and accountability.

Improve specialised

care by working

together

NEL residents are served by a number of high quality and world class specialist services; many

of these are based within NEL, others are across London. We have made progress recently in

reconfiguring our local cancer and cardiac provision. However, the quality and sustainability of

specialist services varies and we need to ensure that we realise the benefits of the reviews that

have been carried out so far. Our local financial gap and the need for collaboration both

present challenges to the transformation of our specialised services. We need to move to a

more collaborative working structure in order to ensure high quality, accessible specialist

services for our residents, both within and outside our region, and to realise our vision of

becoming a truly world class destination for specialist services.

Create a system-wide

decision making

model that enables

placed based care

and clearly involves

key partner agencies

Our plans for proactive, integrated, and coordinated care require changes to the way we work in

developing system leadership and transforming commissioning. We have plans to develop

accountable care systems (ACS) with integrated commissioning with Local Authorities and

capitated budgets. Across NEL, we recognise that creating accountable care systems with

integrated care across sectors will require joining previously separate services and close

working between local authorities and other partners; our plans for devolution have made

significant progress in meeting the challenge of integration. New models of system leadership

and commissioning that are driven by real time data, have the ability to support delivery models

that are truly people-centred and sustainable in the long term.

Using our

infrastructure better

Delivering new models of primary and secondary care at scale will require modern, fit-for-

purpose and cost-effective infrastructure. Currently, our workforce model is outdated as are

many of our buildings; Whipps Cross, for example, requires £80 million of critical maintenance.

This issue is compounded by the fact that some providers face significant financial pressures

stemming from around £53m remaining excess PFI cost. Some assets will require significant

investment, others will need to be sold. The benefits from sale of resources will be reinvested in

the NEL health and social systems. Devolution will be helpful in supporting this vision.

Coordinating and owning a plan for infrastructure and estates at a NEL level will be

challenging; we need to develop approaches to risk and gain share that support our

vision.

See Better Care (p7)

See Specialised Services (p22)

See Governance (p36)

See Infrastructure (p30)





This is our vision for north east London. To implement this we have developed a common framework that will be

consistently adopted across the system through our new model of care programmes. This framework is built

around our commitment to person-centred, place-based care for the population of NEL.

3. Better Care and Wellbeing

Better Care and Wellbeing

Our shared framework for better care and wellbeing


How we will deliver our system vision

Ensure accessible quality acute services

Whilst we need to ensure that people receive high quality care close to home, it is important that when people fall

seriously ill or need emergency care, local hospitals provide strong, safe, high-quality and sustainable services. Given

the significant population rise, our challenge is to ensure we reduce any unnecessary admissions and attendances, and

have best in class length of stay for both planned and unplanned care.

In accordance with the Briggs report, ‘Getting It Right First Time’, our goal is to identify and administer the correct

treatment at the appropriate time to standards. We also want to work towards achievement of the London Quality

Standards.

1. We will enhance triage in urgent and emergency care settings so that patients receive the appropriate care at the

right time according to the severity of their need. Only patients who require more intensive care are admitted,

improving bed capacity.

2. If possible, we will take advantage of appropriate consolidation of planned care services to allow for better

outcomes and efficiency. In this way, there will be more effective use of experienced staff and specialised

equipment available, enhancing clinical productivity.

3. We want to avoid people spending more time than necessary in hospital. We aim to address this through

mechanisms such as early support discharge and greater capability and capacity in the community to help people

recover and return home.

Promote prevention and personal and psychological wellbeing in all we do

In the first instance, we aim to prevent illness and promote personal and psychological wellbeing in our population, with

a focus on tackling health inequalities. By taking a proactive approach to disease prevention, we are addressing

unhealthy behaviours that may lead to serious conditions further down the line and thus reducing the burden on the

healthcare system. We are committed to acting on the London Health Commission’s research on prevention1. Through

the sharing of information between the different stakeholders, we will ensure that people who are at risk are targeted

and appropriate interventions are put in place before escalation.

We will also promote self management by helping people to identify resources available to them that promote personal

health and wellbeing. Motivating people to take ownership of their health is crucial to our system vision. Healthy

behaviours such as physical activity and leisure will be promoted through mechanisms such as social prescribing to

empower people to maintain their health and wellbeing.

As environmental factors are important in influencing people’s health and wellbeing, we will also work with local

authorities to promote healthy environments to enhance the quality of life for people in NEL. We have significant health

inequalities and deprivation, which presents an additional challenge. By linking in with housing, employment and

education, we are better able to address the needs of our population.

Promote independence and enable access to care close to home

In our bid to deliver care close to home, we will use a delivery model to wrap support around the individual. This delivery

model will integrate primary, community and social care.

1. People will be well informed regarding the resources and services that are available to them, empowering them to

choose the most appropriate pathway for their care, reducing the number of unnecessary admissions and A&E

attendances.

2. The foundation of our model is primary care collaboration at scale with hubs, networks and federations treating

populations of up to 70,000 people, accessible 8am-8pm, 7 days a week.

3. For people with complex health and social care needs, we will deliver coordinated care to support their health and

wellbeing.


1 The London Health Commission was an independent inquiry established in 2014 by the Mayor of London to examine how London’s health and healthcare

could be improved for the benefit of our population. In response to its recommendations and unprecedented engagement with Londoners, all London health

and care partners (Londoners 32 CCGs, 33 Local Authorities, NHS England (London) and PHE (London) and the GLA) committed to the overarching goal of

making London the healthiest major global city and 10 supporting aspirations as laid out in ‘Better Health for London: Next Steps’. We remain committed to

this shared London vision and working with London partners in achieving this goal and aspirations.


Promote prevention and personal and

psychological wellbeing in all we do

These places may include home, school, the workplace or

community settings.

We are committed to acting on Healthy London

Partnership’s research that suggests we can improve the

lives of residents and reduce demand on services through

enabling people to change their behaviours. This is

especially true with smoking, drinking and physical activity.

To encourage people to help themselves and take control of

their lives, we will extend social prescribing as one of the

ways to recognise the value of neighbourhoods and build on

the social capital that people hold, while creating less

dependence on services. Staff also need to be supported to

be agents of change and ‘Make Every Contact Count’. This

will include a system-wide focus on smoking cessation.

Wider determinants of health

Working in partnership with and through local authorities

and communities in this way allows us to tackle the wider

determinants of health (in line with Marmot principles):

“The conditions in which people are born, grow, work, live

and age, and the wider set of forces and systems shaping

the conditions of daily life ... Including economic policies,

development agendas, social norms, social policies and

political systems” - World Health Organization

Health interventions alone cannot deliver the change

required to tackle these factors and enable our population to

better manage their own health and wellbeing. We will focus

our work across the system to deliver this change:

1) Early years, schools and healthy families

Local government is driving the “early help offer” by

integrating health visiting, children's centres, nursery

education and other services so children are ready to learn.

A stronger focus on nutrition and dental health in the early

years will enable a reduction in childhood obesity and

unnecessary hospital admissions for dental caries.

The Healthy Schools programme is being driven by schools

and is making an impact on healthy choices. Schools are a

major contributor in focusing on prevention including raising

awareness of addictions to drugs, alcohol and smoking.

Working with Child and Adolescent Mental Health Services

(CAMHS), schools help to build resilience and mental

wellbeing in young children and communities.

As we develop new care models across NEL, we will seek

to integrate education services at a neighbourhood level

and look at how social prescribing can promote education

interventions, as well as aligning the early years offer to

those wanting to start families. We aim to widen the roll-out

of education interventions to reduce the prevalence of

obesity (and Type 2 diabetes) and improve the health and

wellbeing of children and young people to exceed Public

Service Agreement.

2) Environment, leisure and physical activity

Green open spaces and transport systems that promote

physical activity and healthy lifestyles can have a major

impact on health and wellbeing. We will continue to work

together to expand ways to maximise these resources and

encourage their use through social prescribing.

Tailored behaviour change support will address Type 2

diabetes and obesity levels through the National Diabetes

Prevention Programme. We will also address hypertension

through tailored behaviour changes.

3) Housing and planning

We recognise NEL has a lack of affordable housing, and

high levels of overcrowding and homelessness, which will

be exacerbated as our population grows. This requires us to

collaborate to better influence decisions on new building

developments, ensuring health impact assessments are

conducted. We already utilise the Healthy Urban

Development Unit (HUDU) model to help us access

Community Infrastructure Levies (CIL) that guarantee there

is funding to build the facilities that ensure our

developments support health and wellbeing.

We will also monitor pilots for private sector licencing

schemes to understand the impact on housing quality and

feasibility to roll out across NEL.

We will ensure health and housing interventions are better

aligned by commissioning joint pathways to ensure that

those who need support, such as falls adaptations, are able

to receive it in a timely manner.


We recognise that

NEL is unique in its

diversity and the

strength of its

communities. Each

part of this plan

recognises that the

citizen and patient

are part of a vibrant

neighbourhood

community. We will

build on our existing

local health and

wellbeing strategies

and public health

initiatives to ensure

services are built

around, and support

neighbourhoods, so

the places where

people live enable

good health.


4) Employment

The link between good mental health and wellbeing in

employment is well established. We will learn from pilots

(planned or underway) across NEL such as wellbeing hubs,

which combine health and employment services in one

location. We will extend the scope of these hubs to include

housing support to address the shortage of affordable

housing for our key workers.

One of the success measures of substance misuse services

is employment. This principle will be widened to other

services. We will explore options for outcomes based

commissioning in this area through the BHR Accountable

Care System (ACS) work.

There are also opportunities to better link the recruitment

challenges we have in health and care services with

employability services in the community. This will provide an

opportunity to upskill local people to fill local vacancies.

We will work together to create additional internship and

apprenticeship opportunities in the health sector for young

people, building on the work already underway at Barts

Health. As part of the WEL Transforming Services Together

(TST) programme, we are specifically exploring new

courses to support people into new roles such as physician

associates and advanced nurse practitioners.

Multidisciplinary primary care staff will widen access to

primary care including an expanded and integrated role for

pharmacists and Allied Health Professionals (AHPs).

Through these combined activities, we aim to empower

people of NEL, and reduce their dependency on services.



Promote independence and enable

access to care close to home

millions of encounters with health and social services in

NEL every year.

A crucial enabler of self-care is IT literacy; residents need to

have the skills and the access to technology to identify the

right information at the right time and use technology as a

route to proactive self-management.

Self-care approaches can be used at all stages of ill-health,

with the greatest impact likely to be for those who are living

with long-term conditions, frailty or at end of life (see

national profile below).

Self-care has the potential to reduce activity across the

pathway and can be applied for a range of conditions, as

such the scope of potential impact is broad.

We intend to further develop and scale up our range of self-

care schemes, based on local good practice, as well as

evidence from the UK and internationally. These focus on:

• Enhancing patient education on how to self-manage.

• Peer support on a one-to-one or group basis (online or in

person).

• Providing alternative care or services that facilitate self-

care.

• Proactive management and planning for those with

complex needs.

• Social change to promote healthy communities.

An example of how we already provide alternative care or

services that facilitate self-care is through social prescribing.

Through social prescribing, patients are empowered with

the confidence to manage their own health so that they visit

the GP only when needed. GPs therefore focus on higher

risk patients and the demand for high-intensity acute

services will be lowered.

Our social prescribing schemes integrate primary,

community and social care, as patients are referred by their

GPs to non-medical and community support services to

provide psychosocial and practical support. We plan to

scale up successful social prescribing schemes across the

NEL patch to tackle diseases such as depression. In

addition to our evidence based approach, we will also

collaborate with the national Social Prescribing Network to

guide the scaling-up process.

Screening and early detection

As part of our goal to achieve a step-change in uptake of

screening, we plan to address the inconsistency in quality

and levels of screening across the NEL patch and spread

best practice. We plan to implement the NICE referral

guidance, the ‘faster diagnosis standard’ and also increase

early diagnostic capacity to reduce the number of patients

with emergency cancer presentation, particularly colorectal

cancer.

We are looking into integrating health screening services

within our overall system framework. We would like to build

on the bowel screening work in Newham, where they have

been partnered with a voluntary charity, Community Links.

Community Links calls every patient who has not been

screened to improve screening rates. We already have local

GP endorsement and it has been endorsed by the London

Bowel Cancer Screening Hub.

Screening of complex diseases allows early diagnosis

and detection, reducing patients with late or emergency

presentation. In doing so, we aim to improve outcomes

and reduce health inequalities in the long-term; this will

support specialist services by reducing complexity of

issues earlier.


• People will be well-informed about the resources and services that are available, empowering them to choose the most appropriate pathway for their care

• Support the development of primary care collaboration at scale with hubs, networks and federations

• Improve the population mental health and wellbeing

• Enable all people to access a consistent high quality integrated urgent and emergency care

To bring alive the

system-wide vision

we have for NEL, we

have identified a

number of service

transformation

programmes.

Self-care

management and

patient activation

Self-care happens

when patients are

'activated‘. We will

promote better self-

care, not only by

providing better

information and

resources, and easy

access to advice (for

example pharmacy)

but also through the


Healthy living and smoking cessation programmes

Our prevention programmes targeted at reducing the risk

factors for avoidable lifestyle conditions such as diabetes

and cancer require coordination between primary and

community care providers. We will proactively target at risk

patients within the groups and work in a multidisciplinary

way to provide support and prevent escalation of need. This

is a focus of our local plans to develop place-based care

models delivered through Accountable Care Systems.

Our current smoking cessation programmes have mixed

results across the NEL patch. As a result of this and the

impact it has on the health of our population we have

targeted this as an initial priority area for our collaborative

prevention work. We aim to reduce the number of people

smoking by a further 5% by implementing 2021 by

improving the interventions we deliver when smokers

access other services – such as hospital and mental health

services.

We also wish to widen the implementation of healthy living

programmes such as the National Diabetes Prevention

Programme to achieve Prostrate Specific Antigen obesity

and diabetes targets. However, we have found it difficult to

demonstrate its impact. To improve its impact, we will

expand our mapping of diabetes prevalence and its risk

factors to help identify at-risk patients.



Enhancing our primary care programme to deliver

equality for people in NEL

The implementation of our common framework for better

care and wellbeing, and the development of accountable

care systems, require the radical transformation of primary

care to lead the progression and development of a

successful out of hospital health and care system in NEL.

Key Issues –national and local

At present primary care is under unprecedented

strain, nationally demand for appointments has risen

about 13% over the last five years, recently there

has been a 95% growth in the consultation rate for

people aged 85-89.

• In response to a BMA survey of 3,000 GPs last year,

over half of respondents consider their current

workload to be unmanageable or unsustainable; and

over half rated their morale as low or very low.

• The primary care workforce is aging and facing a

‘retirement bubble’ which has the capability to put

the system under greater strain.

• Currently there is little support for struggling GP

practices, with an increased number of practices

facing closure or serious viability issues.

Significant unwarranted variation in outcomes

between practices is a concern, there is little

standardisation of practice and collaboration

between GPs is very variable.

While patients have access to a number of excellent, high

quality primary care services across all CCGs, as a whole,

north east London needs to make significant progress to

ensure equality and address these gaps.

Within north east London there are examples of how quality

improvement initiatives have been used in partnership

between commissioners and providers to deliver some

good outcomes – e.g. some of the best outcomes nationally

under Quality Outcomes Framework (QOF) in Tower

Hamlets and City and Hackney and Quality Improvement

(QI )initiatives supported by UCLP in Newham, BHR and

East London Foundation Trust. We will work together to

deliver equality for people in NEL drawing on available best

practice.

Our shared vision

Our enhanced primary care offer will ensure that GPs will

be able to focus on coordinating care for those with

complex problems and long term conditions, providing

continuity of care where that is important to patients and

outcomes. This will be enabled by a greater role for other

clinicians supporting those with minor illnesses. We will

actively consider how the creation of new roles supports

this.

There will be joint care planning to enable seamless

delegation to the extended primary care team and

collaboration with social care, freeing up time for patients

and helping to deliver person-centred, planned and

preventative care. This is already happening – for example

through social prescribing models underway across north

east London.

Patients will also have greater accessibility to GPs, with

practices working together in local networks to offer longer

opening hours for appointments from 8 – 8, seven days per

week, aided by e-consultations.

These are examples of how we are working together to

implement the London Strategic Commissioning

Framework for Primary Care, delivering proactive,

accessible, and coordinated care.

Working together

The change required to realise our common vision for

primary care across NEL will be owned and driven locally,

but aligned to a common set of principles:

• We need to support the stabilisation of practices in the

short term to ensure continuity.

• We will develop and implement a common quality

improvement approach, supported by a shared

performance dashboard and peer review.

• We will steer this approach through a joint board and

utilise Personal medical Services (PMS) reviews to

move towards equalisation and support local delivery of

the standards of the Primary Care Strategic

(SCF)Commissioning Framework.

• We will look at the initiatives that are in place in CCGs to

better manage demand through implementing optimal

pathways across the primary and secondary care

interface and at how we can support embedding this

work across NEL.

• We will work together on key enablers that we need to

address at a NEL level, with a focus on workforce,

digital and estates.

• We need to support primary care collaboration at scale

to improve quality and sustainability across practices.

• We will work together to share good practice including

around primary care technology.

• We will look at options for adopting a common approach

to primary care contracting across NEL.

Across NEL we are developing a programme of primary

care transformation that contains three key priorities: quality

improvement in primary care, organisational development

of at scale primary care providers, and development of the

NEL primary care workforce.

To support the delivery of our shared ambition for improving

quality we will develop a NEL-wide Primary Care Quality

Improvement Collaborative, underpinned by strong,

dedicated clinical leadership.

Primary care collaboration at scale is a crucial feature

of our universal framework and will improve patient care

experience.



Integrated health and social care

The integration of health and care services to deliver joined

up care is a crucial part of our vision for person-centred

services across NEL. Progress is at different stages and

there are detailed borough level delivery plans in place for

2016-17. These have been developed jointly by CCGs and

local authorities in order to meet the requirements of the

Better Care Fund (BCF).

Each borough has a detailed action plan and stretching

target for improving performance against the Delayed

Transfers of Care measure, through better patient flow

within secondary care and integrated discharge services.

BCF plans also describe how seven days services in

community and social care services will be implemented to

support safe and timely discharge from hospital.

Across NEL our ambition is to go further in integrating

health and social care services in order to implement person

centred care models. A key part of doing this will be

developing Accountable Care Systems that bring together

providers of health and social care services around a single

service model and a set of outcomes. There is also

commitment to the integration of commissioning functions to

support new population based contracting models. Through

this work we will meet the national requirement for the full

integration of health and social care services by 2021.

New models of community care

In order to deliver our vision of person centred care across

north east London we will need to radically transform the

way in which services are delivered in the community. This

will see a shift towards the clustering of services for a

geographically defined population across traditional health

and social care, and primary and community care

boundaries.

This will require providers to work in partnership to deliver

care against population based and outcome focused

contract models. This will form a core part of the plans for

the development of Accountable Care Systems in each

economy. It will require local providers to respond by

adapting their service models, ensuring their workforce are

supported and trained to deliver in new ways, and flexing

their own organisation priorities to embrace a new

approach to planning and contracting.

Integrated urgent and emergency care (UEC)

The NHS Shared Planning Guidance set out three asks for

urgent and emergency care systems by 2021:

1. All patients admitted via the urgent and emergency

care pathway have access to acute hospital services

that comply with four priority clinical standards on every

day of the week.

2. Access to Integrated Urgent Care, to include at a

minimum Summary Care Record (SCR) clinical hub

and ‘bookability’ for GP content; with mental health

crisis response in hospital and part of the Ambulance

Response Programme.

3. Improved access to primary care in and out of hours.

In NEL we will work together to meet these asks through the

implementation of our common framework for better care

and wellbeing, in three different ways:

• At a local level the implementation of our person-centred

service models will focus on meeting the eight criteria for

Integrated Urgent Care and provide improved access to

primary care.

• In BHR the Urgent and Emergency Care (UEC)

vanguard will provide a an example of rapid movement

towards our planned UEC model, with a fast-tracked

timeline for meeting the eight criteria for Integrated

Urgent Care.

• Across NEL we will work together to implement a 24/7

integrated 111 urgent care service that connects to

clinical hubs at all levels, including dental and pharmacy

hubs and CAMHS. We will also implement referral

pathways between UEC providers.


The NEL UEC network has been reviewing our current

emergency departments to evaluate whether they meet

the London Quality Standards and UEC facility

specifications. In 2016/17 we will be working to meet the

four priority seven day standards for vascular surgery,

stroke, major trauma, STEMI heart attack, and children’s

critical care. We will also establish a work programme

and road map to meet these same standards for general

admissions to achieve 95% performance by 2020, and

meet all three of the asks set out above.

We are already making progress on the integration of

health and social care at a borough level:

• In City and Hackney the One Hackney provider

network uses an alliance contract to support the

collective delivery of metrics and outcomes focused

on integrating health and social care. This will be

continued and expanded under devolution.

• As part of the ACS work in BHR there is a proposal

to establish a Joint Strategic Commissioning Board

between the three BHR CCGs and LAs. Pending

approval this will launch in November 2016.

The Redbridge Health and Adult Social Care Service

(HASS) is an integrated service for health and adult

social care, jointly provided by NELFT and the London

Borough of Redbridge, was introduced on 1/4/16. The

HASS consists of four multidisciplinary community health

teams which focus on early intervention and prevention

to support people who are over the age of 18 and are

vulnerable older people or adults with a learning

disability and/or on the autistic spectrum, or a physical

and/or sensory disability or a mental health issue.


High quality integrated mental health care and support

Mental ill health has a very high prevalence in NEL, with

inner east London CCGs in particular reporting the highest

levels of new cases of psychosis in England, and very high

levels of common mental health problems. Progress has

been made to improve the quality of care and treatment

across primary and secondary care. The STP represents

an opportunity for health and care services across NEL to

work together with the voluntary sector and communities to

further improve health and life outcomes, and manage the

projected increase in demand over the next five years.

We will do this by building community capacity and

capability, including self-care and prevention and providing

integrated primary and community care as close to home

as possible. We will support children with and at risk of

mental health problems through our Future in Mind

commitments. These commitments are contained in each

CCGs’ Local Transformation Plan (LTP) for CAMHS. The

LTPs are currently being refreshed and will reaffirm our

commitment to improving the mental wellbeing of our young

people, which will have a longer term impact on adult

mental health prevalence. We will also improve access to

dementia and perinatal mental health services, and

services for people when they are in crisis.

We know that people with mental health problems

experience a range of health inequalities, and that there is

significant variation in how they utilise wider health and

care support. We will ensure that mental health is at the

heart of our delivery model for integrated care to address

this and improve the physical health of people with serious

mental illness. This will also help us improve the mental

health of people who are frail, or who have complex and/or

long-term conditions.

To develop the excellent mental health services we want

for the future, the infrastructure needs to be right. We will

work together as provider and commissioner partners to

ensure that improving outcomes for people with mental

health problems, and developing high quality productive

mental health services, are at the centre of our work on

new models of care.

We are developing a five year NEL mental health strategy

that will enable us to implement the Five Year Forward

View for Mental Health. We have completed an analysis of

demand and capacity, quantifying the affordability gap over

the next five years.

Five areas have been agreed:

• Improve population mental health and

wellbeing: In partnership with citizens and

the voluntary sector, improve population-

based approaches to mental health, tackling

the wider determinants, reducing inequalities

and managing demand

• Improve access and quality: Deliver 5YFV for

mental health and GP 5YFV commitments

regarding mental health

• Ensure services have the right capacity to

manage increasing demand: Improve

capacity and productivity by developing best

practice urgent and community care

pathways orientated around community and

primary care, with a particular focus on

psychosis pathways

• Supporting improved system outcomes and

value: Integrated preventative mental and

physical healthcare to improve outcomes and

reduce utilisation of primary care, acute,

community health services, social care

• Commissioning and delivering new models of

care: Join up whole personal care

commissioning, supported by new

approaches to contracting to ensure good

value, integrated services.

The strategy development addresses the mental health

task force ‘Must Do’s’ and we have work underway to:

• Develop a Childrens’ and Young People’s

(CYP) community eating disorders service

• Improve access for early intervention in

psychosis. NEL has made good progress

here and met the national target.

• Develop local suicide prevention plans

across all CCGs to reduce suicide rates by

10% relative to 2016/17 baseline.

• Prevent child sexual exploitation.

Across partners we are committed to the principle of parity

of esteem, that there is “No Health without Mental Health”

and therefore it will be considered across all we do through

the STP to improve quality, experience and value.

Mental health services which integrate primary,

community and social care support will prevent

unnecessary admissions and provide a smooth

transition to acute services if needed.



Integrated children’s and young people's care:

Children and young people (CYP) are a key area of

focus for NEL, given the high proportion of children and

young people in NEL and the anticipated growth over

the next five years. Across NEL, we aim to place

children and young people at the centre of care and

services in health, social care and education. Effective

services from early years into adulthood will support this

generation, and begin to establish healthy lifestyles and

self-care as the norm for future generations. We will

utilise national best practice frameworks with emphasis

on local implementation and delivery.

The Transforming Services Together (TST) programme

has identified four priorities which we will adopt across

NEL to deliver this vision, as outlined below:

Realising the benefits in terms of improved care for

children and young people will require collaboration

between organisations to deliver the transformation that

is needed. In accordance with the Children and Families

Act (2014), commissioners and local authorities in NEL

will develop local integrated care plans and identify

opportunities for joint commissioning. Furthermore, local

models of coordinated care have been developed,

whereby multidisciplinary teams of health, social care

and educational professionals collaborate to develop

structured care plans, with input from parents, carers

and patients. To support this we are starting to

implement Integrated Personal Health Budgets for

children and young people in parts of NEL from 2016-17

onwards. Care coordinators will proactively arrange and

direct care.

We recognise that we need to do more of this across

NEL and provide more care in the community, where it

is appropriate to do so. The high numbers of referrals to

general paediatrics and dermatology for conditions that

could better managed in primary care, such as asthma

and eczema, will be addressed through our ‘patient

pathway and outpatients’ initiative. We plan to review

referral criteria and guidelines for these conditions to

identify opportunities to provide care in the community.

Evidence-based clinical pathways for these conditions

will be co-designed with children and young people and

their families to better support them to manage their own

conditions, even through the transition to adulthood.

We will work towards meeting London’s Out of Hospital

Standards for Children and Young People as we make

these changes.

We recognise that a child’s chances in life start with the

conditions of their birth; we will improve maternity

services to ensure that every child has the very best

start.

The need to provide high quality and appropriate urgent

care for children and young people will be addressed

through our plans to develop integrated urgent and

emergency care models across NEL. In particular

through increased access to urgent appointments in

primary care outside of core hours.

Localised programmes for learning disabilities

Whilst we have relatively low numbers of people with

learning disabilities in inpatient facilities, we know that

we do not currently meet the National Service Model

requirements for patients with learning disabilities.

The Transforming Care Partnerships in NEL are

committed to working together to deliver the national

service model. In particular, we will improve the

resilience of our providers so that they can support

people with learning disabilities who are exhibiting

challenging behaviour. In doing so, we aim to reduce

inpatient admissions. We will also work to increase

access to local housing and education to reduce out of

area residential provision.

The unnecessary admission of patients with learning

disabilities can be reduced if we strengthen local support

with input from primary, community and social care.


Integrating CYP plans locally

• Proactive care planning for younger populations

with co-morbidities is being introduced in City and

Hackney

• In Tower Hamlets community paediatric virtual

ward service (Bridge) and a paediatric rapid

access clinics have been established

• We are preparing to implement Integrated

Personal Health Budgets for children and young

people in City and Hackney, Tower Hamlets and

Waltham Forest during 20161-7

• In Waltham Forest a ‘Children’s BCF’ will be

developed to pool budgets between the CCG and

local authority and drive the integration of CYP

health and social care services

• In BHR better support is being developed for

looked-after children and those leaving care


Community-based end of life care

We recognise the need for joined up care to ensure a

better response from the health and social care systems to

sudden, unpredictable or very gradual dying.

Nationally up to 81% of people say they would prefer to die

at home. However, locally the majority of patients die in

hospital - with four of our CCGs having the highest rate in

England, 20% above the English average. This indicates

that, among other things, we need to get better at having

open conversations with families and patients around end-

of-life options.

We plan to build stronger partnerships with social and

voluntary sectors to increase the provision of community-

based, 24/7 access to end-of-life care services. We will

improve personalised care planning through better sharing

of patients’ preferences and care plans with other providers.

We will utilise national best practice frameworks with

emphasis on local implementation and delivery.

Transforming sexual health services

NEL experiences high prevalence rates for common

Sexually Transmitted Infections (STIs) relative to England

and London, including HIV, with some areas diagnosing

HIV later than average. In addition three CCGs have above

average teenage pregnancy rates and all CCGs have

lower-than average prescriptions of long-acting reversible

contraceptives (LARC).

We recognise that due to London’s array of open access

services and NEL’s mobile population, a high number of our

residents use services in central London. Therefore, we

need to work collaboratively at scale to successfully

improve access and outcomes. To do this, we are working

with the London Sexual Health Transformation Programme

(LSHTP), of which NEL is one of six sub-regions.

So far the NEL SHTP has been formed across Newham,

Redbridge, Tower Hamlets and Waltham Forest to

overcome these challenges by jointly planning and

commissioning integrated sexual health services. A number

of opportunities have been identified to:

• Improve access to sexually transmitted infections (STI)

diagnostics outside the acute environment (for example

self-sampling available online and in primary care).

• Improve access and uptake for LARC.

• Create appropriate STI treatment opportunities.

• Develop effective partner notification, which is mindful of

the LSHTP model and is fit for purpose for NEL.

We will work together across NEL to ensure that we share

good practice and adopt a consistent approach to the

incorporation of sexual health services into local integrated

delivery models.

Personalisation and Choice

As part of our commitment to deliver person-centred care

we will be working with patients and health professionals to

expand our offer of Personal Health Budgets (PHB) across

NEL. Currently, adults and children in receipt of continuing

care packages have the right to ask for Personal Health

Budgets, which will help them to meet the outcomes agreed

between themselves and their health professionals. PHBs

operate within all individual boroughs across NEL but the

number of children and adults to whom they are available

varies. Changing how we commission services to offer

more personalised care, whilst not destabilising services for

others, is a complex challenge and individual CCGs will be

looking to pilot approaches following consultation. Tower

Hamlets CCG is one of the Integrated Personal

Commissioning (IPC) 'demonstrator' sites, and, further to an

NHS England (NHS E) request for Expressions of Interest

in becoming an IPC 'early adopter' site. Newham and

Waltham Forest CCGs have confirmed their intention to

have a conversation with the national team about potentially

making a formal application too.

Integrating beyond health and social care

We also recognise the potential to maximise the use of

resources across public services by exploring opportunities

beyond traditional health and social care boundaries. At a

London level we have confirmed our interest in formally

collaborating with the London Fire Brigade on local 'Fire as

a Health Asset' initiatives. This will commence with a pilot

programme based on a joint assessment of the Fire and

Rescue Service initiatives that are likely to have most local

impact.

Driving integration through devolution

• Both our devolution pilots in north east London are

exploring the potential for integrating health services

more closely with other public services.

• City and Hackney is also seeking devolved public

health powers to take a more integrated approach to

prevention, focusing on tackling the wider

determinants of health.


Our local plans aim to:

• Improve advanced care planning and systems for

sharing of records to ensure a patient’s preferences

are understood by all (including exploring the use of

software packages such as Coordinate My Care).

• Provide personalised care for those in last year of

life, and increase the number of patients dying in

their chosen place

• Improve patient and carer experience in the last year

of life, and improve access to advice, support and

care

• Improve information gathering on end-of-life-care to

support quality improvements

• Ensure confident and competent workforce to

support end-of-life-care patients


Pathway redesign and best-in-class clinical productivity

To deliver the best outcomes for patients and make the best

use of our resources across the health and care system in

NEL we must identify and administer the correct treatment

at the appropriate time to a high standard.

The importance of these principles have been established

through ‘RightCare’ and in the ‘Getting It Right First Time’

Briggs Report. These show that we can reduce the need for

revision surgery and reduce mortality rates. In this way we

can also support the sustainability of high quality and

efficient acute services across NEL.

To do this effectively it is important to take a system wide

approach, recognising that there needs to be consistent,

agreed procedures and guidance in place across the whole

pathway to support clinicians in making the right decisions.

Under the STP we are launching a NEL-wide clinical

productivity programme that for the first time will take a

system wide approach to identifying unwarranted variation

and implementing effective care pathways.

Utilising benchmarking data to drive clinical

productivity

This cross-cutting programme will utilise benchmarking data

from RightCare and other sources to identify pathways and

areas of spend where there is currently the greatest

variation in the quality of care delivered, or the cost of its

delivery. This will tell us ‘where to look’ in order to carry out

further focused analysis to understand whether any

variation is unwarranted and therefore presents an

opportunity to drive out improvements in quality or savings

through increased efficiency.

This system wide approach will be led by the north east

London Clinical Senate, ensuring that this is a clinically led

programme with a clear focus on quality improvement. We

aim to learn from existing best practice throughout NEL and

utilise this benchmarking approach to encourage its spread

and drive greater consistency for patients.

We have agreed a process for identifying and exploring

opportunities, which is designed to build on and

complement existing work underway across NEL. Crucial to

this will be an agreed decision tree to ensure consistent,

transparent and appropriate decision making.

Identifying opportunities is only the first step in this process,

and we recognise that the design and implementation of the

changes required to drive out efficiencies requires collective

leadership and commitment. To support this we are

developing a NEL-wide approach build around the

‘RightCare’ Health System Reform approach:

1. A service review – to identify what is driving variation

2. A policy development process - to learn from existing

practice and embed this in a deliverable policy

3. A business delivery process – taking learning from the

above and translating it into a plan that can be agreed

and delivered across the system

4. A programme approach to delivery – to drive through

the process and behaviours change required within and

across organisations.

Managing demand

Within this approach will be a focus on how we manage

demand into the system as our population grows. This starts

with our whole system approach to prevention and building

healthy communities. It will also focus on learning from the

outstanding examples within NEL of primary care clinicians

being provided with the tools and information needed to

make the correct referral, first time. This can both prevent

unnecessary activity entering the pathway and ensure those

who really need acute care most urgently get to the right

place, sooner.

We are adopting the framework for demand management

published by NHS England and will be conducting a review

to establish the extent to which each element of the

framework is in place and working effectively across NEL.

Pathway redesign

Work is already underway to improve clinical productivity

within NEL through more efficient delivery of our outpatient

care and optimising each clinical pathway. We plan to

manage referrals to secondary care in a more effective way

and streamline the referral to treatment process, including

diagnostics.

In 2016-17 there is already a particular focus on the

following pathways and projects:

• Ear, nose & throat 9ENT), Orthopaedics,

Gastroenterology (BHR)

• Ophthalmology, Gynaecology (BHR and WEL TST)

• GP specialist advice service (WEL TST)

• Renal (NEL-wide)

Through our common approach we plan to learn from and

build upon these examples to achieve a shift change in

clinical productivity across NEL.


City and Hackney have put in place consultant advice

lines with The Homerton Hospital for 40 clinical

pathways and now have low rates of outpatient referrals.

They have improved long term condition care and have

low rates of admissions for conditions amenable for

primary care.

In areas where we are most challenged we also have a

20% reduction target for face-to-face outpatient

appointments over the next five years. This will in part in

be enabled by the use of telehealth and other alternative

platforms.


Improving the treatment of cancer in community and

secondary settings

We recognise that we have much to do to deliver the

ambitions outlined in ‘Achieving World-class Cancer

Outcomes, 2015-2020’ written by the National Cancer

Taskforce. Aside from reducing incidence through risk factor

reduction (addressed earlier in ‘prevention and proactive

care’), we also need to raise our one year survival from

c.65% to the national standard of 75% and also integrate

95% of cancer survivors with after care plans.

We will reduce variation in access and quality of service by

implementing whole pathway improvements which has

already begun under the leadership of the NEL Clinical

Senate.

For better post-treatment care, we will accelerate the

delivery of the ‘recovery’ package, including an agreed

after-treatment plan. We will also implement stratified follow

up pathways to increase the proportion of patients in long

term care programmes.

NEL and north central London also have the poorest

delivery of the cancer waiting time (CWT) standards out of

the five London regions. By working with the Transforming

Cancer Services team (TCST) and the National Cancer

Vanguard, we will implement a system-wide programme to

deliver sustainable CWTs.

Reduce unnecessary diagnostics

National evidence suggests that 25% of pathology testing is

unnecessary and recent audit work in CH revealed that 20%

of primary care initiated MRI requests could have been

avoided.

Over the next five years, we plan to introduce a rolling

programme of work focused on standardising the most

requested tests across sites. This will reduce unnecessary

testing and improve access to testing when it is most

needed. We will give GPs the ability to book people in for

tests directly without having to see a specialist where testing

is appropriate. IT improvements will allow the sharing of test

results between GPs and hospitals to reduce duplication.

Medicines Optimisation

Leading on from the Five Year Forward View, the

opportunities for medicines optimisation interventions have

been established through a number of national documents,

including the GP Forward View and the Carter review. In

NEL we recognise the potential value of these opportunities

in building a sustainable health and social care system.

Central to this is the role of pharmacists and their teams

(community, prescribing clinical pharmacists and others

across the primary and secondary care system) in

improving patient care through pathway redesign, promoting

patient empowerment and self-care and efficient use of

NHS resources through procurement and reducing waste.

The NEL wide Medicines Optimisation Steering Group has

been formed which will explore nine priority programmes,

including:

• Promoting self-care, patient awareness and self-

management to reduce unnecessary prescribing of

medicines available over the counter.

• Developing consistent pathways and medicines usage

across NEL for the management of long term conditions.

• Expanding e-prescribing in secondary care and work

with other providers to avoid medicines related delayed

discharges.

• Developing a pharmacy workforce strategy, to address

gaps in primary and secondary care, and expand the

role of prescribing pharmacists.

• Developing a common approach to decommissioning /

de-prescribing with consistent responses for patients

regardless of setting.

• Reviewing and optimising of biosimilar medicines.




for those who need it

As with the out-of-hospital components of our service vision,

transformation is also required in our secondary care service

model to improve patient experience. These are focused

closely on the features of the hospital model: streamlined

outpatient pathways, urgent and emergency care,

ambulatory care, coordinated surgery and provider

collaboration. Further details are set out below:

We will reduce long waiting times and unnecessary

hospital admissions by making ambulatory care the

default setting

To support our vision of urgent and emergency care being

delivered in the right setting, we will develop ambulatory care

hubs at each hospital. These hubs bring together clinicians

and services that focus on the initial assessment and

stabilisation of acutely ill patients.

A greater proportion of patients will be able to gain access to

emergency consultant care, so patients with less urgent

needs can be treated quickly and sent home. Only patients

requiring more than 48 hours of care will be admitted to a

specialised ward, thereby significantly improving bed

capacity and support the flow of patients, which will help

meet A&E targets.

Improve the quality of surgery services

We are exploring the creation of surgical centres of

excellence at each site. At the moment WEL and Barts

Health are more advanced in the stages of planning these

changes than BHR and City and Hackney, but there is a

commitment to expanding surgical centres of excellence

across NEL1.

Through consolidation of planned care across NEL, we can

improve length of stay, reduce referral to treatment times

(RTT) and improve clinical outcomes for our patients by

standardising surgical offerings across sites. We are

exploring the ability for each site to have a ‘core’ surgical

offering, combined with a ‘core-plus’ set of services where

safer procedures can be delivered at a higher volume. A

‘complex’ surgical offering would be consolidated and

available in a few sites to make provision safer and more

sustainable.

We are planning for patients to be able to access pre-

operative appointments and low-risk surgical procedures at

their local hospital, while avoiding long delays and

cancellations. They will only travel if they need specialised

offerings.

Delivering the Seven Day Standard for Emergency Care

Across the NEL Urgent and Emergency Care (UEC) Network

we have been reviewing our current emergency departments

to evaluate whether they meet the London Quality Standards

and UEC facility specifications.

Throughout 2016/17 we will be working to meet the four

priority seven day standards (2,5,6, and 8) for vascular

surgery, stroke, major trauma, STEMI heart attack, and

children’s critical care. We will also establish a work

programme to meet these same standards for general

admissions to achieve 95% performance by 2020.


These surgical centres of excellence will operate in

networks with strengthened cross-site working and inter-

hospital transfer, leveraging the use of any free capacity

to deliver emergency surgical interventions without

delay. This will support the vision of providers

collaborating to deliver efficient and high quality care

and will reduce our failure to meet quality measures

such as transfer delays.

Acute care hubs including ambulatory care will support

our vision in ensuring that patients are seen at the right

place in the right time. They will reduce demand on our

secondary providers by ensuring that people are not

admitted to hospital unless it is necessary.

1 see: http://www.transformingservices.org.uk/downloads/Strategy-and-investment-case/TST-Part-3-High-impact-changes.pdf

Through encouraging

prevention, self-care

and improved care

close to home we

envision that this will

reduce demand.

However given the

significant population

rise, our challenge is

to ensure we reduce

any unnecessary

admissions and

attendances, and

have best in class

length of stay for both

planned and

unplanned care. The

only other alternative

would be to increase

the total beds across

NEL significantly,

which would require

an additional hospital

to be built. This is not

practical or realistic.

http://www.transformingservices.org.uk/downloads/Strategy-and-investment-case/TST-Part-3-High-impact-changes.pdf


Health commissioners and providers in NEL remain

committed to the safe and timely transition of King George

Hospital emergency department from a full admitting A&E

department to a 24/7 urgent care centre in order to improve

the quality and sustainability of acute services. This is in line

with the original proposals and public consultation

undertaken as part of the Health for north east London

programme and the changes ultimately agreed by the

Secretary of State.

Our operational plans for 2016/17 provide the foundation on

which providers and commissioners will build towards

implementing the changes by summer 2019. In order to

achieve this, partners across the system will continue to work

together to ensure the agreed enabling actions are executed

and that the gateway process provides assurance of the

required progress.

Our system plans are already delivering improvements and

we have identified the following key conditions for successful

implementation:

• The Independent Reconfiguration Panel (IRP)

recommendations being met, including sustained

performance improvement of the emergency pathway.

• Significant capital investment at both Queen’s and

Whipps Cross Hospitals to support the changes.

• Successful reduction in demand and length of stay at

Whipps Cross hospital to create additional bed capacity.

• Effective workforce planning and recruitment to ensure

that all clinical areas can be staffed safely

• Clear and effective public communication of the plans for

changes, in particular to address the risk that partial

closure leads to a bigger shift of activity than currently

anticipated

• That the surrounding emergency care system maintains

or improves its stability, in particular services at North

Middlesex and Princess Alexandra hospitals.

Offer a greater choice of settings for births

We recognise that the projected increase in births is the most

pressing challenge for maternity provision in NEL. To reduce

the risk of needing interventions in obstetric-led wards and

improve capacity management, we plan to offer expectant

mothers a greater choice of delivery settings. There is

currently under utilisation of midwifery led care pathways and

birth settings.

We plan to increase the uptake of midwifery led births and

expand home birthing services, in alignment with the

National Maternity Review. Newham, Tower Hamlets and

Waltham Forest CCGs are maternity choice and

personalisation pioneers. Through the neighbourhood

midwives pilot we will offer an expanded range of options to

local women.

We are also focusing on models of care that allow continuity

of care to be the normal offer for all women. With continuity

of care, expectant mothers will experience better, safer care

with a lower risk of intervention. To that end, we are

establishing midwifery model of care pilots at Barts Health

hospitals and at Queen’s Hospital.


This chapter has focused extensively on introducing our system-wide vision. The remainder of this plan addresses the

other critical inputs, including collaborative productivity and enablers, which will need to be simultaneously developed to

fully address the NEL wide system challenges.

2016-17 deliverables By 2021

Continue implementation of TST and finalise ACS

business cases in BHR and CH.

Develop 24/7 local area clinical hubs, to be available to

patients via 111 and to professionals.

Primary Care:

Strengthen federations.

Develop a Primary Care Quality Improvement Board

to provide oversight.

Utilise PMS reviews to move towards equalisation

and delivery of key aspects of Primary Care SCF.

Extended primary care access model will be established

with hubs providing extended access for networks of

practices implementing the Primary Care SCF.

Ensure community-based 24/7 mental health crisis

assessment is available close to home.

Active plan in place to reduce the gap between the LD

TC service model and local provision.

Establish a NEL cancer board to oversee delivery of the

cancer elements of the STP.

Establish a NEL-wide MH steering group and develop a

joint vision and strategy.

New care models operational across NEL.

Implementation of SCF standards with 100%

coverage in line with London implementation

timetable.

Reduction acute referrals per 1000 population

through improved demand management and

primary / community services.

Access across routine daytime and extended

hours (8am-8pm) appointments within GP

practices and other healthcare settings.

Alignment with NHS E 2020 goals for LD

transforming care.

95% of those referred will have a definitive

cancer diagnosis within four weeks or cancer

excluded, 50% within two weeks (“find out

faster”).

Provide the highest quality of mental health

care in England by 2020.

Deliver on the two new mental health waiting

time standards and improve dementia

diagnosis rates across NEL.


Given the challenges outlined in this document and the

needs of our residents, we are focused on making

specialised services a core component of our STP. Whilst

we have had past successes in reconfiguring our cancer

and cardiac provision across north central and east London,

there is a need to address the demand, cost and quality of

care challenges for all specialised services.

A number of specialised care issues must be addressed in

NEL:

• A number of quality issues exist, including the meeting

of waiting time targets.

• There is insufficient preventative action and active

demand management.

• There is a predicted financial gap of £36m by 2020/21

due to a growing and increasingly ageing population,

new technologies and new treatments. The financial gap

is currently being reviewed by NHS E.

• On occasion, patients living in NEL have to travel to

providers across London or nationally. While this may

be reasonable where services are centralised, it is

sometimes caused by capacity issues in local services.

These challenges will require us to work closely with NHS E

and other footprints to deliver greater productivity, better

services and financial sustainability.

Our approach

The STP provides us with an opportunity to assess how our

specialised services are delivered and to formulate a vision

for how we expect them to look in the future. Through

discussion with key stakeholders, we have subscribed to a

vision for how specialised services are delivered:

“Working together to deliver evidence-based, high-quality

and affordable specialised services with demand

appropriately managed in the community and in secondary

care through defined pathways”.

We will work with NHS E’s strategic framework and the

London Specialised Commissioning team’s supporting

vision:

We have held several workshops with clinicians to identify

initiatives to take forward improvements in specialist renal

and cardiac care, and are now developing business cases

and implementation plans.

Workshops were also held for cancer and

neonatal/specialist paediatrics, which enabled some high-

level opportunities to be identified. These will be worked up

in due course in alignment with NHSE’s pan-London

programme.

We will also review the provision of neuro rehabilitation

services to address pressures on the Royal London Hospital

trauma centre.

Collaborative commissioning and planning

One of our key priorities is to work collaboratively with NHS

E to develop the best way to commission services in NEL

and for NEL residents, including supporting the

development of a London wide commissioning structure.

This may include developing new contractual arrangements

to encourage the management of demand.

As patients in NEL move between other footprints for

specialised services, we will need to work closely with other

STPs to consider and plan patient flows between us.

We have already had success working with other STPs

through the UCL cancer vanguard and the Barts/Royal Free

renal collaboration.

We have developed a local delivery governance structure

involving specialised commissioners. We will involve CCG

and local authority partners in this delivery when

considering opportunities to reduce demand for specialised

care in the whole-system.

4. Specialised Services

(for local testing

and

engagement)

NH

S E

Fra

mew

ork

Lo

nd

on

Vis

ion

Specialised Services

• Development of

single care models

for specialist

pathways (renal

and cardiology)

• Review community

neuro rehabilitation

provision

• Earlier diagnosis

and more efficient

pathways in

specialist cancer

• Specialist mental

health planning

The provision of

specialised services

is a key component of

the NEL health

economy. Patients

from across the UK

are treated by our

providers, and an

allocated resource of

more than £500m for

the NEL population

makes up a

significant proportion

of the income of our

five NHS providers.

We need to transform

specialised services

so that our residents

can receive the

highest quality when

they need complex

care, be it at our

providers in NEL or at

other providers in

London.


Prevention, demand management and early intervention

Specialised services must align with our preventative,

person-centred service model. It is vital that we reduce

demand for specialised services by empowering our

population to self-manage their illnesses and lead healthy

lives. When people develop conditions like diabetes, it is

crucial that we screen them early and intervene early; this

will ultimately lead to better health outcomes and will reduce

pressure on specialist services.

Financial sustainability

Pathways must be reviewed and reconfigured to repatriate

patients (where appropriate), resolve quality concerns, and

reduce variation.

As part of our productivity programme, quality and cost

improvements need to be achieved so that we can deliver

specialised services in a financially sustainable manner.

Reaching our objective

To reach our objective of becoming a world-class

destination for specialist services with excellent outcomes

for residents, we have identified these areas of action:

• Transforming pathways ( see next page for NEL 5

priority pathways)

• Drugs and devices efficiencies

• Improving value

See separate appendices for a detailed chapter on

specialist commissioning.

Approach to identifying priorities for Specialised

Services

Any changes to Specialised Services need to be driven by

evidence, targeted according to impact and feasibility, and

aligned with the priorities of Transforming Specialised

Services in London (TSSL).

We have identified the following NEL priorities based on five

key dimensions:

• The views of the five NEL providers and the clinical

senate.

• Variation and opportunities highlighted in Right Care,

Commissioning for Value and Commissioning for

Prevention analyses.

• Areas of high activity, high spend, and high London

market share.

• Known quality issues from existing

programmes/reviews.

• Feasibility in addressing the challenges within the

timeframe.


42% of spend in NEL goes on 5 service areas:

The graph above illustrates the proportion of spending by

service area, and the table below forms our local priorities

which we will continue to align with TSSL.


Cancer

Realising the full benefits

of the Cancer Cardiac

programme; improving

early identification and

quicker access to

treatments

• Reviewing the implementation of the Cancer Cardiac reconfiguration to ensure the full benefits of the

change are being realised.

• Earlier identification: enhanced diagnosis and better access to services through implementing stratified

pathways in outpatient services.

• Enhanced access to smoking cessation services to reduce incidence.

• Improved pathways for faster identification and access to treatment, for example paediatric oncology

(joint with Great Ormond Street Hospital), haemato-oncology, lung and breast cancers.

Cardiac

Integrated pathways, with

better prevention,

identification, early

intervention and access

to new treatments

• Develop pathways across primary, secondary and tertiary care in order to strengthen prevention,

earlier identification and quicker treatment, therefore reducing demand downstream for specialist

services. For example, a primary prevention service could reduce the risk of cardiovascular disease

through reducing cholesterol levels and smoking.

• Improve case-finding, prevention and treatment for atrial fibrillation; in partnership with UCLP and local

primary care leaders.

• Ensure innovations in treatment can be accessed in the world-class Barts Heart Centre. New

techniques in surgery and use of devices are being trialled to ensure better outcomes for patients.

Mental health

Closer integration of

specialised and

secondary care

pathways; repatriation

and consolidation

• Step-down and step-up support for patients in forensic mental health services, and admission

avoidance for Tier 4 CAMHS will be integrated through bilateral commissioning arrangements and

pathways, ensuring the most appropriate use of resources across the MH pathway.

• We will also develop an efficient pathway to enable patients with a learning disability in secure mental

health settings to be repatriated to NEL and back into the community.

Renal

Better community

support, and prevention

and secondary demand

management improving

outcomes and reducing

demand

• Roll out of the community kidney services across NEL to improve identification of those with or at risk

of Chronic Kidney Disease (CKD), improve patient information and education, and integrate care.

Where this already exists, these services are delivered through electronic advice clinics and

surveillance services offered by the Queen Mary University London (QMUL) clinical effectiveness

team. This has reduced the number of new referrals to services.

• Better prevention and secondary demand management through blood pressure control initiatives.

• Slow the rise in end-stage renal failure by increasing identification or CKD and Acute Kidney Injury

(AKI).

Neonatal

Addressing the capacity

gap to repatriate care and

reduce use of inpatient

facilities

• Providers in NEL act as neonatal centres for NEL and South Essex pathways; Royal London Hospital

(RLH) is the primary neonatal surgical provider. Due to lack of capacity, 30% of neonatal surgical

referrals are treated outside the STP footprint.

• Admissions of patients are relatively low but there is some potential to reduce admissions through

implementing a specialised services review of neonatal hypoglycaemia and jaundice management.


These priorities will be iterated following further analysis by NHS E, and collaborative clinical planning sessions and involvement of

patients to agree on a set of high impact and appropriate initiatives to improve specialised services


Alongside this, for the following areas of non-clinical work,

providers have developed task and finish groups aiming to

reduce spend through consolidation and collaboration:

pathology, back office finance and HR, procurement and IT.

This chapter gives an overview of the collaborative

opportunities and detail of the work providers have recently

to develop hypotheses.

NEL has undergone large changes over the past few years

and we have recently seen a consolidation of acute

providers, resulting in internal collaborative opportunities for

the trusts in NEL due to their scale.

The internal productivity savings above the ‘do minimum’

from providers totals £84m of which £45m comes from

Barts, £25m from BHRUT, £8m from ELFT and £6m from

NELFT. The main contributors to this are: implementing

Carter recommendations; theatre and Length of Stay (LoS)

productivity; reducing spend on bank and agency staff; skill

mix and establishment reviews; and internal clinical

programmes.

There are both clinical and non clinical opportunities for

productivity between providers.

1) Clinical productivity opportunities provide the most

potential for collaborative gains

There are great opportunities for clinical services across

NEL. We see two main stages to realising these benefits:

• Providers want to move all services in NEL to at least

the current median in NEL and best in class if possible.

This will be facilitated by having a data driven approach

to understand drivers in differences across NEL and

share best practice.

• In the longer term, a NEL wide clinical strategy

developed for each service, where we may see services

consolidate on fewer more specialised sites.

2) Non-clinical opportunities across the system are also

being explored by providers

Through the STP development, our trusts have come

together to assess the prospects for collaboration in non-

clinical areas. To date these only consider a few areas of

non-clinical spend but early hypotheses suggest that the

benefits could total between £21m and £56m in these

areas.

We could be making more productive use of estates across

NEL. The output of this work will be considered alongside

the overall NEL estates strategy development to make sure

that they align.

There is also scope in other parts of the NEL health

and care system:

1) Commissioners

For true collaboration across NEL, we need to ensure that

there is equity in commissioning. This involves a system

review on how the seven CCGs and their commissioning

support can start working collaboratively to purchase care

effectively in the best interests for the NEL population.

There are efficiencies to be gained through commissioning

at a more strategic level. As commissioning evolves, and

an integrated and outcome based approach to contracting

is developed as part of accountable care systems, more

efficiencies will be released. Multi-year outcomes based

contracts will have a significant impact on commissioners,

as they will require different skills and potentially fewer

resources.

There are further transactional savings which can be made,

such as sharing estates with providers or local authorities.

Commissioners are working together to identify

collaborative productivity initiatives. For example the IT task

and finish group mentioned above covers both

commissioners and providers.

2) Primary care

Federations are developing across NEL to increase

productivity and are saving money through consolidation of

back office functions and procurement. There are also

schemes planned to reduce variation in referrals and

improve prescribing practices across NEL which will enable

system-wide savings. Some of the significant opportunities

in primary care are explored in the primary care annex.

3) Social care

Each of our eight local authorities has its own

transformation programme. Health and social care

integration means we can work together to reduce

duplication in health and social care through

multidisciplinary teams and joint assessments.

5. Improving Productivity

• Consolidation of corporate

services: Developing a

flexible and scalable shared

services model for our back

office functions where this

will release value for NEL

• Bank and Agency:

Agreeing NEL wide rates of

bank and agency pay and a

shared bank service

• Procurement:

consolidating and

standardising key

consumables list and

moving to NEL wide

contracts where feasible

e.g. on patient transport

•IT: Maximising

opportunities for procuring

and delivering services at

scale.

Significant productivity

opportunities exist

across the health and

social care landscape in

NEL

The evolution of the health

and social care landscape

in the next two to five

years provides

opportunities for all

partners to create a more

productive system in NEL.

To this end, health

providers in NEL have

begun discussing

opportunities for

productivity across both

clinical and non-clinical

areas.

In two areas we have

started early work to

understand the scale of

opportunities: providers

have articulated CIP

targets over and above the ‘do minimum.’

Productivity


Collaborative opportunities

Providers in NEL have developed hypotheses for

collaborative opportunities which could save between

£21m and £56m

Over the past few weeks, NEL providers have come

together to discuss potential opportunities and options for

collaboration. This has considered some non-clinical

opportunities with intent to explore other opportunities in the

coming months. The result is a series of hypotheses about

where collaboration could bring system-wide gain over and

above internal CIP plans.

In this early phase, the savings hypotheses have been

informed by NEL sector experts as well as by examples of

other work across the country. Costs which could be

addressed by collaboration in the next five years have been

considered.

Detailed work will be done in the next phase to test these

hypotheses. Internal CIP plans will be explored further as

part of this to ensure that best practice is shared amongst

providers. This will help support the internal work being

done by the trusts themselves. Investments required for

implementation will also be reviewed.

Four key priorities, outlined below, have emerged and will

require detailed consideration in the next phase of this

work.

1) Collaborative procurement

Our procurement leads have identified a number of areas

where there may be collaborative opportunities. Initial high-

level analysis suggests that our current spend across these

categories is £231m.

Areas highlighted for potential collaboration by providers

include:

• Soft facilities management: through consolidation of

contracts across providers.

• Consumables: through the rationalisation and

standardisation of catalogues, and purchasing across all

trusts.

• Patient transport and home deliveries: by procuring

transport services as a system, suppliers will be able to

optimise their fleet over a continuous geography.

Early work suggests an indicative saving opportunity of £5-

14m on this spend, equivalent to 2-5% of total spend. This

broadly aligns with work the London Procurement

Partnership has done with other London areas to find

opportunities between providers. While this figure is lower

than some estimates (such as the Carter Review), our

varied provider landscape suggests our collective buying

power may be less than other footprints. We should be able

to realise some opportunities in the next 12-24 months as

contracts come up for renewal. In other areas, more

planning may be needed (and existing contracts either

exited or extended) to realise full system-wide benefits.

2) Common bank and agency approach

At present, NEL spends £196m with agencies a year.

Whilst each organisation has CIP targets aimed at reducing

this, there are further opportunities to reduce this amount

through a common approach. In particular, two solutions

have emerged:

• Virtual bank: clinical staff from our trusts are doing bank

and agency shifts at other trusts in NEL. A virtual bank

will allow for a more data driven approach to managing

bank and agency staff.

• Common approach with agencies: early conversations

suggest that many of the trusts in NEL and our

neighbours are using the same few suppliers. A

common approach across the providers may provide a

stronger platform for negotiations with agencies.

Examples in industry suggest that between 13%-25% could

be saved through collaboration, demand management and

better use of data. In NEL there is a potential collaborative

saving of £4-12m over and above what providers do

themselves (2%-7% of spend).

3) Consolidating pathology

NEL currently spends £71m on running pathology services.

While some reports, such as Carter’s Phase 2 Pathology

report, have suggested that 10%-20% of pathology spend

could be saved through consolidating services, work has

already been begun in this area:

• Barts Health operates a hub and spoke model across its

sites, with a major hub at the Royal London.

• BHRUT has consolidated its cold pathology to the

Queen’s Hospital site.

• The Homerton is currently considering options for its

pathology service and will make a decision in 2016/17.

Therefore, our early hypothesis for testing is that NEL could

save £2-5m (3%-7%) through consolidating services and

making better use of automation. Different models need to

be explored; there are precedents that NEL can learn from,

such as South West London Pathology and the Kent

Pathology Partnership.

4) Back office functions

NEL providers currently spend £113m on central

procurement, finance, HR and IT functions. Business cases

and projects developed elsewhere suggest that savings of

12%-25% could be realised by consolidating these

functions.

In NEL we have realised some collaborative savings, with

the Homerton, Barts Health and ELFT using a shared-

service centre for payroll, and Homerton and Barts sharing

their financial systems. Trusts also have aggressive internal

CIP plans with regards to back office functions. We

therefore hypothesise that we could save in the region of

£5-16m across NEL through collaborative working (5%-

14% of total spend) over and above CIP programmes.

A number of factors mean that much of this saving is likely

to be realised in years 4-5 as existing long term contracts

and ongoing work on the IT strategy across NEL. There

are, however, shorter term actions that can be taken in the

next 24 months to help maximise savings across the

system. These include standardising processes, sharing

best practice between the providers and beginning to

evaluate potential future operating model options.

Productivity


Collaboration and timescales

We are committed to exploring options for formal

collaboration between providers

Formal collaboration presents an opportunity to achieve the

benefits of collaboration in a way which shares risk (and

rewards) amongst participating organisations while

potentially reducing transactional costs. In addition to

productivity advantages, formal collaboration may support

the NEL health and care system to accelerate the

realisation of clinical productivity gains and implementation

of new system models of care. This work should not

compromise either the sovereignty of the current providers

or the development of future models of care such as ACSs.

Over the coming months, we will evaluate a number of

options for formal collaboration between NEL providers

The focus of a NEL collaborative partnership will depend on

the scale of ambition and partners involved. Practical

arrangements should be as clear and simple as possible

with the capacity to incorporate a wide range of schemes

within a single approach.

At present, a partnership between the five provider trusts in

NEL offers the most practical initial scope for the work in

order both to realise economies of scale and to maintain a

level of simplicity to ensure the ability to achieve gains in

the short to medium term. To this end, we intend to develop

a Memorandum of Understanding (MoU) between our five

providers to ensure clarity of purpose and senior

commitment. In the longer term, other providers such as

primary care federations could contribute and share in the

benefits.

The initial focus of the collaborative will be on productivity

opportunities which offer the greatest potential joint benefit.

In the longer term, the scope could develop to include:

• Collaborative productivity (such as procurement and

back office functions).

• Infrastructure planning (such as estates and IT).

• Workforce development (such as workforce planning,

leadership development and collective training).

• Service planning (such as pathway redesign across

NEL).

• Identification of future productivity opportunities and

best practice sharing.

We will need to develop an arrangement that is flexible and

can develop over time. It is possible that a greater level of

collaboration will offer greater benefit in the longer term.

We will need to review various contractual and governance

arrangements to make this a reality, which could include a

membership model (see South Yorkshire example) or a

joint venture model.

The options outlined would represent a radical shift in our

thinking and approach; they are changes that have not

been attempted in London yet and therefore we need to

proceed sensitively. Through this STP we have the

opportunity to develop our shared thinking around

collaborative arrangements, and drive forward

conversations that will enable the kind of transformative

changes that will enable our system to be sustainable.

Phasing for realising collaborative savings

Our current hypothesis is that from 2017/18 we can realise

non-structural collaborative benefits through benchmarking,

sharing best practice and aligning ways of working to ease

later implementation. The majority of collaborative savings,

however, will be realised in 2019/20 and 2020/21 as some

will require structural change and capital investment.

The more complex productivity savings, such as better use

of estates and service transformation, are also likely to

come in the later years of the STP delivery.

South Yorkshire may provide a useful guide to

achieving the benefits of collaboration, bringing

together seven acute providers with a collective

turnover of around £3bn. This collaboration has a

number of features:

• Driven by strong chief executive-level leadership

enshrined in a MoU.

• Collectively funded with a total cost of around £700k

per annum.

• Covers clinical and financial improvement, best

practice sharing and informatics.

• Has delivered early benefits on shared procurement

and shared patient records.


MoU between providers underpinned by principles of

collaboration.

Clear timescales for consolidating non-pay contracts.

Joint approach for agencies in place with key suppliers.

Options analysis of collaborative opportunities with pathology

across NEL with agreement on a preferred option.

Options analysis for consolidating back office functions

completed with a preferred option across the system.

Proactive approach to finding areas for collaborative working

in NEL.

Vision for shared back office approach and functions realised

Joint infrastructure and workforce planning across NEL’s

organisations. This may be done only to inform rather than

replace organisation plans.

All trusts in NEL have implemented the findings of Carter and

achieved agreed efficiency savings contributing to their

financial sustainability.

22

16

14

13

4

6

14

14

17/18

18/19

19/20

20/21

Internal above BAU Collaborative savings

Productivity


1. Workforce

Our workforce transformation needs to be based on the

specifications of the new service models and through

working closely with professional bodies and staff. As the

development of these models will take time, we have

focused our efforts in year one on establishing the

infrastructure required to realise this change and will

subsequently develop our approach in response to any

changes in the models.

Developing the existing workforce is critical for the scale,

pace and sustainability of the required transformation. We

envision our ‘workforce of the future’ will have the capability

to fully support the new service models. For example, the

workforce should be able to work across integrated health

and social care systems.

Our NEL workforce strategy recognises the local initiatives

across our footprint, and seeks to agree the overarching

priorities we will work on collectively. We have established a

Local Workforce Action Board (LWAB) to deliver our vision.

Our current workforce is not sufficient to meet the

challenges of growth in demand and system

transformation.

• Given the anticipated growth in our local population, we

will have varying gaps between supply and demand of

professional groups, with a 30% shortfall in nursing and

a surge of Specialist Training (ST3-8) doctors

completing their training. The cost of meeting demand in

primary care is unaffordable and we need to rethink how

we work to maximise resources.

• Vacancy rates and turnover rates across secondary care

are too high, leading to a strong reliance on temporary

staff against a required reduction in agency spend.

• About 17.5% of registered roles in social care lie vacant,

illustrating the difficulty of recruiting the right staff. We

need to make NEL a better and more affordable place

for NHS staff to live in.

Our five key priorities to transform the workforce are

outlined below:

6. Enablers for change

1) Retention of existing staff

It is more cost-effective to retain existing staff.

• We will analyse key reasons for people staying versus leaving

the workforce through exit data and interviews with long-

serving staff.

• We will create an action plan to maximise retention of people

who plan to leave in the future and set our five year goals

through our LWAB and map any savings.

2) Promoting NEL as a place to live and work

To recruit more staff, we need to make employment within NEL

more attractive.

• Jointly market the benefits of living in NEL with social care to

attract more health and social care workers.

• Create career opportunities via central recruitment of

apprenticeships and engaging with local business partners to

develop shared opportunities. Our Community Education

Provider Networks (CEPN) can support this engagement with

local communities.

• Keeping the NEL health and care workforce healthy.

• Address the lack of affordable housing for our health and

social care workforce with the Mayor of London office.

3) Workforce integration to support new models of care

• Our Year One focus will be to standardise and promote new

‘integrated’ roles such as care navigators.

• We will work with local authorities and schools.

• We will transform the workforce using education initiatives to

enable staff to work across all settings. As new service

models develop, we will be in a position to train and deploy

the required workforce.

4) Whole systems organisation development

There are operational and financial benefits of working together.

• We plan to streamline our HR functions to offer faster mobility

of staff across a greater footprint, through integrated HR

policies and services (for example central recruitment to

support general practice).

• In year one, we will mobilise our LWAB to steer local

transformation programmes. We will also break down the

education and training barriers for social and health care. We

will build on this work to establish clear HR and OD

operational models to be deployed.

5) Primary care transformation

To support the shift of patients from hospitals, we need our primary care workforce to have the right skills.

• Our primary care practitioners will need to act as a single point of care coordination to support the new models of care. Furthermore,

we will need to provide a shared resource bank to support and build GP federations.

• In year one, we will build on our existing workforce modelling work to assess new roles (e.g. care navigators and physician

associates) and new ways of working. We cannot rely solely on creating new roles but need to also consider extending the skills of

our existing workforce to work in multidisciplinary teams. This will include supporting the development of community pharmacists

and allied health professionals. We will work with local education providers to ensure there is training available.

• We will also develop our CEPNs using the model in place in CH where the CEPN has taken the lead for workforce development

planning and implementation. This will ensure they can support us in implementing the new roles and delivery of workforce

development initiatives in years two to five.

Enablers for Change


Local Workforce Action Board.

Development of retention and joint attraction strategies to promote health and social care

jobs in NEL.

Standardisation, testing and promotion of new/alternative roles.

Preparation to maximise the benefits of the apprenticeships levy as a sector.

Enhanced workforce sustainability models for our Community Education Provider Networks

Preparation for the removal of bursaries through strategic engagement with HEIs.

Developing the education infrastructure to realise changes with our education providers.

Retention improvement targets set in year

one and bank/agency reductions, delivered.

Full implementation of the right roles in the

right settings.

Integration of roles at the interface of

health/social care.

All staff to have structured career pathways.

Aligned/converged HR processes.


2. Digital enablementA significant and immediate opportunity exists for digital to

transform our current delivery models and seed completely

new, integrated models of health and social care. We

recognise the strength of both the clinical and financial

case for digital and its potential impact in strengthening

productivity, providing ease of access to our services,

minimising waste and improving care. We will accord

priority to quickening the pace of appropriate digital

technology adoption, realigning the demand on our

services by reducing the emphasis on traditional face to

face care models.

Our current technology landscape and its direction

NEL Informatics have defined a series of key themes for

the delivery of this vision. This achieves three key themes

of shared care records (including care co-ordination),

advanced informatics, and patient access. These themes

are supported by the delivery of fit for purpose

infrastructure.

Our system vision:

1) Shared care records enhancing collaboration

Providers will collaborate with health, social and community

care. Systems will therefore need to be interoperable to

allow for providers from primary, community, social and

secondary care to work together. At present, fully

interoperable systems across providers remains a crucial

objective; we have already made some good progress

towards interoperable systems through the east London

Patient Record (eLPR) programme. CH and WEL, have

already started to share the health records between GPs

and providers. In BHR, interoperability has also made

progress and the area is aiming towards a shared care

record across sectors.

eLPR links between Barts Health, ELFT, GP practices and

Homerton allow doctors in hospitals to view ten pages of

GP held patient records and GPs to access discharge

summaries, future appointments and test results for

radiology and pathology. This is already used around 6000

times a week by clinicians across the system and this

usage continues to rise. The integration of other care

providers is planned with social care integration starting

with LB Newham, LB Hackney and City of London

Corporation in 2016/17 and then expanding to other

councils in subsequent years. Further care settings are also

planned with urgent care and GP out of hours systems to

be integrated in 2016/17.

As further organisational systems are joined, the richness

of patient information available to all will increase.

2) Patient Enablement

Patients require the ability to view their own health records

and book appointments with their GP. This functionality is

already available in GP practices across NEL but it is not

widely enabled or well communicated. At present, our GPs

offer very few appointments online for fear of reducing

access to patients without access to technology. Currently

all of the NEL CCGs are planning to enhance the

availability of current technologies for patient access and

booking. Bids for money from the Estates and Technology

Transformation Fund (ETTF) are being made to employ

extra resources to make a significant effort to increase the

use in each CCG. We are also piloting the use of

alternative online channels for patients’ appointments

including the use of video consultations. It is crucial that we

share best practice and that this functionality is integrated

across NEL.

3) Proactively preventing patients from escalating ill

health, and evidence-based interventions

At present, each CCG has separate corporate business

intelligence (BI) tools. In the future we will need advanced

system-wide analytics to provide insight and prompt early

interventions at both the patient and system level to enable

informatics driven health management programmes.

There has been some progress on this in WEL where the

Discovery Project will be used to enable real time reporting

on programmes by providers and commissioners,

supporting outcomes-based mechanisms and to use

predictive analytics to anticipate individual patient health

needs. Detailed work is underway which has seen data

feeds established and the system itself created in its initial

form. A Community of Interest Company is being created

that will hold the application and the data from all sources.

This set of capabilities will need to be delivered on an NEL

level by 2021.

Looking forward

Our technology roadmap will need to progress according to

the key aims of interoperability, patient access and unified

analytics. A NEL local digital roadmap has been developed.

NEL is signed up to the Healthy London Partnership’s

aims of access for clinicians and patients. We are fully

engaging in the HLP digital programme which is

connecting up all health and care systems across London

and all of our approaches, although different, are

supportive of this London-wide transformation programme.

Enablers for Change


Gap analysis: ensuring we have sufficient capacity to deliver on

the transformation objectives set out in the other work streams

Further refinement of a common technology vision and strategy

for NEL.

Establish detailed implementation plan for 2017/18 and

beyond.

Improve delivery against targets in online utilisation, shared

care records, e-referrals and e-discharges.

Full interoperability by 2020 and paper-free at the point of

use

Every patient has access to digital health records that

they can share with their families, carers and clinical

teams

Offering all GP patients e-consultations and other digital

services

Utilizing advanced/preventive analytics towards achieving

population health and wellbeing


3. Infrastructure

Estates are a crucial enabler for our system-wide

delivery model. We need to deliver care in modern, fit-

for-purpose buildings and to meet the capacity

challenges due to a growing population.

Our diverse population is projected to grow at the fastest

rate in London (18% over 15 years to reach 345,000

additional people) and this is putting pressure on all

health and social care services. Due to rapid population

growth, we will need to increase our infrastructure to

handle the increased number of GP attendances,

outpatient attendances and an estimated additional

7,000 births p.a.

The principles underpinning our emerging strategy

are:

• Better health and care outcomes assisted by

delivering health and social care delivery from a fit for

purpose estate

• Partnership between commissioners, providers, and

other public sector organisations to align incentives

for estate release and support the delivery of new

models of care

• Alongside the estate currently used for health service

delivery, there are significant opportunities for out of

hospital services to be delivered using local authority

estate, such as children’s centres and libraries, e.g.

BHR CCGs; WF Council, NELFT and WFCCG have

mapped the health estate against the wider local

authority estate, and are using this to develop local

opportunities. Across NEL we want to undertake

similar mapping to facilitate the delivery of our

strategic aims for the health and care estate.

• Optimising the utilisation and costs of the health and

care estate.

• Provide expertise and resource for the development

of infrastructure programmes for NEL

We have agreed to a number of priorities for our

estates roadmap

• Respond to clinical requirements and other changes

in demand to put in place a fit for purpose estate

• Increase the operational efficiency of the estate and

maximise utilisation of the core estate

• Enhance capability to deliver; and

• Enable delivery of a portfolio of estates

transformation projects (ETTF and provider capital

programmes / cross – Boundary Projects).

This covers both clinical and administrative estates, both

of which will need to be rationalised.

Priorities for estates

• Implementing the changes required to support new

models of care, such as surgical centres of

excellence and primary care delivered at scale.

• Improving estates to deliver quality care.

• Development of urgent and emergency care facilities

as part of the KGH reconfiguration of emergency

services.

• Review the location of acute inpatient mental health

services to improve productivity and provide more

flexibility for the delivery of other services across

acute sites in NEL

• Reducing the amount of unoccupied land in NEL.

• Focusing on utilisation, reducing non-patient

occupied areas


Agree common estates strategy and governance and

operating model.

Establish detailed implementation plan, which reflects

opportunities for savings and investments as well as

demand and supply implications resulting from other

workstreams and demographic factors.

Achieve a consolidated view for utilisation and productivity,

PFI opportunities, disposals, and new capacity opportunities

and requirements across the patch.

Explore sources of capital, working with NHS and Local

Authorities for example One Public Estate.

Realise opportunities to co-locate healthcare

services with other public sector bodies and

services.

Dispose of inefficient or functionally unsuitable

buildings and sites in conjunction with estates

rationalisation.

More effective use of ‘void’ space and more

efficient use of buildings through improved

utilisation.

Investment in capital development works to support

strategy delivery.

Enablers for Change

In many places services will be delivered from

facilities where primary care practices can work

together with their own access to on-site diagnostics

(e.g. blood testing and ultra-sound). The smallest

facility that services will be offered from will cater for

10-15,000 patients.

Provider organisations, together with commissioner

and partner organisations are working across NEL in

an ambitious programme to redesign the delivery of

health and social care services across the whole

footprint including Whipps Cross, King George,

Queen’s, St George’s, Newham, Homerton and Mile

End. Whipps Cross will continue to provide acute

services, and major health and wellbeing community

facilities are proposed for St George’s, Whipps

Cross, Mile End and St Leonard’s sites.

Summary of indicative investment and savings

opportunities

Estimated net capital investment: £500-600m

Annual net savings: £10-20m


3.60

3.80

4.00

4.20

4.40

4.60

4.80

5.00

FY15/16 FY16/17 FY17/18 FY18/19 FY19/20 FY20/21

£b

n

Total system-wide income and expenditure for 'do nothing' and 'do minimum' scenarios

Income Expenditure (do nothing) Expenditure (do minimum)

1 ‘Do minimum’ scenario includes: no QIPP delivery and only 2%CIP delivery for FY18 onwards2 Specialised commissioning is estimated to be an additional c£36m pressure for NEL.3 Contract assumption differences between CCG expenditure and provider income are modelled

as an additional affordability pressure to the system.

Five Year Affordability Challenge

7. Five year affordability challenge

Introduction to NEL finance and activity

modellingSince the 30 June submission, substantial progress has been

made on the NEL STP finance and activity plan. However, it is

important to note that further work on detailed financial

modelling, especially related to solutions and investments, is

still planned or ongoing at this stage.

The basis for the financial modelling has been the refreshed

draft five year CCG Operating Plan and provider Long Term

Financial Model templates. These have been prepared by

individual NEL commissioners and providers, all of whom

followed an agreed set of key assumptions on inflation,

demographic and non-demographic growth, augmented with

local judgement on other cost pressure and necessary

investments in services.

The individual plans have then been fed into an integrated

health economy model in order to identify potential

inconsistencies and to triangulate individual plans with each

other. Activity has been modelled across NEL utilising the TST

model.

Key changes since the June submission include:

• FY17 figures are now based on M6 FOT rather than initial

Operating Plans, reflecting a deterioration of the position at

BHR CCGs by c£37m and at ELFT by c£6m. The Barts

Health forecast remains unchanged with a deficit of c£83m

though this might only be achieved through greater use of

non-recurrent measures.

• 5YFV investments are now assumed to require funding

equal to the entire FY21 STF allocation of £136m. However,

since some of these investments are being planned for as

part of the solutions, there should still be a remainder of

c£26m available for direct financial support. This is

significantly less than the £65m assumed in the June

submission.

• Specialised Commissioning cost pressures had previously

been notified as c£134m in FY21, but this figure has now

been revised to c£36m. Since one of the underlying

assumptions is that Specialised Commissioning cost

pressures will be offset by savings of equal size, this

change has no overall net impact.

• London Ambulance Services have been included and

treated in the same way as Spec Comm

• For CCGs, historic carried forward surpluses are explicitly

considered in the modelling and projections.

• The risk adjustment has been amended to reflect both the

changes above and the latest view in relation to the level of

risk in the mitigation plans.

The NEL NHS FY21 affordability challenge is £578m in

the ‘do nothing’ scenario to break even

A number of different scenarios, based on different levels of

CIP and QIPP delivery have been developed for NEL to identify

the potential five year NHS affordability challenge.

The forecast NEL FY20/21 ‘do nothing’ affordability challenge is

c£578m to break even (an additional c£30m to reach 1%

surplus target for commissioners). This assumes growth and

inflation in line with organisations’ plans but that no CIP or

QIPP would be delivered in any year.

In the ‘do minimum’ scenario1, in which ‘business as usual’

efficiencies of 2% across all years have been included, the

affordability challenge would be c£336m by FY20/21.

Specialised commissioning2 and any differences in contract

assumptions3 are included in these projections. The local

authority position is modelled separately and a summary is

available in this chapter.

A number of factors are driving our rising expenditure. One

significant factor is our growing and ageing population in line

with GLA projections. We also face a non-demographic

demand growth which are due to factors such as new

technology and increases in disease prevalence; we have

assumed that this growth is approximately 1% per year. Pay

and price inflation have been assumed in line with NHS I

guidance. This results in a steady increase in expenditure over

the planning period.

We see significant increases in CCG allocations throughout the

planning period. However, Sustainability and Transformation

Funding (STF) and some other non-recurrent provider income

(such as gains by absorption) primarily affect the initial years

and have no impact in the projections of in-year movements

from FY18 onwards.


FY20/21 bridge in ‘do nothing’ scenarioThe forecast NEL provider deficit in FY16/17 is c£88m which will rise by £319m to £414m in FY20/21. NEL CCGs are projecting a

£26m surplus (including carried over surpluses from prior years) but CCG allocations uplifts of £297m are not sufficient to offset

cost pressures over the planning period. Differences in contract assumptions net out to around £12m by FY21 overall and

specialised commissioning and LAS add a £49m pressure, resulting in a total financial challenge of £578m in the ‘do nothing’

scenario to reach a break even position.

Achieving a 1% surplus target for commissioners increases the gap by another c£30m to around £610m.

Detailed bridges for each organisation which provide further transparency about the assumptions underpinning this scenario and

the challenge faced by each individual organisation are found in the finance appendix.

NEL local authority challengeAll NEL local authorities and the Corporation of London have provided financial data for the STP modelling, though it is recognised

that further detailed work is required to confirm assumptions and what effect local authority funding challenges and proposed

services changes will have on health services and vice versa.

For the ‘do nothing’ scenario, the combined FY17 Local Authority challenge is estimated as £87m reaching £238m by FY21. This

figure is based on adult social care, Better Care Fund, children’s services and public health at all local authorities.

If Children Services were excluded from the gap analysis, the gap in FY17 would be estimated as £60m reaching £174m by FY21.

A ‘do minimum’ scenario, where ‘business as usual’ savings are assumed, will still need to be completed.


88 (45)

263109 414 (26)

170

27733 (30) (297)

(12) 49 578

NEL commissioner and provider financial bridge from FY17 to FY21 in £m

Providers Commissioners


336

92

(37)

578 (242)

(84)

251 (15) (54)

(42)(25)

(38)(10) 24

136 (136)

(26) (49)

(53)

Closing the gap in £m - workstream view

Total STF

£136m

tbc (55) (45) (50) (56) (20)

tbc (45) (34) (5) (21) (10)

Min-max savings ranges for NEL

programme workstreams:

Closing the gap – work stream viewStarting from the ‘do nothing’ gap of £578m, ‘business as usual’

efficiencies of 2% provider CIP per year would reduce the

affordability gap to £336m. This assumption is aligned with the

implied efficiency requirement in the tariff guidance issued by

NHS Improvement (NHSI) and with the average assumptions

made by the other London STPs. Furthermore, reported

average CIP achievement over the last three years has been

above 2% for NEL providers.

A number of providers have put forward savings plans slightly

higher than 2%; these are valued at £84m and will be realised after

FY16/17 and would bring the gap down to £251m. Delivery risks

around these targets are being assessed and closely monitored so

that a realistic risk rating can be included in our planning. The

FY21 position shown in the closing the gap charts below is the

recurrent position. For Barts Health, there are challenges evident in

achieving the planned level of recurrent CIPs this year even though

the FY17 control total remains unchanged at this point and ought

to be delivered through greater use of non-recurrent CIPs.

The bridge below includes transformational savings of c£136m

from the Hackney devolution pilot, the WEL TST programme,

the BHR ACS programme and the Healthy London Partnership

(see Better Care section). Some of the targeted savings of

these programmes can only be delivered in close collaboration

with local authorities and have to be considered in this context.

A further contribution of £38m to closing the gap is expected

from collaborative productivity opportunities. Key areas across

all categories of provider productivity include bank & agency

spend, back office, procurement, theatre productivity,

diagnostics, length of stay and pharmacy (see Productivity

chapter). Due to the consolidated provider landscape in NEL,

some efficiencies that would be considered ‘collaborative’

elsewhere can be captured by provider internal initiatives in

NEL.

Infrastructure savings opportunities of £10m relate

predominantly to the acute reconfiguration at KGH, which is

reliant on capital investments of c£75m. Additional major

capital investment costs relate predominantly to the Whipps

Cross site, and while a range of different options are being

explored, a solution will have to be found in any scenario.

Business cases are under development for both KGH and

Whipps Cross.

In addition to risk assumptions already made in organisations’

base line plans, a further risk adjustment of 5% has been

applied across all solutions.

By FY21 STF is expected to be £136m, which is equal to the

amount assumed to be required to deliver the NHS Five Year

Forward View investment priorities. However, c£26m of those

investments were already included in existing plans.

As a result, NEL projects excluding specialised commissioning

and London Ambulance Service (LAS), if additional funding for

excess PFI cost (estimated at £53m) can be made available, a

surplus of up to £37m by FY21, which would meet CCG

business rules.

Selected key sensitivities are illustrated on the next page.



Illustration of selected key sensitivitiesIt has to be noted that the financial projections are to a high degree dependent on the assumptions made. For example,

• CCGs assumed average demographic growth of c1.5% p.a. Should actual growth be 0.5% p.a. above that level for FY18 to

FY21, CCG spend would be around 60m higher in FY21

• CCGs assumed average non-demographic growth, other recurrent cost pressures and investments of 2.2% p.a. Should actual

pressures be 1% below that level in FY18 to FY21, CCG spend would be around 122m lower than planned in FY21

• CCGs and local providers assume in total £483m in annual savings by FY21. Should delivery fall short by 25%, costs to the

system would be around £121m higher

Closing the gap – functional viewAn alternative analysis of how NEL aims to close the gap can be provided by describing and classifying the efficiencies along

functional levers that align with the Five Year Forward View.

Additional detail of the preliminary mapping is provided in the table below for reference.


336

(37)

49

0

578 (242)

(30)(28)

(36)(57)

(4) (17)

(22)(27) 24 92

136 (136)

(26)(49)

(53)

Closing the gap in £m - functional lever view

Total STF

£136m

BHR HUH ELFT BH NELFT

BAU efficiencies – provider (242.4) (242.4)

Footprint system transformation (10.1) (1.9) (18.4) (30.3)

Estates management 0.0 (15.2) (2.6) (10.0) (27.8)

New care model (5.0) (21.8) (8.8) (35.6)

Pathway changes (5.0) (20.5) (8.8) (14.5) (7.3) (0.9) (57.1)

Reduce costs of care (2.9) (0.9) (3.8)

Reduce costs of system mgmt (6.8) (0.6) (1.8) (7.6) (16.9)

Reduce demand growth (5.0) (8.8) (8.8) (25.0) (0.9) (48.5)

Workforce management (3.9) (6.6) (2.4) (8.6) (21.5)

Other (1.0) (24.7) (1.0) (49.5) (53.0) (129.2)

Total (242.4) (15.0) (54.1) (41.6) (25.0) (25.2) (8.3) (44.7) (6.1) (38.4) (10.0) (49.5) (53.0)

HLP -

PreventionNEL workstreams in columns,

functional levers in rows

Values are in £m

2% CIP

FY17-21

Hackney

devolution

pilot

WEL - TST BHR ACS

Beyond 2% CIPsCollaborative

productivity

Infra-

structure

Specialised

comm. & LASTotalPFI support


Finance outlook

It is recognised that a number of key questions will still need to be answered over the next months:

• Specialised commissioning gap: specialised commissioning is important for all of our providers. To date, the specialised

commissioning gap is not yet fully broken down to CCG level and the opportunity analysis is in early stages. NEL recognises

the importance of specialised commissioning for its providers. We welcome and will fully participate in the announced

specialised commissioning programme initiated by NHS London.

• Organisation level financial balance: the bridges in the finance appendix indicate the magnitude of the financial challenge for

each organisation. We appreciate that the impact of business as usual (BAU) and transformation efficiencies on each

organisation and their ability to achieve financial balance needs to be worked up in more detail. In parallel, system-wide risk

sharing agreements are being explored.

• Monitoring of delivery: operating plans are based on delivery of substantial savings in this financial year. We recognise the

associated risks and the necessity to monitor delivery carefully to ensure plans are based on realistic assumptions and are

updated without delay once the level of achievement versus operating plans becomes clearer.

• Firming up savings estimates and delivery plans: for several of the NEL work streams, savings estimates and delivery plans will

be worked up in greater detail over the next months.

Next steps

The five STPs in London are working jointly to understand the implications of out of area flows on constituent STPs and ensure

these implications are accounted for, and where necessary mitigated, in local plans. An approach is expected to be defined by

December 2016. This is being taken forward by a working group of the STP finance leads, and will be overseen by the London

Strategic Finance Group. Further work is also underway within specialised commissioning, overseen by the London Board and

Executive.



Developing our system level governance

We established robust governance arrangements to

oversee the development of the NEL STP. However, as we

move into the next phase of the programme, focusing on the

mobilisation and implementation of our delivery

programmes, the governance and leadership arrangements

are being updated to ensure they continue to remain

effective with appropriate membership.

We are developing an authentic governance framework for

NEL that recognises the strengths of the sector, as well as

its unique challenges. The development of effective and

owned governance arrangements represents a significant

piece of cultural development across the system that needs

to be undertaken inclusively and with an evidenced

approach.

This will be an iterative process as the ways of working

evolve. We have agreed a route map that involves a

consultative and deliberative approach to the development

of the new ways of working and decision making. We will

establish a shadow governance arrangement, reflecting our

current starting point, which will be reviewed and refined as

we build our method of working together and there is further

clarity about the new operating requirements and

landscape.

The shadow arrangements will be put in place at the end of

October 2016, with a route plan to implement the refined

governance arrangements that will be worked up over the

course of the six months, by April 2017.

This timeframe will also enable wider engagement, with

local people, clinicians, staff, and other stakeholders to help

shape our method of working and governance. The benefit

of this approach is that it builds on the existing good

foundations and means we will develop robust governance,

that is supported by all partners, has been tested and is less

likely to unravel at the first challenge.

As part of this route map and consultative approach a

Governance Working Group has been established with

representation from across NEL including commissioners,

providers, Local Authorities, patients and Healthwatch. This

group has made significant progress in the development of

the shadow governance arrangements, developing a draft

Memorandum of Understanding, draft governance structure

and initial terms of reference.

Governance principles

The Governance Working Group has agreed a set of

governance principles , which are captured in the draft

Memorandum of Understanding and summarised below:

Participation: Representation and ownership from health

and social care organisations, patients and lay members

Accountability: Define clear accountabilities, delegation

procedures, voting arrangements and streamlined

governance structures to support continuous progress and

timely decision making. Delegation to appropriate groups.

Sovereignty: Recognise the sovereignty of the health and

social care partners. Operate in a manner that is compliant

with legal duties and responsibilities of each constituent

organisation and the NHS as a whole. Ensure alignment

with local organisations’ governance and decision making

processes recognising statutory and democratic procedures

Subsidiarity: Ensure subsidiarity so that decisions are

taken at the most local level possible, and decisions are

only taken at a system level where there is a clear rationale

and benefit

Professional leadership: Demonstrate strong professional

leadership and involvement from clinicians and social care

to ensure decisions have a robust case for change and

support

Accessibility: Ensure complete transparency in all decision

making to support the development of mutual trust and

openness. Provide the necessary assurance to system

partners on key decisions. Collaborative working and

information sharing between working groups.

Good governance: Recognise that good system level

governance will require robust planning and horizon

scanning to align with local governance and decision

making processes. However, where unavoidable local

organisations will try to be as flexible to support the system

level governance

Collaboration: All parties will work collaboratively to deliver

the overall NEL STP strategy, in the best interests of the

patient

Engagement: Local people will be engaged and involved in

the NEL STP governance to ensure their views and

feedback are considered in the decision making processes.

Governance structure

Through the Governance Working Group we have

developed a shadow governance structure, and initial terms

of reference for the key governance forums This draft

governance structure is included in the appendices.

This governance structure recognises and respects the

statutory organisations, while providing the necessary

assurance and decision making capability for system level

delivery. In addition to reinforcing some of the existing

governance forums (i.e. re-focusing the membership of the

NEL STP Board), several new bodies have been added to

strengthen the level of assurance and engagement, most

notably:

• Community council – A council of residents, voluntary

sector, councillors and other key stakeholders to

promote system wide engagement and assurance

• Audit Chairs Committee – An independent committee

of audit chairs to provide assurance and scrutiny

• Finance Strategy Group - To provide oversight and

assurance of the consolidated NEL financial strategy

and plans to ensure financial sustainability of the NEL

system.

8. Governance and system leadership

Governance and System Leadership


Ongoing dialogue with stakeholders

Continuous and meaningful communications and

engagement is central to achieving our vision to

transform local health and care services and

ultimately delivering the vision set out in the Five

Year Forward View.

Our communications objectives are:

• To inform and involve local communities in the

development of the STP and our emerging

vision for health and care in NEL.

• To clarify and reassure how the STP will

interface with other plans that are currently in

development or delivery.

• To involve local people in the creation of plans

and services.

• To reassure people that this is a piece of work

which will make a positive impact on their lives

and the quality of care they receive.

Since 30 June we have been engaging partners,

including Healthwatch, local councils, the

voluntary, community and social enterprise sector,

and patient representatives. We have:

• Published the draft and summary versions of

the plan on our website and published regular

updates

• Offered to meet all MPs which has resulted in a

number of 1:1 meetings

• Arranged for elected members from each

borough to meet the STP Executive

• Actively sought involvement of the eight local

authorities facilitated through the local authority

representative on the STP Board.

• Local authorities are represented on the

Governance Working Group and have taken

part in the workshops developing the plans for

transformation (with a Director of Public Health

leading the work on prevention).

• Engaged the Local Government Association

(LGA) to provide support to individual Health

and Well Being Boards (HWBs) to explore self-

assessment for readiness for the journey of

integration and to a NEL-wide strategic

leadership workshop to consolidate outputs

from individual HWB workshops.

• Engaged with council and partner stakeholders

such as the Inner North East London and Outer

North East London Health Scrutiny Committees;

Barking, Havering and Dagenham Democratic

and Clinical Oversight Group; the eight Health

and Wellbeing Boards; Hackney and Tower

Hamlets councillors; and Newham Mayor’s

advisor for Adults and Health

• Met with local Save our NHS, 38 Degrees and

Keep our NHS Public campaign groups

• Presented at meetings to discuss specific

clinical aspects of the STP, for instance the

NEL Clinical Senate; the NEL maternity network

and maternity commissioners’ alliance; mental

health strategy meetings; and clinical

workshops on the specialist commissioning of

cardiac services and children’s services. The

proposals have also been discussed at a

number of Local Medical Committee forums.

• Discussed the plans with NHS staff.

• Discussed the plans in open board meetings of

all our NHS partners and offered opportunities

to talk to patients and the public at various

annual general meetings and patient group

meetings.

• Held wider events on specific topics and

developments, e.g. urgent care events involving

patients and a wide range of stakeholder such

as the London Ambulance Service and

community pharmacists.

The feedback has been incorporated into the

revised STP for the October 2016 submission.

We published a plain English summary version of

the plan on our website www.nelstp.org.uk.

Governance and System Leadership



Forward plan for engagement

From 21 October to 31 December, Local Healthwatch

organisations will be working together to help us

gather and understand the views of patients and

communities. Our joint aim is to ensure engagement

is relevant to local needs.

Healthwatch organisations will focus on gauging

public views on a) promoting prevention and self-care

b) improving primary care and c) reforming hospital

services; with a local emphasis on:

• The Barking, Havering and Redbridge devolution

pilot

• The Hackney devolution pilot

• Transforming Services Together in Newham,

Tower Hamlets and Waltham Forest

• The vanguard project in Tower Hamlets

We will continue to offer alternative formats for our

communications materials to ensure that we are

reaching groups that are sometimes missed.

We will also continue to work with clinicians, local

authorities and staff to ensure they are actively

involved in the development of the STP.

We will encourage patient involvement at the design

stage and work jointly with local authority engagement

colleagues to reduce the burden on patients and the

public and to help ensure a joined up approach;

undertaking formal consultation when required.

We are committed to National Voices’ six principles

for engaging people and communities that set the

basis for good, person-centred, community-focused

health and care and will embed these across our

work. We also believe that staff have a crucial role to

play in the success of the STP. We want them to

contribute to its development, to understand and

support its aims, and feel part of it, and be motivated

by it.

We recognise that any changes proposed in the STP

may require public consultation, and are committed to

the government’s principles for consultation (2016).

We will look at how to tailor consultation to the needs

and preferences of particular groups, such as older

people, younger people or people with disabilities that

may not respond to traditional consultation methods.

Meeting our equalities duties

We are committed to ensuring that everyone has

equal access to high-quality services and care,

regardless of gender, race, disability, age, sexual

orientation, religion or belief. We will work closely with

patients, staff, partners and voluntary organisations to

help reduce inequalities and eliminate any

discrimination within NHS services and working

environments. As part of the development of the final

STP we will carry out engagement with people who

have protected characteristics as set out in the

Equality Act 2010. We will conduct equality impact

assessment (EIA) screenings to identify where work

needs to take place and where resources need to be

targeted to ensure all groups gain maximum benefit

from any changes proposed as part of the STP.

An overarching EIA screening is underway which will

identify which work areas will require detailed EIAs.


Delivering our system vision through local

Accountable Care Systems

A common framework to implement our shared vision is

being developed. It will focus on sharing the best elements

of our local plans in developing local place based

accountable care systems.

We have been exploring new service models through

devolution pilots and transformative models of care

Each health economy in NEL has been developing

innovative service models. In CH and BHR this has been

achieved through two of London’s flagship devolution pilots.

In WEL it has taken the form of a large scale transformation

programme, within which sits the Tower Hamlets Vanguard

programme

Our shared foundations

We will continue to support these programmes to develop

locally, whilst ensuring we collaborate and learn from each

other where it makes sense. We recognise the need to take

the best from existing plans and scale the benefits. This has

enabled us to come to a NEL service model founded on

place-based, integrated, person-centred care delivered at

scale. We have formed a NEL wide group to share learning.

An ambition for integrated community based service

models

Localities, networks or hubs servicing populations of 50,000

will be the centre of integrated working in each area,

providing a range of community health and social care

services in the local area.

Joint accountability for care

This model requires different providers of health and care

services to work together in new ways, removing the

traditional barriers joint working. To enable this we will

develop local systems whereby all providers are jointly

accountable for the delivery of the model. This

accountability will be based on a shared responsibility for

improving the health and wellbeing of our local population.

New approaches to contracting and payments

To drive this change in accountability we will need new

contracting models, underpinned by capitated population

based budgets. We will move away from commissioning on

a tariff based or block contracting approach, and towards

commissioning for outcomes. Whereby payments are made

based on the joint delivery of a locally agreed set of

outcomes to improve the health of the population.

These systems will ultimately encompass the whole

population within an area, although at first specific cohorts

may be targeted during the development phase

Centring care in the community

Our systems will be underpinned by the development of

high quality primary care at scale, as the foundation of an

integrated community based model of care. The extended

primary care offer will be supported by integrated locality

based multidisciplinary health and social care teams.

We will integrate other core services such as urgent care

and mental health into this model, ensuring patients

experience seamless care and only need to access acute

services when absolutely necessary.

We will use local delivery models to ensure care is delivered

in the right setting every time. BHR is also exploring the

development of health and wellbeing hubs with a range of

services designed to address the wider determinants of

good health.

Integrating the commissioning of care

To enable providers to work together in this way we also

need to align the way in which we plan and pay for local

services. To do this we will fully integrate our health and

care commissioning functions between local authorities and

CCGs at a borough level.

We will build strong local governance systems across

providers and commissioners to oversee the transformation

that is required, and establish joint decision making. We will

shift the focus from organisation-based performance to

system wide population outcome measures.

Our common principles

We will do all of this openly and collaboratively, actively

engaging with our local partners, stakeholders, and our

population. We will continue to develop these systems

locally but actively seek to collaborate across NEL where it

makes sense to do so, to make the best use of our

combined resources and collectively drive forward the

system wide transformation that will enable our local

systems to flourish.

We are using the STP as a starting point to achieve

system-wide change

This STP provides us with the impetus to harness the best

that each area has to offer and move towards a visionary,

system-wide transformation plan. This offers us our only

opportunity to achieve a sustainable position as a NEL

health economy and will enable a healthy population to

thrive.

We will collaborate on our common challenges to give

ourselves the best possible chance of success, whilst

allowing local programmes to flourish.


9. System reform


Making our framework a reality

Plans to implement integrated place-based care were

underway before we began working on the STP, with each

local health economy pursuing an innovative and ambitious

programme to make this a reality.

We will support and enhance these programmes by working

together, but they will continue to operate independently

with separate programme and governance structures which

allow each area the flexibility to best meet local needs.

We are already implementing new models outlined in

the Five Year Forward View including a Multi-Specialty

Community Provider (MCP)

There are two vanguard programmes already underway in

NEL, and each of our delivery models embraces the models

outlined in the Five Year Forward View. It is only with new

models of care and supporting business models that the full

range of benefits from a place based service model can be

achieved.

WEL – Transforming Services Together (TST)

The TST programme has developed the vision around

accountable care systems for Newham, Tower

Hamlets, and Waltham Forest.

• Care delivered close to home, with accessible GPs

working at scale in collaborative provider networks

serving at least 10,000 people. This will be combined

with integrated health and social care targeted

towards to at-risk patients in their own homes,

helping them stay well and manage their illnesses.

• Hospitals that are strong and sustainable with the

development of acute care hubs that allow patients to

be seen and treated without being unnecessarily

admitted. Hospitals will also work in collaborative

networks, with hubs which will all deliver a core set of

surgeries. Some hubs will also provide specialised

surgical procedures.

WEL is taking a phased approach to capitated budgets

to ensure payment is outcomes based. Within WEL,

Tower Hamlets has developed an Integrated Provider

Partnership called Tower Hamlets Together (THT) with

Barts Health, East London NHS Foundation Trust, the

London Borough of Tower Hamlets and Tower Hamlets

GP Care Group, which will provide community health

services and form the basis of their ACS. This is a lead

provider model where payment is based on outcomes

rather than activity. Newham and Waltham Forest are

planning a similar model.

CH’s Devolution pilot

CH are using the opportunity of devolution to develop a

fully integrated commissioning function with

governance across the CCG and the two LAs. Through

this, they will commission for outcomes and encourage

provider collaboration in order to deliver integrated,

person-centred care.

They have developed a range of integrated service

models and commissioning arrangements already with

the help of the Better Care Fund. This includes an

integrated care model underpinned by an alliance

contract, a health and social care independence team

that focuses on intermediate care and reablement, and

a fully integrated mental health service.

CH is exploring ways to further improve the quality and

coordination of out of hospital services through the

“One Hackney” provider network, which uses an

alliance contract to support the collective delivery of

metrics and outcomes.

A priority will be to implement a single point of access

for crises backed up by rapid access to clinical support,

and further enhance use of proactive risk stratification

and targeted actions for patients who are most at risk of

admission.

In addition CH is developing a prevention strategy

facilitated by devolution status that is directed towards

population health priorities, exploring additional public

health powers that can be devolved.

BHR’s Devolution pilot

BHR are using the opportunity of devolution to bring

health and wellbeing services together as an

Accountable Care System. Their devolution business

case outlines a plan to achieve fully integrated health,

social and other LA services, which places people at the

centre and achieves care at scale.

Such changes are only possible with wide-scale system

reform, and therefore the plan is underpinned by the

pooling of health and social care budgets,

commissioning by outcomes, and an ACS business

model to enable aligned incentives and collaborative

working.

In this model, there will be a single leadership team

accountable for both the development of the ACS and

BAU activities. An ACS model represents an opportunity

to address BHR’s current system challenges. This will

ultimately work towards the creation of a person-

orientated, sustainable service model that will radically

improve the lives of local people and build strong

resilient communities across BHR.

BHR is already piloting a small scale ACS building on its

work as Year of Care and Prime Minister's Challenge

Fund (PMCF) pilots - Health 1000 is a specialist primary

care provider led by a Consultant bringing together

primary care, community health, and social care enabled

by a capitated budget. It serves a small population of

complex patients with five or more long term conditions

who are supported by an integrated team to keep them

well and out of hospital.

Health and wellbeing services are clustered in a locality

delivery model, with boroughs divided into localities. A

new staffing model is being created within localities to

deliver health, social care and wellbeing services. This

model will extend across traditional organisational

boundaries and seek to ensure clinicians and others are

able to work in the locality.



Enabling accountable care

Our ambitious vision for accountable care systems NEL-

wide will require fundamental changes to how we work and

operate the health and care system. Place-based care

requires providers, local authorities and CCGs to work

together to focus on outcomes. At present, most providers

across sectors are not incentivised to work together to

deliver integrated care or rewarded on outcomes.

It will also require a step-change in the development of

supporting systems that enable integrated care: digital

interoperability, shared care records, fit for purpose

infrastructure to host community networks or hubs, and the

properly trained and equipped workforce to deliver it.

Provider reform

Our plans for developing Accountable Care Systems that

are person-centred can only be achieved through providers

collaborating with a focus on patient outcomes and

affordable high quality services. Old ways of working, in

which providers are incentivised to compete for activity will

no longer support this vision. We will need to enhance our

collaboration with each other and with our national

stakeholders to create a system of incentives that

encourages providers to work towards our vision of person-

centred care.

Our providers already have significant plans for improving

their clinical and collaborative productivity. Overall providers

will need to:

• Develop new models for joined up working. With

increased accountability they will need to develop inter-

organisational forums and processes for decision

making and holding each other to account.

• Change their focus towards outcomes: Capitated

budgets will require significant provider reform as they

reorient their systems towards achieving outcomes

rather than activity.

• Collaborate to deliver integrated care: Integrated care

will need to depart from traditional, competitive and silo-

ed behaviours by focusing on patient pathways.

• Make the most of opportunities for efficiency and

productivity through collaboration, for example by

sharing back-office functions.

Enablers for change

The delivery of place-based accountable care requires

integrated digital systems that can talk to one another, and

allow clinicians across providers to access the same

information about their patients. Technology can also drive

proactive care by utilising risk stratification tools that identify

patients who are at high risk and enable actions to be taken

to manage their care before they reach crisis.

Our new models of community care will also require estate

that can house a range of providers, services, and

multidisciplinary teams in the same place to encourage

integrated behaviours.

This will also require a new staffing model to deliver health,

social care and wellbeing services on a place basis. This

model will extend across traditional organisational

boundaries and seek to ensure clinicians and others are

supported to access the training and development required

to work in new ways.

We have grasped the opportunity of the STP to build joint

infrastructure, digital and workforce plans that will enable

local change by tacking system wide barriers to reform.

Our systems reform ‘asks’

Our plans to reform the system through devolution and the

development of Accountable Care Systems share common

foundations. Taken together they are the vehicle for

achieving our system vision, and as such, they are aligned

with a common set of ‘asks’ for the STP as a whole.

Within that, we have collaborated to form a number of ‘asks’

that will enable our local plans. These ‘asks’ include:

• Regulation: Accountable Care Systems and integrated

care require whole system collaboration and a shared

commitment to patient outcomes. As such, they need

consistent regulatory responses that treat the underlying

partners in care as a single system. We request that

where plans exist for accountable systems, the system

be regulated as a whole, despite the fact that there are

distinct underlying organisations.

• Governance: We welcome the freedoms of devolution

pilots and are looking to achieve similar standards

across NEL. We request flexibility on health and social

care funding arrangements and freedom to break from

existing regulation to deliver system-wide objectives.

• Accountability: We request specific governance

arrangements that are agreed with the centre between

NEL and our accountable care systems. We request

that these arrangements cover safety, quality, finance

and health and wellbeing standards and outcomes.

• Commissioning: We request the ability to develop and

account for single system-wide budgets for all health,

wellbeing, and social care services.

• Contracting: We request that there is flexibility around

tariffs and payment mechanisms.

Taking reform forward

The challenge now is to leverage these innovations and

collaborate with local, national and regional partners to

achieve our system vision of integrated and joined-up-care,

where local authorities and NHS providers intentions are

aligned.

The first step towards this will be through an integrated

approach to operational planning for the next two years. By

taking an open-book approach to planning together we will

start to break down traditional boundaries and build

contracts that align to our shared objectives.

We will implement our local Accountable Care Systems over

the next four years, at a pace that allows the co-design and

engagement that is required to successfully embed change.

BHR are leading the way and plan to establish their ACS in

April 2018. The other two systems in NEL will follow their

own timetables, learning from the work in BHR, elsewhere

around NEL, and across the country.

We will hold each other to account to ensure that we deliver

the new models of care needed in north east London.

System Reform


Through our STP development process we have developed

a delivery structure comprised of four work streams

(transformation, productivity, infrastructure, specialised

commissioning) and four supporting enablers (workforce,

technology, finance, communications and engagement).

Senior responsible owners, delivery leads and programme

managers have been aligned to each area. The work

streams have been mobilised, developed delivery plans and

will drive these plans forward.

We recognise that the further development and delivery of

the plans in the NEL STP involves significant financial

modelling, project management and design resources. It is

crucial that we secure these resources in order to ensure an

appropriate level of grip and the realisation of benefits.

Therefore we have agreed that all partners will contribute

resources and have devised a set of core principles that will

define the appropriate level of investment from each

organisation.

We are implementing a robust benefits management

process as part of our delivery plan to ensure that all

benefits are clearly articulated, quantified, tracked and

realised.

Throughout this process we will continue to ensure that

there is total alignment between the five year plans outlined

in the STP and the operational plans that our CCGs

develop.

Managing risks to the delivery of our plans

We have established a robust proactive risk management

process. The key risks to the delivery of our STP that we

are currently managing are:

• The plans defined in the NEL STP may not be sufficient

to address the full scale of the financial gap.

• The system partners may not able to work together

collaboratively to deliver the cross-system plans to close

the health and wellbeing, care and quality and financial

gaps.

• Due to the size of NEL and the range of stakeholders in

this area, it may not be possible to secure the required

level of stakeholder buy-in for the STP.

• There may be a legal challenge to the plans outlined in

the STP.

• There may be adverse media coverage of the NEL STP,

leading to public suspicion of the plans.

10. Making progress

Making Progress


We will work together to achieve our system vision, but this will require significant collaboration with the centre and a reform

of the way our system relates to national and regional bodies. These ‘asks’ are NEL wide and are reflective of the individual

asks that support our devolution pilots.

11. Our ‘Asks’

Governance

and

accountability

1. In order to achieve our long term aims we need consistent accountability and

governance over the next five years. We request clear and specific governance

arrangements are developed and agreed between NEL and our accountable care

systems, and regulators. We request that these arrangements cover safety,

quality, finance and health and wellbeing standards and outcomes.

2. We welcome the freedoms of devolution pilots and are looking to achieve similar

standards across NEL. We request flexibility on health and social care joint funding

& commissioning arrangements (see note below) and freedom to break with

existing regulation to deliver system-wide objectives.

Estates3. This sector has a number of PFI funded arrangements including the UK’s largest

hospital development. To succeed, we need to have central support to cover PFI

costs above normal levels.

4. We request that we are allowed to retain control of capital receipts and use them

for reinvestment, including NHS Property Services, to support the STP vision.

5. We request that there is a support for a consistent NEL approach to estates

management across providers/agencies, including NHS Property Services and

Community Health Partnerships (CHP) for all relevant assets.

Commissioning

and contracting

6. We request that the role of central commissioning arrangements is explored

especially in areas of devolution. We want to develop and account for a single

system-wide budget for all health, wellbeing, and social care services.

7. We request specific financial risk regulations are modified to reflect the

consequences of holding health economy wide budgets and provisions are made

for the first two years while transitional arrangements are executed (which may

include double running).

Specialised

Commissioning

8. We welcome the opportunity for collaboration with NHS E as the main

commissioner of specialised services. We request the ability to review and vary

clinical specifications/standards and contract for outcomes, in collaboration with

NHS E, to improve value for our population.

Regulation9. For system-wide leadership to work, we need regulators to support system

accountability. We request a consistency of response across regulators so that all

organisations are able to respond in a way that maximises system gain. For

example when dealing with an ACS, we request the system be regulated as a

whole, rather than applying a regime to the underlying organisational units.

10. We also request that all regulators and other external bodies work with us to agree

the assurance criteria, accountability structures and provision relating to risk

mitigation new care models.

Investment11. To achieve transformation we will need funding, either through STF funding or

through other means. We request that we have access to CCG surpluses and the

1% top slice in order to reinvest in achieving our system vision.

12. We request support to devolve some central Public Health England (PHE)budgets

to strengthen public health and specialised service transformation in NEL.

Primary Care13. We request that the resources identified in the GP Five Year Forward View to

support the management of workload and care redesign are delegated to the STP

to manage. We will establish a new governance arrangement that will involve our

GP federations, Royal College of GPs, LMCs and UCLP to oversee the

programme to deliver the support and improvements we need at pace.

Conclusion

Note: This is linked with devolution asks regarding amendments to existing statutory provisions, including section 14Z3 of the NHS Act 2006 (as amended by the Devolution Act 2016) to ensure that London CCGs and London local authorities can commission jointly, including via the establishment of a joint committee


We have set out a bold plan for how we intend to work together as one system to deliver outstanding health and wellbeing

services for all local people. We began by recognising the six key priorities that we needed to answer as a system. A

summary of the actions we are going to take in response to each question is set out below:

12. Conclusion

The right services

in the right place:

Matching demand

with appropriate

capacity in NEL

To meet the fundamental challenge of our rapidly growing, changing and diverse population we

are committed to:

• Shifting the way people using health services with a step up in prevention and self-care,

equipping and empowering everyone, working across health and social care.

• Ensuring our urgent and emergency care system directs people to the right place first time,

with integrated urgent care system, supported by proactive accessible primary, community

and mental health care at its heart.

• Establishing effective ambulatory care on each hospital site and mental health community

based crisis care, to ensure our beds are only for those who really need admission, so we

don’t need to build another hospital.

• Ensuring our hospitals are working together to be productive and efficient in delivering

patient-centred care, with integrated flows across community and social care.

• Addressing demand for acute and mental health inpatient services: streamlining outpatient

pathways, introducing new technology, delivering better urgent and emergency care,

coordinating planned care/surgery, maternity choice, improving psychosis pathways, and

encouraging provider collaboration

• Ensuring our estates and workforce are aligned to support our population.

Encourage self-care,

offer care close to

home and make sure

secondary care is

high quality

We have a unique opportunity to bring alive our system-wide vision for better care and

wellbeing. We are already working together on a system-wide clinical strategy:

• Transforming primary care and addressing areas of poor quality/access, this will include

offering accessible support in localities and hubs from 8am to 8pm (seven days a week),

with greater collaboration across practices to work to support localities, and address

workforce challenges.

• Investing in mental health, community, Learning Disability, & substance misuse services to

improve quality and tackle health inequalities. Ensuring parity of esteem and good mental

wellbeing, embedding this throughout all of our services.

• Ensuring our hospitals are working together to be productive and efficient in delivering

patient-centred care, maximising new technologies and pathway redesign.

Secure the future of

our health and social

care providers. Many

face challenging

financial

circumstances

Our health and social care providers are committed to working together to achieve

sustainability. Changes to our NEL service model will help to ensure fewer people either attend

or are admitted to hospitals unnecessarily (and that those admitted can be treated and

discharged more efficiently):

• We have significant cost improvement plans, which will be complimented by a strong

collective focus on driving greater efficiency and productivity initiatives. This will happen both

within and across our providers (for example procurement, clinical services, back office and

bank/agency staff).

• The providers are now evaluating options for formal collaboration to help support their shared

ambitions.

• ACS development (CH/BHR devo business cases Oct 31 2016) in development with LA and

efficiencies being established.

Improve specialised

care by working

together

We will continue to deliver and commission world class specialist services. Our fundamental

challenge is demand and associated costs are growing beyond proposed funding allocations.

We recognise that this must be addressed by:

• Working collaboratively with NHS E and other STP footprints, as patients regularly move

outside of NEL for specialised services.

• Working across the whole patient pathway for our priority areas from prevention, diagnosis,

treatment and follow up care – aiming to improve outcomes whilst delivering improved value

for money.

Create a system-

wide decision

making model that

enables placed

based care and

clearly involves key

partner agencies

We are committed to establishing robust leadership arrangements, based on agreed principles,

that provide clarity and direction to the NEL health and wellbeing system, and can drive

through our plans.

This will be achieved through genuine partnership between the health system and Local

Authorities to create a system which responds to our population’s health and wellbeing needs.

Using our

infrastructure better

We need to deliver care in modern, fit for purpose buildings and to meet the capacity

challenges produced by a growing population. We are now working on a common estates

strategy which will identify priorities for FY16/17 and beyond. This will contain a single NEL

plan for investment and disposals, utilisation and productivity and managing PFI, with a key

principle of investing any proceeds from disposals in delivering the STP vision.

Conclusion


No. Section Page

1 ‘Ten Big Questions’ outlined by NHS E 46

2 Key Deliverables 47

3 The Nine Must Do’s 49

4 Draft shadow governance structure 53

5 List of Acronyms54

Appendix

Note that further appendices are available in a separate document.


Our approach to the ‘Ten Big Questions’ outlined by NHS E

As a whole, our STP meets the ten questions outlined by NHS E in the guidance. This is done in various sections. A tick below indicates that the section covers the relevant question.

1.

Better Care

2.

Specialised

Services

3.

Productivity

4.

Enablers

5.

Finance

6.

Governance

How are you going to

prevent ill health and

moderate demand for

healthcare?

3 3

How are you engaging

patients, communities and

NHS staff? 3 3 3

How will you support,

invest in and improve

general practice? 3

3

How will you implement

new care models that

address local challenges? 3 3 3 3

How will you achieve and

maintain performance

against core standards3 3 3 3

How will you achieve our

2020 ambitions on key

clinical priorities?3 3 3 3 3 3

How will you improve

quality and safety? 3 3 3 3 3 3

How will you deploy

technology to accelerate

change?

How will you develop the

workforce you need to

deliver? 3 3

How will you achieve and

maintain financial

balance?

Financial balance runs throughout our plans. It is tackled in-depth in the finance

section.

3

33

Appendix

‘Ten Big Questions’


2016-17 By 2021

Better Care

and

Wellbeing

Continue implementation of TST and finalise

ACS business cases in BHR and CH.

Develop 24/7 local area clinical hubs, to be

available to patients via 111 and to

professionals.

Primary Care:

Strengthen federations.

Develop a Primary Care Quality

Improvement Board to provide oversight.

Utilise PMS reviews to move towards

equalisation and delivery of key aspects of

Primary Care SCF.

Extended primary care access model will be

established with hubs providing extended

access for networks of practices implementing

the Primary Care SCF.

Ensure community-based 24/7 mental health

crisis assessment is available close to home.

Active plan in place to reduce the gap between

the LD TC service model and local provision.

Establish a NEL cancer board to oversee

delivery of the cancer elements of the STP.

Establish a NEL-wide MH steering group and

develop a joint vision and strategy.

New care models operational across

NEL.

Implementation of SCF standards with

100% coverage in line with London

implementation timetable.

Reduction acute referrals per 1000

population through improved demand

management and primary / community

services.

Access across routine daytime and

extended hours (8-8) appointments

within GP practices and other

healthcare settings.

Alignment with NHS E 2020 goals for

LD transforming care.

95% of those referred will have a

definitive cancer diagnosis within four

weeks or cancer excluded, 50% within

two weeks(“find out faster”).

Provide the highest quality of mental

health care in England by 2020.

Deliver on the two new mental health

waiting time standards and improve

dementia diagnosis rates across NEL.

Transforming

Hospital

Services

Establish joint vision for surgical hub model

across NEL.

Establish midwifery model of care pilots at

Barts Health and Queen’s Hospital

(community hubs are already in place at

Homerton).

Midwifery services will be reorganised to

ensure that women can be offered continuity of

care and improved choice for each part of the

maternity pathway.

Increase numbers of women giving birth at

home and in midwifery-led birth centres – with

new midwifery-led unit opening at RLH.

Develop a clear roadmap for the safe transfer

of our existing patients from KGH and ensure

that care outside of the hospital will be resilient

to support this transition.

Begin implementing full ambulatory care model

on all Barts Health sites.

Implemented phase 2 and 3 7DS

standards.

Establish surgical hubs at each

hospital site that work together in a

network.

Midwifery services will be reorganised

to ensure that women can be offered

continuity of care for each part of the

maternity pathway.

Community care hubs will be

established with full IT integration to

allow seamless communication across

the maternity pathway.

Safely complete King George

Hospital’s changes.

Productivity MoU between providers underpinned by

principles of collaboration.

Clear timescales for consolidating non-pay

contracts.

Joint approach for agencies in place with key

suppliers.

Options analysis of collaborative opportunities

with pathology across NEL with agreement on a

preferred option.

Options analysis for consolidating back office

functions completed with a preferred option

across the system.

Proactive approach to finding areas for

collaborative working in NEL.

Vision for shared back office approach

and functions realised

Joint infrastructure and workforce

planning across NEL’s organisations.

This may be done only to inform rather

than replace organisation plans.

All trusts in NEL have implemented the

findings of Carter and achieved agreed

efficiency savings contributing to their

financial sustainability.

Appendix

Key Deliverables


2016-17 By 2021

Specialised

Commissioning

Agreed service priorities governance

structure for the programme.

Understand of the gap and size of the

opportunities.

Agreement as to level of commissioning

for each service (national, London, local).

Governance structure for managing any

new commissioning arrangements in

place.

Plans in place for redesigning pathways

and services by 2020/21.

Workforce Local Workforce Action Board.

Development of retention strategies

Standardisation, testing and promotion of

new/alternative roles.

Enhanced workforce modelling based on

new service models.

Joint attraction strategies to promote

health and social care jobs in NEL.

Preparation to maximise the benefits of

the apprenticeships levy as a sector.

Sustainability models for our Community

Education Provider Networks.

Preparation for the removal of bursaries

through strategic engagement with HEIs.

Developing the education infrastructure to

realise changes with our education

providers.

Retention improvement targets set in

Year One and bank/agency reductions,

delivered.

Full implementation of the right roles in

the right settings.

Integration of roles at the interface of

health/social care.

All staff to have structured career

pathways.

Aligned/converged HR processes.

Infrastructure Agree common estates strategy and

governance and operating model.

Establish detailed implementation plan for

2016/17 and beyond, which reflects

opportunities for savings and investments

as well as demand and supply

implications resulting from other

workstreams and demographic factors.

Achieve a consolidated view for utilisation

and productivity, PFI opportunities,

disposals, and new capacity opportunities

and requirements across the patch.

Explore sources of capital, working with

NHS and local authorities for example

One Public Estate.

Realise opportunities to co-locate

healthcare services with other public

sector bodies and services.

Dispose of inefficient or functionally

unsuitable buildings in conjunction with

estates rationalisation.

More effective use of ‘void’ space and

more efficient use of buildings through

improved space utilisation.

Investment in capital development

works to support of strategy delivery.

Technology Create a common technology vision and

strategy for NEL.

Establish detailed implementation plan for

2016/17.

Start to deliver against targets in online

utilisation, shared care records, and

eDischarges.

Full interoperability by 2020 and paper-

free at the point of use.

Every patient has access to digital

health records that they can share with

their families, carers and clinical

teams.

Offering all GP patients e-consultations

and other digital services.

Utilizing advanced/preventive analytics

towards achieving population health

and wellbeing.

Appendix


Appendix

The Nine Must Do’s

Must Do Deliverable Addressed inNEL STP

Reference

1. STPs Implement agreed STP milestones, so that you are on track for full achievement by 2020/21

Yes Included in 8 Delivery Plans

Achieve agreed trajectories against the STP core metrics set for 2017-19

Awaiting publication of national metrics

2. Finance Deliver individual CCG and NHS provider organisational control totals, and achieve local system financial control totals.

Awaiting confirmation of control totals for all organisations

Implement local STP plans and achieve local targets to moderate demand growth and increase provider efficiencies

Yes Plans defined and business cases under development

Demand reduction measures Yes Finance template

Provider efficiency measures Yes Finance template

3. Primary care

Ensure the sustainability of general practice in your area by implementing the General Practice Forward View, including the plans for Practice Transformational Support, and the ten high impact changes

Yes • Practice Resilience Plans outlined in NEL Primary Care Plan (and Care Close to Home Plan)

• Primary Care Quality Improvement Collaborationreferenced in narrative

Ensure local investment meets or exceeds minimum required levels

Ongoing work to confirm funding sources

Tackle workforce and workload issues Yes • Workforce Delivery Plan• Care Close to Home Delivery

Plan (slide 5)• NEL Primary Care Plan

By no later than March 2019, extend and improve access in line with requirements for new national funding

Yes • Care Close to Home Delivery Plan (slide 5)

• Detailed plans for extended access submitted to HLP

• GP Access Fund requests for 2017-19 submitted to NHSE

Support general practice at scale, the expansion of MCPs or PACS, and enable and fund primary care to play its part in fully implementing the forthcoming framework for improving health in care homes

Yes Care Close to Home Delivery Plan (slide 6)


Appendix


Must Do Deliverable Addressed in STP

Reference

Urgent and Emergency Care

Deliver the four hour A&E standard, and standards for ambulance response times

Yes • Care Close to Home Delivery Plan (Workstream 3 – slide 8)

By November 2017, meet the four priority standards for seven-day hospital services for all urgent network specialist services


Awaiting outcome of NWL pilot

Implementing the Urgent and Emergency Care Review, ensuring a 24/7 integrated care service for physical and mental health is implemented by March 2020 in each STP footprint


Deliver a reduction in the proportion of ambulance 999 calls that result in avoidable transportation to an A&E department


Initiate cross-system approach to prepare for forthcoming waiting time standard for urgent care for those in a mental health crisis


Referral to treatment times and elective care

Deliver the NHS Constitution standard that more than 92% of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment (RTT)

• Acute Services Delivery Plan

Deliver patient choice of first outpatient appointment, and achieve 100% of use of e-referrals by no later than April 2018

Yes • Acute Services Delivery Plan (Surgery Workstream 3a–slide 7)

• Digital Delivery Plan (slide 21 )

Streamline elective care pathways, including through outpatient redesign and avoiding unnecessary follow-ups

Yes • Acute Services Delivery Plan

Implement the national maternity services review, Better Births, through local maternity systems

Yes • Acute Services Delivery Plan (Maternity workstream 1 –slide 5)

Cancer Working through Cancer Alliances and the National Cancer Vanguard, implement the cancer taskforce report

Yes • Acute Services Delivery Plan (Cancer workstream 2 – slide 6)

Deliver the NHS Constitution 62 day cancer standard Yes • Acute Services Delivery Plan (Cancer workstream 2 – slide 6)

Make progress in improving one-year survival rates by delivering a year-on-year improvement in the proportion of cancers diagnosed at stage 1 and stage 2; and reducing the proportion of cancers diagnosed following an emergency admission


Ensure stratified follow up pathways for breast cancer patients are rolled out and prepare to roll out for other cancer types.


• Acute Services Delivery Plan (Screening workstream 3d –slide 10)

Ensure all elements of the Recovery Package are commissioned Yes • Acute Services Delivery Plan (Cancer workstream 2 – slide 6)


Appendix



Reference

Mental health

Deliver in full the implementation plan for the Mental Health five Year Forward View for all ages, including:including: - Additional psychological therapies - More high-quality mental health services for children and

young people- Expand capacity- Increase access to individual placement support for people

with severe mental illness in secondary care services- Commission community eating disorder teams - Reduce suicide rates

Yes Care Close to Home Delivery Plan (Mental Health workstream 2 – slide 7)

Ensure delivery of the mental health access and quality standards including 24/7 access to community crisis resolution teams and home treatment teams and mental health liaison services in acute hospitals

Yes • Care Close to Home Delivery Plan (Mental Health workstream 2 – slide 7)

Increase baseline spend on mental health to deliver the Mental Health Investment Standard


Maintain a dementia diagnosis rate of at least 2 thirds of estimated local prevalence, and have due regard to the forthcoming NHS implementation guidance on dementia


Eliminate out of area placements for non-specialist acute care by 2020/21


Mental health

Deliver in full the implementation plan for the Mental Health five Year Forward View for all ages, including:including: - Additional psychological therapies - More high-quality mental health services for children and

young people- Expand capacity- Increase access to individual placement support for people

with severe mental illness in secondary care services- Commission community eating disorder teams - Reduce suicide rates

Yes Care Close to Home Delivery Plan (Mental Health workstream 2 – slide 7)

Ensure delivery of the mental health access and quality standards including 24/7 access to community crisis resolution teams and home treatment teams and mental health liaison services in acute hospitals


Increase baseline spend on mental health to deliver the Mental Health Investment Standard


Maintain a dementia diagnosis rate of at least 2 thirds of estimated local prevalence, and have due regard to the forthcoming NHS implementation guidance on dementia


Eliminate out of area placements for non-specialist acute care by 2020/21



Appendix



Reference

People with learning disabilities

Deliver Transforming Care Partnership plans with local government partners, enhancing community provision for people with learning disabilities and/or autism

Yes • Care Close to Home Delivery Plan (LD workstream 4 –slide 9)

• Narrative Plan – Section 3

Reduce inpatient bed capacity by March 2019 to 10-15 in CCG-commissioned beds p/million population, and 20-25 in NHS England-commissioned beds p/million population



Improve access to healthcare for people with learning disabilities



Reduce premature mortality by improving access to health service, education and training of staff



Improving quality in organisations

All organisations should implement plans to improve quality of care, particularly for organisations in special measures

Yes • Primary Care Quality Improvement Collaborationreferenced in narrative

• NEL organisations have own organisational quality plans in place

Drawing on the National Quality Board's resources, measure and improve efficient use of staffing resources to ensure safe, sustainable and productive services

Yes • Productivity Delivery Plan (Bank and Agency Workstream 1 – slide 5)

Participate in the annual publication of findings from reviews of deaths, to include the annual publication of avoidable death rates, and actions they have taken to reduce deaths related to problems in healthcare

Yes • NEL organisations have own organisational quality plans in place


Draft shadow governance structure

Appendix


Acronym Name

ACS Accountable Care System

AKI Acute Kidney Injury

Barts Barts Health NHS Trust

BAU Business As Usual

BCF Better Care Fund

BHR Barking, Havering and Redbridge

BHRUTBarking, Havering and Redbridge

University Hospitals NHS Trust

BI Business Intelligence

CAMHSChildren and Adolescent Mental Health

Services

CCG Clinical Commissioning Group

CEPN Community Education Provider Network

CHP Community Health Partnerships

CH City and Hackney

CIPs Cost Improvement Programmes

CKD Chronic Kidney Disease

CQC Care Quality Commission

CWT Cancer Waiting Time

CYP Children and Young People

DS Dental Services

ELFT East London Foundation Trust

GLA Greater London Authority

GOSH Great Ormond Street Hospital

HEE Health Education England

HEI Healthcare Environment Inspectorate

HLP Healthy London Partnership

HUDU Healthy Urban Development Unit

HWBB Health and Wellbeing Board

IAPTImproving Access to Psychological

Therapies

List of Acronyms

Appendix

Acronym Name

IMD Index of Multiple Deprivation

IT Information Technology

IPC Integrated Personal Commissioning

LA Local Authority

LARC Long Acting Reversible Contraceptives

LoS Length of Stay

LWAB Local Workforce Action Board

LMC Local Medical Councils

MCP Multispecialty Community Provider

MDTs Multidisciplinary Teams

MRI Magnetic Resonance Imaging

NEL North east London

NELFT NELFT Foundation Trust

NHSE NHS England

NHSI NHS Improvement

NICENational Institute for Health and Care

Excellence

PFI Private Finance Initiative

PHB Personal Health Budgets

PHE Public Health England

PMS Primary Medical Services

PSA Public Service Agreement

QIPPQuality, Innovation, Productivity and

Prevention Programme

QMU Queen Mary University

QOF Quality of Outcomes Framework

RCGP Royal College of General Practitioners

SCF Strategic Commissioning Framework

STB Sustainability and Transformation Board

STI Sexually Transmitted Infection

STEMI Segment Elevation Myocardial Infarction

STF Sustainability and Transformation Fund

TCST Transforming Cancer Services Together

THIPPTower Hamlets Integrated Provider

Partnership


List of acronyms

Appendix

Acronym Name

TSSLTransforming Specialised Services in

London

TST

Transforming Services Together (working

across Newham, Tower Hamlets and

Waltham Forest)

UCLP UCL Partners

UEC Urgent and Emergency Care

WELTower Hamlets, Newham and Waltham

Forest Clinical Commissioning Groups


Transformation underpinned by system thinking and local action

DRAFT – POLICY IN DEVELOPMENT

Delivery Plan 1 of 8:

Promote prevention and personal and psychological wellbeing in all we do

Draft policy in development

No. Section Page

1 Initiative map 4

2 Delivery Plan on a page 3

3 Workstream Plans 5

4 Route map 9

5 Expected Benefits and Metrics 10

6 Resources and Delivery Structure 11

7 Risks 12

8 Dependencies, Assumptions and Constraints 13

9 Dependency map 14

10 Summary of Financial Analysis 15

11 Contribution to our Framework for Better Care and Wellbeing 16

12 Addressing the 10 Big Questions 17

13 Addressing 9 ‘Must Do’s’ 18

Contents

Promote prevention, and personal and


2


Initiative map N

EL S

TP

Level •Smoking cessation

•Diabetes: NEL-wide coverage of the NDPP

•Workplace health

•Development of other initiatives including: alcohol, childhood obesity, mental and sexual health, hypertension

•‘Make Every Contact Count’

•Embed prevention throughout our transformation plans

Lo

cal A

rea L

evel •Implementation of

elements of the STP level plans may be delivered at local area level where appropriate

•Devolution pilots including taking on of new Public Health powers to enhance our ability to tackle wider determinants of health

CC

G/b

oro

ugh

Leve

l •Health and Wellbeing Board strategies in each of the 8 boroughs

•Prevention priorities identified in each borough including wider determinants of health

•Self-care management

•Social prescribing

•Devolution pilots

London

-wid

e

•Tobacco & smoking

• Diabetes

Healthy London Workplace Charter

• Alcohol

•Obesity

• Mental health

• Sexual health

• Hypertension

•Haringey devolution



Our approach

There are a wide range of programmes that support our aim of promoting prevention, and personal and psychological wellbeing in all that we do. These are

outlined in our narrative plan for north east London. We have agreed through the STP the most appropriate level at which each programme should be led

and delivered within the health and care system. We have done this based on the partnerships and scale required to best implement the specific

programmes, using the following rationale for choosing to progress an initiative in north east London:

1. There is a clear opportunity / benefit in doing it jointly (which is above and beyond what would be achieved through a local programme), to

deliver improvement in terms of finance, quality, or capacity;

2. Doing something once is more efficient and offers scale and pace;

3. Collective system leadership is required to make the change happen.

We have set out below the result of this mapping as it relates to this delivery plan and the NEL STP level programmes that are described in more detail here.

3


Delivery Plan on a Page

Expected Impact • Reduced incidence in smoking (of 5% by 2021) and related admissions

• Reduced growth in diabetes incidence and improve treatment

• Healthier and more productive workplaces created and collaboration

between employers

• Demand channelled for services through prevention and self care

• People motivated to take ownership of their health within their

communities

• Other impacts to be confirmed - from initiatives to be developed to

include child obesity, hypertension and social prescribing.

Vision

A proactive approach to disease prevention within all that we do, addressing unhealthy behaviours that may lead to serious conditions further down the line and thus reducing the burden on the healthcare system. We will take action to motivate people to take ownership of their own health and encourage healthy environments to enhance the quality of life for our population.

Background and Case for Change • Health inequalities remain a significant issue in NEL with ill health disproportionately affecting people in

poverty. Our plans seek to encourage people to help themselves and take control of their lives.

• We are committed to acting on Healthy London Partnership’s research that suggests we can improve the

lives of residents and reduce demand on services through enabling people to change their behaviours. This

is especially true with smoking, drinking and physical activity. Evidence suggests we could save up to £25M.

• NEL is unique in its diversity and the strength of its communities. We will build on our existing local health

and wellbeing strategies and public health initiatives, as well and integrated care services to ensure services

wrap around and support neighbourhoods, so places where people live enable good health.

• To support this, we are identifying where there is benefit of working at scale to develop new models of care,

focused on prevention. These currently include smoking cessation, diabetes and workplace health and we

are also developing other initiatives, including strengthening prevention across our STP. This includes

systematic approaches to ensure we ‘Make Every Contact Count’ across all our interactions with the public.

Workstreams

Priorities and Objectives

1. To support boroughs in delivery of Health and Wellbeing Strategy prevention priorities

2. To embed prevention within our local transformation programmes

3. To collaborate across NEL on areas where there is benefit of working at scale. Initially

these have been identified as:

• Smoking cessation

• Supporting full coverage of the National Diabetes Prevention Programme in NEL

• Improving Workplace Health

4. To continue working together to identify other NEL wide opportunities, which may include

alcohol, childhood obesity, hypertension, mental and sexual health and social prescribing

5. Support prevention in other workstreams / systematising ‘Making Every Contact Count.’

16/17 17/18 18/19 19/20 20/21

1. Smoking cessation and

tobacco control

2. Diabetes

3. Workplace Health

4. NEL Prevention

Collaboration Programme

Planning and implementation

Implementation

Incorporate

into pathways Pre-diabetes

registers

Review and implementation Review and implementation

Scoping of NEL wide programme

Review and implementation

Mobilise

teams Scoping of initiative

opportunities

Local schemes, part of

NDPP (subject to bid)

Delivery of our joint plans

Agree

governance 4




Detailed Plan - Workstream 1: Smoking cessation

Case for change

Despite recent successes in reducing smoking prevalence, tobacco

remains the most significant preventable cause of death and disease. It

is also a major cause of health inequalities - accounting for half the

difference in risk of premature death between rich and poor.

NEL has 280,000 smokers and rates of smoking-related mortality are

high (notably in B&D, TH and Hackney). The cost to the NHS in NEL is

£56m pa with total societal costs estimated at £450m pa. Smoking

remains persistently high in some local communities and, as else-where,

numbers accessing SSS are falling (due in part to increases in use of e-

cigarettes). Innovative and tailored approaches are required to reach

smokers who do not engage with ‘mainstream’ services.

SRO: Meradin Peachey, Director of Public Health,

London Borough of Newham

Delivery

lead:

Jayne Taylor, Consultant in Public Health

London Borough of Hackney & City of London

Objectives

• To contribute to a reduction in smoking prevalence across NEL of 5% (at least one

percentage point) over 5 years

• To implement ‘smoking cessation as treatment’ across NEL NHS, through a social marketing

programme driving whole system change in trusts to embed the CO4 principles

(londonsenate.nhs.uk/helping-smokers-quit/)

• To implement an integrated smoking in pregnancy pathway, in line with Saving Babies’ Lives

Bundle (including CO validation & automated opt-out referrals to local SSS) across NEL trusts

• To promote and enable access to alternative (digital/telephone) support to quit to allow

reducing local budgets to focus on targeted support on high risk/harder to engage smokers.

Vision

A NEL system-wide focus on smoking cessation to provide improved, integrated

access to stop smoking services (SSS)

Initiatives Enablers Benefits and Metrics Deliverables

1 Smoking Cessation as

Treatment

Securing funding

for online bid.

Workforce training

NHS E metrics:

• Reduced number of smoking attributable admissions & and

support as appropriate

• Increased levels of very brief advice on smoking cessation in all

clinical encounters (inc acute, maternity and mental health)

NEL local metrics:

• 5% decrease in number of smokers, including groups with

higher rates of tobacco use*

• A pan NEL metric on smoking cessation

• Referrals to an evidence-based SSS, behavioural support and

pharmacotherapy; validation of successful quit attempts by

assessment for carbon monoxide levels

1. Establish integrated smoking in pregnancy

referral pathways across NEL (including routine

CO monitoring for all pregnant women)

2. CO4 plans are agreed and principles

embedded across all NEL acute and mental

health trusts, including mandatory Very Brief

Advice (VBA) training of all clinical staff

3. Smoke free NHS estate across all NEL sites

2 Integrated smoking in

pregnancy pathway

Maternity

programme 1-2. As above

3

Promote and enable

access to alternative

(digital/telephone)

support

Digital: develop-

ment of systems

to support

alternative options

NEL local metrics:

• Savings to be scoped from Optimity modelling

4. Design/implementation of social marketing

campaign to support whole systems change in

line with C04 principles; 5. All NEL boroughs sign

up to the London channel shift social marketing

strategy & service enhancement pilot 5

*Including: some ethnic communities, pregnant women, people with severe mental illness and people in lower socio-economic groups




Detailed Plan - Workstream 2: Diabetes Prevention

Case for change

Diabetes disproportionately affects people in poverty.

There is an increased risk of mortality among people with

diabetes in NEL and an increasing 'at risk' population.

The proportion of people with Type 1 & Type 2 diabetes

who receive NICE-recommended care processes is

variable. Primary care prescribing costs are high for

endocrine conditions (which includes diabetes). Diabetes

is therefore an agreed prevention priority. WELC is

already active in the NDPP - BHR has a bid pending.



Delivery

lead: Jeremy Kidd, Redbridge CCG

Objectives

To roll out full coverage of the National Diabetes Prevention Programme across NEL by:

• Continuing the WELC programme to embed learning and extend impact

• Launching the BHR schemes and develop a diabetes register and increase referrals

• In order in NEL to:

• Reduce incidence of diabetes

• Seek earlier interventions for patients who have developed the disease

• Improve health outcomes for people who have diabetes as a long term condition

Vision

Full coverage of the National Diabetes Prevention Programme across NEL in order to increase impact and reduce incidence of diabetes and improved treatment


1

Continue delivery of National

Diabetes Prevention

Programme in WELC

• Reduce the projected growth in incidence of

diabetes and self-care in people with a

diagnosis of diabetes

• Improve the treatment and care of people

with diabetes including plans to refresh and

implement new models of care/pathways

including integration with local services

• People with diabetes diagnosed less than a

year who are referred to structured

education

1. Local diabetes schemes delivered in WELC

2

Rollout National Diabetes

Prevention Programme in

BHR

Approval of

expression of

interest for

funding to

National

Diabetes

Prevention

Programme

2. Mapping of a clear pathway for NHS Health Checks that

incorporates a pathway for type 2 diabetes and its prevention

3. Expanded mapping of prevalence and its risk factors to help

identify at-risk patients

4. Prevention Programme to achieve PSA obesity and diabetes

targets

5. Pan NEL learning and evaluation including from WEL

programme through workshops

Widened implementation of healthy living programmes such as

the National Diabetes

6. Aligned governance across NEL

• As above and:

• Increased impact across NEL drawing on

learning from WEL delivery to date

3

Review further approaches to

joint working across Diabetes

prevention & pathways

• Increased opportunities for learning across

NEL through strengthened governance &

networks

7. Expansion of above deliverables

8. Clear, consistent pathways

6




Detailed Plan - Workstream 3: Workplace Health

Case for change

24m working days are lost in London due to sickness absence or injury. The Greater

London Authority is supporting a London-wide focus on workplace health. The London

Healthy Workplace Charter sets organisational standards for official accreditation,

including: health & safety, mental health, physical activity & attendance management.

From 2016 NHS providers are incentivised to improve the support offered to frontline

staff to stay healthy. The national incentive fund, worth £450m in 2016/17, supports

achievement of a number of outcomes relating to workforce health including healthy

food and flu vaccinations.

SRO: Ian Basnett,

Director of Public Health, Barts Health

Delivery

lead:

Andrew Attfield, Associate Director Public

Health,Barts Health

Objectives

• To improve workplace health through a co-ordinated,

accredited, incentivised approach

• To improve recruitment, retention and motivation of staff,

including frontline NHS staff

• As a result, to reduce reliance on bank and agency staff

• To support, to deliver on workplace health plans linked to

local prevention strategies / devolution work in BHR and CH.

Vision

To support the health and wellbeing of our workforce across NEL, to make the NHS a

place where people are happy and motivated to work and want to stay to develop their

careers.


1

To review each organisation

against the Healthy Workplace

Charter and seek accreditation

or for those accredited, aiming

for and maintaining excellence Alignment with

workforce

retention

strategy in

enabler

workstream

Public Health England measures: • Healthier and more productive workplaces, including NHS, LAs

and SMEs signed up to the Healthy London Workplace Charter

• Increased capability of the NHS workforce to improve workplace

health via a range of peer support, mental first aid, & availability

of facilities

• Increased collaboration between the NHS, wider public and

employer systems to maximise health.

1. Accreditation of all NEL organisations by

The London Healthy Workplace Charter

2. Implementation of signed up Providers’

Health & wellbeing project plan which includes

solutions for: better management of stress and

mental health issues, physical health

2 Participation in national

workplace incentive and funds

As above and addition NEL measures under development: • A healthy and engaged workforce with increased productivity i.e.

fewer sick days and less presenteeism*

• improved workplace health and safety and quality: re reduction in

accidents, better inflation control, better mortality rates, better

patient experience and a healthier and engaged workforce

• Improved physical health especially musculoskeletal

• Improved mental health and wellbeing

• Improved general health linked to exercise, healthy weight & diet.

As above and

4. Overarching strategy/implementation plan

5 Reduced levels of workplace absence 3 Explore options for a common

NEL Healthy Workplace strategy

4 Explore options for a common

NEL Food & Nutrition Strategy

Contracting

(procurement)

7 *The Health and Wellbeing of NHS Staff, Independent report, 2008, Dr Steve Boorman




Detailed Plan - Workstream 4: NEL Prevention Collaboration Programme

Case for change

Our health and wellbeing challenges across NEL go

beyond the areas we have identified for

collaboration on prevention so far. Whilst we are

addressing these through our local Health and

Wellbeing strategies and Devolution pilots, we also

need to continue to identify opportunities at STP

level to target the reduction of risk factors for

avoidable lifestyle conditions beyond what we have

already agreed. Prevention needs to be embedded

within all that we do to maximise the impact of

services and Making Every Contact Count.



Delivery

lead: [To be confirmed by Directors of Public Health]

Objectives • To maximise the impact of prevention through collaboration

• To scope further initiatives including: alcohol, child-hood obesity, hypertension, mental health & sexual health, in line

with national priorities

• To support other STP workstreams with prevention:

• To shift early intervention and planned care support self management & social prescribing (primary care)

• To provide universal health promotion of advice /support, particularly for LTCS & health concerns for pregnant women

• To support reduced incidence: reduce smoking & obesity and increase physical activity (cancer)

• To increase greater focus on community and prevention services including dental care (Learning disabilities)

• To improve patient experience and prevention (mental health)

• To promote self-care, patient awareness & self-management (Medicines Management)

• To learn from and develop the local ‘Make Every Contact Count’ strategy (Outpatient pathways).

Vision

Our preventative interventions are as impactful as they can be in improving the health of our population, through collaboration on commons issues across NEL, participation in London wide initiatives, and by embedding prevention within all of our transformation programmes


1

Establish governance

& modelling to support

NEL wide initiatives

Optimity

modelling

Subject to agreed initiatives, to include increased nos of:

• GP appointments related to prevention/health promotion

• Patients and carers active in their self care

1. Detailed financial modelling to clarify how we will

deliver our ambitions for STP preventative cost savings

2. Design & establish NEL wide governance structures

to enable scaling up of future prevention joint working

2 Making Every Contact

Count (MECC)

MECC

report

Delivery of best practice: NICE Guidance 49 Behaviour Change: Individual

Approaches (best practice in very brief and brief interventions)

3. Learning (report due Oct 2016) from our four LAs who

participated in the MECC project/mapped programmes

3 Blood pressure

control

To be

confirmed

depend-

ing on

prioritis-

ation

Alcohol, obesity, mental and sexual health:

• Reduce alcohol-related hospital re-/admissions, LoS and ambulance call-outs

• Reduce long-term impact of obesity on CYP including consequences for

physical & mental health in S/T & L/T

• Support to place based approaches to improving the food and activity

environment including via schools

• Implement digital mental & sexual health programmes

• Improving earlier, wider access to mental health services inc CYP & new mothers

• Improving the physical health of those with mental health problems including

access to preventive services

• Improved access to STI testing & range of effective contraceptive methods

• Expand access to HIV testing in high-prevalence areas.

1-3. As above

4. Scoping and prioritisation of initiatives including

achievement of national metrics

5. Implementation plans for 2018-19, 2019-20 and 20-

21 developed

4 Childhood obesity

5 Hypertension

6 Support of prevention

in other workstreams

8




Route Map 2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

1. Smoking cessation

1.1 Smoking cessation as

Treatment

1.2 Integrated smoking in

pregnancy

1.3 Promote and enable

access to alternative support

2. Diabetes

2.1 NDPP in WELC

2.2 NDPP in BHR

2.3 Joint working across

Diabetes pathways

3. Workplace health

3.1 Healthy Workplace Charter

accreditation / excellence

3.2 Participation in national

workplace incentive and funds

3.3 Delivery of Bart Health’s

HWB workplace programme

3.4 Food outlets at BH in line

with Food & Nutrition Strategy

4. NEL Prevention

Collaboration programme

4.1 Self-care management and

patient activation

4.2 Childhood obesity

4.3 Hypertension

4.4 Social prescribing

4.5 Support of prevention in

other workstreams

Agree Plan

Local diabetes schemes

Scoping of initiatives and prioritisation

Review and implementation Local diabetes schemes

Mobilise teams Implementation

Implementation

& review Implementation

& review

Implementation

& review

Diabetes register Incorporate

into pathways

Scoping of wider opportunities

Barts Health continued delivery plan implementation

Implementation of wider plans

Accreditation / BH aiming for excellence

Prevention social marketing campaign

Establish referral pathways

Smoke free NHS Estate

9

Scoping of initiatives and prioritisation

Agree

governance Scope opportunities Mobilise teams Implement

Design/implementation of social marketing campaign to support whole

systems change in line with C04 principles




Expected Benefits & Metrics Benefit

description

Measurement (metric) Current performance Target

performance

Target date

(default 2020)

Linked

workstreams

Reduced incidence of

smoking

Reduced incidence of smoking 280,000 (14%) smokers Reduction

of 14,000 (5%)

2020 / 2021

1. Smoking

cessation and

tobacco control

Reduce the number of smoking attributable

admissions

To be agreed based on current NHS Stop

Smoking Services statistics

Reduction 2020 / 2021

Increased prevention

interventions

Increase delivery of very brief advice on smoking

cessation in health care settings with introduction of

pan NEL metric

To be established potentially using existing

QOF indicators. QOF 15/16 data available from

31/10/16

Increase 2020 / 2021


diabetes

Reduce the projected growth in incidence of

diabetes and self-care in people with a diagnosis of

diabetes

To be established using HSCIC indicators Reduction 2020 / 2021

2. Diabetes

Prevention

programme in

NEL

Quality of treatment Diabetes prevalence data (available from QOF) QOF 15/16 data available from 31/10/16 Improvement 2020 / 2021

People with diabetes diagnosed less than a year

who are referred to structured education

82%

(National Diabetes Audit)


Improved wellbeing in

the workplace,

including health and

social care staff

Healthier, more productive workplaces, inc a focus

on the NHS, LAs & SMEs; sign up to the Healthy

London Workplace Charter

To be established based on Healthy London

Workplace Charter

Improvement 2020 / 2021

3. Workplace

health

Increase capability of NHS workforce /improve

workplace health

To be established using NICE guidance

recommendations e.g. Mental wellbeing at work

(PH22), Physical activity in the workplace

(PH13), Workplace health: long-term sickness

absence (PH19)


Reduce rates of staff sick leave Reduction 2020 / 2021

Increasing collaboration between the NHS & wider

public & employer systems to maximise health and

work initiatives


Support to place based approaches to improving the

food and activity environment

Improvement 2020 / 2021

Making Every Contact

Count (MECC)

Increase in very brief and brief interventions across

NEL

To be established using MECC Competence

Framework, NICE Guidance 49 on Behaviour

Change and NICE QS84 and PH47


4. Prevention

Collaboration

programme

Childhood obesity Reduce the longer term impact on children and

young people including consequences for the

physical and mental health

Reduction 2020 / 2021

Hypertension To be developed potentially using existing QOF indicators and national guidance e.g. NICE Reduction 2020 / 2021

Social prescribing To be developed Increase 2020 / 2021

Screening Uptake in screening programmes 1-7% Increase 2020 / 2021 Acute services 10



Note: Integrated outcomes and measures will be established in line with NHS E national metrics and current best practice guidance


Resources & Delivery Structure

Meradin Peachey is the SRO for this delivery plan. Below are other SROs and delivery leads:

SRO Delivery Lead

Delivery Plan

Meradin Peachey,

Director of Public

Health, London Borough

of Newham

To be confirmed

Smoking cessation

Meradin Peachey,

Director of Public

Health, London Borough

of Newham

Jayne Taylor,

Consultant in Public

Health, LB of Hackney &

City of London

Diabetes

Meradin Peachey,

Director of Public

Health, LB of Newham

Jeremy Kidd

Redbridge CCG

Workplace health

Ian Basnett,

Director of Public

Health, Barts Health

Andrew Attfield,

Associate Director

Public Health

Barts Health

Other initiatives

Meradin Peachey,

Director of Public

Health, LB of Newham

Dependent on which

initiatives are agreed by

Directors of Public

Health

6.1 Resources 6.2 Delivery structure

NEL STP Transformation

Steering Group

Prevention Care close to

home

Acute

Services

NEL

Clinical Senate

NEL ACS

Development Group

Directors of

Public Health

NEL STP Board

Health &

Wellbeing Boards

Smoking

Working Group

NEL wide

steering group

Workplace

Health working

group

BHR WELC

Diabetes

11



NEL STP Executive


Risks

Risks

Workstream Description: impact Mitigating action RAG

Diabetes There is a risk that funding bids are not approved and

therefore funding and delivery is constrained

Current plans are being developed to build on and enhance

existing workstreams and initiatives.

R

Smoking cessation Some NEL localities are less able to sign up to plans at

this point due to decisions that have been made locally

about the commissioning of stop smoking services

Governance of planning group ensures membership of local

TC leads with good oversight of local priorities, decisions

taken back to localities after each meeting for local 'sense

checking' and agreement, engagement with localities who are

not members ensured through STP Prevention SRO.

External/matched funding sources being sought to maximise

acceptability of plans.

A

Smoking cessation

Limited referral pathways for identified smokers as a

result of reduced / dis investment in SSS by NEL

boroughs

Pan-London channel shift communications and digital service

enhancement will provide an alternative (but see risks below)

A

Smoking cessation Pan-London channel shift work not implemented - failure

to elicit required support/funding; pilot unsuccessful

London TC Transformation Board is seeking external funding

to cover/supplement this activity.

Pilot planned to run in tandem with targeted communications

campaign to optimise uptake.

A

Smoking cessation

Widening of inequalities through replacement of

'traditional' evidence-based SSS with digital offer

Plans to be subject to health equity audit and informed by

pan-London insight work

A

Workplace Health There is a risk that no agreement is reached on options for

increased collaborative working across NEL

Although the opportunity cost is unknown, no additional system

saving is currently assigned to the surgery initiatives

A

Other initiatives There is a risk that no agreement is reached on options for

increased collaborative working across NEL


saving is currently assigned to the surgery initiatives

A

12 This is a list of the highest-rated risks. Additional risks identified at a lower mitigated risk rating




Dependencies, Constraints and Assumptions

Dependencies, constraints & assumptions (in order of impact)

Workstream Type: Dependency/

constraint/ assumption Description Actions / next steps

All Assumption

We have a working assumption that initiatives can be jointly

agreed, planned and delivered by 2020 to achieve the £25M

estimated through ROI modelling (net of transformation and

implementation costs)

Take forward local modelling drawing

on evidence from Optimity and the

Association of Directors of Public

Health to develop greater

understanding of deliverability

All Dependency That our Health and Wellbeing Board Strategies and ambitious

new plans for devolution pilots continue to tackle aligned

prevention priorities as well as wider determinants of health

Develop scoping and planning with all

borough directors of public health

All Assumption We have a working assumption that we can achieve aligned

governance and joint working arrangements across all

boroughs and organisations in NEL

Develop scoping and planning with all

borough directors of public health. LA

level discussions already underway.

Smoking cessation,

diabetes and

workplace health

Constraint A current constraint is that funding could only become

available through pending funding bids to resource

transformation change initiatives identified

Map bid decisions into initiative

timelines and contingency plans to

ensure timely resourcing

Other initiatives Assumption

We have a working assumption that the collaborative initiatives

(including alcohol, childhood obesity, hypertension and social

prescribing) will be jointly developed, agreed and delivered to

contribute to the prevention priorities and achieve savings for

the local health economy

Set up a task and finish group to

scope next steps to work up a

collaborative programme

Smoking cessation Dependency

The success of other delivery plan initiatives for particular

population groups - including people with cancer, pregnant

women, people with mental health needs and some ethnic

groups - are dependent on the design and implementation of

the smoking cessation initiative

(Identified in as dependencies in other

initiatives). To be addressed in STP

programme governance and planning

Diabetes Dependency

The success of other delivery plan initiatives for particular

population groups - including pregnant women and people with

learning disabilities - are dependent on the design and

implementation of the diabetes initiative

(Identified in as dependencies in other

initiatives). To be addressed in STP

programme governance and planning

13




Dependency map

Prevention Access to care

close to Home

Accessible quality

acute services

Infra-

structure

Product-

ivity

Special-

ised

Services

Work-

force

Digital

1. Smoking

cessation

and tobacco

control

C&H: Prevention

strategy devolution

status is directed

towards population

health priorities

Community services:

prevention in care

plans and support

Primary care: early

intervention with

patients and carers

supported to take an

active role in self

management

Learning Disabilities:

community and

prevention services

including dental care,

screening, diabetes

Mental health:

prevention support in

care plans, patient

experience and new

care models

Cancer: support

reduced incidence;

reduce smoking &

obesity and increase

physical activity

See

cancer

(left)

Digital:

opportun-

ities for

support of

accessible

patient

tools for

prevention

and self

manage-

ment

2. Diabetes Maternity: Universal

health promotion of

advice and support,

particularly for

women with LTCS &

health concerns

3. Workplace

health

Workforce:

Promote

self-care,

patient

awareness

& self-

manage-

ment

4. Other

initiatives to

be scoped

Other initiatives:

Alcohol, childhood

obesity, hypertension

and social

prescribing

Screening uptake

Outpatient pathways:

Learn from and

develop the local

‘Make Every Contact

Count’ Strategy

Social

prescrib-

ing

14

This dependency map highlights where this delivery plan is linked to another delivery plan within our STP:




Summary of Financial Analysis

The basis for the financial modelling has been the five year Operating Plans prepared by individual NEL commissioners and providers, all of whom followed an agreed set of key assumptions on inflation, growth and efficiencies. The individual plans have then been fed into an integrated health economy model in order to identify potential inconsistencies and to triangulate individual plans with each other. In the June submission the starting point for this modelling was the 16/17 operating plans. This has since been refreshed to be the month 6 forecast outturn.

The NEL STP financial template summarises the:

• Latest financial gap projection

• The anticipated financial impact of the workstreams on closing the gap

• The BAU effect on closing the gap

• The capital requirements for the STP

• The investment requirements including 5 year forward view investments

While substantial progress has been made on the financial and activity modelling for the NEL STP, the finance and activity plan for the October 21st submission should not be regarded as the final position. Further detailed worked-up analysis will follow over the coming months.

Work done since 30th June

• Expanded the Transforming Services Together capacity and activity model across the whole NEL STP footprint

• Updated the new capacity and activity model to include the BHR ACO schemes

• Refined the capital investment requirements

• Incorporated the estimated costs for the delivery of the 5 Year Forward View requirements

• Refreshed the underlying financial calculations to be based on month 6 forecast outturn

• Agreed the STP resourcing requirements

• Commenced detailed analysis of the financial and activity impact of the workstream initiatives

• Applied the capacity and activity model to calculate the capacity requirements for the Whipps Cross capital business case

Planned future work

• Update the new capacity and activity model to include Hackney Devolution pilot

• Identify opportunities to obtain additional funding from national investment funding sources (e.g. the Mental Health 5 Year Forward View)

• Undertake more detailed modelling of the financial and activity implications of workstream initiatives

• Reach agreement on the STP wide system control total (taking into account organisational control totals).

• Agree the implementation of the system control total, including handling of key dependencies (e.g. the NHS E specialised commissioning)

15




Return on investment (ROI) opportunities

16

Intervention Outcome Recurrent

Investment (£)

Recurrent Gross

Cost Savings (£)

Recurrent Net

Savings (£)

Supporting

Healthier Choices

Smoking: cessation through use of combination

therapies and NRT

Reduce smoking prevalence to 13% £3,010,007 £3,236,803 £226,797

Alcohol: increase screening and capacity of liaison and

outreach teams

Improve uptake of services £2,940,224 £5,291,707 £2,351,484

Obesity: NHS referral to evidence based weight

management services

7.5% of overweight/obese referred to weight

management service

£784,203 £1,307,006 £522,802

Falls: multifactorial intervention to reduce incidence

and harm from falls

Reduce hospital admissions by 10% £703,617 £2,822,250 £2,118,633

Unplanned pregnancies: contraceptives to prevent

unplanned pregnancies

Reduce unplanned pregnancies by 4% £428,885 £2,261,082 £1,832,197

Earlier diagnosis

and proactive

management in

primary care

Hypertension: control of hypertension through use of

anti-hypertensives

66% of hypertensives to have controlled blood

pressure

£486,041 £4,698,665 £4,212,623

Atrial Fibrillation: anticoagulation drugs in patients with

AF whose latest record of a CHADS2 score is ≥1

52% of AF patients to be treated with anti-

coagulants

£1,854,163 £2,359,844 £505,681

Diabetes: control of blood glucose through use of anti-

diabetic medication

74% of diabetics to have good glucose control £687,586 £850,548 £162,962

Workplace

wellbeing

Workplace Wellbeing Charter 5% of NHS and LA employees to receive WWC Requires further

development

Requires further

development

Requires further

development

A Workforce For

Prevention

MECC, MHFA, Dementia Awareness Training Requires further development Requires further

development

Requires further

development

Requires further

development

Total costs / saving identified to date: £10,894,726 £22,827,905 £11,933,178

Further estimated prevention savings opportunities: £13,066,822

Total estimated prevention savings opportunities through the STP: £25,000,000

Our financial bridge includes a £25m saving that we plan to deliver by scaling up our combined efforts across a range of preventative interventions. This

figure has been reached using a midrange estimate from the Health London Partnerships modelling produced to support STP planning. In addition to the

work outlined on the previous slide, we have begun more detailed modelling work utilising tools produced by the Association of Directors of Public Health to

establish how these opportunities will be realised under the NEL STP. The below table sets out an intervention level view of how we believe a significant

portion of those savings can be achieved.



16


Summary of impact

Promote prevention, and personal and psychological wellbeing in everything we do

Promote independence and

enable access to care close to home Ensure accessible quality

acute services for those who need it

• Our plans for ensuring the sustainability of accessible quality acute services across NEL are reliant on our ability to reduce the prevalence of disease by improving wellbeing and preventing ill health, and therefore reducing the demand on acute services

• By collaborating to reduce the prevalence of smoking we will lessen the burden on acute services for related conditions such as cancer or respiratory diseases

• Our plans for workforce health would improve health and wellbeing of all of our health and social care staff

• The delivery of our combined

plans for improving the

wellbeing of people in north

east London and preventing ill

health we will reduce the

frequency of acute episodes,

and enable more people to be

cared for in the community,

reducing the need for acute

care

• Establishing the National

Diabetes Prevention

Programme across NEL will

further enable the

management of people with

diabetes in primary care

• The delivery of the collaborative plans set out in this

delivery plan will help enable a step change in our

approach to prevention in all that we do across north

east London.

• These priorities have been chosen to enhance the

impact of our local prevention plans that are

already being driven through Health and Wellbeing

Board strategies and our innovative devolution pilots.

• Our commitment to continued collaborative working will

ensure that we continue to take a strategic approach to

working together to tackle our congratulations across

north east London

PEOPLE-CENTRED SYSTEM

17

This delivery plan sets out how it will deliver improvements against the core areas of prevention, out-of-hospital care and in-hospital care.




Addressing the 10 Questions

Q1. Prevent ill health and moderate demand

for healthcare

•Diabetes Prevention Programme: workstream plan 2 re diabetes (see slide 6 above)

•Tackling smoking, alcohol and physical inactivity: Reducing avoidable admissions: Childhood obesity: we are developing an initiative (see slide 8)

Q2. Engage with patients, communities

& NHS staff

•Step change in patient activation and self care: smoking cessation and diabetes (see slides 5-6 above) • Workplace health initiative (see slide 7 above)

Q3. Support, invest in and improve general

practice

•Support primary care redesign: support in prevention agenda and ‘Make Every Contact Count’ (see slides 3 & 4)

Q4. Implement new care models that

address local challenges?

• Support Integrated 111/out of hours through prevention agenda and ‘Make every contact count’ (see slides 3 & 4)

Q5. Achieve & maintain performance against

core standards

• Our focus on Make Every Contact Count will contribute towards reduced A&E waits (see slides 3 & 4)

• Our Diabetes prevention programme will contribute to reduced emergency admissions (see slide 6)

Q6. Achieve our 2020 ambitions on key clinical priorities

•Cancer survival rates: This delivery plan identifies the link to prevention and healthy lifestyle support for people diagnosed with and surviving cancer and people diagnosed and living with mental ill health (see slides 5 & 8)

Q7. Improve quality and safety

• Our Workplace health initiative aims to address staff wellbeing leading to improved care and safety (see slide 7 above)

Q8. Deploy technology to accelerate change

•This delivery plan identifies a dependency between the opportunities for digital support of more accessible tools for public prevention and self management (see slide 16)

Q9. Develop the workforce you need to

deliver?

•Develop and retain a workforce with the right skills and values: initiative 3 included in this plan re workplace health (see slide 7)

Q10. Achieve & maintain financial

balance

•A local financial sustainability plan: contribute efficiencies to the NELP STP plan through £25m savings identified in the Optimity modelling (see slide 10)

18




Addressing the 9 Must Dos

1. STPs

• This delivery plan outlines our agreed STP initiatives and milestones and the timeline for delivering them, where these are planned. In addition, we have an initiative to scope further collaboration

• We have also begun to map out the metrics against which we will measure our progress, which incorporate the relevant STP core metrics

2. Finance

•We are working collaboratively to develop scalable service models where this will deliver value for NEL through prevention and supported self care;

•Included in this delivery plan is initial analysis of how interventions could help deliver the £25m of potential savings as identified in the Optimity modelling

3. Primary Care

• Refer to the primary care delivery plan

•This delivery plan identifies a dependency between primary care and prevention in terms of supported self management and secondary prevention

4. Urgent & Emergency Care

• Refer to the urgent and emergency care delivery plan

• Consideration of prevention interventions including Making Every Contact Count

5. Referral to treatment times and elective care

• Refer to the acute services delivery plan

6. Cancer

• Refer to the acute services delivery plan for cancer and screening initiatives

• This delivery plan identifies a dependency between cancer and prevention both in terms of whole population prevention interventions and targeted support for people who have been diagnosed with cancer (for example physical exercise and smoking cessation)

7. Mental health

•Refer to the mental health delivery plan

•This delivery plan identifies a dependency between mental health and prevention both in terms of whole population prevention interventions and targeted support for people who experience mental illness (for example smoking cessation)

8. People with learning disabilities

•Refer to the learning disabilities delivery plan

9. Improving quality in organisations

•We are working collaboratively across NEL to develop scalable service models, underpinned by a workforce strategy

19










No. Section Page

1 Initiative map 3



4 Route map 10



7 Risks 14

8 Dependencies, Constraints and Assumptions 15

9 Dependency Map 16





Contents



2


Initiative map N

EL S

TP

Le

vel

• Enhanced primary care

• High quality, sustainable, integrated mental health care and support

• Integrated urgent and emergency care

• Learning disabilities - Transforming Care Programme

Lo

ca

l Are

a L

eve

l

• Hackney Devolution Pilot

• BHR ACO programme

• Transforming Services Together (WEL)

• Transforming sexual health services

CC

G /

Bo

rou

gh

Le

ve

l

• Personalisation and choice

• Self-care management and patient activation

• Integrated Health and Social Care

• Integrated children’s and young people’s care

• Community based end of life care

Lo

nd

on

-wid

e

• PAN London LAS Commissioning Strategy

• PAN London consistent UCC offers

• PAN London Strategic Commissioning Framework for Primary Care

Our approach There are a wide range of programmes that support our aim of promoting independence and enabling access to care close to home. These are outlined in

our narrative plan for north east London. We have agreed through the STP the most appropriate level at which each programme should be led and delivered

within the health and care system. We have done this based on the partnerships and scale required to best implement the specific programmes, using the

following rationale for choosing to progress an initiative in north east London:





We have set out below the result of this mapping as it relates to this delivery plan and the NEL STP level programmes that are described in more detail here.

3





Expected Impact

• Reduction in the number of unnecessary admissions

• Meet the national urgent and emergency care access standards

• Improved ability to meet current / future demand in primary care

• Improved access to Mental Health treatment

• Better enable people to access integrated urgent and emergency

care services appropriate to their need 7 days a week

• Improved coordination and enhanced service for patients with

complex conditions who need care from multiple professionals

Vision

Locally designed, integrated models of

care in place across north east London,

that wrap around the individual,

supporting them to manage their own

care and to access services that are

delivered close to home.

Workstreams

Priorities and Objectives We have identified four priority areas where transformation programmes are required across north east London to support the delivery of our local plans to implement new care models and enable people to access care close to their home. These programmes will be led or coordinated at a north east London level, and support delivery of our joint objectives: 1. People will be well-informed regarding the resources and services that are available to

them, empowering them to choose the most appropriate pathway for their care; 2. Support the development of primary care collaboration at scale with hubs, networks and

federations. This will improve access, quality and coordination of care; 3. Improve the population mental health and wellbeing, improving self care & prevention 4. Enable all people to access a consistent high quality integrated urgent and emergency

care offer across north east London, 7 days a week.

16/17 17/18 18/19 19/20 20/21

Enhanced Primary Care 1

Enhanced Primary Care 2

High quality, integrated mental

health care and support

Integrated urgent and

emergency care

Learning disabilities

Background and Case for Change

• Currently across north east London too many people go into hospital or stay in hospital longer than

necessary. Early, co-ordinated support that focuses on their wellbeing as well as their health and social care

needs can reduce their dependency on services in the long run. It can also ensure they are admitted to

hospital only when it’s really needed.

• Our local programmes for developing new care models are building new partnerships with local authorities,

communities and employers, and seeking to break down barriers between GPs and hospitals, physical and

mental health services, health and social care, and building new links to other public services.

• These plans will only succeed if they are supported by system wide transformation through the STP. Our

current models for Primary Care, Mental Health, Urgent and Emergency Care, and Learning Disabilities

need to be radically transformed to support these new models of integrated community care

Business case, commissioning intentions and implementation Initiative

development

System review

and strategy

development

Implement coordinated care plans Implement 8-8 access plans

Establish NEL QI

collaboration Implement joint work plan to improve quality, strengthen our providers, and support our workforce

Initiative

development

Procurements and pilots to develop Integrated

Urgent Care New model live

Implement Rollout national service model 4 Agree plan for

reducing inpatient beds




Detailed Plan - Workstream 1A: Enhanced Primary Care: Strategic Commissioning Framework delivery

Case for change

• Services are faced with significantly rising demand (29% population

increase in some boroughs) together with variation in quality

• 6 out of 7 of NEL’s CCGs are in the lower quartile for patient experience

when compared to rest of the country

• The rising burden of chronic disease alongside a population that is living

longer and with more years lived with poor health and complex care

needs, all contribute to increase demand for primary care services.

Objectives

• Deliver the aims of the GP Forward view

• Deliver London’s specification and ambition for the future of primary care outlined in

the Strategic Commissioning Framework (SCF)

• Stabilise General Practice in the context of the current workforce and financial

challenges

• CCG’s to support provider networks and federations to deliver primary care at scale,

as a step towards the ambition of establishing Accountable Care Systems

• Enable the rapid sharing of knowledge, learning and innovation across the footprint

Initiatives (17 SCF specifications) Enablers Benefits and Metrics Deliverables

1

7 Access initiatives giving

patient’s better choice of

access, easier ways to contact

the practice & same day

contact with a clinician if they

need it

Digital – e-Consult,

Telephone Triage, Share

records. Workforce &

Estates – extended

access, PMS &

equalisation

• Reduction in A&E attendances

• Reduction in variation –shared best

practice

• Improved patient satisfaction levels &

increased ease of making appointments

• Improved ability to meet current / future

demand

• Extended access to pre-bookable primary care

provided at scale, with some local variation and

phased delivery

• Demand management initiatives (such as e-

Consult, QI projects, practice resilience projects)

• All practices operating within routine opening hours

2

5 Coordinated initiatives

providing an enhanced service

for patients with complex

conditions who need care from

more than one professional

Digital for single shared

care plan, e-referrals &

self care apps.

Workforce for new roles

& skill mix, MDTs,

• Improved coordination and enhanced

service for patients with complex conditions

who need care from multiple professionals

• Flexible appointment lengths available

• Shared care record available to aid clinical

decisions

• Care plans reviewed and managed with MDTs

• MiDoS available to clinicians and patients

3

5 Proactive initiatives to

empower patients to self care,

remain healthy and build

community resilience

Digital for self care apps.

Workforce for new roles

& skill mix

• Patients empowered to remain healthy –

and supported by new roles

• Patients are engaged in co-designing their

local services

• Improve patient participation and engagement

• Social prescribing to be in place across all NEL

boroughs for targeted patient groups

• Increased uptake of Patient Online, through

facilitation to increase number of bookable slots

available online and awareness in patients

Vision: High quality and locally responsive primary care as the platform for system sustainability, delivering the Strategic

Commissioning Framework specification. This includes easier and more convenient access to GP services, shifting the balance

of work to proactive and planned care, with GPs providing an ongoing relationship for care coordination for patients, seamless

delegation to the extended PC team, and GPs freed up and enabled to spend time with patients with complex conditions on

person-centred, planned and preventative care.

SRO: Steve Gilvin, Chief Officer,

Newham CCG

Delivery

lead:

Sarah See, Director of Primary

Care Transformation, BHR

CCGs

*Detailed NEL primary care delivery plan has been developed, with breakdown of SCF specifications, timeframes, enablers and deliverables planned

5




Detailed Plan - Workstream 1B: Enhanced Primary Care: Enabler delivery

Case for change

• 26% of services in NEL are rated are ‘inadequate’ or ‘requires

improvement’ by the CQC versus 13% nationally

• Higher patient demand, a growing population, and a larger amount

of time spent on administrative tasks has seen workload increase

across NEL.

• Staff and skills shortage, with 1,769 patients per WTE GP

compared to the London wide average of 1,660

• High number of small practices, some of which are not run from fit-

for-purpose premises

Objectives

• Embed the Quality Improvement Collaboration

• Deliver Workforce, Practice Resilience/ Provider Development, Digital and Estates aims of

the GP Forward view

• Stabilise General Practice in the context of the current workforce, workload and financial

challenges

• Develop provider networks and federations to enable delivery of primary care at scale

• Enable delivery of the Strategic Commissioning Framework (SCF)

• Deliver approved Estates and Technology Transformation Fund (ETTF) projects in NEL


1

NEL Collaboration focus

areas Quality improvement,

access, workforce & provider

dev.

Workforce & Digital: new ways

of working & provider dev.

Estates: ETTF delivery

• Common quality improvement approach for

general practice - reducing variation and

supporting benchmarking against quality metrics

• Establish NEL Quality Improvement Collaboration Board, with

workstreams focusing on workforce, practice resilience,

estates and access.

• Develop QI programme, collaborating with partners e.g. CEG,

UCLP, HLP, National QI

2

NEL and system level plans

for provider development

and practice resilience

Workforce: leadership training,

technology to support demand

/ capacity mgmt.

• Build resilience in primary care at practice level

and at scale, with a view to releasing time for

patients and avoiding practice closure

• Undertake benchmarking survey of all practices to identify

support requirements

3

Workforce development to

ensure services are

appropriately resourced to

deliver new care models

Workforce, commissioning and

engagement with partners

(CEPN, networks /

federations)

• Patients supported by new roles including

physician associates, clinical pharmacists in

practices and care navigators

• Increased recruitment and retention of GPs and

nurses in primary care

• Better management of workload pressure

• At scale working (MDTs, workforce, access)

• Local Workforce Action Board (LWAB) in place addressing

ambitious shared NEL plan for PC workforce

• Develop Workforce integration work plan

• Commission / evaluate Physician Associate pilot

4 Estates, improving quality

and safety in all services

Estates funding, including

ETTF and Improvement grants

• Hubs providing extended access to patients,

supported by new roles/ skill mix

• Digital facilitation to maximise EMIS functionality and other

CCG/joint initiatives/local Digital Roadmap

• Pilot new Smart Telephone systems – for triage system

• Patient record sharing functionality in place across networks

for extended access delivery

SRO: Steve Gilvin, Chief Officer,

Newham CCG

Delivery

lead:

Sarah See, Director of Primary

Care Transformation, BHR

CCGs

Vision: NEL’s vision for the primary care enablers are that patients will experience consistent high quality primary and

community care services, The primary care workforce will be valued, developed and have an attractive place to train and

work, patients will be supported by new roles, including physician associates, clinical pharmacists in practice settings and care

navigators. Services will be seamless, with effective digital signposting, co-ordination of care and exchange of information.

Estates will be fit for purpose, enable multidisciplinary working and make best use of combined health and social care estate.

6




Detailed Plan - Workstream 2: High quality, integrated mental health care and support

Case for change

• Mental Ill-health is highly prevalent in NEL, particularly due to deprivation. Austerity

policies add pressures on housing, employment and income. Co-morbid physical & mental

health adds system strain.

• Demand increase of c.20% by 2020/21 => potential system pressure of c.£60m;

mitigations (minimum investment standard and CIP) leave a gap of up to c.£25m to be

met through system transformation.

• Significant progress has been made in quality and performance against national

indicators, CAMHS transformation, dementia . But variation in performance (e.g. bed

usage, placements) still exists across NEL, and sustainably meeting the FYFV objectives

requires transformation across the system.

Objectives

• Improve the population mental health and wellbeing, improving self care & prevention,

including the use of digital support

• Improve access to and quality of services incl. perinatal, psychological therapies, EIP, crisis

care and dementia, meeting national requirements

• Sufficient capacity for predicted additional demand for MH services, including productivity

and demand reduction

• Mental health at the heart of our integrated care models, across 1° and 2° care and as

close to home as possible; improve psychological support for those with LTCs and physical

health of those with SMIs

• Efficient, sustainable use of resources


1

Improve the prevention of mental

health problems, and strengthen

community resilience

• Prevention workstream

• LA services & Public Health

• Health & Wellbeing Boards

• Open Dialogue pilot (NELFT)

• Improved access to meet national standards

• Reduce suicide rates by 10%

• Prevent premature death

• Improved employment rates when on CPA

• FYFV commitments

• Suicide prevention strategies

• Systematised primary care mental health support

2 Early Years MH initiatives – CYP MH

and Perinatal

• Transformation funding for

perinatal services and Local

Transformation Plans

• Improved access to perinatal MH (2,000 extra

women), CYP MH (35% target), crisis and liaison

psychiatry, primary care MH and digital MH.

• CYP MH Future in Mind commitments, improved access,

perinatal services (subject to funding bid) community

Eating Disorders services, and 24/7 urgent support

3

Improve access to psychological

treatment for people with anxiety and

depression

• GPFV and 1° care MH

• Workforce and

commissioning plans

• 25% of people with CMDs access IAPT services;

meeting the 6week / 18week waits

• 10% Reduced suicide rates

• Enhanced primary care services

• Additional capacity for IAPT

4

Improve psychosis support –

productive pathways, crisis &

accommodation

• Demand and capacity model

• BHR UEC vanguard

• 60% of first episode psychosis cases starting

treatment within 2 weeks

• Reduce non-specialist out of area placements

• Productive, sustainable psychosis pathways.

• 24/7 crisis and home treatment teams (all ages)

• Core 24 Liaison psychiatry services in all hospitals

5

Support system effectiveness:

physical and mental health

integration

• Place-based care model

• Local integration plans

• Better psychological support for LTCs

• Reduction in lost years of life; access to physical

health checks for those with SMIs

• Specific deliverables to be confirmed during Q3 and Q4

2016/17 (e.g. psychological support for LTCs, health

checks for those with SMIs on GP registers)

6 New models of commissioning to

support recovery-focussed services • Budget balance / surplus • New sustainable commissioning models

7 Specialist MH - capacity, step-up/-

down & demand management

• Specialised commissioning

(forensic and CAMHS Tier 4)

• Referrals, admissions, LOS and occupied bed

days

• Age-inclusive core24-compliant Liaison Psychiatry

• Revised forensic and CAMHS community pathways

SRO: Caroline Allum, MD, NELFT

Navina Evans, CEO, ELFT

Delivery

leads:

Richard Fradgley, D. Integrated Care, ELFT

David Maher, Deputy CO, City & Hackney CCG

Sharon Morrow, COO, BHR CCGs

Vision

Sustainable and person-centred mental health services as part of a whole health and

social care system, placing mental health at the heart of new models of care

7




* Vascular surgery, stroke, major trauma, STEMI heart attack and children's critical care

Detailed Plan - Workstream 3: Integrated urgent and emergency care

Case for change

• High demand in NEL with 710,021 emergency department (ED) attendances in 2015/16

across the 6 Hospital Trust Sites. Overall Trusts have seen a rise of 11%.in 2016/17

• Projected population increase of 6.1% over next 5 years , with increases in age groups

shown to access UEC services more (0-14 years and the over 65s)

• Current UEC pathway is fragmented and confusing with public knowledge of the full

range of services and how to access them being poor

• Lack of access / resilience to support people with urgent primary care needs

• Lack of digital transformation in London Ambulance Services leading to underutilisation

of alternative care pathways in the community

• NEL trusts struggled to meet national emergency access standard in 2015-16, with 4 out

of the 6 Hospitals failing to achieve the 95% 4 hour target, and collective performance of

88.69%. In 2016/17 as of September 2016 all 6 Hospitals are not meeting the 95% 4

hour target. Whilst BHRUT are currently meeting the trajectory, both Barts Health and the

Homerton University Hospitals Trust are not meeting their agreed trajectories.

• Demand for the LAS service rose by 121% from 2013-14 to 2015-16

Objectives

• To meet the national urgent and emergency care access standards

• To meet right place, first time principles

• To implement Integrated Urgent Care (IUC) across 7 CCGs, improve the delivery

of shared care records, implement direct booking from IUC into general practice

(including extended hours) and other parts of the urgent care system .

• Higher utilisation of alternative care pathways including ambulatory care and rapid

response

• Ambulance & mental health services that are integrated within the urgent care

system

• Urgent Care Centres and ED’s that meet the UEC Facility Specifications guidance.

• All people that need to be admitted via the urgent and emergency care pathway

have access to consistent high quality acute hospital services on every day of the week.


1 IUC e.g. NHS 111 / Clinical Hub with

the wider urgent care system

Technology to integrate

urgent care systems

• 10% increase in self care through 111 online;

20% increase in closed calls through the

establishment of clinical hubs

• Implement 24/7 integrated 111 urgent care service that connects

to clinical hubs (that include GP’s, dentist, pharmacists, MH) with

clear onward referral pathways

2 Primary Care Extended Access Enhanced Primary Care

Workstream

• A contributory 39% reduction in unnecessary

ED attendances • Primary care extended access with urgent care capacity

3 London Ambulance Service (LAS) Pan London

Commissioning Strategy • A 10% reduction in LAS conveyances to ED

• Implement integrated commissioning strategy for LAS, including

digital transformation

4 Ambulatory Care (AC) Review of current AC

pathways

• A 48% reduction (phased over 5 years) in less

than 1 day admissions • Consistent ACU pathways in place across NEL

5 Acute Transition Plans and UEC

Facility Specification guidance AE Delivery Plans

• Increased quality of services through meeting

core standards • Business case for reconfiguration of KGH ED (March 2017)

6 Seven Day Working Learnings from early

adopter sites

• % reduction in lengths of stay (awaiting

outputs from early adopter sites

• Meet 7DS for 4 priority areas* in Autumn 2017; and for general

admissions by 2020

7 Improved Discharge flows AE Delivery Plans • % increase in people discharged appropriately

at weekends and before noon weekdays • Improved bed capacity and flow

SRO: Alan Steward, Chief Operating Officer, Havering

CCG

Delivery

lead:

Kendel Fairley, Urgent and Emergency Care

Network lead, north east London

Vision: Create a simplified streamlined urgent care system to ensure right care, right place, first time access principles for people in north east London. The NEL Urgent and Emergency Care (UEC) system will be able to respond to current and future demand whilst meeting quality standards and within a financially stable framework

8




Detailed Plan - Workstream 4: Learning disabilities

Case for change

• The service model in place across NEL does not

currently meet the national service model standards

• Utilisation of inpatient beds varies across NEL with a

proportion of people placed out of borough

• There is not enough capability and capacity in the

community to support people of all ages at times of

crisis which increases the risk of hospital admissions

We need greater control over outcomes within the

hands of people who use or experience services

Objectives

Working together the two established Transforming Care Partnerships (which are formed of

CCGs, Local Authorities, and wider partners) in NEL have agreed a set of joint objectives:

• To reduce the number of inpatient beds commissioned in NEL with a greater proportion of

beds commissioned locally

• To implement the national service model to ensure service quality meets national standards

• To increase the proportion of the "at-risk" population receiving services at home;

• To develop a workforce transformation plan - developing the skills and capacity in the

workforce to enable better community support

• To expand access to personal health budgets to enable individual control of support by

people and their families


1

Reducing reliance

on inpatient beds by

enhancing

community support

and crisis

management

• Engagement / co-production with

users, their families and staff on

alternatives to inpatient bed model

• Workforce – with Local Authorities to

ensure sufficient community based

workers

• Procurement support

• CCG inpatient beds (adults) in INEL and

ONEL TCP partnerships reduce to below

15 inpatients per million by April 2019.

• Reduction in out of area placements by

2019

• Preferred providers list across NEL

• Co-production community based

housing development plan - giving

people choice and control on

where they live

2

Developing a new

service model, co-

designed with

people with lived

experience

• Workforce development

• Technology to integrate systems

• Engagement in design process

• Joint working with local authorities to

develop housing options

• Improved access to healthcare for people

with a learning disability

• Mental and physical health and wellbeing

improves for individuals in this cohort

• Levels of challenging behaviour for

individuals reduces

• Good quality housing will be available

when people need it

• Funded workforce development

plan that supports delivery of the

national service model

• NEL case for change that models

current and future demand for

services

• Implementation of new service

model (ATU and community)

SRO: Sharon Morrow, Chief Operating Officer, Barking

and Dagenham CCG

Delivery

lead:

Susan Storrar, WELC Transforming Care

Partnership - LD. Programme Lead

Vision

People with learning disabilities and/or autism who display behaviour that challenges, including those with a mental health condition, are supported to live as independently as possible.

9




Route Map (1) 2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

Enhanced Primary Care

Quality Improvement

Collaboration

SCF

Accessible

Coordinated

Proactive

Provider dev. / resilience

Workforce

Estates

Demand capacity / QI projects

Same day access

Quality improvement collaboration (QIC) across NEL

8-8pm pre-bookable access – with some local variation (where evidence of alternative local requirements Implement 8-8 plans

Implement coordinated care plans

MDTs in place Extended appointments for complex care

Implement proactive care plans

Asset maps in place

Shared care summary

Coordinated care delivered

Accessible care delivered

Proactive care delivered

OD support incl. Network / locality modelling, working at scale and clinical leadership

Establish practice resilience projects (linked to QIC initiatives – such as Making Time to Care)

NEL Collaborative of GP Federations established

Local Workforce Action Board (LWAB) in place

Patients will be supported by new roles

Leadership dev / organisational skills programmes

New specification for workforce requirements

Activities to promote NEL as a

place to work

Estates strategies / infrastructure plan defined

Delivery of infrastructure plan

Delivery of successful ETTF bids (3 year funding cycle)

QIC Programme

Board established

NEL Shared dashboard developed – with primary care metrics

Series of engagement workshops to scope QIC & embed approach

*for digital enabler see digital detailed plan

8-8 plans for delivery in place

Increase patient online uptake (by practices & patients)

Systems piloting physician associates

10




2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

High quality, integrated

mental health care and

support

Integrated urgent and

emergency care

Integrated Urgent Care e.g.

NHS 111 / Clinical Hub

London ambulance service

Ambulatory care

Acute reconfiguration plans to

include KGH and meeting UEC

Facility Specifications

Seven day working


Reducing inpatient beds

Developing the new

service model

Route Map (2)

Develop ATU

case for change

Agree

model New model of

commissioning

Ongoing Transformation and investment:

CAMHS Local Transformation Plans, Crisis Care Concordat, parity of esteem, etc.

Develop sustainable commissioning model options Shadow running

Invest in services to sustainably deliver FYFV-MH

Deep dive into psychosis

pathways across NEL

Determine FYFV-

MH investment

required

Pathway redesign – productivity, crisis

and accommodation

CYP service

expansion and

development

Community ED in

all CCGs

Reduce bed use Revised

pathways

London Digital Mental Health programme

Application for perinatal

MH funding Commissioning

intentions

Implement perinatal MH

service

Develop further

initiatives*

Business case

development

Strategic

delivery plan Implementation

Perinatal MH

services

Increase access to CYP

community services by 7% Increase access to CAMHS and community ED

services

Whole system

review

Size of gap and

opportunities identified

Meet CYP access

targets

Meet FYFV

commitments

Meet perinatal

access target

* OOA placements, 1° care MH, Crisis services

All patients receive a Care

Treatment Review (CTR)

Implement new

model

Complete self-assessment and

analysis of spend across agencies Develop case for change and

commissioning plan for specialised

New service model implemented with providers

Prioritisation of

improvement actions

Housing development plan co-

produced with service users Improved access to respite services

Piloting of Beta 111 online

Procurement for NEL NHS 111 New service mobilised New 111 service live

Review of current UCC facilities

against standard specifications

Implement plans to ensure all UCCs

meet specifications All UCCs meet specification requirements

Evaluation of 2 existing LAS models

in place across NEL

Adaptation and rollout of most

impactful models across NEL Aligned integrated model in place

Baseline review of current ACU

pathways across NEL Review of ACU condition

based pathways across NEL Consistent ACU pathways in place across NEL Rollout

Learning from NWL pilot Business case for


7DS standards met for

key specialised services

7DS standards met

for all services

Confirm plans with Barts Health & BHRUT that will create

the necessary capacity at receiving sites

11

Business case agreed Develop plan for KGH 24/7 enhanced UCC by March 2017




Expected Benefits & Metrics

This section provides a summary of the key benefits that we expect to achieve through the implementation of this Delivery Plan.

Benefit description (Health & wellbeing, care &

quality or financial)

Measurement (metric) Current

performance

Target

performance

Target date

(default 2020)

Linked workstreams

At scale federations / networks to provide primary

care services at scale, improving access, patient

satisfaction, efficiency and reduced variation

Federations / networks to provide

coverage over 100% of NEL

95% 100% 2020 Primary care, Workforce, Digital,

Estates

Increase patient online - leading to improved

patient satisfaction with booking an appointment;

reduced workload for clerical staff and potentially

fewer DNA’s

50% of all appointments available

online for booking and cancellation

Varies across the

footprint – some at

early stages of

implementation

50% 2018 Primary care, Digital

Further primary care metrics to be defined by the end of 16/17, as the NEL Quality Improvement Collaboration (QIC) plan to implement a common quality improvement approach, supported by

a shared performance dashboard and peer review. The QIC plans to agree on some shared measures for access, patient experience, and workforce, as well as at least one long term condition

(for example Diabetes) to monitor progress with new ways of working and of care coordination.

Improved access to MH treatment First episode psychosis cases

starting treatment in 2 weeks

60-97% 60% 2016/17 Mental health

People with CMDs accessing IAPT

services (c.297,000 (15.3%) of

NEL population have a CMD)

14.3-22.3%

(Mar ‘16)

25% (approx.

75,000 people)

2016/17 Mental health, Primary care

IAPT waiting time targets 6w: 77-100%

18w: 96-100%

6w: 75%

18w: 95%

2016/17 Mental health, Primary care

Access to dedicated perinatal MH

services

No dedicated

services provided

2,000 extra

women

2020/21 Mental health, Perinatal MH

Access to CAMHS for CYP with

diagnosable MH condition

Monitored through

LTPs

35% 2020/21 Mental health, CAMHS LTPs

Improve employment for those with CMD and SMI Employment for those on CPA 6.8% Increase 2020/21 Mental health

Better enable people to access integrated urgent

and emergency care services appropriate to their

need 7 days a week

Unnecessary ED attendances

(attended not admitted)

710,021 / TBC 39% reduction 2018 Urgent and Emergency care,

Primary care

No. facilities compliant with UEC

facility specifications

Under assessment Full compliance TBC Urgent and Emergency care

Meet seven day standards

(specialised & general) Under assessment

100% 2020

Urgent and Emergency care

To implement the national service model to ensure

service quality meets national standards and

improve outcomes for the cohort

Proportion of the "at-risk"

population receiving services at

home

Data not currently

available

Less that 15

inpatients per

million

April 2019 Learning Disabilities

These represent the main benefits and metrics - other local and national standards exist and form part of the improvement objectives. 12






SRO Delivery Lead

Delivery Plan

Conor Burke

Chief Officer

BHR CCGs

Luke McCartney

NEL STP PMO

Enhanced

Primary Care

Steve Gilvin

Chief Officer

Newham CCG

Sarah See

Dir. Primary Care

Transformation

BHR CCGs

Mental Health

Navina Evans

Chief Executive

ELFT

David Maher

Deputy Chief

Officer

City and Hackney

CCG

Integrated Urgent

and Emergency

Care

Alan Steward

Chief Operating

Officer

Havering CCG

Kendel Fairley

Urgent and

Emergency Care

Network lead

North east

London

Learning

Disabilities

Sharron Morrow

Chief Operating

Officer

Barking and

Dagenham CCG

Susan Storrar

LD. Programme

Lead

WELC

Transforming

Care Partnership



Steering Group

NEL

Clinical Senate

NEL ACS

Development Group

NEL Urgent and

Emergency Care

Network

NEL Leadership Group

( STP PC Working

Group)

NEL Mental Health

Programme Board

Joint NEL STP


Working Group

ONEL Transforming

Care Partnership

INEL Transforming

Care Partnership

NEL Primary Care

Quality Improvement

Collaborative

GPFV workstreams (inc

workforce provider

development, access

and estates)

NEL STP Board

NEL STP Executive

Local delivery

(including local

programme boards)

13




Risks Workstream Description: impact Mitigating action RAG

Primary care

Risk that some ETTF bids are unsuccessful and delay

delivery ( significant amount of deliverables are

dependant on timely ETTF investment)

NHSE to confirm ETTF bids that have been successful in October 2016. Any

further mitigations will be developed following announcement. R

Primary care

Risk that there are insufficient workforce to staff the

new ways of working, particularly will models going live

at the same time across London (i.e. hubs)

Review workforce modelling - with support from HLP Workforce team. Engage

with HEE to determine workforce plan required. R

Learning disabilities Finances unable to be secured to establish key

priorities

Financial modelling to inform a business case that supports a shift in

investment form inpatient beds to community services R

Primary care

Delay to completion of the PMS Contract review results

in delay to delivery of primary care plans (particularly

for extended access)

NHSE working closely with LMC to progress in order to release PMS funds.

NEL are utilising available transformation funds (inc GPFV) to progress

delivery

A

Primary care Risk that the networks have limited capacity &

capability for QI due to low maturity in Y1

QI programmes to be developed with input from providers; commission

protected learning time; Submitting bid to support practice development to

HLP – National support also available A

Primary care

Risk that the workforce service models are not

sufficiently developed to inform education

commissioning requirements

LWAB members to advise on emerging requirements, and Quality

Improvement Collaborative to support development of consistent requirements

across NEL in support of vision A

Primary care Risk of GPFV 8Bs not being effective due to delays in

recruitment / scale of transformation projects required

NEL scoping best utilisation and grading of GPFV resource, and governance

arrangements for them. A

Mental health

Funding available for mental health initiatives

potentially limited as the majority is included in CCG

baseline uplift and STF, thus at risk of prioritisation

from other parts of the system. Also potential knock on

effect from any reductions on Local Authority funding.

Obtain commitment to sustainably plug the gap from the whole system through

acceptance of the Carnall Farrar gap analysis highlights the probably gap in

mental health funding by 2020/21, and analysis of the impact of mental health

initiatives on the whole system (e.g. reducing usage of A&E by those with

SMIs and/or chronic physical health conditions)

A

Integrated U&EC

Six key conditions must be met in order to keep to the

timetable to transition King George Hospital ED to 24/7

urgent care centre by summer 2019

Chief Exec / Chief Officer-led programme in place to lead and oversee

progress A

Integrated U&EC Require baseline analysis to agree level of impacts

across 6 priority areas NEL UEC

Chair NEL UEC / Director STP programme to request data fields required and

agreed by network at a NEL level. Require financial support to then model

financial benefits from transformation changes A

Learning disabilities Housing Options can't be found Engage housing providers and seek examples from elsewhere to help develop

local strategy for this cohort A









Delivery plan level Assumption Population will increase by 8.9% over the next 5 years, 19.8% over the next 10 years

Further modelling work to be undertaken to ensure

accurate forecast across NEL

Primary care Dependency The delivery timelines in the plan are dependent on additional investment, for example

from the GPFV, ETTF and Improvement Grants

Develop robust bids for funding. NHSE to confirm ETTF

bids that have been successful in October 2016. Next

steps will be developed following announcement.

Primary care Constraint Some aspects of delivery require contractual levers such as the PMS review in order to

be delivered

NHSE working closely with LMC to progress in order to

release PMS funds

Primary care Assumption That the 17/18 GP Access funding provided is sufficient, alongside additional sources of

funding, to continue 8-8pm extended access delivery

Work closely with HLP to understand how the GPAF £26m

for London in 17/18 will be apportioned

Primary care Dependency HEE to fund training opportunities in Primary Care (note there no consistent training

tariff for roles in primary care).

NEL to work closely with HEE via the Local Workforce

Action Board (LWAB) & outline training requirements for

HEE to include in training plans

Mental Health Assumption Sufficient funding is available to implement FYFV, parity of esteem and other

programmes Fully cost up investments

Mental Health Dependency Tier 4 and Secure MH are NHSE commissioned; Drug & Alcohol services are Local

Authority commissioned – transformation requires close collaboration

Liaise with specialised commissioning STP workstream

and Local Authority partners to develop plans

Mental Health and

Primary Care Dependency

GP Forward View outlines investment in a mental health therapist for every 2-3

practices.

Identify gaps in current primary care mental health

provision and cost up required investment

Mental Health and

Unplanned Care Dependency Link between mental health crisis care and 111/out of hours services

Determine key initiatives to align with unplanned care

workstream.

Mental Health Dependency

Delivering system value through improved mental health will require work with all system

partners to identify savings and efficiencies through MH initiatives. Interdependencies

with Local Authorities are key to improving population MH

Develop plan to engage all providers, CCGs and local

authorities in STP-wide initiative identification and

development

Integrated Urgent and

Emergency Care Constraint

Estate capacity available at the Urgent Care Centres / ED at Queens, KGH, Whipps

Cross, Homerton, Royal London and Newham to meet the demands from population

growth at all and the capacity to provide ambulatory care services 7 days a week, and

manage demand from the KGH transition plans

Implementation of estates strategy

Integrated Urgent and

Emergency Care Dependency

Successful implementation of IT Interoperabity and outcome of Beta phase to support

111 online Link to NHS England and Network IT development plans

Learning Disabilities Dependency Investment in community services will be required to reduce admissions to inpatients

beds, despite pressure on health and social care budgets

Develop a costed commission plan for specialist

community services that supports a reduction in inpatient

beds

Learning Disabilities Dependency Workforce development plan will be needed to ensure staff are trained to support new

model of care Linking into the NEL Local Workforce Action Board

15




Dependency map

Prevention Access to

care close to

Home

Accessible

quality acute

services

Infrastructure Productivity Specialised

Services

Workforce Digital

Enhanced

Primary Care

Patients

empowered to

remain healthy

– and supported

by new roles

Integration of

Mental health

and Urgent and

Emergency

Care

Delivery

infrastructure

aims of the GP

5YFV

Delivery

workforce aims

of the GP 5YFV

Delivery

technology aims

of the GP 5YFV

Mental Health

Wider

determinants

of health;

education;

London digital

MH

Primary care

(GPFV);

Those with LD

and MH

conditions;

Urgent care

Efficiencies,

flows, capacity

across all

sties, incl. John

Howard Centre;

Mile End

Hospital and

Primary care

Tier 4 CAMHS

and Secure MH

Additional

workforce to

deliver

increased

capacity

Access to

health records

and digital

wellbeing

programme

Integrated

Urgent and

Emergency

Care

Plans to support

more self care

through 111

online and

development of

consistent Apps

Primary Care

same day

access

increased to

help manage

urgent care

demand

Acute

plans to meet

UEC facility

specification

guidance

Capacity

available at

UCCs across

NEL to

implement

ambulatory care

Acute

Implementation

of 7 day

standard for

specialised

services

Workforce

plans in place to

support 7 day

working.

Efficiency in use

of current

workforce and

reducing

duplication of

effort

Interoperability

in place to

support the

objectives of

integrated

urgent care.

Learning

Disabilities

Access to

services for

those with LD

and MH needs

Workforce

developed to

deliver new

model of care

16

This dependency map highlights where this delivery plan is linked to another delivery plan within our STP






















Planned future work






17




Contribution to our Framework for Better Care and Wellbeing



enable access to care close to home

Ensure accessible quality


• The sustainability of high quality and accessible acute services across north east London is dependent on our ability to better manage demand by caring for more people in a community setting.

• Key to this will be a consistently accessible and high quality primary care offer across NEL, and the redesign of our urgent and emergency care pathways to release pressure on hospitals to care for those who need it most.

• We will also seek to better care for people with mental health or LD issues settings best suited to their needs. Building capacity and sustainable community services will ensure sufficient capacity in MH inpatient units.

• Improved access, capacity and

quality in primary care will

improve our ability to manage

people with long term conditions

in the community.

• Access to adult and young

people’s community mental

health services will be

increased.

• Integrated urgent care will

reduce the need for people to

attend emergency depts.

• Implementation of the national

service model for LD will enable

that cohort to be cared for in the

community.

• Our enhanced primary care offer is underpinned by a shift

towards prevention to keep people healthy, utilisation of

population risk stratification tools to ensure we identify those

at risk more quickly to support them in managing their own

health, and an upscaling of our efforts to enable self-care

• Integrating MH and Physical health (making every

contact count) - increasing MH support for those with

LTCs and physical health support for those with

SMIs – will reduce the co-morbid health issues for these

conditions, and the lost years of life.

• Investment in CAMHS services will reduce

long-term demand for adult services.

• The London Digital MH programme will provide access to

online support and self-care materials.


18






Q1. Prevent ill health and moderate demand for

healthcare

•Supporting those with LTCs and SMIs with mental and physical health respectively will reduce comorbidities.

•Additional support for those in crisis or with urgent needs will reduce admissions and A&E presentations.

Q2. Engage with patients, communities & NHS staff

•The London Digital MH programme will provide access to online support and self-care materials.

•Increased uptake of Patient Online, through facilitation to increase number of bookable slots available online and awareness in patients.

Q3. Support, invest in and improve general practice

•Deliver London’s specification and ambition for the future of primary care outlined in the Strategic Commissioning Framework (SCF).

•Deliver the aims of the GP Forward view .

Q4. Implement new care models that address local

challenges?

• CCG’s to support provider networks and federations to deliver primary care at scale, as a step towards the ambition of establishing Accountable Care Systems.

•Productive pathways could reduce OBDs for MH beds.

•Additional support in the community, and closer integration with 111/OOH services will reduce admissions.

Q5. Achieve & maintain performance against core

standards

•Meet the national urgent and emergency care access standards.

•Reduce waits at A&E for MH support.

Q6. Achieve our 2020 ambitions on key clinical

priorities

•Implement EIP and IAPT waiting time targets.

•Improve physical health for those with SMIs.

•Improve access to CAMH services.

•To implement the national LD service model to ensure service quality meets national standards.


•Full roll-out of the four priority seven day hospital services clinical standards for emergency patient admissions.

•Establish NEL Primary Care Quality Improvement Collaborative Board.

•Confirm all A&E departments meet the London Quality Standards and UEC facility specifications.


•Offer all GP patients e-consultations and other digital services.

•Shared care record available to aid clinical decisions.

•MiDoS available to clinicians and patients.


deliver?

•Development of primary care workforce plan.

•Development of Mental Health workforce to deliver increased capacity required to meet rising demand.

Q10. Achieve & maintain financial balance

•More robust projections of MH demand.

•Productive psychosis pathways.

•New commissioning models, including risk/gain shares with NHS E.

19





1. STPs

• This delivery plan outlines our agreed STP initiatives and milestones and the timeline for delivering them.

•We have also begun to map out the metrics against which we will measure our progress.

2. Finance

•Delivery of our plans for primary care at scale underpin the development of new care models and Accountable Care Systems in NEL.

•Integration of UEC and MH services will reduce unnecessary demand on acute services, ensuring services are delivered in the right place, first time.

3. Primary Care

•Our enhanced primary care workstream within this delivery plan will deliver London’s specification and ambition for the future of primary care outlined in the Strategic Commissioning Framework (SCF), Deliver the aims of the GP Forward view, and address workforce issues.


•This delivery plan sets out our plans for meeting the UEC must do’s (slide 8), including; meeting national access standards, delivering 7 day services, responding to the Urgent and Emergency care review, and developing an integrated commissioning strategy for ambulance services.


•The details of this are set out in our acute services delivery plan.

•This will be supported by the delivery of our local plans for person centred, community-based models of care, which are enabled by the system wide change set out in this delivery plan.

6. Cancer

•The details of this are set out in our acute services delivery plan,

7. Mental health

• This delivery plan sets out how we will implement the MH FYFV and meeting national access targets through our ‘High quality, integrated mental health care and support’ workstream (slide 7).


•This delivery plan sets out how we will deliver the transforming care programme through our ‘Learning disabilities’ workstream (slide 9).


•This delivery plan sets out how we will improve quality to meet national standards for:

•Primary care

•Mental health

•Urgent and Emergency care

•Learning disabilities

20







Ensure accessible quality acute

services for those who need it




Contents

No. Section Page

1 Initiative map 3



4 Route map 12



7 Risks 16


9 Dependency map 18



12 Addressing the 10 questions 21

13 Addressing the 9 must-do’s 22

2


Initiative map N

EL S

TP

Level

• Future transform-ational planning and impact modelling of:

• Maternity: NEL Maternity Network

• Cancer (board and network)

• Surgical hubs

• Diagnostics

• Outpatient pathways: acute level

improvement in addition to pathways

• Screening: uptake of

national programmes

Lo

cal A

rea L

eve

l

• Current transform-ational planning and delivery at BHR, CH and WEL levels relating to:

• Surgery (inc Referral to treatment targets)

• Diagnostics

• Outpatient pathways

• Screening

CC

G/b

oro

ugh L

evel • Each CCG/borough

has scrutiny over how initiatives integrate with the local health and social care economy/ devolution plans

• Some initiatives will continue to be locally led

London-w

ide

• National maternity review ‘Better births’

• Maternity: Growth assessment protocol trial

• Cancer taskforce report

• ‘Getting It Right First Time’: identify & administer the correct treatment at the appropriate time to standards

• Work towards achievement of the London Quality Standards.

Our approach There are a wide range of programmes that support our aim for transformational change in our secondary care service model . These are outlined in our

narrative plan for north east London. We have agreed through the STP the best level at which each programme should be led and delivered within the health

and care system. We have done this based on the partnerships and scale required to best implement the specific programmes, using the following rationale

for choosing to progress an initiative at a north east London:





We set out these different levels below.

3




Re-organised midwifery services, with NEL wide

co-ordination of demand & capacity

Review &

implementation

Review &

implementation


Expected Impact

• Significant reduction in avoidable deaths

• Reduced avoidable admissions

• Managed rising demand and acuity for maternity services and increase births in

midwifery settings (TST is an average of 30% by 2021)

• Increased cancer one year survival rates (to 75% by 2020)

• Increase in earlier detection rates (to 62% detected at stage 1 & 2 by 2020)

• Improved improve referral times

• Ensuring patients get advice in the right place, at the right time

• Reduced unnecessary testing, outpatient appointments & more expensive prescribing

• Increased local uptake of national screening programmes.

Vision

When people fall seriously ill or need

emergency care, local hospitals

provide strong, safe, high-quality and

sustainable services

Background and Case for Change • We anticipate that encouragement of prevention, self-care and improved care close to home will help

reduce demand for our acute services. There are a number of areas where we are working jointly across

NEL already, and others where we are just beginning to explore joint opportunities.

• Given, however, the significant population rise, our challenge is to identify ways of working together to

ensure we reduce any unnecessary admissions and attendances, and have best in class length of stay for

both planned and unplanned care. Managing demand is an imperative - modelling for Transforming

Services Together (TST) demonstrates the only other alternative would be to increase total beds across

NEL significantly, which would require us to build an additional hospital.

• Transformation is also required in our secondary care service model to ensure we meet the required

standards and improve patient experience.

Workstreams

Priorities and Objectives To manage rising demand for services and bring the health system into balance, while improving or maintaining standards and patient experience, by:

1. Jointly explore opportunities for collaboration 2. Jointly develop transformational plans for all acute services

including maternity, cancer and planned care (and links with Integrated Urgent and Emergency Care)

3. Exploring opportunities for shared learning (including Vanguard and Pioneer participation as well as best practice) across NEL and performance management

4. Where this will not affect pace of current delivery, seek earliest collaboration of local /area level programmes currently underway.

16/17 17/18 18/19 19/20 20/21

1 Maternity

2 Cancer

3 Planned care including:

Surgical Hubs,

Diagnostics, Outpatient

pathways and screening

4 Medicines Optimisation

Pilots, Pioneer site

activity

Find out Faster Pilot

Vanguard work

Focus on: expenditure on biosimilar biologics; Improved pathway for patients;

Expenditure on DROP list medicines

NEL wide implementation TST delivery

Joint planning of NEL opportunities Joint scoping of NEL opportunities

TST delivery

4




Detailed Plan - Workstream 1: Maternity

Case for change

We recognise the coming challenge of increasing demand and complexity. To meet it, the

maternity system needs to work more efficiently: to support safety, women’s choice and have

staff that are enabled to grow and develop to bring the required change. The WEL (TST &

pioneer) maternity & newborn care work is aligned with ‘Better Births' primarily by its focus

on models of care that allow continuity of care as the norm for all women, not just those with

straight-forward pregnancies. Across NEL there is a drive to: increase access to midwifery-

led birth environments, improve the transitional care offer, currently being piloted, and ensure

universal access to appropriate perinatal mental health services, whatever level of need.

SRO: Wendy Matthews, Deputy Chief Nurse/Director of

Midwifery, BHRUT NHS Trust

Delivery lead: Kate Brintworth, Head of Maternity Commissioning

North East London

Objectives

1. To manage rising demand and acuity for maternity services and liaison

with neonatal services

2. To improve the experience of women accessing maternity services in NEL

3. To provide increased opportunity for births in midwife-led settings

4. To improve continuity of care

5. To reform the delivery of transitional care

6. To support step change in self care / personal health budgets for women

Vision Accessible services, centred around women and families: maternity services in North East London to be caring, compassionate and offering women the very best experiences of safe care, with kindness and choice at the heart of this offer, in line with ‘Better Births’.


1

Management of

demand and

capacity

For all initiatives – to

facilitate the

programme of change:

• Horizon scanning

• Workforce

programme for

recruitment and

retention of

experienced staff;

• Capital nurse

programme

• Infrastructure

(removal of current

constraints and

capacity planning for

future demand);

• Digital: real time

access to records at

multiple sites/

patient-held records

• Increased births in midwifery settings (the TST target is that on

average 30% of births will be in midwifery led settings by 2021)

• Improved fetal and maternal medicine networks

1. Redesigned Midwifery services so women are offered

continuity of care at each stage in the maternity pathway

2. Established community care hubs with full IT integration

to allow seamless communication across the maternity

pathway

3. A workforce programme to address recruitment and

retention & include new community/integrated models

4. Co-ordinated demand and capacity in the area through

the NEL Maternity Network & NELCSU

2 Quality safety and

outcomes

• Reduction in still birth rates particularly in the antenatal period

and reduced neonatal death rates'*

• Reduction in direct maternal mortality and physical and mental

health morbidity

• Measures identified in the NHSE Saving Babies Lives care

bundle & ‘Every Baby Counts initiative'

3 Women's

experience

• Women experience continuity of care from both midwives and

obstetricians;

• The CQC Maternity Services Survey December 2015 including

being treated with respect & dignity

• Vulnerable women experience support via initiatives such as

‘Maternity Mates’ in WEL & multi-disciplinary care hubs

1 - 3. As above

4. Improving ease of access to both services and high

quality information

4 Better Births

pioneer work

• Good experience for local women as in CQC survey and in line

with principles of Better Births 1-4. As above

5 Transitional care

redesign

• Reduced in-patient stay and improve community provision for

babies requiring transitional care.

5. New models of transitional care to keep mother & baby

together spending minimal time in acute settings. 5. *Recent data from MBRRACE shows the majority of local services perform better on measures of stillbirth & neonatal mortality than their peers. NEL will have the most units participating in the GAP trial in London.




Detailed Plan - Workstream 2: Cancer

Case for change

The national cancer taskforce report sets out how to

achieve world-class cancer outcomes by 2020.

NEL benchmarks poorly against a range of outcome

measures. We require a step change in diagnosis

quicker and earlier; increasing uptake to screening and

reduction variation in care provision. We will focus on:

reducing cancer waiting times, reduction of incidence,

improving 1 year survival rates & earlier presentation /

diagnosis.

SRO: Paul Haigh, Chief Officer, Hackney CCG

Delivery

lead:

Sue Maughn, Clinical Advisor,

Transforming Cancer Services Team

Objectives

• To achieve earlier presentation and detection rates and reduce emergency presentations to 62%

• To reduce new primary cancers and recurrence in people surviving with cancer

• To improve one-year survival rates to 75%

• To improve equitable access to high quality patient centred services & care for, during & after their treatment

• To supporting people living with cancer as a long term condition with 95% of patients with an agreed after

treatment plan

• To align NEL plan with the National cancer task force strategy & Model of care for Cancer London 2010.

Vision Fewer people in NEL get cancer and for those who do, they are identified earlier and so have an improved chance of survival, with timely, equitable access to high quality modern treatments so that they live well after treatment and report a better experience throughout their care


1 Sustainable delivery of

cancer waiting times

Workforce: planning

capacity & organising

teams

• Patients given definitive cancer diagnosis, or all

clear, within 28 days of GP referral*

• Reduction in DNA rates for diagnostics to 5%

1. Deliver recommendations of the Independent Cancer

Taskforce, inc 2. significantly improving 1-year survival & 3.

patients given definitive cancer diagnosis within 28 days.

Prevention Digital (patient records) &

workforce (Public Health) [Refer to Prevention Delivery Plan re smoking cessation]

2 Earlier diagnosis Digital and workforce

communication (public)

• Increase in earlier detection rates to 62%

detected at stage 1 & 2 by 2020

• Increase in ‘Find out faster’ diagnostic target

• Reduction in patients who first present with

cancer as an emergency to 18% by 2020

• Reduction in avoidable admissions

1-3 As above. 4. Development and delivery of a range of

interventions to promote earlier diagnosis including an

informed popn using all stakeholders

5. Find out Faster pilot in 17-18 following the outcome of

national pilots in 2016/17

3 Improving cancer

treatment Digital and workforce

• Introduction of stratified follow up in breast,

colorectal and prostate cancers (various)

5. Developed plans to demonstrate improving patient

experience by 2020

4 Living with cancer and

beyond: survivorship Workforce (as above)

Increase in 1 year survival rates to 75% by 2020

1-5 As above. 6 As below.

5 Joint participation in

UCLH/NEL Vanguard

Communication and

engagement As above

6. Improvement plan and outcomes to reduce variation

through the cancer vanguards, through priority pathways. 6

*Note: This is a new national standard to deliver by 2020 with the expectation that it will replace the current 2 week wait standards **University College London Hospitals.




Detailed Plan - Workstream 3a: Planned care: Surgery

Case for change

NEL is exploring the creation of surgical centres of excellence at each site. All

hospitals with EDs would provide core surgical services. Some hospitals

would provide core plus in one or more specialties whereas complex services

would only be offered once across the TST patch. There is potential to

replicate and expand this model across the STP footprint.

WEL are advanced in planning through the TST programme. Sites with core,

core plus or complex offerings would operate in networks with strengthened

cross-site working and inter-hospital transfer, leveraging capacity to deliver

emergency surgical interventions. Patients would access pre-operative

appointments & low-risk surgical procedures at their local hospital.

SRO: Julie Lowe, Director of Provider Collaboration, NEL

STP

Delivery

lead:

[For TST: Kevin Nicholson, Surgical CAG DoO, Barts

Health and Philippa Robinson, Hospital

Transformation Lead, WELC]

Objectives

• To explore jointly opportunities for collaboration working across NEL

• To include consideration of collaborative approaches to:

• Areas for consolidated services (such as orthopaedics in SW London) and

• Surgical procedures outsourcing (cost effectiveness & planning for NEL approaches).

• To bring demand & capacity into balance, by managing surgery through surgical hubs

• To consider ways of strengthening cross site working, including development of hubs

working together as a network

Vision

To improve quality, consistency and sustainability of surgery services through the

implementation of aligned surgical offerings across providers in NEL.


1

To develop the evidence

base for NEL wide

collaborative planning /

working

Communications and

engagement; Analysis:

including baselining activity

and referral rates

• Reduced variation of standards of care

• Improved quality measures eg Dtoc

Reduction in first referrals and follow ups

• Improved patient experience

• Delivery of financial efficiencies

• Better use of scarce workforce

1. Building on the below initiatives, to develop the evidence

base/case for change for collaborative working through a

NEL surgical network providing: At each hospital site a ‘core’

surgical offering, combined with a ‘core-plus’ set of services

where safer procedures can be delivered at a higher volume;

At a few sites a ‘complex’ surgical offer which would be

consolidated to make provision safer and more sustainable.

2

To deliver Transforming

Services Together

surgical hubs in WEL

Workforce: organising teams

to deliver at agreed sites in

agreed ways; Digital: real time

patient records across sites

• Reduction in length of stay (LOS)

• Reduction in cancelled procedures

• Reduction in avoidable admissions

• Improved clinical outcomes

• Improved quality of care

2. Standardised surgical offerings across sites

3. To implement TST plans for surgical hubs at pace across

Barts Health’s 3 surgical sites

3

To improve achievement

of RTT targets across

BHR & WEL

Communications and

engagement; Digital: e-

referrals

• Reduction in referral to treatment times

(RTT)

• Achieve 100% of use of e-referrals by no

later than April 2018

4. Developed approaches to understand and improve referral

to treatment times

4 To maintain and share

learning from CH RTT

Communications and

engagement Potential for all the above 4. As above. 7




Detailed Plan - Workstream 3b: Planned Care: Diagnostics

Case for change

National evidence suggests that 25% of pathology testing is

unnecessary* and a recent local audit suggested that 20% of

MRI requests could have been avoided. In 2014/15 £42.5m

on GP-requested diagnostics was spent. Local demand for

pathology and imaging is expected to grow by 10.6% in 5

years. Unnecessary investigations are an avoidable burden at

a time of growing demand and increase waiting times. Tests

need to be the least invasive and offer value for money.

Inconsistent referral suggests inconsistent care, including non

referral of patients who should be.


STP

Delivery lead: [For TST: Archna Mathur, Director of Performance &

Quality, Tower Hamlets CCG]

Objectives


• To build on initial key lines of enquiry, for example through TST, undertake a clinically-led

programme focusing on the top 20 highest impact imaging and pathology diagnostics in terms

of volume and cost. We will:

• Consider options for standardising our approach and roll out clear referral guidance across NEL

• Continue to engage to explore, understand and challenge variation and target outliers

• Bring together clinicians from across 1° and 2° care to identify opportunities for best practice

• Consider moving to ‘direct access’ for selected imaging diagnostics, enabling referral straight to test

before patients see a 2° specialist).

Vision

Ensure consistent provision of investigations for patients when they need them in the most appropriate setting.


1 Explore opportunities for

collaboration & sharing best practice

Communication and engagement;

Analysis: including baselining

referral rates

• Reduction in inconsistent referral practice

• Increase in consistency of care

1. Standardised diagnostic approach

2. Roll out of NEL wide diagnostic referral

guidance

2

Transforming Services Together

implementation of diagnostics &

pathology

Digital: Improve IT connectivity for

better access to test results and

diagnostic pathway

Digital: Customise IT systems to

give GPs more control over the

tests they request

• Increase in appropriate patient referrals

• Reduction in unnecessary patient referrals and

diagnostics

• Reduction in duplicate investigations

• Reduction in investigations relating to medically

unexplained symptoms

• Increased digital access to results and the

diagnostic pathway

• Efficiency savings from reduced waste and earlier

referral and diagnosis of those patients who need

treatment.

1-2. As above across WEL

3. Local intelligence on diagnostic referral

variation and outliers

4. Increased opportunities for clinicians

across 1° and 2° to share clinical best

practice

5. Potential introduction of ‘direct access’

for selected imaging diagnostics.

3

Transforming cancer services team

Pan London capacity and demand

work inc optimisation of radiology

and endoscopy services

Digital: Implement electronic GP

requesting for imaging diagnostics

& pop up referral guidance;

Workforce: Expand capacity*

As above, plus refer to Cancer metrics 6. Supported GPs including shared best

practice.

8 *Report of the Review of NHS Pathology Services in England, COI for the Department of Health. August 2008




Detailed Plan - Workstream 3c: Planned Care: Outpatient pathways

Case for change

As outlined in the ‘Getting It Right First Time’ Briggs Report, it is important to identify

and administer the correct treatment at the appropriate time to a high standard. We

will draw on the principles of ‘Right Care’ to ensure the most appropriate use of

secondary care. One way this can be achieved is through more efficient delivery of

outpatient care and clinical pathways, optimising each clinical pathway. We plan to

manage referrals to secondary care in a more effective way and streamline the

referral to the treatment process, including diagnostics. This is a significant clinical

area, which will lead to quality and improved use of NHS resources. Change is

necessary because without it, in WEL will need an additional 141,000 appointments

per year by 2020/21.

Objectives

• To explore jointly opportunities for collaboration working across NEL,

drawing on CH best practice on consultation advice lines*

• To continue focus in TST on the following pathways and projects:

Vision

To improve outpatient pathways when patients need them in the most appropriate setting by reducing reliance on traditional appointments where they are not required.


1 Explore opportunities for

collaboration

Communication and

engagement; Analysis: including

baselining referral rates

See specific pathways in objectives Transforming Services Changing Lives identified 7

areas for improvement to OP and pathways:

1. Focus more on early identification and prevention

2. Manage referrals to 2° in a more effective way

3. Streamline referral to treatment, including

diagnostics and ‘Straight to test’ referrals

4. Improve models of care for ineffective follow-up

5. Improve access to specialist advice according to

need

6. Support patient understanding & self management

including return to self care post treatment

7. Reduce numbers of do not attend appointments

2

Transforming Services

Together:

implementation of WEL

outpatient pathways Workforce: use of nurse

specialists to manage long term

conditions and different types of

professionals to manage clinics

in non-hospital sessions

• In areas where we are most challenged (in

WEL) we also have a 20% reduction target

for F2F outpatient appointments over the

next 5 years. This will in part in be enabled

by use of released capacity for alternative

platforms: hot clinics & aspects of the acute

care hubs model; technology based

appointments (Skype, email, telephone);

working more closely with GP and community

services to improve skills and capability

• Reduction in first referrals and follow ups

3

Focus on pathways and

projects as summarised

in objectives

4 Outpatient pathways &

transformation Engagement, workforce

• Comprehensive pathways inc consultant

advice lines* and corresponding rates of

outpatient referrals

8. Clear pathways

9

• ENT (BHR)

• Orthopaedics (BHR)

• Gastroenterology (BHR)

• GP specialist advice service (WEL)

• Renal (NEL wide)

• Ophthalmology (WEL and BHR)

• Gynaecology (BHR and WEL)


STP

Delivery lead:

[For TST: Kevin Nicholson, Surgical CAG DoO, Barts

Health and Philippa Robinson, Hospital Transformation

Lead, WELC]

*C&H’s comprehensive programme of pathways includes when to refer, patient decision aids, direct access to diagnostics, primary care demand management and peer review of referral

practice as well as consultant advice lines.




Detailed Plan - Workstream 3d: Planned care: Screening

Case for change

• Cancer screening uptake is below the England average and

emergency presentation is 5% higher than the national average.

There is inconsistency across NEL in uptake of screening and

therefore variation in the numbers of cancers detected by

screening - from 1% to 7% across our footprint.

• As part of our goal to achieve a step-change in uptake, we will

address inconsistency in screening quality/levels and scale up

best practices. How screening/earlier detection will impact on

treatment activity & modality need to be modelled and planned.

SRO: Julie Lowe, Director of Provider Collaboration,

NEL STP

Delivery

lead: [To be agreed with Directors of Public Health]

Objectives


• To implement the NICE referral guidance, the ‘faster diagnosis

standard’ and increase early diagnostic capacity to reduce the

number of patients with emergency cancer presentation, particularly

colorectal cancer

• To explore integrating health screening services within our overall

system framework, building on the bowel screening work in

Newham, where in partnership with Community Links, non

screened patients are called.

Vision

Screening of complex diseases to allow early diagnosis and detection, reducing patients with late or emergency presentation. We aim to improve outcomes and reduce health inequalities in the long-term; this will support specialist services by reducing later complexity.


1 Review of uptake and treatment of

national screening programmes

For all initiatives:

HWBB Strategies

Increased take up for the following NHS

population screening programmes:

• Abdominal aortic aneurysm (AAA)

• Bowel cancer screening (BCSP)

• Breast screening (BSP)

• Cervical screening (CSP)

• Diabetic eye screening (DES)

• Fetal anomaly screening (FASP)

• Infectious diseases in pregnancy (IDPS)

• Newborn and infant physical

examination (NIPE) Newborn blood spot

(NBS) screening

• Newborn hearing screening (NHSP)

• Sickle cell and thalassaemia (SCT)

screening

• Screening and quality assurance.

1. Delivery of local screening priorities in Health and

Wellbeing Board Strategies

2. AAA: Increase take up (Offered at Barts Health only)

3. Uptake of treatment which may be volume related

4. BCSP: Expected increase in take up due to the FIT

test soon

5. BSP: some areas are moving towards screening

those at moderate risk too

6. CSP: there are big changes due with the introduction

of primary HPV testing

7. DES: Address issues including possibly moving to a

new Optical Coherence Tomography Test rather than

the traditional photography screening and access to

treatment.

2

Horizon scanning of PHE potential

screening programmes and their

timescales

Baselining NEL wide

uptake of screening

rates

3

Lung cancer - is currently being

evaluated by the NSC (see right).

NEL may want to consider being an

early adopter, if approved

National Screening

Committee (NSC)

decision

10




Detailed Plan - Workstream 4: Medicines Optimisation

Case for change

Several national policies and guidelines identify opportunities

for delivering savings and improved patient outcomes through

optimal prescribing. Many readily achievable improvements

have been delivered in recent years and initiatives now require

significant resource investment and collaboration across the

sector to be successful. It is critical to develop patient centred

programmes and ensure quality is the primary driver in the

Medicines Optimisation programme.

SRO: Dr Anwar Khan, Chair, Waltham Forest CCG

Delivery lead: Moira Coughlan, Joint Head of Medicines

Management, Tower Hamlets CCG, NEL CSU

Objectives

• To review medicines of low priority, poor value for money or with safer alternatives

• To promote self-care, patient awareness and self-management

• To develop consistent pathways and medicines usage across NEL for the management

of long term conditions.

• To expand e-prescribing in secondary care and work with other providers to avoid

medicines related delayed discharges.

• To develop a pharmacy workforce strategy, to address gaps in primary and secondary

care, and expand the role of prescribing pharmacists.

Vision

Improvement of medicines optimisation to help build a sustainable health and social care system.


1 Review and optimisation of

biosimilar medicines Digital: e-

prescribing

• Increased use of biosimilars, leading to increased patient

choice and cost savings (metric: % prescribing rates of

originator to biosimilar)

• Increase in patient awareness and self-care

• Consistent advice in prescribing of over-the-counter

medicines

• Reduction in medicine waste

1. Improve patient awareness and self-care,

and support self management

2. Review opportunity for efficient medicine

procurement and supply

3. Reduced medicines wastage 2

Review prescribing of medicines

of low priority, poor value for

money or with safer alternatives

3

Scope remaining 7 workstreams

(ref objectives 3-5 and

deliverables above)

Including:

Organisational

Development:

pathway redesign

Workforce:

workforce

strategy

• Increase in e-prescribing in 2° care and links with other

providers, to achieve:

• Reduction in medicine-related delayed discharges

• Reduction in inappropriate antibiotic prescribing

• Potential for cost efficiencies from medicine procurement

and supply

• Potential for improved quality within acute & specialist

prescribing

1-3. As above

4. Pathway redesign to ensure consistent

approach to medicines/pathways across NEL

5. Develop a pharmacy workforce strategy to

support gaps in primary/secondary care,

particularly the role of prescribing pharmacists

6. Develop medicine decommissioning/de-

prescribing process across NEL

4 Review readily achievable

outcomes delivery Clinical review

• Safety & savings for: insulin switches; BM strip prescribing

• Decreased harm and cost from hypoglycemia in people

with diabetes and savings from NSAIDS

7. Potential quick wins

11




Route Map (1/2)

2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

1. Maternity

1.1 Management of demand and capacity

1.2 Quality Safety and Outcomes

1.3 Women's Experience

1.4 Maternity Better Births Pioneer

1.5 Transitional Care service redesign

2. Cancer

2.1 Sustainable delivery of cancer waiting times

2.2 Prevention

2.3 Earlier diagnosis

2.4 Improving cancer treatment

2.5 Living with cancer and beyond: survivorship

2.6 Joint participation in UCHL/NEL Vanguard

3a. Planned Care: Surgical

Hubs

3.a.i TST implementation of surgical hubs in WEL

3.a.ii To improve achievement of RTT targets across BHR and WEL

3.a. iii To maintain and share learning from CH RTT

3.a.iv To develop the evidence base for NEL wide collaboration

Pilots, pioneer site activity Milestone

Deliverables

Re-organised midwifery

services, with NEL wide

co-ordination of demand

& capacity




Implementation

Find out Faster pilot

Analysis, monitoring and review

Milestone

New models of

transitional care Design concept, approval and planning

TST planning and implementation

Joint scoping of NEL opportunities Joint planning of NEL opportunities NEL wide implementation

12




Route Map (2/2)

2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

3b. Planned Care:

Diagnostics

3.b i TST implementation of diagnostics & pathology

3.b. ii TST implementation of imaging and endoscopy

3.b.iii TCST Pan London capacity and demand work

3c. Planned Care:

Outpatient pathways

3.c.i TST implementation of WEL outpatient pathways

3.c.ii Focus on pathways and projects

3.c.iii Consultant advice lines

3d. Planned Care:

Screening

3.d.i Review of uptake and treatment of national screening programmes

3.d.ii Horizon scanning of PHE potential screening programmes

3.d.iii Lung cancer

4. Medicines Optimisation

4.1. Biosimilar medicines

4.2. Biologics

4.3. Prescribing review

4.4. Scope other workstreams/review outcomes delivery

Implementation

Implementation


Deliverables

Deliverables

Deliverables

Scope and plan





For further details, refer to the

Transforming Services Together plan





Deliverables

Deliverables

13





Benefit description (Health

& wellbeing, care & quality or

financial)


performance

Target date

(default 2020)

Linked

workstreams

Increased access to

midwifery led birth settings

for eligible women

Place of birth activity reported* To be established using local data

15-16 reported for HSCIC indicators

Maternity Provider level analysis

Increase to

average of 30%

in WEL

2020 Maternity

Improvement on women’s

experience

Patient responses in the CQC Maternity

Services Survey December 2015 including

being treated with respect and dignity*

To be established using CQC

Maternity services survey December

2015

Improvement

on Dec 2015

responses

2020 Maternity

Reduced infant mortality Reduction in still birth rates particularly in

the antenatal period & reduced neonatal

death rates*

To be established using MBRRACE

Perinatal Mortality Surveillance

Report for 2014 Births

Reduction 2020 Maternity

Improved cancer survival NHSE Taskforce standard of overall 1 year

survival at 75% by 2020

Established using

HSCIC indicator: 63.9 - 69.3%

Increase to

75%

2020 Cancer

Earlier cancer diagnosis Increase in earlier detection rates (to 62%

detected at stage 1 & 2)

Established using

HSCIC indicator: 39 - 52%

Increase to

62%

2020 Cancer

Reduction in cancelled

surgical procedures

a) Cancelled operations and b) Cancelled

operations which are rebooked*

Established from Cancelled Elective

Operations Data

Reduction

to 5%

2020 Cancer

Improved referral to

treatment waits

(Reduction in RTT times)

92% of patients on non-emergency

pathways wait no more than 18 weeks from

referral*

Established using NHS E RTT

waiting times statistics, May 2015

BH and BHRUT: non reporters

Homerton: 92.9%

Reduction

to 92%*

2020 Surgery

Improved quality of referrals Reduction in duplicate investigations To be established from NHS E Diagnostic & Imaging

dataset or local measure to be agreed

2020 Diagnostics

Outpatients appointments Reduction in Face to face outpatient

appointments

Established from TST SIC**:

920,000 in WEL

Reduction by

20% in WEL

2021 Outpatients

pathways

Screening uptake Uptake of population screening

programmes

Established from Public Health

England screening data: 1-7%

Increase 2020 Screening

Increased use of biosimilars,

leading to increased patient

choice and cost savings

Prescribing rate (%) of originator to

biosimilar for agreed drugs

To be developed as part of local KPIs, based on what is

clinically appropriate and subject to agreement of

associated funding arrangements

2019 Medicines

Optimisation

14 * Data is reported at Trust level. **Transforming Services Together Strategic Investment Case






Acute Services Delivery is led by Julie Lowe, Director of Provider Collaboration, NEL, as SRO. Governance arrangements for the workstreams

vary and are at different stages of development – key networks and boards are included in the delivery structure below:

SRO Delivery Lead

Delivery Plan

Conor Burke

Chief Officer

Barking & Dagenham,

Havering and

Redbridge CCGs

1. Maternity

Wendy Matthews

Deputy Chief Nurse/

Director of Midwifery

Barking, Redbridge

and Havering NHS

Trust

Kate Brintworth

Head of Maternity Commissioning

North East London

2. Cancer

Paul Haigh

Chief Officer

Hackney CCG

Sue Maughn

Clinical Advisor Transforming

Cancer Services Team

North East London

3. Planned Care

Julie Lowe

Director of Provider

Collaboration

NEL STP

[For Archna Mathur, Director of

Performance & Quality, Tower

Hamlets CCG, Kevin Nicholson,

Surgical CAG DoO, Barts Health

and Philippa Robinson, Hospital

Transformation Lead, WELC]

4. Medicines

Optimisation

Dr Anwar Khan

Chair, Waltham Forest

CCG

Moira Coughlan

Joint Head of Medicines

Management, Tower Hamlets

CCG



Steering Group

Cancer Maternity Planned Care

NEL

Clinical Senate

Medicines

Optimisation

NEL ACS

Development Group

Cancer

Commissioning

Board

NEL Maternity

Network

TST Programme

Board NEL wide Medicines

Optimisation Group

NEL STP Board

15



NEL STP Executive


Risks

Risks

Workstream Description and impact Mitigating action RAG

Maternity

Current demand for maternity services: If targeted, urgent

responses are not sufficiently timely to respond to demand in

terms of volume and complexity, there is a high risk of women not

having their needs or choices met appropriately

Plan, resource and deliver the NEL proposed improvements to

respond to the national 'Better births' strategy - focusing on 16-

17 and 17-18 deliverables and quick wins R

Maternity

The pace of estate, digital and workforce enabler responses are

insufficient and impede the necessary step change required to

manage maternity service demand

Plan, resource and deliver the NEL enablers across the

footprint

R

Maternity

Future demand for maternity services: If targeted, urgent

responses are not planned and sufficiently timely to respond to

demand in terms of volume and complexity, then there is an even

higher risk of women not having their needs or choices met

appropriately

• Plan, resource and deliver the NEL proposed improvements

to respond to the national 'Better births' strategy - developing

medium term deliverables in 2018-21

• Births may be higher than initially indicated and we have a

process currently underway to review modelling

R

Cancer Achievability of the national outcome target on one year survival

rates given current performance levels and data lags

Explore the required trajectory in further detail and enter into

focused discussions within the STP and nationally R

Planned care:

Surgery

There is a risk that no agreement is reached on options for

increased collaborative working through networks / across NEL


saving is currently assigned to the surgery initiatives. (The WEL

savings are already assigned to TST) R

Cancer The current governance structure will not enable decision-making

across all partners within the STP footprint

The Cancer Commissioning Board is being established. An

option to enhance the current governance structure is being

actively considered

A

Planned care:

Diagnostics

As per surgery risk above As per surgery mitigation above A

OP pathways As per surgery risk above As per surgery mitigation above A

Screening How screening will impact on treatment activity and modality and

whether we are factoring this into our plans To be addressed in demand and capacity planning and

modelling A

Medicines

optimisation

A lack of resources to drive changes forward Local plans to develop gain share or similar funding

arrangements between commissioner and providers. A

16

This is a list of the highest-rated risks. Additional risks identified at a lower mitigated risk rating








All Assumption That resources will follow the patient so that capacity is available in

alternative settings as services are moved out of hospitals.

Continue to monitor and review through the

STP as plans are implemented

Maternity Constraint Service redesign: It is difficult to provide accurate financial

modelling until there is definitive description of the midwifery

models to be adopted.

Process currently underway to review

modelling. In terms of an accurate description

of the midwifery models

Maternity Constraint Workforce: Providers are struggling with difficulties in recruiting

and retaining experienced staff (a London wide issue)

Current and future workforce issues included in

the DRAFT Workforce Delivery Plan (DP)

Maternity Constraint Infrastructure: Providers are struggling to provide care in estates

that in some cases are not fit for purpose and others will develop

insufficient capacity

Current and future issues included in the

DRAFT Infrastructure DP

Maternity Constraint Digital: providers are constrained by inadequate IT systems Issues included in the DRAFT Infrastructure DP

Cancer Dependency Prevention programmes - smoking, physical activity and obesity

programmes all led by Public Health teams

To be addressed in programme governance

and planning

Cancer Dependency Screening for cancer: referral, diagnosis stages & treatment rates To be addressed in demand and capacity

planning and modelling Cancer Dependency Specialised commissioning: Screening for specialist cancer –

referral, diagnosis stages and treatment rates

Surgery Constraint Referral to Treatment: Focus on transformational change cannot

take place until the immediacy of the RTT backlog issues are

addressed and associated cost of outsourcing

Providers are currently considering approaches

and options

Diagnostics Dependency Primary care: GP referral rates for diagnostics and imaging To be addressed in demand and capacity

planning and modelling

OP pathways Dependency Primary care: pathway redesign diagnostics and imaging Redesign to be jointly developed by

community, mental health 1° and 2° care

Screening Dependency Cancer (see above) and national programme decisions As above and horizon scanning for national

screening committee decisions

Medicines

Optimisation Dependency Prescribing across primary and secondary care To be addressed in planning

17




Dependency map


care close to

Home

Accessible

quality acute

services


Services

Workforce Digital

1. Maternity Patient

Activation /

self care

Smoking

cessation

Primary care:

maternity care

hubs

Diagnostics:

right place,

maternity

screening

Improved

facilities

(current

constraint)

Specialist

services:

perinatal care

plans

Midwifery,

nurse

practitioner

and HCA

workforce

Access to

electronic care

records

2. Cancer Smoking

cessation,

obesity and

physical

activity

Cancer

survivorship:

patient care &

co-morbidity

management

Diagostics:

medically

unexplained

symptoms

Diagnostics

(Screening)

Supported Self

management

Specialised

cancer:

referral,

diagnostic and

treatment

rates; oral

chemotherapy

Endoscopy

and

community

nurse

workforce

Access to

electronic care

records

3. Planned

care:

Self care and

self manage-

ment: Make

Every Contact

Count

Diagnostics:

GP referrals

Outpatient

path-ways:

co- design with

Primary Care

Surgery: RTT

(standard

achieve-ment)

Surgery:

Potential

changes in

capacity

Workforce

strategies

within all

redesigns

Interoperability

/ access to

electronic care

records

Integrated UEC: Reduced

emergency activity

4. Medicines

Optimisation

Self care and

self

management

Prescribing – protocols, process

design and rates

E-prescribing

Access to

electronic care

records

18

This dependency map highlights where this delivery plan is linked to another delivery plan within our STP:





19


















Planned future work













Ensure accessible quality


This delivery plan sets out the transformation that is required to support sustainability of high quality and accessible acute services across north east London. Each of the four workstreams described the aim to achieve a step change in the delivery of acute care.

For patients, this means an experience of healthcare that is as planned as possible, avoiding unplanned episodes, coordinated around them, and designed so they spend less time travelling to and staying in hospital, both planned unplanned.

This delivery plan describes

elements of planned care -

development of pathways,

approaches to diagnostics and

screening – which are all

intrinsically linked to and with

the development of primary care

for physical and mental health.

For patients, this means that as

much of their care as is possible

is planned and designed so it

can be managed close to

home, including through

supported self management.

This delivery plan describes the development of acute care

which is designed and planned to move services out of hospital

to complement our aims of greater emphasis on prevention,

keeping people well and living healthy lives at home.

For our residents, this means greater emphasis on advice and

support to improve avoid and reduce risk of illness, to

support their own self management at home, with

care planned & co-ordinated within their care plan.

For patients receiving acute care services - pregnant women,

people recently diagnosed or living with cancer as well as

people undergoing any diagnostic test, surgery or follow up -

planned care means greater certainty to understand and

manage their condition and lesser impact on their daily lives.

This puts patients and carers truly at the centre

of their care and therefore more in control.


20






Q1. Prevent ill health and moderate demand for

healthcare

•Reducing avoidable admissions: improvements to maternity, cancer and surgery / planned care all seek to offer planned care when appropriate and reduce unplanned admissions (see slides 5-7)

Q2. Engage with patients, communities & NHS staff

•Step change in self care / Integrated personal health budgets: this is one of our maternity objectives (see slide 5)

Q3. Support, invest in and improve general practice

•Support 1° care redesign: outpatient pathways – redesign involving both community, primary and secondary care for end to end design solutions (see slide 9)

Q4. Implement new care models that address local

challenges?

•Hospital networks, groups or franchises: surgery / planned care – we will explore options for increased collaborative working through networks (see slide 7)

Q5. Achieve & maintain performance against core

standards

•Referral to Treatment (RTT): surgery / planned care is focused on improvements to meet targets and improve patient experience. This includes increasing e-referrals (see slide 7)

• Implement the national maternity services review, Better Births, through local maternity systems (see slide 5)

Q6. Achieve our 2020 ambitions on key clinical

priorities

•By 2020 to improve one-year survival to 75%; to achieve earlier presentation: this is one of our cancer delivery objectives, supported by our high priority focus on earlier diagnosis (see slide 6)


•Achieve a significant reduction in avoidable deaths: transformation in maternity, cancer, and surgery / planned care will contribute to safety and quality improvements (see slides 5-7)


•Full interoperability by 2020 and patients having access to records: this is a key enabler to most detailed plans described in this delivery plan and captured in NEL’s digital delivery plan (see slides 5-10)


deliver?

• Reduce agency spend; develop, retrain and retain a workforce with the right skills and values

•Integrated MDTS to support new care models: digital improvements are key enablers to most detailed plans in this delivery plan (see slides 5-10)

Q10. Achieve & maintain financial balance

•Support of credible, sustainable delivery plan: this delivery plan’s emphasis on planned care and reduced unplanned episodes of care (see slides 5-10)

21





1. STPs

• This delivery plan outlines our agreed STP initiatives and milestones and the timeline for delivering them. We have also begun to map out the metrics against which we will measure our progress, which incorporate the relevant STP core metrics

2. Finance

•We are working collaboratively to develop scalable service models where this will deliver value for NEL;

•Initiatives are in place for NEL wide maternity and cancer delivery

•Our intention is to explore wider roll out of WEL / TST planned care initiatives

3. Primary Care

• Refer to the primary care delivery plan.

•Planned care improvements including proposed pathway improvements will require collaborative working across community, primary and secondary care.


• Acute services described in this plan relate to planned care, however, successful redesign will depend on collaborative working with urgent and emergency care clinicians and teams

•Refer to the urgent and emergency care delivery plan


• RTT is covered in the detailed plan for surgery: one of our initiatives is to improve achievement of RTT targets across BHR & WEL (slide 7) above

6. Cancer

• Cancer is covered in the detailed plans for cancer and screening

•This includes NEL’s joint participation in the Cancer Vanguard as well as planned improvements to Stage 1 & 2 detection rates and 1-year cancer survival, supported by planned improvements in screening uptake (see slides 6 & 10 above)

7. Mental health





•We are working collaboratively across NEL to develop scalable service models, underpinned by a workforce strategy.

22






Delivery Plan 4 of 8: Provider Productivity


No. Section Page

1 Initiative Map 3



4 Route map 10



7 Risks 14


9 Dependency Map 16





Contents

2

Provider Productivity


Initiative map N

EL S

TP

Le

ve

l • Consolidation of corporate services: Developing a flexible and scalable shared services model for our back office functions where this will release value for NEL;

• Bank & Agency: Agreeing NEL wide rates of bank and agency pay and a shared bank service;

• Procurement: consolidating and standardising key consumables list and moving to NEL wide contracts where feasible e.g. on patient transport

•IT: Maximising opportunities for procuring and delivering services at scale.

Lo

ca

l Are

a L

eve

l •Pathology: Developing options for collaboration and consolidation;

•Bank & Agency: Locally agreed rates of bank & agency pay where appropriate.

•Procurement: Locally agreed buying prices where appropriate.

C

CG

/ B

oro

ug

h L

eve

l •Local CIPs plans and stretch targets. This delivery plan focuses on initiatives over and above individual organisation’s CIP plans.

Lo

nd

on

-wid

e

•Consolidation of corporate services: NHS Improvement benchmarking and business case development;

•Procurement: Alignment to London workstream and national NHS supply chain work on negotiation of best price list;

•HR back office: London HR Transformation programme.

• IT back office: London benchmarking

•Finance: Future Focused Finance

Our approach There are a wide range of programmes that support our aim for productivity across our NEL provider Trust organisations. These are outlined in our

narrative plan for north east London. We have agreed through the STP the best level at which each programme should be led and delivered within the

health system. We have done this based on the partnerships and scale required to best implement the specific programmes, using the following rationale

for choosing to progress an initiative at a north east London level:

1. There is a clear opportunity / benefit in doing it jointly (which is above and beyond what would be achieved through a local programme),

to deliver improvement in terms of finance, quality, or capacity;




3




Expected Impact (Non-clinical) • Reduced provider Trust combined back office costs (potential savings opportunities identified as up to c.£10.7m)

• Reduced provider Trust bank and agency costs (potential savings opportunities identified as c.£8.6m)

• Reduced provider Trust pathology costs (potential savings opportunities identified c.£3.5m)

• Reduced provider Trust procurement costs (potential savings opportunities identified as c.£7.6m)

Vision

Sustainable NHS provider Trusts across NEL which are enabled to meet the needs of the local populations and communities that they serve by working collaboratively to find new ways of delivering productivity and efficiency

Background and Case for Change Through the STP development our NHS provider Trusts have come together to assess opportunities for collaboration in non-clinical

areas. NEL providers currently spend £113m on central procurement, finance, HR and IT functions. We have already realised some

collaborative savings, with Homerton, Barts Health and ELFT using a shared-service centre for payroll, and Homerton and Barts

sharing their financial systems. Trusts also have aggressive internal CIP plans with regards to back office functions.

We are taking forward 5 productivity workstreams which align with national and regional priorities. NHS Improvement has given

clear guidance for all Trusts to consider where corporate services may be consolidated across STP footprints and all of our

productivity workstreams are considering what a flexible and scalable shared service model could look like for us. The NHS Supply

Chain has negotiated a national best price on key products. In NEL we will utilise this and look for opportunities to agree a NEL best

price on other products. The national blueprint of a Future Focused Finance has outlined what good looks like and our plans seek to

ensure that our finance functions help us to be sustainable and forward facing organisations. We are working in parallel with the

Londonwide HR Transformation work to reduce bank and agency costs by developing a NEL wide rates card and approach to

managing temporary staff. Our IT workstream will consider how at scale provision of business intelligence and analytics might

support emerging models of care (e.g. ACS) as well as delivering efficiencies on telecoms, shared data services, and network

services.

Our focus for Pathology productivity is to deliver a sustainable service whilst maximising the savings opportunities available through

collaboration and potentially consolidation. We also recognise there are significant opportunities for releasing efficiencies through

clinical productivity and in the STP narrative documents we have described the NEL wide approach to this.

Workstreams

Priorities and Objectives • To develop a flexible and scalable shared

services model for our back office functions where it improves productivity and value for NEL;

• To capitalise on the savings opportunities available through procuring and operating goods and services at scale;

• To utilise benchmarking, peer collaboration and best practice sharing to ensure that all of our organisations are providing high quality services for our local populations and communities.

16/17 17/18 18/19 19/20 20/21

Bank & agency and back

office (HR)

Back office (Finance)

Pathology

Procurement

IT (back office)

Impleme

ntation

Planning

Business Case Development

Collate baseline info

Agree NEL

options /

approach

Phased implementation

Detailed

options

development

Agree

NEL

options /

approach

Phased implementation Implement

ation

Planning

Detailed options

development

Agree NEL

options /

approach

Implementa

tion

Planning Phased implementation



Develop NEL

contract

specs Phased implementation

Implementa

tion

Planning



Agree NEL

options /

approach Phased implementation 4



Detailed Plan - Workstream 1: Bank & agency and back office (HR)

Case for change

At present, NEL spends £196m with agencies. Each organisation has CIP targets aimed at

reducing this, but there are further opportunities through sharing data and approaches to

managing temporary staff. We aim to develop consistent practices to attracting, contracting,

remunerating and managing bank staff.

Examples from industry suggest that 12%-25% could also be saved through collaboration and a

shared HR back office service model. The London HR Transformation Programme is developing

a baselining, benchmarking and modelling methodology to support the development of shared

services and NEL provider Trusts have committed to participating in this. This will be a

secondary care provider project initially but we would look to expand the scope over time e.g. to

primary care.

SRO: Matthew Hopkins, Chief Executive, Barking Havering

and Redbridge University Hospitals

Delivery

lead:

Daniel Waldron, Director of Organisation

Transformation, Homerton University Foundation Trust

Objectives

• To reduce temporary staff costs through establishing a

common approach to agency management

• To reduce the demand for temporary staff through

collaboration;

• To reduce temporary staff costs through establishing a

common approach managing staff banks;

• To develop a flexible and scalable shared service model

that improves productivity and value at an STP level.

Vision

A reduction in the cost of temporary staffing across NEL’s NHS provider Trusts through developing consistent practices and rates for engaging bank and agency staff. To improve the productivity of workforce functions across NEL through collaboration across our NHS provider Trust organisations to develop a shared service model


1 Benchmark current bank and agency rates and

agree a single NEL rate card.

Stakeholder engagement:

to ensure NEL wide

agreement

Reduced transactional costs

through collaborative working and

establishing a shared approach to

setting and managing bank rates

• A shared rates card for bank and agency staff.

• A NEL wide approach to managing and

remunerating temporary staff that maximises

value for money at a provider and sector level

2

Establish a shared and consistent set of polices

and procedures for managing temporary staff

supply and demand including a single approach

to roster management.

Technology: to maximise

e-rostering capabilities;

Procurement: to negotiate

with local agencies

Reduced transactional costs

through establishing a shared

approach to managing supply and

demand

• A NEL approach to managing temporary

staffing

• A NEL approach to e-rostering

3

Base lining, benchmarking and modelling of

workforce functions to inform an option

appraisal of workforce shared services

solutions.

Stakeholder engagement:

to carry out benchmarking.

London workforce

modelling

Identified best practice and lowest

price service model based on

London workforce modelling

• Options appraisal of workforce shared services

solutions

4

Establish agreed approach to shared services

including any requirement for a shared

temporary staffing function.

Engagement: to agree

preferred option

A flexible and scalable shared

service model that improves

productivity and value at an STP

level

• Shared back office solution that delivers the

triple aim of improved value for money,

customer satisfaction and staff satisfaction. 5



Detailed Plan - Workstream 2: Back office (Finance)

Case for change

NEL providers recognise the financial pressures on

the NHS and the opportunities for productivity in

accordance with the recommendations set out in the

Vision and Blueprint for finance in the NHS.

Transforming the business functions across NEL's

providers will require freeing up resources from

transactional work and supplying the tools for

delivering insightful information on the organisations

e.g. by maximising benefits of technology, sharing

best practice and through supporting the workforce to

shift from providing transactional activities to adapting

a future focused role.



Delivery

lead:

Jonathan Wilson, Director of Finance,

Homerton University Hospital NHS Foundation Trust

Objectives

• To consolidate transactional finance functions in a shared service facility or by using business process

outsourcing (BPO) providers;

• To develop a flexible and scalable shared service model that improves productivity and value at an STP

level

• To rationalise and standardise transactional functions in procure to pay, order to cash, accounting to

reporting and planning to budgeting;

• To have an accounting function that offers self service to end users, automates as much of the

processing as possible and accounts for the transactions correctly first time;

• To build on the work undertaken by the Future Focused Finance initiative in developing a vision and

blueprint for the service and to collaborate and share best practices so that by mid-2017, all

organisations will be at the same maturity level on each of the detailed levels set out in the FFF

diagnostic tool.

Vision

The NEL healthcare provider Trusts are committed to working closely together and sharing finance expertise and resources to achieve upper quartile cost performance and best in class levels of service. We will achieve this through lean process designs, leveraging the functionality of leading edge technology and investing in the training and development of our staff


1

Implement a common financial platform

operating as a shared service or outsourced

to a business process specialist

Technology: to deliver shared

platform Reduced finance back office costs

• Consolidated transactional finance

functions in a shared service facility or

by using BPO providers

2

Explore options for sharing scarce specialist

resources such as costing and financial

planning and investment analysis

Stakeholder engagement: to

develop options and agree

preferred approach to sharing

specialist resources

Reduced finance back office costs and

improved quality of financial analysis

though sharing specialist resources

• Agreed approach to shared scarce


3 Develop standardised, role specific business

analysis dashboards


agree standardised

dashboards

Reduced finance back office costs and

improved quality of business analysis

through sharing best practice

• Shared format of provider accounts with

common role specific dashboards

combining financial and activity data

4

Develop specification for a collaborative

planning tool and undertake competitive

tender and commence implementation

Procurement: to develop

specification

Reduced finance back office costs

through procurement of tool at scale.

Improved quality of financial through

use of a collaborative planning tool

• Collaborative planning tool for

forecasting and financial planning

6



Detailed Plan - Workstream 3: Pathology

Case for change

There is a need to support & enabling care pathways which improve patient experience of care. We

have a national and regional mandate to review pathology service provision for productivity at a

health economy level and other models of consolidation (S W London Pathology and Kent

Pathology Partnership) to learn from. A growing demand for pathology services means we may not

be financially sustainable in the future. There are currently differing practices within the three acute

trust services for procurement and contracts, IT and test ordering and reporting processes. We

have identified opportunities to build on individual Trust plans:

• Proposed service changes to centralise services across BHRUT including a hot/cold split

• Proposed services changes set out in Homerton’s options appraisal;

• Proposed service developments at Barts Health;

SRO: Matthew Hopkins, Chief Executive, Barking, Havering and Redbridge University Hospitals Trust

Delivery

lead:

Jason Seez, Director of Planning and Governance, Barking, Havering and Redbridge

University Hospitals Trust & Simon Milligan, Director of Capital, Costing and Development,

Barts Health

Objectives

• Design and delivery of appropriate and best practice services across the

network and within each individual Trust

• Design and delivery of clinically efficient and quality services which meet

the needs of patients and commissioners

• Design and delivery of services which are able to meet demand, meeting

key quality and operational standards and targets

• Joint/collaborative working between Trusts to reinforce clinical practice and

strengthen the local workforce

• Deliver financial savings of £3m-£5m on a sustainable basis without

compromising on quality of care and whilst improving patient pathways

Vision: To work together across North East London in delivering quality, financially sustainable and cost effective pathology services which reflect the needs of the local hospitals and the communities they serve. To collaborate (and possibly consolidate services) as supported by the case for change.


1 Options development and evaluation of longer term

collaboration and consolidation

Stakeholder engagement: to review Trusts’

current plans and develop future options;

Review of case studies for consolidation

Reduction in under-utilised capacity

for activity re-rerouted to NEL Trusts

- activity and financial impact

• Options appraisal for long term

collaboration and consolidation

of services

2 Review test ordering processes to identify potential to

move to a NEL test

IT: including GP links;

Workforce: training and development

Reduction in pathology back office

costs • Review test ordering processes

3 Review outsourced contracts to identify activity which

could be brought back in house to NEL partner Trusts. Contracts: Specialist service provision

Realised financial savings from

moving to favourable contractual

terms for procurement

Reduction in sendaways for activity

re-rerouted to NEL Trusts - activity

and financial impact

• Review of current outsourced

contracts

4

Review capacity and demand across NEL partner

Trusts to identify surplus capacity to alleviate demand

pressures.

Activity and demand modelling: Demand

management initiatives; Transportation

Best possible use of existing capacity

and reduces the need to invest in

additional capacity in the future

• Capacity and demand modelling

5 Review contracts (reagents, consumables, equipment,

IT) for opportunities to amalgamate and reduce price.

Procurement (Contracts)

IT (including GP links)

Realised financial savings through

moving to NEL wide contracts

• Shortlist of priority contracts to

be procured at scale across NEL

6

Review the potential for joint posts and combined on-

call arrangements to alleviate recruitment pressures

and generate savings.

Workforce: to agree approach to shared

staff arrangements Reduction in on-call costs

• Agreed approach to joint posts /

on-call arrangements 7



Detailed Plan - Workstream 4: Procurement

Case for change

Our plans for collaborative procurement in NEL are to ensure stronger negotiation with suppliers,

rationalisation of catalogues and sharing of best-practice and data. Our provider landscape suggests our

collective buying power may be less than other footprints, however we will realise some opportunities in the

next 12-24 months as individual Trust contracts come up for renewal and can be moved to a NEL wide

contract. In other areas, moving towards alignment will require longer phasing as existing long term contracts

are either exited or extended to realise full system-wide benefits. The NHSI national procurement strategy is

to move to a single price nationally for med / surg consumables and to redirect purchasing of high cost pass

through items via NHS England procurement. We will ensure alignment to this strategy, however this may

reduce the scope for negotiating local pricing for our STP footprint.



Delivery

lead:

Ralph Coulbeck, Director of Strategy, Barts Health NHS

Trust / Simon Milligan Director of Capital, Costing and

Development, Barts Health NHS Trust

Objectives

• To develop a flexible and scalable shared service model

that improves productivity and value at an STP level.

• To reduce unwarranted variation in the cost of procuring

goods and services across the NEL healthcare provider

Trusts.

• To capitalise on the savings opportunities available from

procuring goods and services at scale for NEL

Vision

A reduction in unwarranted variation in the cost of procuring goods and services

across the NEL healthcare provider Trusts and to work collaboratively to

capitalise on the savings opportunities available through procurement at scale.


1 Shared resource across NEL (excluding agency

and bank)

Stakeholder engagement: to develop viable

options

Reduction in procurement

back office costs

• Options appraisal for a shared resource

across NEL

2 Consolidation of soft facilities management

contracts across NEL providers

Stakeholder engagement: to develop

specification and negotiate single contract

Reduction in cost of soft

facilities management

across NEL

• Shared soft facilities management (where

market testing indicates significant

savings potential)

3

Rationalisation and standardisation of

catalogues, and purchasing for all medical &

surgical categories including consumables

Clinical engagement: to agree core

products

NHSI supply chain: aligning to national

buying price where agreed

Increased buying power

NEL on key medical and

surgical categories

• Shortlist of priority areas for rationalisation

and standardisation

• NEL wide procurement of key medical and

surgical categories

4 Procuring transport services as a system e.g.

patient transport and home deliveries

Stakeholder engagement: to develop

specification and negotiate single contract

Reduction in cost of

transport services

• Shared contract on patient transport and

home delivery (where market testing

indicates significant savings potential)

5 Shared Workplan System i.e. software system to

enable shared planning of contracts across NEL.

Stakeholder engagement: to procure shared

software

Reduced transactional

back office costs through

data sharing

• Shared workplan system

6 Temporary labour requirements, supplychain,

community services (wheelchair services).

Workforce: to provide right skill mix;

Engagement: to agree specifications and

best prices

Reduced bank and agency

costs

Increased buying power

• Review of further savings and productivity

opportunities through procuring services

at scale, sharing temporary staff 8



Detailed Plan - Workstream 5: IT (back office)

Case for change

The current use of IM&T resources across NEL may not be as

effective as it might be, particularly when solutions are applied

at scale across more than one organisation and across

sectors. Opportunities for collaboration have been identified

across both commissioner and provider organisations. These

include standardising processes, procuring services at scale

and beginning to evaluate potential future operating model

options. NEL STP are baseline.

SRO: Matthew Hopkins, Chief Executive, Barking

Havering and Redbridge University Hospitals

Delivery

lead:

Luke Readman, Chief Information Officer (WELC

CCGs)

Objectives

• To realise the financial benefits of delivering services at scale where there is opportunity for this;

• To ensure continued strategic alignment across NEL at STP level in relation to ICT and clinical

informatics and ensure that the local digital roadmaps properly reflects the available opportunities;

• To develop a flexible and scalable shared service model that improves productivity and value at an STP

level;

• To continue to deliver a high quality IM&T function which supports excellent clinical outcomes and

patient experience.

Vision

To work together to reduce the cost of providing IM&T services across the NEL health system and to ensure a high quality of IM&T services across our organisations.


1

Benchmark current IT service provision

across NEL to identify lowest cost service

model consistent with quality, flexibility

and scalability requirements


complete London benchmarking

exercise

Increased efficiency / reduced cost of IT

(back office) service provision across

NEL where a shared service model is

identified as delivering productivity for

NEL

• Benchmarking of NEL IM&T services

identifying lowest cost service model

2 Develop options for moving to a single

NEL wide telecoms provider

Procurement: to review current

contracts and develop NEL

specification

Realisation of financial savings from

procuring and delivering services at

scale

• Detailed options appraisal of where

financial benefits of delivering services

at scale can be realised across NEL.

3

Develop options for shared data centre

provision including a shared rental model

for servicing hardware and devices


contracts and develop NEL

specification



scale



at scale can be realised across NEL.

4

Explore the opportunities to re-align our

business intelligence services based on

the emerging Accountable Care System

model

Contracting / Commissioning: to

agree NEL approach to business

intelligence based on ACS

vanguard

Business intelligence services to support

new models of care

• Modelling of future business

intelligence service based on emerging

ACS model

5

Explore opportunities for procuring

services at scale e.g. legacy medical

records storage, management print

services, patient letter services


contracts



scale



at scale can be realised across NEL. 9



Route Map (1 of 2) 2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

1. Bank & agency and back office

(HR)

1.1 NEL rate card for bank &

agency

1.2 Shared policies & e-rostering

1.3 Baselining and modelling

workforce functions

1.4 Establishing agreed approach

to shared services

2. Back office (Finance)

2.1 Common financial platform

2.2 Sharing scarce specialist

resources

2.3 Standardised dashboards

2.4 Collaborative planning tool

3. Pathology

3.1 Options development for

collaboration / consolidation

3.2 Review test ordering processes

3.3 Review contracts

3.4 Review outsourced contracts

3.5 Review capacity and demand

3.6 Joint posts and on-call

arrangements

Renegotiation of contracts (phased) TBC Further analysis and

mapping of contract end dates

Service change to move to benchmark (inc.

training and development) Revised test ordering processes Further analysis and

agreement of NEL benchmark

Local ‘specialised’ service development Revised contracts to address

sendaways (where economical) TBC Further analysis and mapping of

sendaways

TBC Further analysis and

mapping of capacity and demand

Identify potential

options for

consolidation TBC

Review of individual Trust plans

Revised contracts Demand and capacity modelling

Complete baseline assessment & review of

case studies/best practice

Evaluation options

for consolidation

Communicate and implement options for

consolidation

Revised service models

TBC

Revised contracts

Further review of workforce pressures &

arrangements Workforce modelling

Revised workforce and

oncall arrangements TBC

Complete business case, procure

subject matter expertise to develop

initiatives

Collate baseline

info of current

rates

Collate baseline information of

current policies and e-rostering

approach

Develop options for a single

NEL rates card

Agreement with NEL providers and align with

London agency framework

Roll out of NEL rates card

Develop shared approach and

options for synchronised e-rostering

Agree approach with NEL providers

Roll out of shared policies and synchronised e-rostering

Collate baseline

data London workforce

modelling

Develop options

and agree

preferred option

Develop

implementation plan Phased delivery


of current service

models

Develop options for sharing


Agree approach with NEL providers Roll out of agreed service model

Develop

implementation plan

Collate baseline and best

practice info Agree NEL approach Roll out of NEL dashboards

Collate baseline and

best practice info

Develop spec and

business case

Procure tool for

NEL Roll out planning tool

Develop detailed options for

shared platform Agree approach with NEL providers Roll out of agreed shared platform where significant savings potential have been identified

10



Route Map (2 of 2) 2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

4. Procurement

4.1 Consolidation of soft FM

contracts

4.2 Rationalisation and

standardisation of

catalogues

4.3 System wide transport

services

4.4 Shared resource

4.5 Temporary labour

requirements, Supply chain,

community services

5. IT (back office)

5.1 Benchmark current

service provision

5.2 Shared data centre

options

5.3 Shared business

intelligence & analytics

5.4 Procurement at scale e.g.

medical records storage,

printing, patient letters

Oct-Nov complete

London benchmarking

Ensure alignment of infrastructure / back office IT plans with implementation with LDRs

Collate baseline information

of existing contracts

Develop NEL wide contract

specific & test market offer

Phased procurement of NEL wide provision of soft facilities

management (where market testing indicates significant savings

potential).

Collate baseline view

of current catalogues.

Work with clinical staff to identify

priority areas for

rationalisation/standardisation.

NEL wide pricing negotiation and procurement of priority

catalogue areas.

Ongoing cycle of rationalising and standardising catalogues in

line with NHS Supply chain national agreements.

Collate baseline information

of existing contracts

Develop NEL spec & test market

Phased procurement of NEL wide provision of soft facilities

management (if market testing indicates significant savings

potential).

Collate baseline information of

existing contracts

Develop NEL wide

specification & test market

Phased procurement of NEL wide services (where market testing

indicates significant savings potential).


subject matter expertise to develop

procurement initiatives


subject matter expertise to develop IT

initiatives

Collate

baseline data.

Develop detailed

options.

Agree preferred

option.

Develop

implementation

plan

Phased delivery

Collate

baseline

data.

Develop options

Agree preferred

option.

Develop

implementation

plan Phased delivery

Collate baseline data. Agree preferred

option.

Develop

implementation

plan

Phased delivery

Collate baseline

info of existing

contracts .

Develop NEL

wide contract

specs

Phased procurement of NEL wide services as existing contracts end

and where significant savings potential has been identified.

Develop options based on

proposed ACS models

11




This section provides a high level summary of the metrics that are being developed against the initiatives outlined within the productivity delivery

plans.

Benefit description (Health &

wellbeing, care & quality or

financial)

Measurement

(metric)

Current

performance

Target

performance

Target date

(default

2020)

Linked workstreams

Reduced cost of back office functions

across NEL

% cost reduction

against agreed

baseline

£113m on central

procurement,

finance, HR & IT

back office

functions

Potential savings

opportunities

identified as up to

c.£10.7m

2020 HR (back office),

Finance (back office),

Procurement (back office)

and IT (back office)

Bank & agency and back office (HR):

Reduced cost of bank & agency staff

% cost reduction

against agreed

baseline

Currently £196m on

agencies

Potential savings

opportunities

identified as c.£8.6m)

2020 Bank & Agency

productivity

Pathology: Design and delivery of

appropriate and best practice services

across the network and within each

individual Trust

To be developed in line with national benchmarking 2020 Pathology productivity

Procurement: Reduced cost of

consumables through standardisation

(including product and service

specification across NEL) and reduced

costs from procuring goods and services

at scale across NEL e.g. patient

transport

% cost

reduction

against agreed

baseline

Baseline cost to be

agreed

Potential savings

opportunities

identified as c.£7.6m

TBC Procurement productivity

12





A governance structure has been established to oversee the productivity workstreams for NEL STP. This is structured of 5 task and finish groups are made

up of operational leads from each of the provider Trusts. The IT task and finish group also contains representatives from NEL’s CCGs and from NEL CSU.

The task and finish groups report into the productivity steering group which in turn reports into the provider Chief Executive Board. There is a single SRO for

this work whilst the delivery leads have been allocated across all of the provider Trusts and, in the case of the IT workstream, through the WELC CCGs.

Delivery Plan

SRO Delivery Lead

Workstream 1:

Bank & agency

and back office

(HR)

Matthew Hopkins, Chief

Executive, Barking

Havering and Redbridge

University Hospitals

Daniel Waldron, Director of

Organisation Transformation,

Homerton University Foundation

Trust

Workstream 2:

Back office

(Finance)


Executive, Barking



Jonathan Wilson, Director of

Finance,

Homerton University Hospital NHS

Foundation Trust

Workstream 3:

Pathology


Executive, Barking



Jason Seez, Director of Planning

and Governance, Barking,

Havering and Redbridge University

Hospitals Trust & Simon Milligan,

Director of Capital, Costing and

Development, Barts Health

Workstream 4:

Procurement


Executive, Barking



Ralph Coulbeck, Director of

Strategy, Barts Health NHS Trust /

Simon Milligan Director of Capital,

Costing and Development, Barts

Health NHS Trust

Workstream 5:

IT (back office)


Executive, Barking



Luke Readman, Chief Information

Officer (WELC CCGs)


13

Provider Chief

Executive Group

Task and finish:

Procurement

Task and finish:

Bank / agency

and back office

(HR)

Task and finish:

Pathology

Task and finish:

Back office (IT)

Task and finish:

BO (finance)

Provider collaboration

productivity steering

group

STP Board


NEL STP

Executive


Risks

Risks


Back office

(Finance)

Existing long-term contracts some of which relate to already

outsourced back office functions to SBS, Serco etc. may impact

the net savings through collaboration in some areas.

Include cost of exit fees or phased approach to consolidation when developing options for

moving to a shared platform / shared business service. R

Pathology Existing contracts may be difficult to terminate or renegotiate

and different end times may impact the net savings through

collaboration in some areas e.g. equipment.

Work with procurement workstream to carry out a baseline assessment of contracts

R

Procurement Long-term contracts in place with costly exit fees may impact

the net savings through collaboration in some areas

3-5 year shared workplan where contracts are amalgamated as they expire R

IT (back office)

Long-term contracts in place including PFIs with costly exit

fees may impact the net savings through collaboration in

some areas.

Include cost of exit fees or phased approach to consolidation when developing options

for moving to shared contracts / shared services. R

Bank & agency and

back office (HR)

Existing contracts and agreements relating to temp staffing and

shared services could limit options for shared working and

collaboration.

Options development to include review of contracts and consider whether a phased

approach can be utilised as contracts expire. A

Back office

(Finance)

Any change from status quo is likely to be resisted by staff

groups especially if further outsourcing is needed.

Establish a programme of education and development to support the workforce to move

from implementing transactional activities to supporting forward facing forecasting. A

Back office

(Finance)

High levels of vacancies and high proportion of agency interims. Redesign roles to redistribute lower level work to and admin support workforce where local

recruitment would be possible. Use work from Future Finance and Finance Skills

Development to implement training programmes and communication, establish STP trainee

and apprenticeship schemes and make contact with local schools and colleges and

universities to recruit.

A

Pathology Consolidation of IT contracts may be hindered by information

governance and patient confidentiality requirements.

Work with IT and IG to understand confidentiality requirements. A

Pathology All trusts have existing plans and there is a risk that these may

be ignored or may be developed in isolation to STP plans.

Baseline assessment to document and build on existing plans. A

Pathology Service disruption/destabilisation from changes to services e.g.

staff changes and changes to IT systems

Services need to continue to run optimally to support Trust infrastructure through

development of clear implementation plans. A

Procurement Risk of non-compliance to legislation if we rush

procurements

Robust workplan that has been scrutinised and approved by Procurement Heads and

external legal advice where appropriate. A

IT (back office)

Infrastructure informatics may already be under-resourced.

Use benchmarking and data collation to identify lowest cost service model consistent

with quality, flexibility and scalability requirements. A

IT (back office)

The cost of proposed changes may be greater than savings

opportunities

Maximise available national and regional funding sources.

A

Note: This is a list of the highest-rated risks. Additional risks identified at a lower mitigated risk rating

14





Workstream Type: Description Actions / next steps

Bank & agency

and back

office (HR)

Constraints /

Dependencies

• On-going recruitment and retention challenges continuing to drive demand for temp

staffing

• Format and completeness of data across organisations to be able to carry out

required benchmarking, modelling and analysis

• Align with workforce plans for meeting

recruitment and retention challenges;

• Standard template and approach has been

developed and work being coordinated by

London HR transformation programme

Bank & agency

and back

office (HR)

Assumptions

• LLP re-procurement of agency framework will support compliance with NHSI cap and

data sharing on agency shifts worked by substantive staff

• Benchmarking, modelling and analysis phase will be supported by the London HR

Transformation programme

• Await further guidance on LLP re-

procurement of agency framework;

• Continue to liaise with London HR

Transformation programme;

Back office

(Finance) Assumption

• Any agreement to move all financial services to Barts SSC or to establish an NEL

shared service centre will need investment to set up, recruit and train staff.

• That there will be clear agreement in place regarding how implementation costs and

any subsequent savings are shared across the providers.

• Strategic outline case will need to identify

spend to save opportunities for preferred

option to be viable;

• Early agreement across NEL on how costs

and savings are distributed.

Back office

(Finance)

Constraints /

Dependencies

• Procurement back office collaboration has implications for P2P operating model.

• IT strategy needs finalising across NEL, through the harmonisation of three Local

Digital Roadmaps.

• Review of transactional HR including payroll provision sits with the HR back office

workstream;

• There are existing CIP plans in providers for finance back office functions.

• Discussions with these workstreams will

need to be undertaken to identify synergies

and avoid duplication.

Pathology Constraints /

Dependencies

• It may be difficult to retain staff if service changes are unpalatable – particularly for

difficult to recruit areas.

• Work with workforce workstream, ensure

clear communications and engagement

plans and processes and clear

implementation plans

Procurement Constraints /

Dependencies

• All aspects of the provider landscape needs to be engaged to realise savings in their

area of work (for example in relation to IT contracts, pathology, medical consumables

etc.)

• Ongoing work at a national level on procurement have will have an impact on what the

overall procurement landscape looks like i.e. NHS supply chain pricing negotiations

• Ensure early engagement with key

workstreams e.g. IT;

• Utilise national best price lists where

available;

15



Dependency map


care close to

Home

Accessible

quality acute

services


Services

Workforce Digital

Bank &

agency and

back office

(HR)

Recruitment &

Retention

Back office

(Finance)

Procurement

of finance

systems

Payroll function

sits within

workforce

Recruitment &

Retention and

training &

development of

of finance staff

IT Strategy to

align finance

systems

Pathology

Location of

services

Recruitment &

Retention

Aligning

pathology IT

systems / data

sharing

Procurement Patient

transport &

home delivery

Consolidation

of key IT,

Pathology &

Finance goods

/ service

contracts

Standardisati

on of

consumables

Shared

planning

systems / data

sharing

IT (back

office)

Location of

servers,

helpdesks,

shared

services

Recruitment &

Retention, skill

mix and training

& development

of IT staff

IT infrastructure

needed to

enable digital

road maps

This dependency map highlights where this delivery plan is linked to another delivery plan within our STP.

16





















Planned future work






17








Driving forward the delivery of

efficient and high quality back

office provider services will help

to ensure that our acute services

are of a high quality and

accessible to those who need it.

For example, by improving how

we manage our bank and

agency staff through initiatives

such as shared e-rostering and

developing a NEL wide bank

service, we will be ensuring that

our acute services are

sustainable and that they are run

by staff who know our systems

and processes.

Improving the productivity of our

back office and support services

will continue to enable and

support the provision of care

close to home for patients. For

example, we will maximise any

opportunity there is for procuring

patient transport services at

scale across NEL. This would

include a shared service desk

which would support the smooth

running of this key service.

Our plans for improving our productivity will have an

impact on how we serve our communities. For example,

by delivering a high quality, financially sustainable and

cost effective pathology service, we will be enabling our

local clinicians and our patients to have timely

results to support early intervention and care.


This delivery plan sets out how it will deliver improvements against the core areas of prevention, out-of-hospital care and in-hospital care

18



Addressing the 10 Big Questions


for healthcare

• Supporting other delivery plans to implement change


& NHS staff

•Supporting other delivery plans to implement change


practice




•Exploring the opportunities to re-align our business intelligence services based on the emerging ACS model


core standards





•Design and delivery of clinically efficient and quality pathology services which meet the needs of patients and commissioners


•Utilising shared planning software to synchronise procurement cycles;

•Supporting collaboration and consolidation of pathology services through use of shared IT systems;

•Maximising opportunities for providing IT services at scale e.g. through a shared telecoms provider, and shared networks


deliver?

•Reducing the demand for temporary staff through collaboration;

•Reducing temporary staff costs through establishing a common approach managing staff banks;

•Reducing temporary staff costs through establishing a common approach to agency management


balance

•Capitalising on the savings opportunities available through procuring and operating goods and services at scale;

•Developing a flexible and scalable shared services model for our back office functions that improves productivity and value for NEL

19




1. STPs

• This delivery plan outlines our agreed STP initiatives and milestones and the timeline for delivering them. We have also begun to map out the metrics against which we will measure our progress.

2. Finance

•We are working collaboratively to develop a flexible / scalable back office service model where this will deliver value for NEL;

•Iniatives are in place to develop a NEL bank & agency rates card, synchronised e-rostering and scoping options for a shared staff bank.

3. Primary Care

•Refer to the primary care delivery plan.


•Refer to the urgent and emergency care delivery plan


•Refer to the planned care delivery plan

6. Cancer

•Refer to the cancer delivery plan

7. Mental health





•We are working collaboratively to carry out benchmarking across all of our productivity workstreams and to use standardisation and sharing of best practice to improve quality (refer to individual workstream slides).

20






Estates Infrastructure


No. Section Page

1 Initiative map 3

2 Delivery plan on a page 4

3 Work stream plans 5

4 Expected benefits and metrics 8

5 Resources and delivery structure 9

6 Risks 10

7 Dependency map 11

8 Summary of financial analysis 12

9 Contribution to our framework for Better Care and Wellbeing 13

10 Addressing the 10 „Big Questions‟ 14

11 Addressing the 9 „Must do‟s‟ 15

Contents

2



Initiative map N

EL S

TP

Le

vel

•Reflecting estate implications of NEL clinical workstreams

•Consolidation of local strategies

•Common themes and cross-borough interdependences

•Opportunities for inter-agency collaboration

•Portfolio level investment requirements and devolved receipt potential

•As required, co-ordination relating to multi-borough projects

•Escalation of issues relating to project barriers

Lo

cal A

rea L

evel •Hackney

Devolution Pilot

•BHR ACO programme

•Transforming Services Together (WEL)

CC

G /

Boro

ug

h L

eve

l •Bringing together local partnerships, federations and networks

•Local estates strategies

•Local projects business cases

•Local projects implementation and delivery

•Better Care Together (Waltham Forest)

• Tower Hamlets Together Community Health Services

Lo

nd

on

-wid

e

•London Devolution Pilot

Through the STP we have discussed the best level at which each proposed scheme should be led and delivered within the

health and care system. We have done this based on the partnerships and scale required to best implement the specific

projects

3



Delivery plan on a page

Expected Impact • Provide system oversight for the development and delivery of local infrastructure programmes

• Providing sufficient capacity to meet health needs arising from substantial population growth.

• Anticipating the estates impact of new models of care, particularly the planned shift of care from

hospitals to community.

• Securing financial sustainability within economic context for the NHS and the local health economy

• Improving productivity and efficiency of estates usage

• Better health and care outcomes through the transformation of health and social care delivery,

based in a fit for purpose estate

• Dispose of inefficient or functionally unsuitable buildings and sites in conjunction with estates

rationalisation.

• OPE partnerships of councils and the wider public sector to deliver land and property initiatives,

delivering jobs, homes, income and savings.(Successful Waltham Forest bid, expression of interest

submitted for B&D and Havering)

Vision

To develop good quality and cost effective

estates infrastructure that meets the

complex needs of a diverse and relatively

transient population. Our estates will need

to be flexible, to support the delivery of new

models of care over the next 5 – 20 years.

Background and case for change

• There is wide variety in the quality of our estates infrastructure, from buildings that are more than 100 years old and no

longer fit for purpose, through to the most modern acute and primary care facilities.

• Medical and technological advances, an increasing population, and changes to our models of care will mean that we need

to modernise our infrastructure.

• Lord Carter‟s review of productivity identified a number of areas where improved efficiency in estates could lead to

reductions in running costs, improved utilisation of space, and disposal of facilities that are no longer required, or fit for

purpose.

• Investment will be needed to deliver a modern estate, and capital receipts from estates disposal are an important funding

source for investment

• Infrastructure is a crucial enabler for our system-wide delivery model. We need to deliver care in modern, fit for purpose

buildings and to meet the capacity challenges produced by a growing population

Workstreams


• As we develop our detailed plans we will further develop our governance, respecting the principles of

subsidiarity agreed within the STP, taking account of the governance arrangements for providers,

commissioners and local authorities.

• Delivering new models of primary and secondary care at scale will require modern, fit-for-purpose and cost-

effective infrastructure.

• The foundation of our model is primary care collaboration at scale with hubs, networks and federations treating

populations of up to 70,000 people, accessible 8am-8pm, 7 days a week where appropriate.

• Provider organisations, together with commissioner and partner organisations are working across North East

London (NEL) in an ambitious programme to redesign the delivery of health and social care services across the

whole footprint including Whipps Cross, King Georges, Queens, St Georges, Newham, Homerton and Mile End

hospitals. Major health and wellbeing community facilities are proposed for St Georges, Whipps Cross, Mile End

and St Leonards sites.

• Create a costed, consolidated NEL Estates Strategy with an enabling programme of work with key milestones /

deliverables

16/17 Q1/2 17/18 Q3/4 17/18 18/19 19/20, 20/21

NEL Estates Strategy

Utilisation and Productivity

Disposals

Additional Capacity

Assurance

Define governance

structures

Review priorities and

opportunities from clinical

workstreams

Develop NEL

Estates Strategy

Capital financing need and plan for

investment, disinvestment,

reinvestment and disposal

Implementation: Capability and

mechanisms in place to manage

changing estate

Business Case development and

approval

Refine scope for disposals and define opportunities

Implementation Plan

Define benchmarking analysis

Synthesize output from clinical case and other portfolios, savings and receipts, costs, counterfactual scenario,

demand and capacity implications

Develop implementation plan

Agree appropriate delivery form

Define utilisation improvements

4



Detailed plan – Work stream 1 : Utilisation and Productivity

Case for change • Lord Carter‟s review of utilisation identified a number of areas where improved efficiency in estates could lead to

savings: running costs and improved utilisation of space

• Trusts have been told to plan to operate with a maximum of 35 per cent of non-clinical floor space and 2.5 per cent

of unoccupied or underused space, where appropriate. We hope to embed the recommendations of the Carter

Review on utilisation through joint working, home-working and improvements in IT, in addition to using devolution

as an enabler to facilitate improvements.

• Barts Health Trust reported 18% unoccupied or underused space as % of total and confirmed it is working to make

better use of its surplus space, but pointed to its large education and training facilities as one cause of its high

proportion of non-clinical space.

• Our core community estate is poorly utilised (approx. 35%) with void costs of approx. £3.5m p.a.

SRO: Alwen Williams, CEO, Barts Health

Delivery

lead:

Sven Bunn, Deputy Director of Strategy, Barts

Health

Objectives

• To increase the operational efficiency of the estate and

maximise utilisation of the core estate;

• Optimising the utilisation and costs of the health and care

estate.

• Better health and care outcomes through the

transformation of health and social care delivery, based in

a fit for purpose estate

Vision

Improve patient access to a wider range of services for longer through increased

utilisation and co-location. Identify savings opportunities from reduced voids.

Initiatives Benefits and Metrics Deliverables

1 Develop benchmarking data across NEL Identify savings opportunities from reduced voids, reduce

running cost, increased utilisation and co-locations Achieve a consolidated view for utilisation and productivity / PFI opportunities

2 Improve utilisation and productivity of acute estates

(Carter review)

Identification of opportunities for shared use of accommodation –

which could include office and back office functions, public facing

space (eg leisure centres and libraries)

Improving and utilising estates to deliver quality care including Whipps Cross

redevelopment, development of urgent care and ED facilities as part of the

closure of the KGH ED, St Georges Hospital redevelopment, Thorpe Coombe

redevelopment.

3 Improve utilisation and productivity in core primary

and community care

Identify and anchor in 100% tenants with all sessional use space

being booked and managed centrally by one solution across

NEL to free up capacity currently limited by national under lease

regularisation programme

Additional capacity created in core community and primary care estate allowing

further rationalisation and consolidation of older, poorer quality buildings. All

buildings in NEL operate, look and feel the same for patients, staff and the

public through delivery of whole system solution for operational management

4 Improve utilisation and productivity of mental health

inpatient estate New ways of working, eg shared booking systems

Review the location of acute inpatient mental health services to improve

productivity and provide more flexibility for the delivery of other services across

acute sites in NEL

5 Use Technology to reduce demand for estate More efficient working and reporting, reducing the need for notes

write-up desk space and similar measures.

Innovative approaches to the delivery of healthcare services reducing demands

on the healthcare estate, e.g. use of technology

6 Increase clinical capacity by reducing non clinical

estate

Potential sharing of “back office” functions with local authorities

through One Public Estate and other initiatives.

More clinical operational capacity over longer operating hours.

5



Detailed plan – Work stream 2: Disposals

Case for change

• Department of Health has a target to release land across England with capacity for 26,000

homes by 2020

• Investment will be needed to deliver a fit for purpose estate, and capital receipts from estates

disposal are an important funding source for investment

• A particular focus for the Devolution Programmes is to look at ways of freeing-up NHS estate

and assets

• The vast majority of the NHS estate is owned by hospital trusts, and NHS Property Services.

The size and value is considerable and there is an opportunity to make vast improvements the

way NHS buildings and land are used and – where these are surplus to requirements – to

generate money to reinvest in NEL‟s health and care system


Delivery

lead:


Health

Objectives

• Providing sufficient capacity to meet health needs arising from

substantial population growth before any land/estate is being

declared surplus to requirements.

• Anticipating the impact and infrastructure requirements of new

models of care, particularly the planned shift of care from

hospitals to community before any release of surplus estate.

• Dispose of inefficient or functionally unsuitable buildings and sites

in conjunction with estates rationalisation.

• We ask to recycle the proceeds of sales including NHS Property

Service buildings (Devolution areas C&H/BHR)

Vision

Release of surplus buildings and land for reinvestment and housing

Reduce overall cost of the estate and overall cost per msq which could be delivered though new build and better utilisation (7 days working).


1 Use existing site surveys and productivity

analysis to identify scope for disposals

Use demand and capacity modelling to develop

estimates for future requirements before enable any

release of estate

Establish detailed implementation plan for 2016/17 and beyond to reflect

opportunities for savings and investments as well as demand and supply

implications resulting from other workstreams and demographic factors

2 Develop consolidation strategy Create an overview of the disposals programme and

projects within NEL Achieve a consolidated view for disposals opportunities and requirements

3 Agree appropriate delivery form Release of surplus estate/land for

developments/housing units Reducing the amount of unoccupied land in NEL.

4 Identify revenue savings Releasing capital for re-investment in health and care

transformation in NEL

Facilitate the release of surplus assets and reinvestment of the capital

receipts.

5 Potential developments and disposal

opportunities

Maximise the potential benefits/ receipts in retaining and

developing and/or disposal of some of the existing

surplus land opportunities.

Potential development/disposal opportunities include some land at: • Royal London Hospital

• King Georges

• St Georges

• Goodmayes

• Thorpe Coombe

• Whipps Cross

• Mile End

• St. Leonards 6



Detailed plan – Work stream 3: Additional Capacity

Case for change

• High population increase and high birth rate means that we may need to

increase our physical infrastructure.

• In order to provide safe, sustainable care for the growing population in NEL,

we need all of our acute sites to continue to deliver high quality care. We

also know these sites will need to work together in new ways to ensure that

specialist and emergency care is of the highest possible quality. Developing

the strategy for the future of Whipps Cross University Hospital (WX) and

implementing the approved changes at Queens, King Georges and Newham

are therefore central to the longer term sustainability of the local NHS.


Delivery

lead:


Health

Objectives

• Providing sufficient capacity to meet health needs arising from substantial population

growth.

• Anticipating the impact of new models of care, particularly the planned shift of care

from hospitals to community.

• Only undertaking new build where opportunities to rationalise and/or maximise use

and efficiency of the existing estate have been realised or where such developments

deliver a whole life cost saving versus continuing use of the current estate

• Additional capacity to meet the health, social care and wellbeing needs of our

residents

Vision

Ensure sufficient, fit for purpose estate is available to cater for growing

population


1 Scoping of requirements based on

population growth

Use demand and capacity modelling to develop

estimates for future requirements

Establish detailed implementation plan for 2016/17 and beyond to reflect

opportunities for savings and investments as well as demand and supply

implications resulting from other workstreams and demographic factors

2 Analysis of model of care mitigations Improved ability to meet current / future demand

The new model of care is expected to create additional capacity to ensure

primary and secondary care can cope with future expected growth.

3 Analysis of productivity mitigations

Any additional capacity we propose will need to be

financially affordable and deliver lasting benefits to the

local area.

Capacity across sites may not align with growth – need for further analysis of

rightsizing the estate

4 Provide context for existing development

plans (Whipps Cross, King George‟s)

Deliver a better experience of care, closer to home

wherever possible for our patients

Achieve a consolidated view for new capacity opportunities and requirements

5 Identify high level costs May serve patients from a wider catchment area Explore sources of capital, working with NHS and Local Authorities, for

example: One Public Estate.

6 Identity investment strategy

Disinvestment from not fit for purpose estate not

suitable for modern health care provision and not

compliant with infection control requirements

Review the need for additional maternity and new-born facilities resulting from

the projected increase in the number of births in NEL 7



Expected benefits & metrics



financial)

Measurement

(metric)

Current

performance

Target

performance

Target date

(default

2020)

Linked workstreams

• Create a costed, consolidated NEL

Estates Strategy with an enabling

programme of work with key milestones

/ deliverables

The aim is to have a

costed NEL strategy at

different delivery levels.

50% 100% 2017 Clinical STP workstreams

and enablers

• Use demand and capacity modelling to

develop estimates for future

requirements

Demand and capacity

model in development

across NEL

50% 100% 2017

Modelling workstream,

modelling outputs to be

used to forecast additional

capacity requirements

• Create an overview of the capital

programme and projects within NEL

Next 5 years Capital

Plan 50% 100% 2017

Explore sources of capital,

working with NHS and local

Authorities, for example:

One Public Estate.

• Identify savings opportunities from

reduced voids, increased utilisation and

co-locations

Target to reduce known

void by consolidation and

co-location

Improve

utilisation by

5% by 2021

and 10% by

2026

75% Utilisation

of properties

and no void

space

2021 Productivity

• Commission assurance for investment

and savings assumptions

Identify savings

opportunities and

options in reducing PFI

cost

Investment

requirements

identified

Deliver

approved

schemes/proje

cts

2021 Productivity

• Dispose of inefficient or functionally

unsuitable buildings and sites in

conjunction with estates rationalisation.

Disposals opportunities

identified, to be

developed further

following the outputs of

the NEL capacity model

Disposal

opportunities

identified

Dispose of

surplus

land/estate

2021

Modelling workstream /

Productivity /

Transformation 8




Resources & delivery structure

Trust boards will sign off ultimate proposals and plans recommended to them by their representatives on the Infrastructure Steering Group, with

additional support as needed

• The NEL STP Board is sighted on plans, making sure they are coherent with the overall plans across the STP

• The Estates Steering Group manages the portfolio, ensuring that the work done is aligned and ambitious.

• Workstreams do the detailed work and make recommendations to the Productivity Steering Group. Workstreams include wider group of

stakeholders, including Directors of Estates, Strategy Directors etc.

SRO Delivery Lead

Delivery Plan

Name: Alwen

Williams, Role: CEO

Organisation: Barts

Health

Sven Bunn, Deputy

Director of Strategy,

Barts Health

Workstream 1:

Utilisation and

Productivity

Name: Alwen

Williams

Role: CEO

Organisation: Barts

Health

Sven Bunn, Deputy


Barts Health

Workstream 2:

Disposals

Name: Alwen

Williams

Role: CEO

Organisation: Barts

Health

Sven Bunn, Deputy


Barts Health

Workstream 3:

Additional Capacity

Name: Alwen

Williams

Role: CEO

Organisation: Barts

Health

Sven Bunn, Deputy


Barts Health

Resources Delivery structure

9


Assurance

Additional

capacity Disposals Utilisation

and

productivity

Estates Steering Group

Estates strategy

Trust Boards / CCG Governing bodies

Workstreams

NEL STP Executive

NEL STP Board


Risks

Risks


Infrastructure

Due to complexity of the estates system, including the number of

organisations and the differences in governance, objectives and

incentives between each organisation-type: organisations often

work in silos

Bringing partners together – to provide greater co-ordination and easier

escalation to tackle barriers which can be addressed through improved

local joint working

A

Infrastructure

Sources of funding to support development of Whipps Cross, urgent

care and ED facilities as part of the closure of the KGH ED, St

Georges Hospital redevelopment, Thorpe Coombe redevelopment.

ETTF for Primary Care allocation and availability of funding. The

national allocations have been decided that London will only get

16% of the national pot across the 3 years. This equates to c.£70m

across London (NEL requested c.£52m)

Working with NHS E to confirm sources of funding and agree prioritisation

of the NEL projects. R

Disposals

Affordability: retention of receipts, budget “annuality” and access to

capital investment for re-provision;

This will provide greater incentives to dispose of surplus property for

organisations which do not currently retain receipts and will enable

greater efficiency and flexibility in the estate, reducing voids and

improving utilisation and co location, to deliver financial benefits. Working

with partners across NEL to understand best route/delivery and impact

R

Infrastructure

Complexity of business cases: getting the right balance of speed

and rigour and the different approvals processes facing different

organisation types, for example, different capital approval regimes

operating across the NHS and local government

Our ask will be for delegation of business case approval, coupled with the

retention of capital receipts within the NEL /London systems and the

ability to make local decisions relating to the reinvestment of capital

receipts.

A

Utilisation and Productivity

Immovable agreements already signed up to (LIFT/PFI) limit ability to exit from sites. Current leasing arrangements put in place by NHS PS and CHP limit flexibility for providers, do not allow subletting and lock up potential capacity.

In order to maximise the use of these multi-occupancy sites we need NEL

control over the leasing and management of space allocation through a

whole system solution to building management and room booking system. R

Additional Capacity Demand modelling still in draft and not completed to enable

analysis of additional infrastructure/capital requirements.

Using national guidance to estimate additional capacity based on demand

modelling, also working with NHS E and partner organisations to confirm

sources of funding for development of new capacity required based on

population growth

A

10 Note: This is a list of the highest-rated risks. Additional risks identified at a lower mitigated risk rating



Dependency map


care close to

Home

Accessible

quality acute

services


Services

Workforce Digital

Workstream 1

Utilisation and

Productivity

Deliver services

closer to home

from fit for

purpose

premises

Improved

utilisation of

existing facilities

Working

together with

social care.

Pathology: need

for infrastructure

Corporate:

Consolidation of

back-office

function –

release of

capacity

Joint

procurement of

FM contracts

Suitable out-of-

hospital

premises for

community

dialysis

Workforce

plans in place

to support 7

day working,

better

utilisation of

current estate

Electronic

care records

will enable

release of

storage

capacity and

better

utilisation of

space

Workstream 2

Disposals

Use productivity

analysis to

identify scope

for disposals

May release

storage

existing

records

storage

capacity

Workstream 3

New Capacity

Additional

capacity

required based

on population

growth

Additional

capacity

required based

on population

growth

Shared back-

office function

and

administrative

services

Additional

workforce will

require

additional

capacity

Systems that

will allow

access to

electronic care

records rather

than store on

premises

11




Summary of financial analysis





• The “Business As Usual (BAU)” effect on closing the gap













Planned future work







12


Contribution to our framework for Better Care and Wellbeing





Our acute sites are broadly operating at, or close to capacity in their current configurations. We have some buildings that are not suitable to deliver today‟s standards of care, let alone in the future. Some buildings also create inefficiencies in service delivery and impact on patient experience. Whipps Cross Hospital in particular presents some key challenges that are currently being addresses. Improving and utilizing estates to deliver quality care including Whipps Cross redevelopment, development ofredevelopment, Thorpe Coombe redevelopment. There are opportunities to consolidate and dispose of parts of the estate that are not efficient, or which are sited in locations where they hold considerable value to a residential or commercial market.

NEL has a high number of single

handed practices , some of which are

not run from fit-for-purpose premises.

Whilst estates improvements to these

practices could be made, investment

would be significant and may not be

beneficial to implementing a primary

care model in which multidisciplinary

working is the norm.

This would mean better quality of care

for patients and also help the system

become more sustainable because it

would greatly reduce pressure on

hospital beds at sites.

The improved facilities will enable

services out of hospital to be

commissioned closer to home,

increasing the range of diagnostic and

community services to be available

more locally.

Implementing our vision would result in primary care offering a high quality and consistent service that meets the population‟s needs. Primary care will be working at scale through multidisciplinary teams working together across organisational boundaries, in fit-for-purpose premises.

The current buildings and infrastructure fail to meet current and future needs. There are many examples of poor general practice facilities which do not support multi-disciplinary team working and contribute to a poor patient experience. Working together in shared facilities and improving the estate: this is fundamental to the way care will be offered in the future.


13




Addressing the 10 ‘Big Questions’


for healthcare

•Prevent admission by improving primary care infrastructure and access.

• Right size estate capacity in the right place.


& NHS staff

•Estates strategies have been developed by engaging with out patients, communities and staff members.


practice

•Delivering new models of primary care at scale will require modern, fit-for-purpose and cost-effective infrastructure.

• Seek sources of funding to deliver capital projects.



•North East London (NEL) in an ambitious programme to redesign the delivery of health and social care services

• Implementing any changes from new models of care including surgical centres of excellence and primary care delivered at scale.


core standards

•Contribution towards A&E waits by improving infrastructure .


•Enable and support implementation of our clinical model.


•Improve utilisation and access of our existing premises (7 days access).

• Develop additional capacity to meet expected growth .


•Innovative approaches to the delivery of healthcare services reducing demands on the healthcare estate, e.g. use of technology.


deliver?

•Additional capacity may be required to support additional and new workforce models.


balance

•Reduce estates running costs.

• Improved operational productivity.

• Review PFI contracts where they have been identified as a significant barrier to financial sustainability.

• Invest receipts from disposals to support investment.

14



Addressing the 9 ‘Must Do’s’

1. STPs

•This delivery plan outlines our agreed STP initiatives and milestones and the timeline for delivering them. We have also begun to map out the metrics against which we will measure our progress.

2. Finance

•We are working collaboratively to develop a flexible estate that will enable delivery of the proposed new models of care where this will deliver value for NEL.

•Iniatives are in place to develop a NEL sustainability estates plan that will enable investment in our infrastructure to deliver modern healthcare.

3. Primary Care

•Enable better utilisation of primary and community care estate by increasing access / opening times.

•The new model of care is expected to create additional capacity to ensure primary care can cope with future expected growth.


•Providing more urgent-care appointments in the community, including in the evenings and at weekends will require a better utilisation/improvement of our infrastructure.


•Review the need for additional maternity and new-born facilities resulting from the projected increase in the number of births in NEL.

6. Cancer

•Provide fit for purpose facilities to support cancer model of care

7. Mental health

•Improve utilisation and productivity of mental health inpatient estate

•Review the location of acute inpatient mental health services to improve productivity and provide more flexibility for the delivery of other services across acute sites in NEL.

8. . People with learning disabilities

•Improve Infrastructure/access for people with learning disabilities.


•In order to provide safe, sustainable care for the growing population in NEL, we need all of our acute/ primary and community care sites to continue to deliver high quality care by investing in improving the infrastructure require for modern healthcare.

15






Specialised Commissioning


No. Section Page

1 Initiative map 3


3 Workstream plans 5

4 Route map 8



7 Risks 11

8 Dependencies, constraints and assumptions 12

9 Dependency map 13



12 Addressing the 10 „Big Questions‟ 16

13 Addressing 9 „Must Do‟s‟ 17

Contents


2


Initiative map N

EL S

TP

Level

• Development of single care models for specialist pathways (renal and cardiology)

• Review community Neuro Rehab provision

• Earlier diagnosis and more efficient pathways in specialist cancer

• Specialist mental health planning

Loca

l Are

a L

evel

• Delivery of renal dialysis virtual Chronic Kidney Disease (CKD) clinics and community case finding

• Delivery of AF and HF – closer working between 1° and 2° care; case finding

• Forensic and Tier4 CAMHS pathway improvements

CC

G /

Boro

ugh L

evel

• Preventative initiatives in CKD, Atrial Fibrillation and Heart Failure

London-w

ide

• Drugs and devices – centralised, electronic procurement

• CAMHS Tier 4 bed review

• Improving value through reducing fragmentation, variation and efficiency

There are a wide range of programmes that support the aim of slowing demand growth, reducing variation and improving

efficiency and quality in specialised services. These are outlined in our narrative plan for north east London and in the NHS

England London (NEL) storyboard. Some of these initiatives will be managed centrally by NHS England London (London-

wide capacity and access, variation, commissioning efficiencies). A selection of services provided locally are mostly used by

NEL patients (>60% of the total cohort in 2015) and therefore pathway improvements can be developed at an STP level

and implemented locally.

While initiatives may benefit from system-level development, implementation may occur at local level (for example rolling out the East London Kidney Services).

Governance, design and management of pathways at STP level

Delivery may be at more local levels 3



Reduce fragile services, improve efficiency, reduce variation, QIPP and CQUIN


Expected Impact • Slowed growth in demand for specialised

services through maximised primary and

secondary prevention

• Eliminated unwarranted variation

• Equity of access, outcomes and experience

• Improved quality, safety and cost effectiveness

• Reduced outpatient appointments; other activity

shifts to be determined in Q3 2016/17

Vision

A healthcare system working together to

deliver evidence-based, high-quality and

affordable specialised services to

improve the health of the population.

Background and Case for Change

• Demand for and cost of specialist care are rising due to an ageing and increasing population, and new

technologies and treatments

• With contracts for NEL providers of >£500m for specialist care in 2016/17, specialist services are an

important part of the NEL health economy

• An annual predicted deficit will present a cumulative overspend of £134m by 2020/21

• A number of quality issues exist, including the meeting of some national mandatory standards.

• There is pathway fragmentation, duplication of services and gaps in provision between specialised,

non-specialised and local services

Workstreams 16/17 17/18 18/19 19/20 20/21

Implementation of other pathway initiatives

Financial modelling –

Enabling workstream

Pathway Transformation –

Workstreams 1 - 3

Finalise model and

validate

New initiative development, business cases

Improving Value –

Workstream held by NHS

England London Digital developments,

procurement centralisation


• The solutions to increasing demand in specialised services lie in whole-pathway solutions.

• Pathway Transformation – described within this delivery plan and developed locally

• Whole system, pathway led transformation to improve prevention, active demand management,

improve quality of care and patient flows, whilst reducing variation.

• Understand reasons for variation and barriers to improvement.

• Priorities include renal dialysis, cardiac, paediatrics, cancer, mental health and neuro rehab.

• Improving Value – managed by NHS England London

• Drugs and Devices – reduce variation, implement digital prescribing and centralise procurement

• Improve productivity and efficiency of specialised services through reducing fragmentation and

implementing national service reviews

• Initiatives identified only partially address the financial gap; further opportunities still to be developed

Opportunity

identification and

programme set-up

National service

reviews

Roll-out and spread renal and cardiology

improvements across NEL

4



Detailed plan – Work stream 1: Pathway transformation - Renal Dialysis

Case for change

• Increasing numbers of people with Chronic Kidney Disease (CKD) and Acute Kidney Injury

(AKI) due to population growth, demographic diversity, and lifestyle, resulting in high dialysis

use. Often people present late, reducing opportunities for early intervention.

• An estimated 45% of NEL patients with CKD are undiagnosed; increasing numbers of people

presenting in end stage renal failure (ESRF) previously unknown to the system.

• Renal dialysis spend for 2016/17 is predicted to be c.£35.5m in NEL.

• Earlier identification, diagnosis and treatment, through integrated working between 1° and 2°

care can reduce progression of the disease and its impacts.

SRO: Paul Haigh, CO, C&H CCG

Delivery lead: Russ Platt, Head of Delivery, NHS E London

Objectives

• Slow the growth in demand for renal replacement therapy

• Reduce number of patients presenting with end-stage renal failure

that were previously unknown to the system to <10%

• Increase uptake of home-dialysis, particularly peritoneal

• Further optimise renal transplant rate

• Improve spread of learning through the London Acute Kidney Injury

Network and good practice in primary care management

Vision

Reduce the impact of kidney-related illness in North East London.


1 MDT working between

primary and specialist care

• Primary care – capacity,

capability, new roles.

• Shared care records

• Increase numbers of patients with CKD on QOF registers.

• Improve access to specialist advice.

• Reduce face-to-face outpatient appointments by up to 30%, replaced

with c.3,000 virtual appointments.

• Reduce presentations for ESRF with previously undiagnosed CKD to

under 10% (c.250) of all cases

• Slow the c.4-6% growth (c.100 extra NEL patients p.a.) in ESRF, and

demand for renal replacement therapy (RRT)

• Slow the growth in specialised service spend on renal care

• Virtual CKD clinics

extended to whole STP

area

2 Community surveillance and

case finding • System analytics; shared care

records; GP trigger tools

• Community surveillance /

case finding programme

spread to all boroughs in

NEL

• GP trigger tools

3

Education programmes –

Primary care, patients with

CKD, patients with risk

factors, general public

• Primary care workforce -

capability

• Prevention – healthy living

campaigns (smoking, obesity,

hypertension, cholesterol)

• Increase the number of patients identified as having CKD and

receiving appropriate treatment

• Reducing the deterioration of CKD to ESRF

• Slow the growth in incidence of CKD

• GP and patient education

programmes in all

boroughs in NEL

• Hypertension management

and dashboards.

4

Access to treatments – out-

of-hospital dialysis,

transplant, patient decision

aids)

• Housing – appropriate

housing stock.

• Appropriate primary care /

community facilities

• Intervention rates (including transplant rates).

• Increase out-of-hospital dialysis (satellite clinic, “place in the middle”,

at-home).

• Slow the growth in RRT

• Patient decision aids for

renal replacement

therapies.

5 Benchmarking and best

practice • System analytics and

business intelligence

• Improved performance against various KPIs – spend, referral and

intervention rates, waiting times, RRT rates

• CEG primary and

secondary care dashboard 5



Detailed plan – Work stream 2: Pathway Transformation - Cardiology (AF and HF)

Case for change

• Specialist cardiology interventions will account for over £42m

of expenditure in north east London in 2016.

• Atrial Fibrillation (AF) is a risk factor for stroke;

• Earlier identification, diagnosis and treatment, through

integrated working between 1° and 2° care can reduce

progression heart failure and the associated heath burden.


Delivery

lead: Russ Platt, Head of Delivery, NHS E London

Objectives

• Improve the detection and management of heart conditions, in particular AF and Heart

Failure (HF)

• Reduce the need for costly specialist interventions; improve the care pathways for those

with AF and HF

• Optimise evidence based treatment and delay deterioration of heart conditions and

associated co-morbidities, including by making every contact count

• Slow growth in demand for specialist cardiology interventions

Vision

Reduce the impact of Atrial Fibrillation and Heart Failure, and associated

conditions in North East London.


1

Multi-disciplinary team

(MDT) Interventions,

incl. virtual clinics • Primary care – capacity,

capability, new roles.

• Shared care records

• Increase numbers of patients with AF and HF on QOF registers

and receiving appropriate treatment (e.g. stroke prevention)

• Improve access to specialist advice.

• Reduce face-to-face outpatient appointments by up to 50%

• Reduce presentations for stroke with undiagnosed AF

• Reduce length of stay for cardioversions (up to 100% day case)

• Slow the growth in specialised service spend on cardiology

• Deliver KPIs for specialist cardiac services at Barts

Agreement as to deliverables

to be achieved in Q3 2016/17,

following further clinical

engagement; to include:

• Degree of MDT working with

1° care

• Case finding methodology

• Strategic governance

structures to manage

planning, performance and

sharing of knowledge

• Pathway improvements such

as access to diagnostics and

results.

• Patient and clinician

education programmes.

• Secondary care dashboard

• Metrics to be specified in

Q3/Q4 2016/17

2

Pathway improvements

(e.g. stratified follow-

up) to reduce waste

and duplication

3 Screening and Case

Finding • System analytics;

shared care records

• Increase the number of patients identified as having AF and HF

and receiving appropriate treatment

• Reduce the incidence of in-hospital AKI.

4 Education, prevention

and wellbeing

• Primary care workforce

- capability

• Public Health – healthy

living campaigns

(smoking, obesity,

hypertension)

• Slow the growth in incidence of coronary heart disease.

5 Benchmarking and best

practice • System analytics and

business intelligence

• Improved performance against various KPIs – spend, referral

and intervention rates, waiting times, RRT rates 6



Detailed plan – Work stream 3: Pathway Transformation – Other opportunities

Case for change

• The interventions described in previous slides (renal and cardiac) will not address the full

£134m cumulative gap

• A number of other specialised service lines in NEL have:

• Performance and quality issues (e.g. DToCs, waiting time targets, outcomes)

• Variations in pathways across NEL and London

• Increasing demand and relatively large spends

• >60% of cases seen by the services being NEL residents

• These include cancer, neonatal and paediatrics, mental health and neuro rehab


Delivery

lead: Russ Platt, Head of Delivery, NHS E London

Objectives

• Understand the financial and activity case (NHSE

London workstream – output expected October /

November 2016), in order to:

• Identify opportunities and initiatives to address the

cumulative financial gap

• Determine scope and Identify appropriate governance

arrangements for workstreams

Vision

Delivery of optimal care in specialised services.

Area Possible initiatives Enablers Benefits and Metrics Deliverables

1 Specialised

Cancer

• Stratified follow-up and move towards of self-care

• Reduce risk factors (smoking, etc)

• Standardise recovery packages & mental health support

• Shared access to test results

• Diagnostic pathways (stratification, one-stop, direct

access, molecular testing)

• Shared care

records

• Prevention –

population health

and wellbeing

• Primary care and

community

workforce –

capability and

capacity

• Efficient use of specialist

resource.

• Slow the growth in and

deterioration of cancers

• Reduce duplication in

diagnostics

Scope, project

governance,

initiatives and

metrics to be

determined in

Q3/Q4

2016/17

2

Neonatal

and

Specialised

Paediatrics

• Stratification of support based on risk

• Standardised pathways; capacity and demand review

• Community support – MDT, virtual wards, networks, shared

records

• Transitional care pathways

• Improve care for transitional

care patients, reducing length

of stay (LOS) and delayed

transfers of care (DToCs)

• Reduce Out of Area transfers

3 Mental

Health

• Build on success of children and young people home-

treatment pilot by NELFT.

• Potential co-commissioning for forensic pathways

• Pan-London capacity

• Co-design and co-

commissioning

arrangements with

NHS England

• Slow the growth in demand

for inpatient beds

4 Neuro

Rehab • Pathway improvements & appropriate community support

• Reduce LOS and DToCs for

neuro rehab patients in

specialist beds 7



Route map 2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

Governance

Renal

MDT working

and case finding

Education programmes

Access to treatments

Lifestyle interventions

Cardiology

Other workstreams

Roll out vCKD clinics, GP

trigger tools and community

surveillance in inner NEL

vCKD clinics across NEL Business case for, and implementation of vCKD clinics, GP trigger

tools and community surveillance in outer NEL

Agree metrics and develop dashboards across NEL

Access to primary care diagnostic test results for 2° care clinicians

Develop 1°/2° care MDTs

Implement standardised protocols and advice for unwell CKD patients across NEL

Develop education programmes for 1° and 2° care clinicians

Group / 1:1 education for pts with kidney conditions and risk factors

Patient decision aids for dialysis – consider, develop and implement

Increase out-of-hospital dialysis

Community surveillance programme

GP trigger tools across NEL

Milestone

Deliverable

Roll-out of Diabetes Prevention Programme

Implement best practice models of hypertension control

Agreement of

initiatives and

deliverables

Business

case

development

Commissioning

Intentions Implementation of initiatives

Implementation of initiatives Business case development

Scope and

opportunities

(with NHSE

London) Commissioning

intentions

Initiative development

Patient and GP education

programmes

Patient decision aids

See Appendix for more detail (NHS England London Storyboard)

vCKD clinics across Inner NEL

Governance (NHSE /

STP) for taking forward

each workstream

8




Benefit description (Health & wellbeing,

care & quality or financial)


performance

Target date

(default 2020)

Linked

workstreams

Slow the growth in prevalence of CKD QOF prevalence registers 2.4%

(1.9-3.4%)

Growth to be

projected

2020/21 Renal dialysis

Increase numbers of patients diagnosed

with CKD

Derived from Quality

Outcomes Framework

(QOF) registers

c.55%

(expected prevalence:

2.9-6.7%)

Increase 2017/18 Renal dialysis

Reduce presentations for ESRF with

previously undiagnosed CKD to under 10%

of all ESRF cases.

A&E presentations in

ESRF with previously

undiagnosed CKD

>10% (specific value to

be derived from UK

Renal Registry)

<10% 2020/21 Renal dialysis

Reduce A&E attendances for stroke in

patients with undiagnosed AF

A&E presentations for

stroke with undiagnosed

AF

To be derived from

provider data

Reduce 2020/21 Cardiology

Increase number of HF cases identified

and proactively managed;

QOF prevalence registers Prevalence 0.5% Increase known

prevalence

2020/21 Cardiology

Maintain specialist commissioning spend

at or below allocation

Specialised

commissioning budget

£534m in 2016/17 Maintain

balance

2016/17 and

beyond

All workstreams

Additional metrics to be developed as work progresses, and product of finance and activity projections workstream is realised – see appendix

(NHS England London storyboard) for more information

9


This section provides a summary of the key benefits that we expect to achieve through the implementation of this Delivery Plan.




SRO Delivery Lead

Delivery plan

Paul Haigh, CO,

City & Hackney

CCG

Russ Platt, Head of

Delivery, NHS

England London

Renal dialysis

Paul Haigh, CO,

City & Hackney

CCG

Russ Platt, Head of

Delivery, NHS

England London

Cardiology

Paul Haigh, CO,

City & Hackney

CCG

Russ Platt, Head of

Delivery, NHS

England London

Other pathway

transformations

Paul Haigh, CO,

City & Hackney

CCG

Russ Platt, Head of

Delivery, NHS

England London


NEL STP Board

NEL STP Spec Comm Programme

Delivery Group

Spec Comm

Programme Exec

Board

Clinical,

organisational and

financial advisory

groups

London Spec

Comm Planning

Board

NHS England

Transformation

Programmes:

• Pan-London STP

• TSSL programme

NEL Clinical

Senate

Reporting line Interdependency / Advisory

Spec

Comm HoD

(NEL)

SRO Programme

Manager

Workstream Working Groups

Renal Dialysis Cardiology Other

(Paeds, MH, Cancer,

Neuro Rehab)

Other STP

Programmes

and Enablers

Clinical

Lead • NHS England London Head of Delivery for NEL is

the delivery lead for the NEL STP specialised

commissioning delivery plan.

• NHS England London has Planning and Executive

Boards for oversight of specialised commissioning

programmes, including pan-London STP initiatives;

collaboration between NEL STP and this structure

is necessary to plan changes as a whole system

across London.

• Some pan-London workstreams have yet to be scoped by NHS England London, and thus governance arrangements for delivering these

workstreams have yet to be determined. This is planned for Q3 2016/17, based on NHS England London opportunity analysis and scoping,

and following the output of the NHS England finance and activity projections workstream (see appendix NHS England London Storyboard).

10

NEL STP Executive



Risks

Risks


Renal and Cardiology

Risk that defined workstreams do not result in large

savings for CCGs and providers, reducing financial

incentive to change.

Insufficient risk/gain-shares to manage patients outside

of specialised services

Define projected demand and financial increase in a “do

nothing” scenario.

Identify spend-to-save initiatives

Engage primary care and CCGs in design.

R

Pathway workstreams Insufficient funding available for invest-to-save

initiatives.

Develop robust business cases for investments. Decisions

to invest will be taken at programme level against relative

benefit

R

Pathway workstreams

Risk that demand management initiatives are

insufficient or too long-term to slow growth in demand

sufficiently by 2020/21

Opportunity analysis to identify quick wins, and longer-term

demand mitigation. R

All workstreams

Co-commissioning arrangements and NHS England

improving value initiatives could shift risks and/or costs

to local CCGs and providers.

Changes to the commissioning responsibility for certain

conditions may present additional pressures to CCGs

and providers.

Determine appropriate governance and collaborative

planning arrangements to ensure engagement, buy-in and

agreement to initiatives. A

Pathway workstreams

Long-term demand management requires behaviour

change from patients and members of the public in

terms of lifestyle (smoking, obesity).

Demographic changes (ageing population) may

present higher growth than can be mitigated

Develop preventative initiatives with public health and the

Prevention workstream. A

Pathway workstreams

New demand management initiatives are not

embedded at primary care (for reasons including

behaviours reverting to the norm, lack of buy-in, lack of

capacity and capability)

Engagement with primary care representatives in

developing initiatives.

Implement appropriate technology and protocols A

This is a list of the highest-rated risks. Additional risks identified at a lower mitigated risk rating 11



Dependencies, constraints and assumptions




Pathway

transformations Dependency

Access to 1° care records from 2° care is

possible across NEL (part of Digital

Roadmaps)

Confirm timeline for interoperability with

Technology programme

Pathway

transformations Constraint

Initiatives in prevention, and primary and

community care aiming to reduce demand

for specialist services may require

management of budgets across the whole

pathway – speed of development of different

models of co-commissioning could limit the

implementation of interventions

Confirm timeline for delegation of specialised

budgets. Identify where progress can be made

without co-commissioning.

Pathway

transformations Assumption

Increase in case-finding leads to earlier,

more cost-effective treatment, not simply

more specialist care.

Develop detailed clinical model

Improving value Assumption Sufficient efficiency initiatives can be

identified to reduce variation and costs

Work alongside NHS England London to identify

initiatives

All workstreams Constraint

Progress of local initiatives dependent on

development of pan-London initiatives by

NHS England London.

NHS England London to identify opportunities,

scope and programme governance for delivering

pan-London initiatives (see Storyboard appendix)

12



Dependency map


care close to

Home

Accessible

quality acute

services

Infra-

structure

Productivity Specialised

Commissioning

Workforce Digital

Pathway

transformations:

renal dialysis

Patient

Activation;

improving

lifestyle

(smoking,

obesity,

hypertension)

Primary care

(technology

and

workforce);

Commissionin

g of demand

management

initiatives

Diagnostics

(access to

diagnostics;

availability of

test results)

Reduction of

outpatient

appointments

Medications

management

– use of

biosimilars;

procurement

Suitable out-

of-hospital

premises for

community

dialysis

Cardiology

(similar upstream

interventions)

Primary care

workforce

and MDT

working;

networks

Access to

care

records

Pathway

transformation:

cardiology

Renal (similar

upstream

interventions)

Pathway

transformation:

other conditions

Specialised

elements of

specific

pathways,

incl. mental

health and

cancer

TBC

Centralised

procurement

and

efficient

pathways

NHS England

London pan-

London STP

programmes


13





















Planned future work






14



Contribution to our framework for Better Care and Wellbeing





• Patients will receive quicker

specialist input and advice

without the need to attend a

hospital.

• Follow-ups will be stratified,

reducing outpatient

appointments and to enabling

efficient use of resource

• This will result in more

capacity to manage the

increased demand for hospital

services and allow waiting

times to be maintained or

reduced.

• Patients will manage their

conditions themselves with

fewer outpatient

appointments required.

• Out-of-hospital dialysis will

become more prevalent.

• Patients‟ care will be

managed more in primary

care with access to a

specialist MDT.

• People will be more aware of the impact of their

lifestyles on their bodies, through prevention

programmes and a move towards better self-care

• Blood pressure control, cholesterol reduction, smoking

cessation and alcohol intake moderation will reduce the

incidence of chronic conditions such as CKD, CHD,

cancer, and deterioration of those conditions, improving

the lives of NEL patients and residents.


15






for healthcare

•Roll out of the Diabetes Prevention programme across NEL.

•Deterioration in chronic conditions will be reduced.


& NHS staff

•Patients will be better able to manage their conditions with support from specialist MDTs and education programmes.


practice

•GPs will have better access to specialist advice.

•Communication will be improved through 2° care access and input to 1° care records.



•Introduction of virtual clinics across NEL will result in 2° care having the capacity for the projected increase in demand.


core standards

•Achievement of referral to treatment (RTT) targets through managing more patients in primary care.


•Specialist cancer transformation will contribute to achieving the cancer waiting time target and outcomes.


•Earlier intervention in chronic conditions will result in reduced deterioration, in turn reducing emergency admissions and premature death.


•The use of virtual clinics across NEL will improve access to specialist advice.

•The potential of healthcare analytics and community surveillance to stratify patients will enable resources to be targeted more effectively and reduce harm.


deliver?

•Increasing the use of specialist MDTs will improve access to specialist advice for primary care clinicians and improve care.


balance

•Upstream demand management and earlier intervention will reduce demand for specialist services. This will mitigate increases in demand stemming from population growth.

16




1. STPs


2. Finance

• Pathway transformations are across whole pathways, using prevention, demand management, case finding, virtual clinics and MDT working to slow growth in demand for specialised care.

3. Primary Care

• Improvements to pathways between primary and specialist care, reducing waiting times for specialist advice and improving shared care.

•Reduce variability and spread best practice management via education and dashboards.


• Reduction in demand for urgent and emergency care through better management and self care of chronic and complex conditions.


• Reduce time to receive specialist advice, additionally reducing the number of referrals requiring face-to-face outpatient appointments and follow-ups.

6. Cancer

• Alignment with the cancer delivery plan and through the cancer board, specialist cancers will see an improvement in pathways and achieving the waiting time targets and improving survival rates.

7. Mental health

• Reducing demand for inpatient beds by improving community and step-up / -down care (for example CAMHS Tier 4 in outer NEL).


• Refer to NEL STP Delivery Plan 2 of 8: Care Close to Home.


• Better use of resources, improving access to specialist advice and closer MDT working between primary and secondary care.

• Developing performance dashboards across NEL for chronic and complex conditions and specialist care.

17






Workforce


Contents

Workforce

No. Section Page

1 Initiative map 3



4 Route map 7



7 Risks 10


9 Dependency map 12



12 Addressing the 10 ‘Big Questions’ 15


2


Initiative map N

EL S

TP

Level

• Developing a workforce Programme to support new models of care.

• Supporting the development of HR practice, including primary care.

• New Role - Nursing Associates, AHP extended roles.

Lo

ca

l Are

a L

eve

l

• City & Hackney - Whole systems (H&S Care) leadership.

• Buurtzorg pilot (Self-governing nurse teams).

• WEL Transforming Services Together programme.

• BHR Accountable Care Systems.

• Clinical pharmacists in GPs.

• Physician associates in primary care.

CC

G / B

oro

ug

h L

eve

l • Tailoring of London-wide initatives.

• Non-clinical support roles (including care navigator).

Lo

nd

on

-wid

e

• Staff retention programme (including Primary & Secondary Care).

• Staff Recruitment programme .

There are a wide range of programmes that support our workforce transformation. These are outlined in our narrative plan for north east London. We have

agreed through the STP the best level at which each programme should be led and delivered within the health and care system. We have done this based

on the partnerships and scale required to best implement the specific programmes, using the following rationale for choosing to progress an initiative at a

north east London:






3

Workforce



Expected Impacts • Establish and agree a NEL target for staff retention, based on

robust evidence base

• Achievement of staff retention targets across NEL (subject to

agreement of the target)

• Ensuring a supply of appropriately skilled workforce to support

needs of the health care service and the local population.

• Up-skilling of existing staff and the creation of new roles to

support emerging models of care.

Vision

A NEL-wide workforce which can work across integrated health and social care systems, support the growth of out of hospital care / community based care, shift focus from treatment to prevention and manage whole pathways of care.

Background and Case for Change • Current trajectories of the NEL workforce indicate that by 2020/21, there will be significant gaps between supply and demand

of professional groups, with a 30% shortfall in nursing and a surge of ST3-8 secondary care doctors in London.

• Our local population will grow by 17.7% in the next 15 years and our current primary care workforce needs to be redesigned

to meet these growing needs.

• There are significant staff and skills shortage in primary care, with 1,769 patients per GP compared to the London average of

1,660 (Barking and Dagenham, Havering and Redbridge has the highest number of patients per GP than anywhere else in

London)

• Vacancy rates and turnover rates across secondary care are too high, which has led us to a strong reliance on temporary

staff against a required reduction in agency spend (e.g. 14% turnover rate and 11% vacancy rate in adult nursing across

NEL)

• Most of our healthcare workforce was trained to support a hospital-based model of healthcare. The future workforce will need

to support the shift to a community-based, multidisciplinary way of working that is tailored to seven-day-a week services.

Workstreams

Priorities and Objectives 1. Our Core work in this area includes the development and implementation of a retention strategy

across NEL and harnessing local expertise through a Local Workforce Action Board to steer and deliver workforce transformation in line with the ambitions of the STP.

2. Workforce for new models of care – New partnerships with local authorities, communities and employers are being developed along with breaking down barriers between GPs and hospitals, physical and mental health services, and health and social care to form new models of care.

3. Our enabling work includes mobilisation and support of the HR community to deliver on the ambitions set out in the productivity work stream; and tailored support to each of the other programme areas by way of modelling support, and expertise in the arena of education and training. In particular supporting the workforce elements of the primary care transformation strategy

16/17 17/18 18/19 19/20 20/21

Recruitment & Retention

Workforce for new models

of care

Developing

strategies Detailed Planning and Implementing Retention programme

Workforce Enabling Work

Developing PC

strategy

Supporting bank and agency and HR back office

consolidation*

* Bank / agency and HR back office consolidation is being managed through the Productivity programme

Developing

strategies &

prioritise Detailed Planning and Implementing programmes

Implementation

4

Workforce


Case for change

• There are pockets of high vacancy rates across our system. For example, we will see

a shortfall of nurses across our services of 30% by 2021

• Vacancy rates and turnover rates across secondary care are too high, which has led

us to a strong reliance on temporary staff against a required reduction in agency

spend. There are parts of our footprint which have struggled to recruit the right staff,

and this has implications on patient care across the entirety of NEL.

• There’s a high turnover of staff either leaving NEL or the NHS altogether - e.g. some

26% of adult nurses leave the NHS 5 years after being initially tracked through ESR.

• Staff and skills shortage in primary care, with 1,769 patients per GP compared to the

London average of 1,660 (Barking and Dagenham, Havering and Redbridge has the

highest number of patients per GP than anywhere else in London)

• In addition to the workforce issues in the NHS, 17.5% of registered roles in social

care lie vacant.

Objectives

• Reduce turnover of GPs and Practice nurses.

• Reduce turnover of newly qualified staff.

• Reduce turnover of staff at all Secondary Care Providers.

• Provide an appropriately skilled and trained workforce

• Work in collaboration with the Workplace Health workstream

(Prevention and Wellbeing Programme) to support the health and

wellbeing of the NEL workforce, to improve motivation and

retention

• Support recruitment and retention of social care workforce

• Making substantive recruitment in health and social care an

attractive career option

Initiatives Enablers Benefits / Metrics Deliverables

1 Staff retention Programme (including

Primary & Secondary Care) Technology

• Reduce turnover rate by 1% point.

• Retain newly qualified staff for 1 additional

year.

Workforce retention strategy

Priority staff retention implementation

programmes e.g. incentives and specialisation

opportunities (including measurable goals with

cost savings)

2 Developing a NEL recruitment

programme. Technology

• Reduction in reliance on agency staff,

resulting in financial savings Workforce recruitment strategy

3 Supporting Workplace Health

workstream initiatives Technology

• Improved health, wellbeing and motivation of

the NEL workforce

Healthy workplace initiatives (in collaboration

with Workplace Health workstream)

4 Impact analysis of health workforce

strategy on social care workforce Technology

• Reduction in social care vacancy rates

Impact analysis of health workforce retention

strategy on social care workforce

SRO: Tracey Fletcher, Chief Executive, Homerton

Hospital.

Delivery

leads: Nigel Burgess, HEE.

Vision

Attracting and retaining the staff to work within the NEL health and social care

systems to meet the growing and changing needs of our population.

Detailed plan – Work stream 1: Staff Recruitment & Retention

5

Workforce


Case for change

• New clinical models are being developed and we need to

ensure that our people have the right skills to deliver these.

• A whole systems (NHS and Social Care) approach to workforce

redesign is needed.

• A shift towards more integrated care means we need to address

the balance between primary and secondary care staff.

• Our local population will grow by 18% in the next 15 years and

our current primary care workforce needs to be redesigned to

meet these growing needs.

• Currently the NEL workforce has been trained to support a

hospital-based model of care. The future workforce will need to

support the shift to a community-based, multidisciplinary way of

working that is tailored to seven-day-a week services.

Objectives

• Workforce redesign within Primary Care

• Support recruitment and retention of GPs and practice nurses and the development and expansion of other

primary care roles (e.g. physician associates, clinical pharmacists in practices, AHPs, practice HCAs and

care navigators), to enable primary care transformation

• Workforce integration enabling staff to work across different care settings and organisations across NEL

• Enabling the workforce to support new clinical models through training and support.

• Support development of NEL-wide multi-disciplinary teams working across health and social care, and

between primary and specialist care .

• Support workforce outcomes from mental health strategy review – including additional mental health support

in primary care

• Support development of nurse specialists to manage Long Term Conditions and provide additional capacity

(e.g. nurse endoscopists)

• Provide workforce advice to support development of pharmacy workforce strategy

• Further develop areas of workforce innovation (e.g. Open Doors programme

Vision

A NEL workforce designed and skilled to support the specifications of new

service models overseen by a Local Action Workforce Board (LWAB).

Initiatives Enablers Benefits / Metrics Deliverables

1

Developing a workforce programme to support

new models of care - Working with Clinical

Leads, Activity Planners, Workforce Leads and

Finance to understand activity projections and

requirements, and the leadership skills

required to deliver these new models of care

Technology

• Services supported by new roles including physician

associates, clinical pharmacists in practices and care

navigators

• Patients receiving care from new roles including

physician associates and clinical pharmacists in

practices

• Standardisation and promotion of new roles

• Training for staff to work in other care settings.

• Create opportunities for rotations /

placements.

• Evaluation of the pilot for nurse associates

2 Primary Care workforce redesign. Technology • Increased resilience of primary care

• Improved GP to patient ratios across NEL

• Primary Care workforce strategy

• Pharmacy workforce strategy

3 Multi-disciplinary team working (moving to 7

day a week services) Technology

• Increased patient satisfaction (based on Friends and

Family test)

• Reduction in unnecessary admissions

• Reduction in delayed transfers of care

4 Mental health workforce development Technology • Improved access to mental health professionals /

treatments (meeting IAPT targets) • Mental health workforce strategy

Detailed plan – Work stream 2: Workforce for new Models of Care

SRO: Tracey Fletcher, Chief Executive, Homerton

Hospital.

Delivery

lead: James Cain, HEE

6

Workforce


Route map 2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

Staff Retention &

Recruitment

Staff Retention

programme

Staff Recruitment

programme

Supporting workplace

health initiatives

Impact analysis of health

workforce strategy on

social care workforce

Workforce for new

models of care


of care

Primary Care workforce

re-design

Mental health workforce

development

Detailed Planning and Implementing Retention programme Develop strategy: Primary &

Secondary Care

Detailed Planning and Implementing Recruitment programme

Develop strategy: Primary care &

Pharmacy

Prioritisation of programme delivery

and implementation Implementing e.g. create new roles, educate and train existing staff, creating rotations/placements, MDTs.

Implementing programmes e.g. new roles.

Develop strategy:

Providing input to scoping

Create Impact Analysis

Develop strategy Implementing initial programmes e.g. MDTs

Supporting implementation of wider plans

Evaluate nurse

associate pilot

Implementing further programmes

Scope

agreed

7

Workforce



This section provides a summary of the key benefits that we expect to achieve through the implementation of this delivery plan level.



financial)


performance Target date Linked workstreams

Reduce turnover rate by 1%. Workforce turnover rate (all staff across NEL

trusts)

16%

(July15-July16) 15% 2020

Retain newly qualified staff for 1

additional year.

Newly qualified nursing staff remaining in post

for 2 years

65%

(nursing staff only)

72%

(Retain half of those

that left after one

year)

2020

Reduction in reliance on agency

staff, resulting in financial savings

Proportion of shifts provided by bank and

agency

Awaiting data from NHSI

data capture.

Full compliance

with NHSI set

agency ceilings

2020 4. Productivity

Improved health, wellbeing and

motivation of the NEL workforce

Staff survey Q9a, ‘Does you organisation take

positive action on health and well being?’ 87% answered positively 90% 2020

Reduction in health and social care

vacancy rates Health and social care vacancy rates

Secondary care nursing

and midwifery: 17%

Social Care regulated

professions:18%

16% across all

services 2020

Patients receiving care from new

roles including physician associates,

clinical pharmacists in practices

Total number of consultations undertaken by

PAs and clinical pharmacists per annum 0

>10,000

2020

2. Promote independence and


Increased resilience of primary care GP: Patient list size ratio (across NEL CCGs) 1:2200

(March 2016)

1:2000

(March 2016

national ratio)

2020 2. Promote independence and


Increased patient satisfaction Friends and Family test (A&E as proxy) 87% 90% 2020

Reduction in unnecessary

admissions

Total

number of non-elective admissions TBC by NEL CSU Reduction 2020



3. Ensure accessible quality acute


Reduction in delayed transfers of

care

Total

number of delayed transfers of care TBC by NEL CSU Reduction 2020



3. Ensure accessible quality acute


Improved access to MH treatment IAPT waiting time targets 6w: 77-100%

18w: 96-100% 75% 2016/17



These represent the main benefits and metrics - other local and national standards exist and form part of the improvement objectives 8

Workforce



• A Local Workforce Action Board (LWAB) has been established with representation from workforce professionals from

across the North East London system

• The LWAB is responsible for commissioning the workforce enabler programmes and for assuring delivery


SRO Delivery leads

Delivery plan

Name,

Role,

Organisation

Staff recruitment and

retention

Tracey Fletcher

Chief Executive

Homerton Hospital

Nigel Burgess,

Health Education

England


of care

Tracey Fletcher

Chief Executive

Homerton Hospital

James Cain

Health Education

England

Primary care workforce

Tracey Fletcher

Chief Executive

Homerton Hospital

Gareth Noble, TST


9

NEL STP Executive

Committee

Recruitment and

Retention

Programme

Workforce

Models of care

Local Workforce

Action Board

NEL STP Board

Workforce


Risks

Risks


Workforce

There is a risk that that service models may not be developed in a

timely enough manner to allow time to deliver workforce models

given the long lead time for training

Continual dialogue with all other work streams and

roles/responsibilities agreed early on by all key SROs. A

There is a risk that any recommendations around new workforce

models may not be agreed by providers

Solutions need to be owned by providers, accepting their

responsibility to ensure they are appropriately resourced. A

There is a risk that retention ambitions may not be achieved

despite interventions being put in place locally

Overall strategy will need a local response and to be met by

realistic but ambitious retention targets A

There is a risk that supply of new roles cannot be guaranteed due

to financial constraints

Discussions with all work streams at an early stage to

ascertain precisely how new roles will be funded. A

There is a risk that that competition with other footprints for roles

may lead to supply in NEL being depleted

Encouraging appropriate incentives in line with neighbouring

STPs and continual regional sense-checking. A


Workforce






Workforce

Constraint Limited confidence in supply of newly qualified staff following the

removal of bursaries.

Constraint Availability of STF funding

Constraint Release of resources from within the footprint to support

projects/initiatives.

Constraint Lack of contractual levers within service contracts to ensure

changes are delivered

Assumption Organisations across all care settings agree with new service

models and will work together to enable a shift in services

Assumption Organisations will exercise their own sovereign responsibility to

calculate the workforce numbers.

Assumption

Education and Training funding will be reduced - there will only a

limited number of roles which attract a bursary and HEE

workforce transformation funding will reduce, so the STP will

need to invest locally.

Assumption Each of the workforce ambitions set out in the other work streams

are fully funded and do not rely on reduced HEE funding.

Assumption All organisations across the STP with new service models and

will work together to enable a shift in services

Dependency

Care models need to be developed before workforce models.

11

Workforce


Dependency map


close to Home

Accessible

quality acute

services


Services

Digital

Staff

recruitment

and retention

Healthy workplace

initiatives

supporting staff

motivation and

retention

Attracting new

staff to work in fit

for purpose

facilities

HR back office

shared service

Consolidation of

bank and agency

workforce

Supporting more

flexible working

through

technology –

improving staff

satisfaction

Workforce for

new models of

care

Expansion and

development of

primary care roles:

- Physician

associates

- Clinical

pharmacists in

practices

- Practice HCAs

- Care

navigators

Development of

midwifery, nurse

practitioner and

HCA workforce

Development of

endoscopy and

community nurse

workforce

Support and

enable MDT

working

Workforce

supporting

accountable care

systems

MDT working

between primary

and specialised

care

Workforce

enabling

support

Workforce

education and

training

Leadership skills

development

Delivery of

workforce aims of

GP 5YFV

Workforce

education and

training

Leadership skills

development

Workforce

education and

training

Leadership skills

development

12


Workforce



The basis for the financial modelling has been the five year Operating Plans prepared by individual NEL commissioners and providers, all of whom followed

an agreed set of key assumptions on inflation, growth and efficiencies. The individual plans have then been fed into an integrated health economy model in

order to identify potential inconsistencies and to triangulate individual plans with each other. In the June submission the starting point for this modelling was

the 16/17 operating plans. This has since been refreshed to be the month 6 forecast outturn.







While substantial progress has been made on the financial and activity modelling for the NEL STP, the finance and activity plan for the October

21st submission should not be regarded as the final position. Further detailed worked-up analysis will follow over the coming months.










Planned future work






13

Workforce



Workforce





• The workforce workstream will act as an enabler to support delivery of high quality acute services (including achieving and maintaining the performance against the core standards) through provision of an appropriately skilled and resourced workforce

• The workforce workstream will also support increased productivity and financial sustainability through consolidation of bank and agency spend across trusts and development of a shared services HR function.

The workforce programme will act as an enabler to support the delivery of the other STP schemes through provision of an appropriately skilled and resourced workforce to implement the new models of care, including: • Development of a primary care

workforce strategy • Development of a mental health

workforce strategy • Development and expansion of

primary care roles (e.g. physician associates, clinical pharmacists in practices, practice HCAs and care navigators), to enable primary care transformation

• Increasing resilience of primary care through increased recruitment and retention of key primary care roles

• Support development of multidisciplinary team working across health and social care

The workforce programme will act as an enabler to support the delivery of the prevention programmes through the provision of an appropriately skilled and resourced workforce, including: • Collaboration with Local Authorities to support

development of social care workforce • Supporting development of multi-disciplinary teams

working across health and social care

• Enhancing training programmes to include prevention (i.e ‘Make Every Contact Count’ across all our interactions with the public)

• Development of care navigator role to support better patient engagement and improved signposting to appropriate services


14





for healthcare

•Development of community workforce to support prevention and wellbeing.

•Development of Multi-Disciplinary Teams to manage patients with multiple LTCs to avoid unnecessary admission and support discharge.


& NHS staff

•Development of care navigator role to support better patient engagement and improved signposting to appropriate services.

•Development of new roles to support career path development.


practice

•Supporting achievement of core targets / standards (e.g. RTT, IAPT, A&E waiting times) through appropriately skilled and resourced workforce.

Q4. Implement new care models that address

local challenges?

• Development of the nurse associate role.

• Development of multi-disciplinary teams across primary and specialist care. • Buurtzorg Pilot (Self-governing nurse teams).


core standards

•Retaining more GPs and recruiting targeted roles within primary care.

•Development of clinical pharmacists in practices

• Development of additional mental health support in primary care.

• Development of the physician associate role •Development of non-clinical roles in primary care.


• Alignment of training programmes with 2020 objectives.

• Support development of additional mental health capacity and capability, based on outcomes from mental health taskforce review.


•Supporting development of Multi-Disciplinary Team working across health and social care to move towards 7 day a week services.



deliver?

•Creating and retaining a workforce with the right skills and values through our programmes.

•Supporting new models of care with an appropriate workforce model.

•Introduction of new roles.


balance

•Development of recruitment and retention strategies and plans to reduce / avoid reliance on expensive bank and agency staff.

•Supporting consolidation of bank and agency practices and rates across trusts.

•Supporting development of HR shared services function across Trusts.

Workforce

15



1. STPs

• Supporting the delivery of the NEL STP through providing appropriately skilled and resourced workforce.

2. Finance

•Development of recruitment and retention strategies and plans to reduce / avoid reliance on expensive bank and agency staff.

•Supporting consolidation of bank and agency practices and rates across Trusts.

•Supporting development of HR shared services function across Trusts.

3. Primary Care

•Retaining more GPs and recruiting targeted roles within Primary Care.

•Development of clinical pharmacists in practices.

•Development of additional mental health support in primary care.

•Development of the physician associate role.

•Development of non-clinical roles in primary care.


• Supporting earlier treatment in primary care to reduce the burden on urgent and emergency care services through providing more primary care and community care and Multi-Disciplinary Team working.

•Providing appropriately skilled and resourced workforce to manage urgent and emergency care demand.


•Providing appropriately skilled and resourced workforce to support referral treatment times and elective care.

•Supporting development of multi-disciplinary team working across health and social care to support care closer to home and early access to diagnosis and care to avoid escalation.

6. Cancer

• Provision of high quality survivorship support

• Provision of workforce to support early diagnosis and treatment of cancer (i.e. nurse endoscopists and HCAs in primary care to take blood).

7. Mental health

•Support workforce outcomes from mental health strategy review – including additional mental health support in primary care.

•Supporting development of mental health workforce strategy.


•Support delivery of national Learning Development workforce initiatives

•Supporting development of mental health workforce strategy (which includes learning disabilities).


• Supporting the delivery of the Quality improvement strategy through providing appropriately skilled and resourced workforce, including development of required leadership capabilities.

Workforce

16





Digital Enablement


Contents

Digital Enablement

No. Section Page

1 Initiative map 3



4 Route map 10



7 Risks 16


9 Dependency map 18



12 Addressing the 10 ‘Big Questions’ 21


2


Initiative map N

EL S

TP

Level •Patient access to

records is in some ways down to GP and provider level but public awareness and NEL level communication plans can be co-ordinated

•As Shared Care Records systems mature they will be joined and provide benefits across the STP and feed into the wider London information exchange

Local A

rea L

evel

•Shared care records are currently being achieved at LDR level, although WEL and C&H have connected their primary sharing systems (HIE) and are increasingly working as a single digital footprint

•Population health plans currently exist at LDR level although again WEL and C&H are working on the same programme (Discovery), while BHR is developing its Health Analytics product

CC

G /

Boro

ugh L

evel

•BHR CCGs act as one collaborative organisation for Digital. GPIT decisions are made at CCG level, although combined where economies are available

•Individual organisations make their own investment decisions for IT systems, bearing in mind the LDRs

London-w

ide

•Sharing EoL care plans across London (Coordinate my Care)

•Patient consent

•Elements of patient access to their record, such as a common consent model

•Citizen identity

• N3 replacement

• Digital mental health

Our approach

There are a wide range of programmes that support our aim of supporting the delivery of care and reduction in use of services through the use of digital

technology. These are outlined in our narrative plan for north east London. As the three Local Digital Roadmaps (LDRs) come together we have agreed the

best level at which each programme should be led and delivered within the health system. This process has begun based on the partnerships and scale

required to best implement the specific programmes, using the following rationale for choosing to progress an initiative at a particular level:

1. There is a clear opportunity / benefit in doing it jointly (which is above and beyond what would be achieved through a local programme),

to deliver improvement in terms of enhancing the offer, finance, quality, or capacity;




3

Digital Enablement


LAS Implementation Implementation

BC

BC

Implementation to Q4 18/19 including pan-London links to Q4 20/21 Business case (BC)


Expected Impact

It is recognised locally that the ability for professionals and patients to view and share

patient information across the various care settings, leads to improved:

• Patient safety – supporting, safer more informed treatment by providing health and

social care professionals with timely access to accurate and up to date information.

• Efficiency – reducing the time, effort, cost and resources required to obtain relevant

information regarding patient care, e.g. reducing repeat tests, and transfers of care.

• Effectiveness – supporting appropriate care to patients, elimination of duplicate or

unnecessary testing and unnecessary paperwork and handling.

• Patient experience & engagement– reducing the need for patients to recall or repeat

their medication information and supporting people with difficulties communicating,

and helping patients to be better engaged in their care.

Vision Digital Technology will:

• Support initiatives to help health, social and community care providers meet the needs of local people through shared records and access to information, built around the needs of local people

• Enable the development of new, sustainable models of care to achieve better outcomes for all; focused on prevention and out of hospital care

Background and Case for Change As laid out elsewhere in this document, transformational change is key to providing health and care services in NEL

over the coming years. The NHS has accepted the challenge of being paper-free at the point of care by 2020. We

will accord priority to quickening the pace of appropriate digital technology adoption within our organisation,

realigning the demand on our services by reducing the emphasis on traditional face to face care models. We will

explore new digital alternatives that will transform our services, with the aim of shifting the balance of care into our

communities, enabling new integrated digital outpatient services and providing our patients with the information and

resources to self-manage effectively, facilitating co-ordinated and effective out of hospital care. We will continue to

build on advanced analytics population health management technologies, utilising opportunities for real time, fully

interoperable information exchanges to provide new, flexible and responsive digital services that deliver integrated,

proactive care that improves outcomes for our patients in a more sustainable way.

Workstreams

Priorities and Objectives • Shared care records enhancing collaboration - Providers will collaborate with health, social and

community care. Systems will therefore need to be interoperable to allow for providers from primary, community, social and secondary care to work together

• Coordinated care and care planning to enable more efficient transfers of care, reduce safeguarding risks and support safer and improved management of patients in crisis.

• Patient Enablement - Patients require the ability to view their own health records and care plans, book appointments with their GP and, eventually, the wider health and care system, and have greater access to services online.

• Advanced system-wide health analytics is needed to provide insight and prompt early interventions to enable informatics driven health management programmes; Population Health. Our health system will need to be proactive at preventing patients from escalating ill health and our interventions will need to be evidence-based. At present, each CCG has separate BI tools which are generally used for analysing corporate performance. This initiative will provide game changing health data analysis

• Ensure that the digital infrastructure across the footprint is up to the job of supporting reliable, fast access to systems

16/17 17/18 18/19 19/20 20/21

Shared care records

Coordinated care

and care planning

Patient Enablement

Advanced system-

wide analytics

Digital infrastructure

Implementation to Q3 18/19 including pan-London links to Q4 20/21

Implementation

Implementation

Implementation

Evaluate pilot

WELC BHR

WELC BHR

WELC BHR

WELC BHR

WELC BHR

Options appraisal

Options appraisal Implementation

Business case Implementation

Business

case 4

Digital Enablement


Detailed plan – Work stream 1: Shared care records

Case for change – Digital supports these STP initiatives:

• Lack of a joined up view leads to inefficiencies

• Without a complete picture patient safety can be compromised

• Many tests are ordered that have already been completed recently

but are not visible in discrete system

• Patients are repeatedly asked for information that another part of

the system already has leading to inconsistent data sets, frustrated

patients and wasted time

• Records visible across Social Care and Primary Care is crucial to

help avoid the need for acute care

SRO: Terry Huff, Accountable Officer, Waltham Forest

CCG

Delivery

lead:

Anita Ghosh, IT Enabler Programme Manager, Homerton

Bill Jenks, TST Programme Manager, TH CCG

Simi Bhandal, Project Manager, BHR CCGs

Vision

All health and social care professionals will have access to all of the information directly relevant to the care of the patient or person with whom they have a legitimate relationship.

Objectives

• Improved patient safety – supporting safer and more informed treatment by providing clinicians

with timely access to accurate and up to date information

• Greater efficiency – reducing the time, effort and resources required to obtain relevant

information regarding patient care, e.g. avoiding repeat test requests

• Greater effectiveness – supporting the delivery of appropriate care to patients

• Better patient experience – reducing the need for patients to recall or repeat their medication

information and supporting people with difficulties communicating

• Real-time alerts in A&E

• Paperless results reporting

• Improved safety, efficiency and effectiveness for cross-border patients


1 Shared care records

enhancing

collaboration

• Stakeholder engagement: to ensure NEL wide

agreement and take-up

• Technical delivery by suppliers

• Create and sign data sharing agreement to

cover all providers so maximising availability of

information

• Publish fair processing notices

• HLP Digital Programme

• Improved levels of care and patient

safety through having a more

complete picture

• Efficient use of resources, especially

around repeat testing and referrals

• More satisfied patients because

they’ve experienced a more efficient

and effective system

• NHS bodies implement interoperable standards based

systems

• Connect all health and care providers in WELC to the eLPR

(HIE/MIG)

• Connect the London Ambulance Service via the HLP

solution

• Maximise interconnectedness of BHR providers and connect

eLPR in WELC to key BHR systems

• Implement sharing of structured data rather than web pages

to allow automated actions to be taken

• Connect WELC and BHR systems to HLP health and care

information exchange

• Electronic ordering of diagnostics and access to diagnostic

results across NEL

2 Electronic ordering of

diagnostics access to

diagnostic results




• Faster and more reliable ordering

• Reduced cost and reliance on paper

3 eDischarge

Summaries to GPs




• Improved levels of care and patient

safety through having a more

complete picture

• Reduced cost and reliance on paper

• GPs receive discharge summaries more reliably and faster,

directly into patient record

4 Child protection alerts

for unscheduled care

setting & social care




• Reduced chance of failing vulnerable

children

• National CP-IS system implemented in all relevant

organisations 5

Digital Enablement


Detailed plan – Work stream 2: Coordinated care and care planning


• Patients have a single care plan shared with professionals involved

in their care, resulting in fewer avoidable hospital admissions

• Level of calls to 111 unnecessarily high

• Level of visits to GP Primary Care unnecessarily high

• ED conveyances from other areas too frequent

• Levels of frequent callers unnecessarily high

• Implementation of one platform for End of Life (EOL) care records

accessible across all providers

SRO: Terry Huff

Delivery

lead:




Vision

Patients receive the best care in the ways that they wish, especially towards the

end of life and when multiple care providers are involved.

Objectives

• Professionals able to view and amend care plans for all patients that

require them

• Key health professionals able to create care plans with patients and

their carers

• Shared care plans extended to social care professionals

• Patients and their carers able to view care plans online


1

Implementation of one

platform for sharing of EOL

care records accessible

across all providers in

London

• Stakeholder engagement: to

ensure NEL wide agreement

and take-up


• Create and sign data sharing

agreement to cover all

providers so maximising

availability of information

• Publish fair processing notices

• HLP Digital programme

• Fewer avoidable

hospital admissions

• Reduced level of calls

to 111 and 999

• Reduced level of visits

to GP Primary Care

• Reduced ED

conveyances from

other areas

• Reduced monthly

levels of frequent

callers

• Supports

multidisciplinary team

working; improve

quality of care and

experience by service

users

• Decision in WEL around best approach

• Continuing business change activities in BHR and

C&H to maximise use of Health Analytics and

CMC respectively

• Alerts and sharing of care plans in UEC settings

• Practices sign-up to sharing agreements where

necessary

• Coordinate My Care or similar functionality

provided co-authored plans

2

Sharing care plans directly

into users normal clinical or

social care system

• Easily used information in professionals main IT

system which they can update and share with all

other relevant people

3

Patients have a single care

plan shared with health and

care professionals involved in

their care

• Multi-authored care plans that make a real

difference to the care of patients at key stages of

life 6

Digital Enablement


Detailed plan – Work stream 3: Patient enablement


• Need to improve patient satisfaction levels especially around the ease of making GP appointments, the ability of the NHS to meet demand including evenings & weekend access; reduce A&E attendances and reduce variation of service

• Care plans not visible to or changeable by patients • Personalised budgets need patient access to care plans • Need to improve access to unbiased information to make

choices about care • Patients don’t have the tools, motivation and confidence to

take responsibility for their health and wellbeing • Low levels of self referral to e.g. IAPT services • Patients are not empowered to remain healthy and don’t feel

connected to others and to support in their local community

SRO: Terry Huff

Delivery

lead:




Objectives

Summary of objectives from the work stream level plans:

• Access to detailed coded GP records actively offered to patients who would benefit the most and where it

supports their active management of a long term or complex condition

• Patients who request it are given access to their detailed coded GP record

• Patients can book appointments and order repeat prescriptions from their GP practice

• Usage of online booking extended through enhanced mobile applications availability

• Patient can send electronic messages to GP via clinical systems

• Patient Owned Data (POD) updates to patient records increasing self-management and patients having

greater control over the management of their own care.

• Patients have access to whole record of care - health and social care

• Improved management of capacity within primary care

Vision That patients will become more engaged in their own health care through having more information, leading to better outcomes, and that the provision of services such as appointment booking and ordering repeat prescriptions will reduce costs and increase efficiency in General Practice.


1 Communications campaign • Stakeholder

engagement: to

ensure NEL wide

agreement and

take-up

• Technical delivery

by suppliers

• HLP Digital

Programme

• National Patients

online programme

• CCG

Communications

departments

• Patients are provided with more

information enabling them to be more

engaged in their own health care

(leading to better outcomes), and that

the provision of services such as

appointment booking and ordering

repeat prescriptions will reduce costs

and increase efficiency in General

Practice

• More satisfied patients as measured by

patient satisfaction surveys

• Reduced DNAs through easier access

to cancel and amend appointments

• Richer and more complete patient

record through recording of patient

owned data

• Communications plans

• Patient awareness raising activities

• Advice and best practice guides to practices in terms of levels

of appointments offered online and ways of engaging patients

• Business change activities in general practice

2

Practice engagement to

increase available

appointments

• More GP appointments available on-line

3


encourage take-up of access to

patient online services

• Communications plans at the most beneficial level

• Positive participation by GPs and Practice staff

4

Implementation of phone /

appointment systems

integration

• Patients able to book, amend and cancel appointments in

appointment systems via the phone

5 Web based tools to aid initial

consultation

• Web based pre-consultation software implemented in

practices that can best utilise it 7

Digital Enablement


Detailed plan – Work stream 4: Advanced system-wide analytics

Case for change – Digital supports these STP

initiatives:

• To predict or anticipate individual health needs from

algorithms running in real time (or as near as

possible) and to deliver the insight gained directly into

the patient’s record across the whole of their pathway

thus creating the opportunity to improve or prevent

adverse outcomes.

• To expand the existing informatics driven

improvement programme in east London in primary

care to all health and care sectors.

• To enable the real time reporting of programmes

supporting clinical improvement

• To provide patients with real-time information

SRO: Terry Huff

Delivery

lead:




Objectives

Summary of objectives from the work stream level plans:

• To predict, anticipate or inform individual health needs from algorithms running in real time (or as near as possible)

and to deliver the insight gained directly into the patient’s record across the whole of their pathway, whether in

primary or secondary care or elsewhere, thus creating the opportunity to improve or prevent adverse outcomes.

• To expand the existing primary care informatics driven population health programme in east London, led by the

Clinical Effectiveness Group at Queen Mary, to all health and care sectors

• To enable the real time reporting on programmes by providers and commissioners supporting clinical improvement

and new payment mechanisms. This would involve reporting on either a pseudonymised or identifiable cut of the

clinical data, as appropriate

• To use data by third parties (commissioners, public health, and academics) to support research, development and

planning, whether on consented identifiable data, or the pseudonymised dataset. East London would thus become a

research enabled community. BHR currently use linked datasets for research purposes, e.g. Health1000

• To support the development and delivery of outcome based care

Vision

A Learning Health System that improves the health of individuals and populations by generating information and knowledge from data captured and updated over time and sharing and disseminating what is learned in timely and actionable forms that directly enable individuals, clinicians, and public health entities to separately and collaboratively make informed health decisions.


1 Implement Health Analytics in BHR

• Stakeholder

engagement: to

ensure agreement

and take-up

• Technical delivery

by suppliers

• Create and sign

data sharing

agreement to cover

all providers so

maximising

availability of

information

• Publish Fair

Processing notices

• Patient level alerts provided with

more intelligence behind them

that directly impact on

professional decision making

• The ability to receive accurate

and immediate feedback on

redesigned patient pathways

• High quality and timely

information at a population level

on which to plan the health and

care system

• Complete implementation of Health Analytics in BHR,

building on progress and investment already made

• Options appraisal on how Health Analytics and

Discovery can be used in complementary ways, avoiding

duplication but utilising best features or recommending a

move to one system

2 Implement Discovery in WELC • Complete implementation of Discovery in WELC,

building on progress and investment already made

3 Provide real or near real-time

reporting

• Clinicians and managers receive real time information

and knowledge on which to base decisions

4 Write back functionality to patient /

citizen record

• Professionals across care settings (with systems able to

process them) receive alerts that enable them to make

better or more timely decisions with their patients

5 Link BHR system (Health Analytics)

and WELC system (Discovery)

• Information sharing for patients

receiving cross boundary care'

• Connected systems sharing relevant and appropriate

data 8

Digital Enablement


Detailed plan – Work stream 5: Digital infrastructure


• Having a fit for purpose infrastructure provides the

platform on which all else can be delivered

• Reduced outpatient appointment waiting times through

use of telephone or video consultations

• Reduced back office costs

• Better patient engagement through Wi-Fi provision

SRO: Terry Huff

Delivery

lead:




Objectives

• Public have free Wi-Fi access from all GP surgeries

• Public have free Wi-Fi access from all NHS premises

• Improve Barts Health network to support other initiatives required to meet FYFV goals

• Offering all GP patients e-consultations and other digital services including e-referrals

• Support delivery of digital services

• Allow access to host systems via partner organisation Wi-Fi across NEL

• A Hackney network for care professionals and citizens - Hackney Devolution

• DoS - up-to-date and comprehensive - signposting to services including local services

• Re-procure wide-area network services

Vision

A wholly reliable technical infrastructure with the capacity and capability to deliver the information required securely when and where it is needed across multiple care settings.


1 Barts Health infrastructure • Stakeholder

engagement: to

ensure

agreement and

take-up

• Technical

delivery by

suppliers

• Pan-London N3

replacement

• HLP Digital

programme

• Stable platform over which all other initiatives can

run (99.99% reliable clinical access)

• Fit for purpose infrastructure in Barts Health allowing use

of technology such as video consultations

2 Telehealth expansion • Reduced pressure on acute outpatient departments

• Reduced travel for patients

• Outpatient shift utilising voice and video

3 Replace N3 network • The ability to connect systems as required (no

infrastructure blocks to progress)

• New wide-area network serving all NEL sites

4

Shared Wi-Fi access and

free public access Wi-Fi

(including Hackney network

including mobile working -

Hackney ambition)

• More flexibility in ways information is accessed

(100% of staff able to work from other public sector

sites)

• More engaged patients/citizens (at least 20%

accessing detailed record in 2018)

• Wi-Fi survey complete in all sites and Wi-Fi enabled for

patients

• Sharing required information to allow professionals to

utilise Wi-Fi in other organisations

• Area-wide citizen Wi-Fi to support Hackney devolution

6 DoS improvement • NHS Digital DoS

improvement

project

• More effective e-referral system

• Better sign-posting for patients

• NHS Digital to provide more effective Directory of

Services tool

9

Digital Enablement


Route map (1/4)

2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

Shared care records

Primary care and acute shared

care records

eDischarge summaries to GPs

Electronic ordering of

diagnostics

Shared care records enhancing

collaboration

Child protection alerts for A&E &

social care

Electronic access to diagnostic

results

WELC eLPR complete

BHR shared record complete

Barts Health & Homerton

sharing with GPs

Barts Health & Homerton

sharing with each other

BHRUT & Barts Health

utilising enriched SCR

BHRUT pilot data sharing

with BHR GP practices Barts Health pilot data sharing

with BHR GP practices

BHRUT e-discharge summaries

aligned to AoMRC headings

BHR Plan in place to migrate

to MESH BHR e-discharge summaries via coded CDA

BHR GPs ordering path and

imaging electronically BHRUT ordering path and imaging

electronically BHR electronic ordering of diagnostics

GP records shared with urgent

care hubs in real time with write

back capability

Extend record sharing functionality

to OOH/111 Extend record sharing functionality

to community and social services BHR-wide electronic

record sharing

CP-IS roll out plan for Redbridge

and Havering LAs and OOH/111

Go live of CP-IS in B&D

BHR-wide CP-IS implementation

complete

Pilot with Cyberlab for electronic

sharing of pathology results

Pilot with Cyberlab for electronic

sharing of imaging results

BHR-wide electronic access to

diagnostics

LAS connected

through HLP HLP Digital programme

delivering across STPs

WELC sending Barts Health e-discharge summaries

aligned to AoMRC headings

WELC GPs ordering path

electronically with Barts & HUH(&

Radiology with HUH)

WEL GPs ordering path AND

imaging electronically with Barts WEL electronic ordering of diagnostics

Currently eLPR has active Sharing

between Barts Health and all GP

Practices. Barts also sharing with HUH

and ELFT. HUH sharing with C&H GPs.

ELFT and HUH data to open up to

wider GP sharing by Q4.Newham

council to start work in Q4 also.

eLPR to include Tower Hamlets

Council, Waltham Forest Council

and NELFT. Work should also be

completed with Adastra for OOH

and 111 sharing.

WELC eLPR complete

Cerner integration with CP-IS complete

at Barts and roll out planned with LBs

WELC-wide CP-IS implementation

complete

WELC-wide Access complete Switch planned from Cyberlab to eLPR for

electronic sharing of pathology results

CP-IS roll out plan for

CoL and LB Hackney

LBH/CoL data sharing with HUH

C&H extending ordering and

results to cardiology for GPs

10

Digital Enablement


Route map (2/4)

2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

Coordinated care

and care planning

Implementation of one

platform for sharing of EOL

care records accessible

across all providers in

London

Sharing care plans directly

into users normal clinical

system

Patients have a single care

plan shared with

professionals involved in

their care

Community and social services

access to EoL and ICM care

plans

Urgent Care Hubs, 111/OOH

and 50% of GP practices access

to care plans within system

Functionality extended to

community services and

remaining GP practices

Functionality extended to social

services

BHR patients with single care plan

C&H live. WEL to revaluate Co-

ordinate My Care for EOL care

planning due to better

integration with EMIS.

HLP to begin delivery of document sharing

tools which should enable wider care plan

sharing for WELC

CMC to have read and write

capability with EMIS

HLP’s document sharing tool should

enable read and write access to core

clinical system for WELC

HLP work should deliver the single care

plan for WELC WELC patients with single care plan

11

Digital Enablement


Route map (3/4)

2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

Advanced system-

wide analytics

Implement Health Analytics in

BHR

Implement Discovery in WELC

Provide real or near real-time

reporting

Write back functionality to

patient / citizen record


Barts Health infrastructure

Telehealth expansion

Replace N3 network

Shared Wi-Fi access and free

public access Wi-Fi

Hackney network including mobile

working - Hackney ambition

Community of Interest Network

(COIN)

DoS improvement

Risk stratification live and linked

primary care secondary care

data

Linked social care and

community care data

BHR near real-

time reporting

Complex care patients can

access their care plan online CHC patients can access their

care plan online

Personal Health Budget patients

can access their care plan online BHR patients access care plans online

Review of

contracts

BHR GP and

corporate

network replaced

Bid for funding for

Wi-Fi implementation

Key sites on COIN

network

Additional locality

provisions on COIN

Discovery project to hold data from

pilot GP practices and ADT feeds

from Barts and Homerton

First 5 user cases to be enabled

and activated and rolled out to be

used WELC wide

Discovery to provide some level of

real time reporting around the first

5 user cases

Discovery to have some write back

functionality in the first 5 user cases

LDR sets out the funding gap for Barts

Health infrastructure and future funding to

be based on the LDR

Funding applied for through ETTF

for public access Wi-Fi.

COIN being investigated by WF CCG. TH CCG

and C&H CCG already have a COIN. Expected to

be absorbed into London network

Funding applied for through ETTF

to improve the e-referrals DoS

WELC near real-

time reporting

WELC write back enabled

WELC public Wi-Fi

London network in place

London network in place

12

Digital Enablement


Route map (4/4)

2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

Patients’ access to

their own information

Communications campaign


increase available

appointments


encourage take-up of access to

patient online services

Implementation of phone /

appointment systems

integration

Web based tools to aid initial

consultation

Pilot video consultations with GP

practices

Roll out of video consultations to

PMS practices

Roll out video consultations to

remaining GP practices

Funding applied for through ETTF to

improve both the Practice

engagement and patient

communications around usage and

availability of online services.

Communications campaigns and

practice engagement work will follow

the funding

Newham CCG has applied for ETTF

funding for Babble Voice. THT has

applied for funding for Digital Life

Sciences which has an integrated

phone system element.

Review pilots and seek funding

for wider roll out if pilots

successful.

13

Digital Enablement



Benefit description (Health & wellbeing,

care & quality or financial)

Measurement (metric) Current

performance

Target

performance

Target date

(default 2020)

Linked work streams

New models of care can be developed,

achieving better outcomes for all; focused

on prevention and out of hospital care

Other delivery plans

supported to deliver new

models of care

TBC TBC Incremental to

2020

Advanced system-wide

analytics, Digital

infrastructure

Provide the information needed to enable

organisations to work in partnership to

commission, contract and deliver services

efficiently and safely

Clinically significant

information available

where requested and

agreed by Discovery

board

TBC TBC 2020 in BHR

2018 in WELC


analytics

Improved patient safety – supporting safer

and better informed treatment by providing

clinicians with timely access to accurate

and up to date information

Number of serious

incidents found to be as a

result of lack of

information

TBC TBC Incremental to

2020

Shared care records,

Coordinated care and care

planning

More efficient care –reducing the time,

effort and resources required to obtain

relevant information regarding patient care,

e.g. avoiding repeat test requests

Amount of repeat testing TBC TBC Incremental to

2018/19


analytics, Shared care

records

Better patient experience– reducing the

need for patients to recall or repeat their

medication information and supporting

people with difficulties communicating

Patient satisfaction rating TBC TBC Incremental to

2018/19

Shared care records,

Patient enablement

Intervention for individual patient prompted

by analysis of broad set of data


specific life events

TBC TBC Commencing

20017/18


analytics, Shared care

records

Patients take more active role in their own

wellbeing

Accessing ‘patient on-line’

functionality

4% 20%-30% 2017/18 Patient enablement

14

Digital Enablement

This section provides a summary of high level benefits at Delivery Plan level:




Delivery Plan

SRO Delivery Lead

Shared care records

Terry Huff, Accountable

Officer, Waltham Forest

CCG

Anita Ghosh, IT Enabler

Programme Manager,

Homerton

Bill Jenks, TST

Programme Manager,

TH CCG

Simi Bhandal, Project

Manager, BHR CCGs

Coordinated care

and care planning

Patients’ access to

their own information

Advanced system-

wide analytics



NEL STP Joint Digital Strategy Group

C&H IT Enabler WEL Information Strategy Group

BHR IT Strategy meeting

Commissioners Providers Suppliers In addition to the SRO and delivery needs named above, Luke Readman,

CIO, WEL CCGs is taking the lead for Digital Enablement across NEL STP.

Rob Meaker (Director of Innovation, BHR CCGs) and Niall Canavan

(Director of IT, Homerton), along with Luke Readman in WEL, continue to

provide digital leadership across their respective LDR footprints, working

ever closer.

As ever, much of the delivery on the ground is provided through individual

IT departments, change facilitators and suppliers which will need

augmenting / paying for specific projects.

15

NEL STP Board

Digital Enablement

NEL STP Executive


Risks

Risks

Work stream Description and impact Mitigating action RAG

All

Finance – much of the Digital programme for the STP

is unfunded and is reliant on successful bids to

technology funds

Successful bids to Estates Technology Transformation

Fund (ETTF) and other upcoming funding streams R

All Premature consolidation of BHR and WELC LDRs

would potentially halt or even reverse progress that has

already be made

Take time to consider real benefits verses risk before

creating a single LDR A

Digital infrastructure Poor infrastructure in key areas Successful technology bids allowing improvement

programmes to be launch A

Shared care record,

Coordinated care and

care planning

Compatibility of systems that haven’t yet been

connected

All systems use or soon will use recognised

interoperability standards. Close supplier engagement

underway A

Shared care record,

Coordinated care and

care planning, Patient

enablement

HLP Digital Programme failing to deliver the products

they have committed to

Successful ETTF bid and ongoing funding streams

secured A

Patient enablement,


Progress would inevitably slow if GPIT re-procurement

results in a new provider being selected

Careful consideration as to how and when any new

service is brought on stream A

16

This is a list of the highest-rated risks. Additional risks identified at a lower mitigated risk rating

Digital Enablement






Shared Care

Record, Advanced

system-wide

analytics

Dependency

New Information Sharing Agreements and

fair processing notices need to be in place

before significant further steps can be taken

IG groups across NEL to collaborate on process

and gain approval from all relevant parties

All Assumption

Sufficient funding will be made available to

deliver the transformational digital systems

required. Current national (short term)

bidding system for IT doesn't allow for good

planning

Continuing to make the case for investment in

Digital, bidding for monies from funds as they

become available

All Dependency All suppliers deliver on their commitments Continue existing good supplier engagement

Patient engagement Constraint

Concerns from GPs about the effectiveness

of patient on-line objectives and patient

indifference / lack of awareness

Clinician and public engagement exercises

Patient engagement

Dependency

GP promotion of service to patients and

willingness to publish appointment slots on-

line

Clinician and public engagement exercises

Advanced system-

wide analytics Dependency

Engagement to determine where to focus

initial efforts. Commitment to use information

supplied

Continue discussions with clinicians

All Dependency

Workforce appropriately skilled and engaged

to take advantage of new ways of working

enabled by Digital Enablement

Engage with Workforce team to ensure full

understanding

Coordinated care

and care planning Assumption

Willingness for professionals and patients to

use care plans

Fully engage with professionals and patients once

clear on delivery mechanism

Digital

infrastructure Dependency

Provision of sufficient facilities for IT in new

or refurbished buildings

Fully engage with estates and facilities teams

where physical It assets need housing 17

This section provides a summary of the key benefits that we expect to achieve through the implementation of this Delivery Plan level:

Digital Enablement


Dependency map


close to Home

Accessible

quality acute

services


Services

Workforce

Shared care

records

Workforce

appropriately

skilled and

engaged

Coordinated

care

and care

planning

Willingness for

professionals to

use care plans

Workforce

appropriately

skilled and

engaged

Patients’

access to

their own

information

GPs need to

engage with the

process of

giving patients

access

Workforce

appropriately

skilled and

engaged

Advanced

system-

wide analytics

Engagement to

determine where

to focus initial

efforts.

Workforce

appropriately

skilled and

engaged

Digital

infrastructure

Provision of

sufficient

facilities for IT

Workforce

appropriately

skilled and

engaged

As an enabling delivery plan, Digital Enablement has few dependencies on other delivery plans

This dependency map highlights where this delivery plan is linked to another delivery plan within our STP

18

Digital Enablement






• The anticipated financial impact of the work streams on closing the gap














Planned future work






19

Digital Enablement







Through the use of all of the

Digital Technology described in

this Delivery Plan and in the

LDRs it is possible to reduce

recourse to acute services

because professionals and

patients alike have a much

richer picture of previous care,

current conditions, risks and

ongoing planned interventions.

Such reductions in demand for

acute services allows greater

access for those that necessarily

require them.

There is clear evidence that multi-authored end of life care plans have a significant impact on the ability of patients to die in their preferred place. Wider multi-authored care plans enable all those involved in care to provide what is need in the right place and at the right time, involving carers as necessary. A full Shared Care Record can facilitate safe discharge from hospital but also help prevent admission and attendance at A&E because professionals have a full picture and can make more appropriate decisions based on that information

The Patient Engagement work stream supports patients to improve their own wellbeing through providing information to them and enabling them to provide information, e.g. from an activity tracker or mood score app, back to their clinician. The Advanced System-wide Analytics work stream will provide prompts to clinicians to enable early intervention.

Co-ordinated Care and Care Planning will help patients receive the treatment and social care support they want where and when they want it, initially supporting end of life care. The Shared Care Record will give a sense to the patient that those involved in their care have a complete picture and have the confidence to act upon that information


20


Digital Enablement




for healthcare

• Greater patient engagement (slide 8 - work stream 3).

•Advanced system-wide analytics uses risk stratification and algorithms to alert clinicians to possible early interventions engagement (slide 9 - work stream 4).


& NHS staff

•Greater patient engagement though access to their own record and digital interaction with professionals (slide 8 - work stream 3).


practice

•Greater patient engagement though access to their own record and digital interaction with professionals (slide 8 - work stream 3) can reduce workload on practice staff.



•Advanced system-wide analytics can surface bottlenecks in the health and care system and support new models of care with early evidence of effectiveness (slide 9 - work stream 4).


core standards

•Improved e-referral usage can make significant impact on overall system performance. The Local Digital Roadmaps describe how e-referral performance will be improved.


•Shared care record (slide 6 - work stream 1) and Coordinated care and care planning (slide 7 - work stream 2) generally support professionals delivering care by giving them a more complete picture.

•Advanced system-wide analytics will alert for early intervention (slide 9 - work stream 4).


•Shared care record (slide 6 - work stream 1) and Coordinated care and care planning (slide 7 - work stream 2) support quality improvement by giving professionals a more complete picture

•Advanced system-wide analytics will alert for early intervention (slide 9 - work stream 4).


•All work streams in this delivery plan involve the deployment of technology to accelerate change (see slides 6-10).


deliver

•Work streams 1,2&4 provide the tools required to support MDTs, for example.


balance

•The benefits sections of all work streams identify ways in which digital technology can improve efficiency and reduce demand.

•In addition to the identified work streams, digital is engaged with Carter review recommendations.

21

Digital Enablement



1. STPs


•Much more detail is included in the Local Digital Roadmaps.

2. Finance

•The Digital Enablement plan will enable the other delivery plans to achieve their financial targets.

•We are working collaboratively to develop a flexible / scalable back office service models where this will deliver value for NEL.

3. Primary Care

•Digital underpins primary care activity, as expressed in all of the work streams.


•Access to shared more complete records in NEL and across London, plus the ability to write back into records and care plans underpins changes needed in U&EC.


•The digital capability is already in place to enable 100% use of e-referrals.

•The use of advanced analytics will provide key parts of the information required to streamline elective care pathways.

6. Cancer

•The Shared Care Record and the Coordinated Care And Care Planning work streams in particular, support the Recovery Package information requirements.

7. Mental health

•The Shared Care Record allows professionals to see what interventions have been tried or are ongoing outside of their own organisation.


•Shared Care Records reduce the need to ask patients for information about allergies, previous treatments in other care settings, etc.

•Multi-authored care plans that are accessible by patients and their carers support community provision and avoiding admissions.


•The information provided by Advanced system-wide analytics can be used to drive up quality across the system.

•Access to fuller care record information from beyond own organisations enables professionals to take better decisions, driving up quality and reducing avoidable cost.

22

Digital Enablement

Documents

developing a sustainability and transformation plan for north east London