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London’s Clinical Commissioning Groups and NHS England
(London region’s) response to the London Health Commission’s
report – ‘Better Health for London’
We would like to commend the London Health Commission’s recent report –
Better Health for London and the opportunity it presents to the NHS in London.
The report sets out the challenges that London currently faces and the
recommendations represent an excellent opportunity to bring fresh thinking on
how to bring about the improvements in health and care in the Capital that we all
aspire to achieve. Additionally, the ambitions and recommendations set out in the
report clearly place health, health inequalities and health and care at the centre
of debate for Londoners.
We are pleased that you have accepted the recommendation to convene and
personally chair a group to prepare a unified delivery plan and oversee
implementation of the Commission’s recommendations and make the
recommendations for London a reality.
We broadly support the recommendations detailed within Better Health for
London which highlight the need for the different agencies responsible for health
and care in the capital to each play their part, and in some cases work together
to achieve the ambitions. Importantly, the recommendations demonstrate the
need for the NHS and others to better involve London’s different communities in
the delivery of the solutions in order to truly make London the healthiest global
city.
Working with our partners, we would like to offer our commitment to supporting
making implementation of the recommendations a reality for Londoners.
This response to the recommendations outlined in Better Health for London has
been jointly developed by London’s Clinical Commissioning Groups and NHS
England (London Region). We have considered the recommendations and
recognise the importance of our relationship – and the relationships with our
partners – and it is through the collective effort that we will strive to deliver much
of what is recommended in Better Health for London in order to truly transform
health and care for Londoners.
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We have concentrated our response on:
Who we are;
Our partners;
The Five Year Forward View;
Taking the recommendations of Better Health for London forward;
Our transformation priorities; and
The proposed vehicle to take forward the recommendations pertaining to
the NHS in London.
We trust this response is helpful and we look forward to working with you to
make the ambitions set out in Better Health for London a reality for Londoners.
Whilst we are facing unprecedented challenges, we ask for your support in
accepting the recommendations of Better Health for London as detailed in our
enclosed response. We are confident that this will be an important foundation to
truly make London the healthiest global city.
1. Who we are: London’s Clinical Commissioning Groups
1.1 There are 32 Clinical Commissioning Groups (CCGs) in London. Each
CCG is a statutory NHS body with its own governance arrangements;
these vary according to its Constitution. CCGs are membership
organisations of the GP practices within their boundaries. They are
responsible for meeting the health needs of their populations and their
main focus is on local issues.
1.2 Clinical Commissioning Groups operate by commissioning healthcare
services including:
Elective hospital care;
Rehabilitation care;
Urgent and emergency care;
Maternity services;
Most community health services; and
Mental health and learning disability services.
1.3 Clinical Commissioning Groups work with patients and healthcare
professionals and in partnership with local communities and local
authorities, including though Health and Wellbeing Boards. These
partnerships improve the commissioning and delivery of services across
NHS and local government, leading in turn to improved health and
wellbeing for local people.
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1.4 London’s CCGs also work together in different geographies where it
makes sense to do so, where value can be added across a larger
population.
1.5 The 32 London CCGs work together to discharge their responsibilities and
ensure that robust arrangements are in place to enable effective
collaboration. These arrangements reflect the membership nature of
CCGs.
1.6 The principal objectives for CCG collective working in London are:
To manage collective commissioning arrangements.
To liaise with other London wide organisations such as the NHS
England (London), Mayor’s office and London Councils.
To work in partnership with the NHS England (London) to plan, and
to manage strategic change which cross CCG boundaries.
To promote shared learning to improve performance.
To co-ordinate other activities as required.
2. Who we are: NHS England (London Region)
2.1 While operating within a single organisational structure, NHS England’s
Operations and Delivery Directorate has four regional teams of which
London is one, co-terminous with the Greater London Authority (GLA).
London Region has Area Teams for South; North West; and North Central
and East London. This enables the development of local relationships and
local knowledge essential to effective and efficient working.
2.2 NHS England (London Region) has oversight and leadership for the NHS
in London and commissions more than £15bn of services for the 8.17
million people living in the capital. These include general practitioners
(GPs) and over 140 specialised services such as:
Forensic mental health;
HIV treatment;
Treatment for children with congenital heart conditions;
Cystic fibrosis treatment;
Complex spinal surgery; and
Healthcare for those in the criminal justice system.
2.3 The London Regional Team has directorates aligned to the national
support team: Medical; Nursing; Operations and Delivery; Finance;
Patients and Information; Communications; and Human Resources and
Organisational Development. Unique to the London Regional Team is a
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Transformation Directorate, established in recognition of the unique
challenges facing the NHS in the Capital. In light of the publication of
Better Health for London and the establishment of the London
Commissioning System Design Group there is the shared recognition that
transformation in London needs to be jointly owned with London’s CCGs.
2.4 London’s CCGs and NHS England (London Region) is focused on
improvements against the NHS Outcomes Framework1 and ensuring
citizens receive their rights as set out under the NHS Constitution2.
Putting Patients First: the NHS Business Plan 2013/14 – 2015/16 (will be
annexed) sets out how we are responding to our Mandate. Everyone
Counts: Planning for 2014/15 to 2018/19 (will be annexed) sets out how
we propose that the NHS budget is invested so as to drive continuous
improvement and to make high quality care for all, now and for future
generations into a reality.
2.5 The recently published Five Year Forward View (will be annexed) for the
NHS in England calls for decisive action over the next five years to ensure
that the health and care quality gap does not widen. London’s CCGs and
NHS England (London Region) support this bold vision and recognise the
alignment between the Five Year Forward View and the recommendations
detailed in Better Health for London, and the benefits that implementation
of these recommendations will bring.
3. Our partners
3.1 London’s CCGs and NHS England (London Region) work closely with the
London regional offices of our national partner organisations:
NHS Trust Development Authority (TDA);
Public Health England (PHE;
Health Education England and Local Education and Training Boards
(LETBs);
Commissioning Support Units (CSUs);
Healthwatch England and local; and
Monitor.
3.2 We also closely consider the priorities and guidance of other national
bodies, such as the National Information Board, a recent report from
which (Personalised Health and Care 2020: Using Data and Technology
to Transform Outcomes for Patients and Citizens) will set direction for our
work in this area.
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3.3 In London, we continue to develop relationships with other organisations,
representatives and partners, including:
Patients and service users;
The Mayor and the Greater London Assembly;
London Clinical Senate;
Primary care providers;
16 acute NHS trusts;
Three mental health NHS trusts;
Two community trusts;
18 Foundation Trusts;
The London Ambulance Service;
Three Academic Health Science Centres and Networks;
London Health Board;
London-wide LMCs;
London Councils;
33 local authorities;
Health and Wellbeing Boards; and
Voluntary services and charities.
3.4 Most importantly we strive to work with, and for, Londoners and the people
visiting and working in our great city.
3.5 The opportunities of our clinically-led health commissioning system are
clear in that we are able to respond to local need, supported at scale
where this adds value. However, the challenges of multiple interests and
involvement across a citizen’s pathway of health – from prevention and
care in the home to highly specialised intervention and rehabilitation – are
complex and require very effective partnership working across multiple
organisational boundaries.
3.6 We would like to take this opportunity to outline our ongoing commitment
to working with our partners to take forward implementation of the
recommendations of Better Health for London.
4. NHS England’s Five Year Forward View
4.1 NHS England’s recently published Five Year Forward View sets out why
the NHS needs to change, the actions we will need to take to deliver
transformed care for patients, and the help we need from others. It calls
for action on four fronts.
4.2 Firstly, it argues that the NHS needs to do more to tackle the root causes
of ill health. The future health of millions of children, the sustainability of
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the NHS and the economic prosperity of Britain all now depend on a
radical upgrade in prevention and public health. The Five Year Forward
View backs hard-hitting action on obesity, alcohol and other major health
risks.
4.3 Secondly, it commits to giving patients more control of their own care,
including the option of combining health and social care, and new support
for carers and volunteers.
4.4 Thirdly, it says the NHS must change to meet the needs of a population
that lives longer, for the millions of people with long-term conditions, and
for all patients who want person centred care. This means breaking down
the boundaries between family doctors and hospitals, between physical
and mental health and between health and social care. The Five-Year
Forward View sets out new models of care built around the needs of
patients rather than historical or professional divides.
4.5 Fourthly, it sets out the actions we will need to take in order to develop
and deliver the new models of care, including greater alignment between
the national NHS bodies to provide meaningful local flexibility in the way
that payment, rules and regulatory requirements are applied. It proposes
more investment in our workforce, technology and innovation.
4.6 It concludes that although a better future is in view for the NHS, action will
be needed on three fronts - demand, efficiency and funding. More action
on any one of the three will reduce the pressures on the other two. The
Five Year Forward View shows how delivering on the transformational
changes set out, combined with staged funding increases as the economy
allows could feasibly close the £30 billion gap by 2020/21, and secure a
far better health service for England.
4.7 As commissioners of NHS care in London, we welcome the
recommendations set out in the London Health Commission’s report
Better Health for London which outline important changes that need to
happen to ensure that London is the healthiest global city. It is important
to highlight the broad alignment between the Five Year Forward View and
the London Health Commission’s Better Health for London, the latter of
which sets out ambitions for the Capital and tangible recommendations
that would in part enable a robust response to the challenges highlighted
in the Five Year Forward View.
4.8 In London, Strategic Planning Groups of CCGs and Area Teams –
working with stakeholders and communities – have developed five year
strategic plans to achieve the ambitions set out in our planning guidance.
The five year plans also highlight alignment between the action called for
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in the Five Year Forward View and the recommendations detailed in
Better Health for London.
4.9 We therefore call for you, as Mayor of London and commissioner of the
London Health Commission inquiry, to accept the recommendations
outlined in Better Health for London in order for London’s CCGs and NHS
England (London Region) to take them forward through to implementation,
to enable the Capital to respond to the challenges and deliver the
transformed care for patients identified in Five Year Forward View. We
also call on you in your role as chair of the group that will prepare a unified
delivery plan and oversee implementation of the Commission’s
recommendations to ensure that other agencies responsible for
recommendations do so in order to unlock some significant issues in
London.
4.10 Recognising the challenge ahead, a joint working group between London’s
CCGs and NHS England was established in August 2014 to work through
the implications of implementing the recommendations set out in Better
Health for London through the redesign of commissioning of health
services. The London Commissioning System Design Group has
developed this joint response from London’s CCGs and NHS England
(London Region) to the recommendations in Better Health for London
jointly made to us as commissioners.
4.11 In developing the response, the London Commissioning System Design
Group has been working through the recommendations of Better Health
for London in the context of all the other changes in the NHS, to produce a
coherent plan for taking action forward. This will enable us as
commissioners of health services in London to play a full part in delivering
the vision of Better Health for London.
5. Better health for all
5.1 The Five Year Forward View argues that the NHS needs to do more to
tackle the root causes of ill health. The future health of millions of children,
the sustainability of the NHS and the economic prosperity of Britain all
now depend on a radical upgrade in prevention and public health. The
Five Year Forward View backs hard-hitting action on prevention including
obesity, smoking, alcohol and other major health risks.
5.2 We welcome the Better Health for London recommendations to enable
better health for all of London’s population and to firm take action on
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tackling the root causes of ill health, in order to meet the challenges set
out in the Five Year Forward View.
5.3 We support the approach of Better Health for London: starting from a
simple premise: that a truly great global city is a healthy city. We support
the report’s aspiration to be the world’s healthiest major global city
through:
Reducing smoking rates in the Capital;
Addressing London’s obesity emergency;
Helping Londoners – especially children – to make better and
easier, healthier food and drink choices;
Encouraging work place health initiatives;
Reducing excessive drinking;
Promoting active travel; and
Addressing poor air quality.
5.4 We recognise that tackling these issues will be essential to ensure the
sustainability of the NHS and that preventing ill-health must be a core
focus of the health and care system. Whilst these recommendations are
not made to the NHS in London we recognise that the NHS needs to do
more to tackle the root causes of ill health. In order for truly effective
intervention to take place, we are committed to partnering with Public
Health England and local authorities to support them in leading the way in
delivering preventative initiatives and taking these recommendations
forward Importantly, we will maintain a commitment to continue to engage
with local authorities and Health and Wellbeing Boards to support the
development of Joint Strategic Needs Assessments to support these
important issues.
5.5 NHS England (London Region) also acknowledges its public health role
and is committed to working to improving immunisation rates to positively
impact on health and reduce health inequalities. This is as well as
supporting our partners to take forward the recommendations in Better
Health for London.
5.6 Additionally, the Five Year Forward View calls for a mental health first
aider in every NHS organisation and active travel. Better Health for
London echoes these calls and London CCGs and NHS England (London
Region) are committed to working with Public Health England, the GLA
and local authorities to jointly take this recommendation forward.
5.7 Furthermore, the recent report from Public Health England – From
evidence to action: opportunities to protect and improve the nation’s health
highlighted seven priority focus areas – four of which align to priority areas
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of Better Health for London (the other three being dementia, tuberculosis
and antimicrobial resistance).
6. Better Health for London’s children
6.1 We welcome Better Health for London recommendations for children and
voice our broad support for the public health recommendations within this
section and ensuring that London’s children are a clear priority through:
Supporting London’s most vulnerable families;
Addressing London’s childhood obesity emergency – helping
Londoners – especially children – to make better and easier,
healthier food and drink choices;
School-based interventions for physical and mental health; and
Reducing the variation in the quality of physical and mental
healthcare.
6.2 Outlined in the Five Year Forward View is that the future health of millions
of children is dependent on the radical upgrade of public health, which
mirrors the challenge London faces with the number of primary school
children who are obese. We know, and are deeply ashamed that London
has the highest rate of childhood obesity of any major global city.
6.3 Whilst the Five Year Forward View does not draw on children with a
particular focus or specific issue, we welcome Better Health for London’s
focus and identification that London's children are getting a particularly
raw deal – children of vulnerable families do not always get the support
they need; healthy food and drink choices are not always the easiest
option; healthcare remains fragmented; there is variation in the quality of
care provided; and hospital mortality rates are higher than anywhere else
in the country. This is therefore why it is so important that we give
London’s children a better deal to ensure the very best start in life for them
that we can.
6.4 Similar to previous section which largely focuses on the public health
agenda, we recognise that tackling these issues will be essential to ensure
the sustainability of the NHS and we will support our partners such as
Public Health England, local authorities and those in the education sector
to take these recommendations forward. We particularly express our
support for the recommendation for closer links between education and
health; these links are well evidenced to improve outcomes for children.
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6.5 We outline our broad support for the recommendation to address and
eliminate the variation in quality of care and outcomes for London’s
children and young people. We echo Better Health for London’s call to
improve the health outcomes of London’s children and young people
through the development and implementation of a number of integrated
care systems – spanning physical and mental health and care across all
settings – that ensure the delivery of agreed standards. The need to
develop integrated systems of care has also been highlighted as an area
of focus by London’s Strategic Clinical Network for Children and Young
People.
6.6 Additionally, reducing the fragmentation of services for children and young
people and ensuring clinical dependencies between services are met are
integral to the development of integrated systems of care.
6.7 The London Commissioning System Design Group has agreed children
and young people as one of the clinical priority programmes that will be
taken forward as transformation programme with the aim of reducing the
variation in service provision and patient outcomes. This will build on the
maxim set out in Better Health for London: to start with London’s children
and young people, not London’s NHS. The exact scope of this programme
and timeframes for delivery are currently being jointly developed between
commissioners.
7. Better care
Personalised care
7.1 NHS England’s Five Year Forward View calls for the NHS to take decisive
steps to break down the barriers in how care is provided between family
doctors and hospitals, between physical and mental health, between
health and social care. It outlines that the future will see far more care
delivered locally but with some services in specialist centres, organised to
support people with multiple health conditions, not just single diseases.
7.2 We wholeheartedly agree with Better Health for London’s belief that care
should be more personal, planned around groups of people with broadly
similar needs, rather than around groups of professionals with broadly
similar skills. Rather than care provided around primary versus secondary,
or mental versus physical, a system that holistically considers all aspects
of care for a particular individual.
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7.3 We recognise the importance of the need to understand the different
needs of different groups as the foundation of the new approach proposed
by Better Health for London and this is welcomed. We fully support a
system in which care is provided for groups of similar individuals, in which
people are treated as people, unique and complex, not as an ailment,
condition, or piece of anatomy. This will be a system that will ensure better
care delivery by removing the complexity of the system from the patient
experience and improve patient outcomes.
7.4 We support in principle for the maxim set out in Better Health for London:
start with Londoners, not London’s NHS. Start with people and how best
to meet their needs, their wants, and their expectations – not those of the
system.
7.5 Whilst the approach to looking at the needs, wants and expectations of
different population groupings is supported by London’s CCGs and NHS
England (London Region), local health economies will seek to understand
their own population and develop their own model.
7.6 Providing care that is more personal, planned around groups of people
with broadly similar needs, is a significant shift from care being provided
around institutions – rather than care provided around primary versus
secondary, or mental versus physical, a system that holistically considers
all aspects of care for a particular individual.
7.7 Practically, we understand that this will mean commissioning and
providing more joint teams in the community, more joined up working, and
more integration between health and social care. We strongly support
taking this recommendation forward.
7.8 In conjunction with this, we would like to set out our broad support for
ensuring people who use services are treated as partners in the design
and implementation of improvements to care. Taking the
recommendations forward through transformation programmes to drive
implementation would have the public voice at the heart of developments.
7.9 We also support the indication that the provider system will need to
change and adapt to reflect this new approach. This will also enable the
NHS in London to respond to the expectations set out in the Five Year
Forward View which recognises that a one size fits all approach is no
longer appropriate, and sets out a number of viable models of care for
local health and care services to consider.
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Care for marginalised groups
7.10 We are delighted to see such a strong focus on mental health in the Better
Health for London report. As you are aware with the recent publication of
your own report London Mental Health: the invisible cost of mental ill
health3, mental ill-health alone costs London £5.5 billion a year in lost
working days, and £2.5 billion a year in health and social care costs. More
than a million Londoners will experience mental ill health this year; more
than 100,000 of them will be children. Mental health is all around us.
7.11 We know that too often, physical and mental health are unnecessarily
separated which can result in alarming consequences for patients – the
life expectancy of a man who has experienced psychosis is 14 years less
than the average. We believe that working towards Better Health for
London’s ambition to reduce the gap in life expectancy between adults
with severe and enduring mental illness and the rest of the population by
10% will help us achieve call for ‘parity of esteem’ as set out in the Five
Year Forward View.
7.12 Building on this we would like to outline our broad support for the
recommendations set out in Better Health for London on strengthening the
role of mental health in primary care and timely access to Increasing
Access to Psychological Therapies (IAPT) and early intervention. This
would enable London to strive towards making improvements to care and
services set out in the Five Year Forward View, which are desperately
needed over the next five years. These include the introduction of access
targets to improve earlier diagnosis and treatment as well as better
integrated care for patients with both mental and physical healthcare
needs.
7.13 We also broadly support the recommendation for better care for mental
health patients in crisis. London’s Mental Health Strategic Clinical Network
has recently published mental health standards for patients in crisis and
we would look to build on these through the development of a multi-
agency model of care for this group.
7.14 Furthermore, we welcome the recommendation to design a digital mental
health support system to ensure consistency across all of London and
developing local enhancements if necessary.
7.15 The London Commissioning System Design Group has agreed mental
health as one of the clinical priority programmes that will be taken forward
as a transformation programme to support the development of a multi-
agency model of care for patients in crisis, standards for strengthened
mental health in primary care including access to psychological therapies,
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ensuring the delivery of access targets for the treatment of psychosis and
the design of a digital mental health support system. The exact scope of
this programme and timeframes for delivery are currently being jointly
developed between commissioners.
7.16 A significant amount of work is already underway across London to
improve services and outcomes for homeless people and rough sleepers.
However, this group of people are transitory, and so the issue is
necessarily London-wide and more needs to be done to link programmes
across London with each other and mainstream services. We therefore
welcome the recommendation to develop a multi-agency approach to
healthcare for the homeless population and extend our commitment to
working with our agency partners on developing dedicated care teams and
identifying a lead commissioner of these services.
7.17 The London Commissioning System Design Group are considering the
scope of pan-London support to develop a multi-agency approach to
healthcare for the homeless population to take forward next year.
7.18 Furthermore, NHS England (London Region) maintains its commitment to
improving services for other marginalised groups such as veterans,
offenders, those in immigration detention centres and those in asylum
hostels.
Primary care
7.19 We recognise that the recommendations set out the section for ‘Better
care for all’ will have the greatest impact on primary care, more so on
general practice. The Five Year Forward View outlines that the foundation
of NHS care will remain list-based primary care. However, given the
pressures they are under, we welcome the notion from both the Five Year
Forward View and Better Health for London that a ‘new deal’ for GPs is
needed.
7.20 The Five Year Forward View calls for the NHS to invest more over the
next five years in primary care, while stabilising core funding for general
practice nationally over the next two years. It outlines that CCGs will have
the option of more control over the wider NHS budget, enabling a shift in
investment from acute to primary and community services. Additionally,
the number of GPs in training needs to be increased as fast as possible,
with new options to encourage retention.
7.21 We welcome Better Health for London’s focus on and call for modern
general practice and the recognition that investment in general practice is
required. It is recognised that modern, accessible, purpose-built or
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purpose-designed facilities will cost more to run and so along with the
capital investment, we welcome the call for a commitment to increase the
proportion of total NHS expenditure dedicated to primary medical care
rising for each of the next five years.
7.22 We also outline our support for the recommendations for reform in Better
Health for London that come with the call for investment. We support
reform to end professional isolation and agree with supporting GPs to
work in networks, with the aim that every GP practice has the opportunity
to join and participate in a network of local practices, as well as supporting
those that are already doing so, for example in north east London. It is
important to highlight that patients being able to move freely between
networks will improve access to range of services.
7.23 We welcome the recommendation to allow existing as well as new
providers to set up new GP services in areas of poor provision. We know
that access to general practice is variable across the capital and that 60
per cent of practices in London are rated worse for access by patients
than the England average4, and we therefore agree with the need to
increase access for Londoners. We will learn from previous efforts in this
area in developing criteria for the implementation of this recommendation.
7.24 We offer our broad support for the recommendation around ambitious new
service and quality standards to be set and more tightly enforced. The
Strategic Commissioning Framework that has already been developed by
CCGs and NHS England (London Region) is the first step in responding to
this recommendation.
7.25 The Strategic Commissioning Framework for Primary Care Transformation
in London describes a new vision for general practice in London. The
Framework aims to support local planning to provide more accessible,
proactive and co-ordinated care for all of London, so that Londoners have
access to primary care that meets their needs, wants and expectations;
and also outlines some of the considerations for delivering this vision – for
example that investment, change in the ways of working and workforce,
and provider development are all needed.
7.26 It is expected that the draft Framework will proceed to an engagement
phase from December 2014 to March 2015, where London’s CCGs and
NHS England (London Region) will engage with clinicians and the public
to further develop, and understand implications of the Framework. Full
implementation of the Strategic Commissioning Framework will enable
greater access to general practice for Londoners and a higher quality of
care.
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7.27 The London Clinical Commissioning System Design Group has agreed
that the work on primary care should continue and the Group has agreed
this as an enabling priority transformation programme, building on the
Strategic Commissioning Framework for Primary Care Transformation and
to further support the development of modern general practice. The full
scope of this and timeframe for delivery is currently being considered
between commissioners.
Specialist care
7.28 The Five Year Forward View calls for more integration across care – both
horizontally and vertically. Across the NHS, urgent and emergency care
services will be redesigned to integrate between emergency departments,
GP out-of-hours services, urgent care centres, NHS 111, and ambulance
services.
7.29 Better Health for London recognises that more needs to be done to
reduce the variation in outcomes experienced by Londoners admitted to
hospitals for emergency care and meet the ambition set out to close the
gap between weekday and weekend mortality rates. Whilst we would
agree with meeting this ambition, both London’s CCGs and NHS England
(London Region) recognise that the wider system of urgent and
emergency care requires transformation in order to provide access to the
highest quality of care. We would like to widen the ambition and take this
transformation forward by continuing with our existing programme of work.
7.30 The London Commissioning System Design Group has agreed that
transforming urgent and emergency care in London should be taken
forward as one of the clinical priority programmes that requires a large
scale transformation programme to improve outcomes through the
establishment of urgent and emergency care networks that provide access
to the highest quality of care and support the ongoing implementation of
the London quality standards for acute emergency services. The scope of
this programme will build on the maxim set out in Better Health for
London: to start with Londoners, not London’s NHS consider the different
needs, wants and expectations of London’s population groups that use
urgent and emergency care services. The timeframes for delivery are
currently being considered between commissioners.
7.31 The Five Year Forward View highlights that the future will see far more
care delivered locally but with some services delivered in specialist
centres. Better Health for London also calls for some services to be
provided at scale, in centres of excellence which have the very best
equipment and expertise.
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7.32 Better Health for London recognises that whilst progress has been made
with developing centres of excellence in London, based on life-saving
principles, there remains much more to do in specialist areas like
cardiovascular, cancer, and elective orthopaedic services in particular.
7.33 More widely, Better Health for London urges that the momentum created
by life-saving initiatives for specialist care like Healthcare for London
should be given new impetus. Other parts of the specialist care system
that could benefit from the same approach should be actively directed
towards reform, and those programmes which are already under way
should be accelerated.
7.34 We are committed to working with our partners in the Integrated Cancer
Systems to drive forward the implementation of the Five Year Cancer
Commissioning Strategy for London. Part of this will be to support the
acceleration of plans develop sustainable centres of excellence for rarer
cancer care in order to reduce variation and improve outcomes and
patient experience.
7.35 NHS England is responsible for the commissioning of three national
cancer screening programmes and so just as importantly, we maintain our
commitment to working with the Integrated Cancer Systems to improve
early detection and awareness of cancer. Furthermore, we are committed
to working with our partners to improve the lives of those living with and
beyond cancer.
7.36 Cancer has been agreed as a clinical priority programme by the London
Commissioning System Design Group to be taken forward as a
transformation programme to support the development of centres of
excellence for rarer cancer and the delivery of the Five Year Cancer
Commissioning Strategy for London which sets out a compelling case for
accelerating the pace of transforming cancer services so that every
Londoner receives a world class experience from prevention, through
early detection to treatment, subsequent support and for end of life care.
The exact scope and timeframes for delivery are currently being
considered between commissioners.
7.37 Some consolidation of cardiovascular services has taken place and we
welcome the recommendation to accelerate plans further. Consolidating
the existing providers of cardiovascular procedures into specialised
centres of excellence would cement these improvements further.
7.38 Additionally, we know that patient outcomes for patients undergoing
elective orthopaedic procedures currently vary depending on where
Londoners live and are treated. Huge variations are seen across waiting
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times, infection rates and lengths of stay. We therefore support in principle
the recommendation to review this service area and ascertain the level of
change that may be needed.
8. Maximising science, discovery and innovation to enhance
economic growth
8.1 The Five Year Forward View calls for the NHS to become one of the best
places in the world to test innovations that require staff, technology and
funding all to align in a health system, with universal coverage serving a
large and diverse population. In practice, our track record has been
decidedly mixed, and we have lagged behind other industries in our use of
digital technology to improve experience and outcomes. The Five Year
Forward View highlights that too often single elements have been ‘piloted’
without other needed components. Aligning the work of the Academic
Health Science Networks, NHS Improving Quality and the NHS
Leadership Academy is highlighted as supporting this.
8.2 We offer broad support for the Better Health for London recommendations
to maximise science, discovery and innovation to enhance economic
growth, and for London to be a test site or ‘incubator’ for the development
of innovative practices. In doing so we support the three Academic Health
Science Networks in London to forge greater links with commissioners to
ensure priorities are aligned and supported.
8.3 We support the process of engaging London’s Academic Health Science
Centres and Networks – recognising the dialogues and collaborative
working that has taking place during the London Health Commission.
8.4 Better Health for London highlights the need to build upon our Capital’s
assets such as our thriving research and development in the life science
sector, valuable datasets, global corporations, top class talent and of
course our large and diverse population.
8.5 We echo the call from the Five Year Forward View in recognising the
expanded role of the Academic Health Science Networks in supporting
innovation, not just in technology but in supporting broader care delivery
and prevention too.
8.6 The focus areas identified for further investment and research (digital
health and dementia) are welcomed and supported by London’s CCGs
and NHS England (London Region). Digital health is a particular focus of
the Five Year Forward View and investment in this area in new
approaches within London – including app development and the use of
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other digital technologies – will enable greater self-care and self-
management. We are committed to developing partnerships with the
voluntary sector and industry to support digital inclusion.
8.7 We also welcome the recommendations for London to trial new
approaches to patient reported outcomes and personally controlled
budgets. These recommendations align to the National Information
Board’s framework for action, Personalised Health and Care 2020: Using
Data and Technology to Transform Outcomes for Patients and Citizens.
The framework describes how data and technology should be used to
increase personalisation and improve patient experience and quality of
care through information sharing, improved processes, and greater
efficiency and transparency. The framework references the opportunities
afforded by Better Health for London in providing the conditions to enable
innovation and better access to innovative treatments through the
enhanced use of technology and information sharing between and across
institutions.
8.8 We support data sharing and streamlining of trials. We were pleased to
read that the National Institute for Health Research and the Medical
Research Council have invested to improve recruitment for clinical trials,
improving London’s attractiveness as a place for research. We hope that
our support for data sharing and streamlining of trials will ensure that the
pace of adoption and innovation increases.
8.9 Whilst recognising that industry will be key partners in delivering these
recommendations, it is important to highlight that these are all areas
where London has a key competitive advantage which can therefore
support our Capital city to lead the way – this has the potential to benefit
the whole country.
9. Making it happen
9.1 Better Health for London sets a bold agenda for improving health and care
in London. Implementation of the recommendations relies on our
commitment as commissioners of healthcare in London, as well as our
partner organisations such as Public Health England, local authorities, and
the Greater London Authority to take things forward. As such, we welcome
the focus on the critical enablers to make many of the recommendations
to improve outcomes a reality, specifically changes to:
The way NHS information is handled in London;
How the NHS pays for services in London;
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The NHS estate in London; and
The NHS workforce in London.
9.2 We are broadly supportive of these recommendations. We acknowledge
that changes in reform for each of these critical enablers also echoes the
calls made nationally in the Five Year Forward View for example changes
to regulatory, pricing and funding levers, support for a modern workforce,
exploiting the information revolution and driving efficiency and productive
investment.
Information
9.3 The Five Year Forward View calls for exploitation of the information
revolution and as health and care commissioners we welcome and we will
embrace Better Health for London’s call for advanced data analytics to
better understand care needs and to commission higher quality care.
Again, these priorities are aligned to the National Information Board’s
framework for action, Personalised Health and Care 2020: Using Data and
Technology to Transform Outcomes for Patients and Citizens.
9.4 We welcome the emphasis in Better Health for London on the
personalisation of health and care by supporting the increased sharing
of data through technology for patients, citizens and those that care for
them. London CCGs and NHS England (London Region) are also uniquely
placed to work in collaboration with AHSNs, Local Authorities, the Health
and Social Care Information Centre (HSCIC) and other partners in driving
forward solutions in real-time information exchange – the ‘electronic glue’
that the Five Year Forward View refers to that will enable systems to talk
to one another for the benefit of direct patient care, commissioning and
research.
Funding and allocation
9.5 We agree in principle with Better Health for London’s recommendation to
promote greater equity in financing. Whilst the principle is understood it is
important to highlight that there are different ways to deliver
transformational change. There is an important role for London’s leaders
to ensure that the national allocation formula fairly takes account of and
reflects the real needs of Londoners and the characteristics of inner and
outer city areas.
9.6 As commissioners we support the principle that there needs to be greater
equity in financing the health and care system to effect the
transformational change required in London, we would add to this that
managing transition and having appropriate governance in place is also an
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important principle. There are however different ways of ensuring this
greater equity in financing and along with NHS England (London Region),
London’s CCGs and Strategic Planning Groups should consider
developing local initiatives to promote financial stability, learning from
examples elsewhere.
9.1 London’s CCGs and NHS England (London Region) recognise that there
is a need to invest in transformation at all levels and we offer general
support for the establishment of a transformation fund. We support that
scale is needed to deliver some of the recommendations and some
propositions will be better delivered together where added value is
demonstrated. Some areas of London have already invested in a
Transformation Fund for example, north west London. As the scope of the
transformation work needed in London is further defined in the coming
months, the level of investment in the transformation fund will be agreed.
Estates
9.2 We very strongly support the recommendations for estate and capital and
we would like to note that implementation of these recommendations are
critical to delivering real strategic change. We are enthusiastic at the
prospect of London being a test bed for driving important changes that are
needed not only in the Capital, but across the country.
9.3 Implementation of these recommendations will require new partnerships
and different ways of working which we are committed to. We would also
urge support from our partners for example the Department of Health,
NHS Property Services, Community Health Partnerships, Monitor and the
Trust Development Authority and are pleased to highlight that discussions
to build this support are already underway.
9.4 We would like to highlight our commitment to work with our local authority
partners, NHS Property Services and Community Health Partnerships in
the development of Strategic Planning and Capital Boards to ensure that
estates planning becomes a core element of strategic commissioning and
planning.
9.5 Estates issues are a significant constraint on the development of primary
care. Much primary care estate comprises small residential style
properties not fit for to provide modern primary care and community
services. However, the NHS is unable to improve this estate due to the
ownership model, where most primary care estate is not owned by the
NHS but by practice GPs, self-employed contractors, with their property
their principle asset.
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9.6 We welcome the recommendation to bring changes to rent reimbursement
for general practice, and highlight that for this recommendation to be
implemented, it will require genuine alternative premises offered with the
appropriate revenue implications fully factored in. There is considerable
evidence that the value of the surplus and underused NHS estate in
primary, community and acute settings could help to meet this cost.
9.7 The London Commissioning System Design Group has agreed that
estates will be a priority enabling programme to support transformation in
other areas, for example primary care, as well as supporting the reform of
acute hospital estate and strategic estates planning. The exact scope and
timeframe for delivery of this programme is currently being considered
between commissioners.
Workforce
9.8 There is no doubt that health and care services must change to meet the
needs of our population within the financial constraints which we operate.
The workforce needs to be ready to deliver within new delivery models
which will often require new training and education.
9.9 To achieve the level of transformation of service delivery and clinical
behaviour envisaged in the recommendations set out in Better Health for
London will require significant investment in the development of the
current and future workforce. This requires a level of proactive partnership
working by London’s commissioning community (NHS England (London
Region), CCGs and local authorities), Health Education England and the
provider leadership community to enable the continuation of the journey
we are on to achieve this.
9.10 We extend our support to our partners in Health Education England to
deliver the recommendations to support a modern workforce. The call for
this is outlined in both Better Health for London and the Five Year Forward
View. A modern workforce will enable the delivery of more personalised
care – which as commissioners of health care in London – we all strive to
achieve.
9.11 Not only do we extend our support to Health Education England to deliver
the recommendations to support a modern workforce but we also commit
to working proactively with them to ensure that the levers for change that
we control are aligned to support the pace of change that will be
necessary.
9.12 In addition, we support our partners at the Trust Development Authority
and Monitor to work with the Greater London Authority to encourage the
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transfer of unused NHS buildings for redevelopment and disposal and
hope that this will support affordable housing for our NHS workforce.
10. Leadership
10.1 We wholeheartedly agree with the Commission’s ambition for London to
be the healthiest major global city, and we also recognise that this will take
significant leadership from the Mayor, from local councillors and their
officers, from the NHS and from many other parts of London’s institutions
and society.
10.2 Whilst we note that the recommendation for you as the Mayor to appoint a
London Health Commissioner – a champion for health to lead the better
health agenda between local government, public health and the NHS – is
not one for the NHS in London to lead the implementation of, we wanted
to bring to your attention our thoughts on this recommendation.
10.3 We welcome a role which is facilitative in championing health, and
engaging other GLA departments in health, rather than a scrutiny role.
This would be beneficial in putting London’s case forward nationally,
ensuring we are funded appropriately.
10.4 It is important to highlight that we believe that creating a further level of
bureaucracy should be avoided. Additionally, there would need to be
agreed funding for the post to be successful rather than this being funded
from NHS budgets.
10.5 We agree that one of the greatest strengths and uniqueness of the
London Health Commission has been the joint working between local
government and the NHS to build a strong coalition for change. Moving
forward, we recognise that there is a need to build on this to strengthen
strategic leadership for health in the Capital by closer collaboration. We
are committed to working together with Public Health England to meet this
leadership challenge.
10.6 We broadly support the recommendation for NHS England to further
empower CCGs to work together in different ways – with their local
authority partners – to improve the care across multiple boroughs.
10.7 Whilst the recommendation to devolve further decision-making powers to
Strategic Planning Groups is broadly supported, Strategic Planning
Groups should be able to organise themselves in different ways providing
that their organisation will enable them to function effectively. We highlight
that a ‘one size fits all’ approach is unsuitable.
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10.8 Currently Strategic Planning Groups are responsible for creating five year
strategic plans, and some also play a leading role in major acute service
reconfiguration and developing out of hospital strategies. In addition,
Strategic Planning Groups may play an increasing role in primary care
commissioning, specialist commissioning and the development of
Strategic Planning and Capital Boards.
10.9 The London Commissioning System Design Group is currently working to
consider the relationship between NHS England (London Region) and
Strategic Planning Groups and outline the most effective ways of working
together going forward. In doing this, it may be that Strategic Planning
Groups will have to revisit their current governance structures.
Transparency in this process is supported and we highlight that any
Strategic Planning Group arrangements should be as equally as
transparent as those of CCGs.
11. Our transformation priorities
11.1 Following the publication of Better Health for London, the London
Commissioning System Design Group was established with representation
from London’s 32 CCGs and NHS England (London Region) to take
forward the planning of the delivery of the recommendations made to the
NHS in London.
11.2 The London Commissioning System Design Group has agreed four
priority clinical transformation programmes to be taken forward:
Urgent and emergency care;
Children;
Mental health;
Cancer;
Prevention; and
Homeless services.
11.3 The individual scope of these programmes are currently being considered
between commissioners along with the timeframe for delivery to ensure
the momentum for implementation of the recommendations is maintained.
The fundamentally different way of viewing the population outlined in
Better Health for London will be core to the development of the
programme scopes to ensure the different needs and expectations of
different population groups are reflected.
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11.4 To support the delivery of the clinical priority transformation programmes,
a number of priority enabling transformation programmes have also been
agreed:
Primary care;
Business intelligence and interoperability;
Estates;
Engagement;
Payments and funding;
Specialised commissioning; and
Workforce.
11.5 Similarly to the clinical priorities, the individual scope of the enabling
programmes are currently being considered between commissioners
along with the timeframe for delivery to ensure the momentum for
implementation of the recommendations is maintained.
11.6 London’s CCGs and NHS England (London Region) are committed to
working with our partners to continue to develop the exact scope of these
programmes and outline the resources required to deliver them. The aim
of these programmes will be to address the recommendations set out in
both Better Health for London and the Fiver Year Forward View. Through
implementing these recommendations we will strive to truly transform
health and care for Londoners and deliver the improvements in health,
care and outcomes that we all aspire to achieve.
11.7 At the time of writing, the London Commissioning System Delivery Group
have agreed to take forward the priority programmes outlined in the
previous section and is working to agree the exact scope and timeframes
and the associated resources required. It is expected that these will be
agreed by the end of December 2014.
11.8 By the end of March 2015 it is expected that the level of investment
required will be established and a commitment made to the
Transformation Fund to drive these transformation programmes forward.
11.9 In recognition of the considerable amount of work to do to mobilise what is
being proposed, NHS England (London Region) has agreed to pump
prime the initial process of establishing the transformation programmes
and the governance arrangements to support them. To do this NHS
England (London) will make available £1 million of funding for 2015/16.
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12. Summary
12.1 We hope that you have found this response to be useful and we look
forward to hearing more from you. We recognise that implementation of
the recommendations will require action at all geographic levels –
borough, CCG, Strategic Planning Group and pan-London – and across
all parts of London and nationally. We are looking forward to working with
our partners across London to secure the opportunity that Better Health
for London provides to us as commissioners of healthcare in London, to
make implementation of the recommendations a reality for the benefit of
Londoners – to truly make London the healthiest global city.
12.2 We hope this response has demonstrated real commitment to
transformational change and making the recommendations a reality for
Londoners and hope that this commitment will be matched by our partners
and the Mayor.