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Transforming Services Together Strategy and Investment Case

Part 1: Summary

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About Transforming Services Together The Transforming Services Together programme, established by Newham, Tower Hamlets and Waltham Forest Clinical Commissioning Groups (CCGs) proposes working in partnership to deliver high-quality, safe and sustainable services for local people.

The CCGs have developed these plans with patients, the public and their representatives and over 300 health and social care staff (for instance surgeons, pharmacists, midwives, nurses, GPs, practice managers, healthcare assistants and managers) in Barts Health NHS Trust; neighbouring CCGs – in particular, City and Hackney CCG, Barking and Dagenham CCG, Havering CCG and Redbridge CCG; Homerton University Hospital NHS Trust; East London NHS Foundation Trust; North East London NHS Foundation Trust; local authorities (including public health teams) – in particular the London Boroughs of Newham; Tower Hamlets; Waltham Forest; and Redbridge; NEL Commissioning Support Unit; NHS England – responsible for specialised commissioning; and the Trust Development Authority.

We will be testing our ideas with staff, local communities, partners and patient representatives, through meetings, workshops and other methods of engagement.

To make your views known please contact us:

Phone: 020 3688 1540 Email: TransformingServicesTogether@nelcsu.nhs.uk

Website: www.transformingservices.org.uk

or fill in the questionnaire at the back of this document. Whilst we will continue to discuss these proposals throughout their development, we will be finalising this Strategy and Investment Case early in the summer of 2016, so if you would like to contribute to this, we need your comments back by 22 May 2016 at the latest.

To view the full document please take a look at our website or contact us for a copy.

This document is intended to stimulate debate. We look forward to hearing from you.

Note: East London is the term we use for the boroughs of Newham, Tower Hamlets and Waltham Forest. This is the focus of this strategy.

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Contents

Foreword ............................................................................................................................... 4

1. The challenges we face ................................................................................................. 5

The future challenge means the NHS and social care has to change ................................ 5

Existing challenges ............................................................................................................ 5

2. How we could create high quality, safe and sustainable services ................................... 7

Our strategy....................................................................................................................... 7

The expected outcomes .................................................................................................... 8

3. Getting the basics right .................................................................................................. 9

The estate ......................................................................................................................... 9

IT and informatics ............................................................................................................ 10

Our workforce .................................................................................................................. 10

Multidisciplinary teams .................................................................................................... 11

4. Our proposals in detail ................................................................................................. 12

Prevention ....................................................................................................................... 12

Delivering care closer to home ........................................................................................ 12

Strong sustainable hospitals ............................................................................................ 15

Working across organisations to continually improve care ............................................... 18

5. Finance ........................................................................................................................ 22

6. The health economy .................................................................................................... 22

7. Next steps .................................................................................................................... 23

Questionnaire ..................................................................................................................... 24

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Proposed Foreword Transforming Services Together was established to improve the local health and social care economy in Newham, Tower Hamlets and Waltham Forest – very much in line with the challenges of the NHS Five Year Forward View1, local and regional plans and guidance2.

Celebrating success

Whilst this document focuses on where we need to improve, it is worth recognising some of the huge achievements of the NHS over the past 20 years and appreciate the efforts made by everyone working in health and social care. We have one of the best trauma centres (at the Royal London) not just in the country, but in the world. We have improved the quality and accessibility of primary care services; our services for Tuberculosis, mental health, carers, our websites and management have been recognised nationally. Stroke care is second to none and mortality ratios at our hospitals (a key measure of how safe services are) are some of the best in the country. By working together we are ensuring local people are far more likely to survive diseases such as heart disease than people in many other parts of the country3.

A partnership approach

But, we also recognise the complex challenges: a rising population; financial and workforce pressures; and in some cases poor patient care, estates and infrastructure.

Where we live, our environment and socio-economic situation is critical for wellbeing. We recognise the responsibility that local authorities have for the health and wellbeing of their populations and the potential this has to reduce the burden on the health service. Together we have developed proposals to respond to some of the challenges and take advantage of the opportunities we face. Clinicians have led the discussions, in partnership with key stakeholders and members of the public. We welcome the honesty that everyone has shown in reflecting on what is wrong with the existing system and their dedication in developing new ideas on how to make the changes that are clearly necessary.

We are encouraged by the enthusiasm for change, the willingness of all partners to work together and the strong belief that solutions can be found. Thank you to everyone who has taken part so far (over 1,000 of you). We want to develop a new partnership with local people. It is your NHS, and we know it is a much valued and respected institution. The health service, staff, partners, patients and residents need to work very differently with each other and everyone has a part to play.

Our plan

This document outlines the key health and social care changes and investments needed in East London. We have set out a credible plan to transform the services that almost one million people (and rising) rely on. We must ensure that we provide the patient experience that our populations expect, and the services that keep them well and safe. Most importantly these changes would set the system onto a path towards financial sustainability. We look forward to hearing from you.

Signatures

1 NHS England www.england.nhs.uk/ourwork/futurenhs/ 2 London Health Commission www.londonhealthcommission.org.uk/better-health-for-london/ 3 Health and Social Care Information Centre. January 2015 www.hscic.gov.uk/pubs/shmijul13jun14

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1. The challenges we face The future challenge means the NHS and social care has to change

Our population is projected to grow considerably. Over the next 15 years, the population of Newham, Tower Hamlets and Waltham Forest will probably grow by 270,000 – the size of a new London borough. We anticipate thousands more births each year and, as people live longer, so their health and social care needs will also increase.

But we are approaching the capacity of our buildings if we continue with the current configuration and ways of working. Our hospitals face unprecedented demand for services and population growth will require a further 550 beds over the next 10 years if we don’t change the way we work. Extra funding from the population increase will not cover this cost, and in any case it would be misplaced. We need to redesign services to keep people out of hospital in the first place.

There are changes underway that will impact how our services operate. King George Hospital’s emergency department is expected to close, which will mean an increase in demand at Whipps Cross and Newham hospitals. We need to develop new partnerships; new forms of finance and payments that encourage innovation and efficiency; and new organisations to integrate care.

Existing challenges On their own, these future issues would require considerable focus and attention to address, however the NHS in our area is already facing a number of major challenges.

Health and social care budgets are being squeezed. The spending freeze to NHS budgets, and spending cuts to local authority budgets will place a greater financial strain on services – in particular in areas of care where integration between health and social care is so important. Whilst CCG finances are currently in balance, they are predicted to deteriorate rapidly over the next five years and Barts Health already has the largest expected deficit in the NHS at about £135 million.

We need to improve the quality of care and patient experience. There are issues in access to, and experience of, primary care and other services in the community. Around 40% of respondents to the GP National Patient Survey reported that they could not see a GP of their choice and over 30% found it difficult getting through on the phone. Some of our health services are world class, but too many are not. Barts Health is struggling to meet the London Quality Standards. In June 2015 the Care Quality Commission assessed patient outcomes at Barts Health as being at, or better than, the national average across most medical and surgical at the hospital, but it also highlighted a significant number of areas where improvements are required and rated the trust ‘inadequate’4. In response, the trust published Safe and Compassionate5 which describes how, by working with staff, patients and partners, the trust will deliver lasting improvements.

Our workforce is stretched. We are struggling to recruit and retain the number of staff we need. For example there is an existing shortfall of more than 730 nurses (around 13% of the total) in East London providers and there is a higher than

4 www.cqc.org.uk/provider/R1H 5 www.bartshealth.nhs.uk/media/286492/150915%20BH_Improvement_Plan_FINAL.pdf

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average turnover of staff6 (around 2,800 staff leave our hospitals each year – around 15% of the total). There are significant staff shortages in some critical specialist roles – such as in emergency medicine and paediatrics. There is a shortfall in primary and community care too – over 40% of male GPs in Newham and Waltham Forest are approaching retirement age; we already spend too much on agency staff to plug the gaps.

We need to address the high costs of living, low staff morale in some places and a lack of clear development and training routes.

We need to change the social culture of over-reliance on medical (and often emergency) services. Life expectancy is worse than the rest of England – environmental factors and deprivation are of critical importance and need to be tackled. Supporting people to look after themselves, and better prevention of illness, would make the most significant difference to people’s health – and yet we do not prioritise this area of health. We recognise that influencing this change is particularly difficult given the diversity and transient nature of the population.

Our facilities and IT systems are not always set up to deliver high quality or efficient care. We have some of the most modern and high-tech facilities in the country – such as the new Royal London Hospital and the Sir Ludwig Guttmann Centre in Newham. However, many of our community facilities are under-used or inappropriately fitted out, too small, or in the wrong place for the services we need to deliver. We also have many old buildings that require significant investment just to maintain them (Whipps Cross requires over £80m of investment in its buildings).

Our IT systems are not fit for purpose. Poor equipment and a lack of interconnectivity inhibits delivery of efficiencies and improved services.

If we allow things to continue as they are…

we will need an extra 550 inpatient beds by 2025 (costing around £450 million to build and £250 million a year to run). Overall our organisations will be in deficit by almost £400 million by 2021/22. We wouldn’t be able to recruit the workforce to staff these beds, and we know that hospital is not the right place for many people7.

patient experience will decline and patient safety will be put at risk. People will face a confusing health system, and will need to wait longer for operations or travel outside of the area for some planned care. People with a mental health illness will continue to be poorly treated compared with patients with a physical illness. Too many people will continue to die in hospital rather than in a homely surrounding. Patients and staff will have to cope with poor environments. We won’t be able to bring care closer to home; we won’t take advantage of the opportunities to transform the morale of our workforce and our finances will deteriorate8.

6 Compared with the Health Education North Central and East London area. HSCIC workforce statistics July 2015 www.hscic.gov.uk 7 Audits show that up to 40% of beds are occupied by people who do not need hospital care. 8 The Review of Operational Efficiency in NHS Providers (June 2015) suggested that the NHS overall could save £5 billion a year by making efficiencies in workforce and productivity; and improved medicines, estates and procurement management.

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2. How we could create high quality, safe and sustainable services

Our strategy Our strategy aims to:

support the health and wellbeing strategies of our boroughs, helping people to stay healthier and manage illness; and to access high-quality, appropriate care, earlier and more easily

change the culture of how we commission and deliver care

increase involvement of patients and carers in co-production and shared decision-making

maximise the use of the assets in our communities and voluntary sector

commission activity to be in fit-for-purpose settings of care, often closer to home

focus some surgery in fewer locations to improve patient outcomes and experiences and drive up efficiencies

acknowledge the importance of supporting people’s mental health and well-being

ensure the system is flexible enough to respond to changing demands

help set our finances on a path of sustainability in a challenging environment.

To ensure we will meet these aims, we have established three ‘clusters’ – which are responsible for the overall delivery of the programme. Each of these clusters has developed specific initiatives to address key priorities for change.

Cluster Initiative

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Three important themes are integrated throughout the clusters and initiatives. These are: Helping people manage their health better Mental health Children and young people

The expected outcomes

The impact of these initiatives, if they are delivered through a coordinated, integrated plan over the next five years, alongside productivity improvements, will be:

a fairer service, treating the needs of everyone in society

a healthier population and patients who experience better care

significantly more care being delivered closer to home, in more efficient care settings

a workforce that is more suited to deliver efficient and effective modern healthcare; staff who better understand their role, who feel supported and who are enthused about their job, healthcare and the NHS

that hospitals are able to relieve the existing pressure on beds; can cope with the increase in population and long term conditions; and can reduce waiting times, or create opportunities for new income streams

improvements in clinical quality. We expect these proposals to directly support the Safe and Compassionate improvement programme and the transition of Barts Health out of special measures

net savings from the TST programme of between £104 million and £165 million over five years. By year five the annual saving is £48 million. The most likely position if we deliver the changes described in this document; internal cost improvement programmes (CIPs); and quality, innovation, productivity and prevention (QIPP) programmes, is one of overall balance with some organisations being in surplus and some in deficit.

A significant reduction in the capital requirement. The TST programme proposes a budget for buildings and infrastructure of £72 million by 2021 (excluding essential estates and IT works), but the requirement if TST is not put into action is £250 million.

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3. Getting the basics right

Patients have told us that getting the basics right improves clinical care as well as the patient experience. Patients want to be seen in well maintained buildings; they don’t want to have to tell their story to every member of staff that they meet because our IT is not joined up; they want staff to talk to each other and coordinate care, be caring as well as competent, to understand that little things make a real difference, and above all to recognise that every person is different.

The estate Our aim is for a flexible and fit-for-purpose estate. It will be actively managed and well used, with opportunities taken to share space with other services benefitting the public.

Primary and community care

GP practices are of varying quality and suitability in each borough; the traditional model of small GP surgeries is no longer suitable. We need fewer smaller practices and larger ‘hubs’, where a greater range of primary and community care services can be delivered in an efficient and modern setting. GP practices should cater for 10-15,000 patients or be working as part of a network, or collocated with other practices. Larger facilities of over 30,000 patients should host on-site minor surgery units, sexual health clinics, enhanced test facilities and community learning environments with access to nutritionists, health coaches and community groups.

Newham: The Vicarage Lane site in the north west of the borough would be a good location for a primary care hub. A second hub could be at the Sir Ludwig Guttmann Health Centre in Stratford. Centre Manor Park could be a good location for a third hub with two further hubs in Royal Docks ward and Canning Town.

Tower Hamlets: The hubs could be at: St. Andrew’s Health Centre; Barkantine Centre; East One Health Centre; Blithehale Health Centre with an additional hub in Whitechapel.

Waltham Forest: Wood Street and Comely Bank could provide a good location for a primary care hub. A second hub could be at St James Health Centre; a third at Highams Hill. A fourth hub could be located around the adjoining Ainslie Therapy/Rehabilitation and Highams Court sites; a fifth hub could be at Thorpe Combe Hospital.

Acute care

The Barts Health estate includes some of the most modern and efficient facilities in London, but includes some of the worst. There are opportunities to improve many facilities, and to consolidate and dispose of parts of the estate that are inefficient or in locations where they hold considerable value to a residential or commercial market.

St Bartholomew’s Hospital: Complete the phased redevelopment of parts of the site; consider disposing poorly used or unsuitable parts of the site; develop and preserve elements of the historic, heritage aspects.

Royal London Hospital: Increase the density (and therefore efficiency) and improve the clinical co-location of services on the site; progress the sale and transfer of the old Royal London hospital to the London Borough of Tower Hamlets; progress plans to develop two further plots of land into a life sciences specialist centre, in collaboration with local education partners.

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Mile End Hospital: There is an opportunity to consider greater integration of acute9, community, mental health and primary care services. A system-wide strategy is required to define the most appropriate use of the site.

Newham University Hospital: Develop the Gateway surgical centre to allow greater activity, in particular orthopaedic surgery.

Whipps Cross University Hospital: There is a continuing (and growing) demand for acute and emergency services on the site. Working with local partners, a system-wide long-term strategy is needed for the site.

IT and informatics The NHS collects vast amounts of data and we can use this much more intelligently, systematically and transparently. Developing joined-up information systems will support more effective, integrated healthcare.

We want people to experience services that are truly seamless, with effective signposting, co-ordination of care and exchange of information supporting every patient’s journey. All clinicians should have access to key patient data to make decisions and reduce the risk of gaps and duplications in care. We will focus on ensuring:

1. the infrastructure (computers, cables, services) is up to the job of supporting reliable, fast access to systems

2. wherever a patient is seen or a decision made in the health and care system, the appropriate data from every responsible health and care organisation is available safely in a real-time easy-to-use way

3. we can combine data from every organisation to inform and prompt changes to treatments and care pathways

4. patients get access to their record so they can take control of their own health.

Our workforce There is a limited labour supply in East London, made worse by high turnover and retirement rates. We struggle to recruit to key roles, such as nurses, social workers, allied health professionals and emergency consultants. Rising costs are making living locally impossible for many nurses and support staff, with few key worker incentives offered, such as affordable housing.

We will address some of these challenges through the introduction of new roles, new ways of working and initiatives such as encouraging:

recruitment. We will work with universities and other education providers to offer academic courses for new roles (e.g. physician associates and advanced nurse practitioners). We will encourage young people to work in the NHS by working with local schools and education establishments and develop apprenticeships and internships. We will market the attractiveness of working in the NHS in East London.

9 Acute care is the name we use for care that is normally provided in a hospital for serious conditions needing 24/7 nursing under the direction of a consultant.

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retention of staff through training and development opportunities, flexible working options and financial incentives. These could include ‘golden hellos or handcuffs’, support with the high costs of London living and transport, key worker housing, bursaries or student loans to incentivise hard-to-fill vacancies. We will also look at removing perverse incentives such as high pay for bank and agency staff.

Multidisciplinary teams Delivering care in multidisciplinary teams is central to a number of initiatives including improving surgery, urgent care and primary care:

The services available at the front of our emergency departments need to be broadened by bringing together a wider range of staff and facilities. By doing so we will be able to care for a much greater proportion of patients and conditions without having to impact on the emergency department.

Collaborative working is also needed in the community, with GPs, pharmacies, dental, community health and social care services (all connected by IT systems) working together to provide an integrated urgent care response, closer to where people live.

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4. Our proposals in detail Prevention People in East London have some of the shortest life (and healthy life) expectancy in the

country. We aim to change the existing culture of over reliance on medical/hospital services to one where prevention of ill health is given greater priority, and people take more responsibility for their own health. However this cannot be fixed by health services alone.

The NHS must work with all organisations, including social care and the voluntary sector to:

support people to live healthier lives make our schools and workplaces healthier identify physical ill health earlier – for instance through screening programmes.

Achieving this would mean a healthier population, with improved quality of life, a reduction in emergency department attendances and admissions to hospital, more supportive patient care, and healthier staff.

Delivering care closer to home GPs with a registered list of patients need to remain as the foundation of NHS care. Over the next five years the NHS will invest more in primary care. The number of GPs in training needs to be increased as fast as possible, with new ways to encourage retention.

We need to integrate emergency and ambulance departments, GP out-of-hours services, urgent care centres and NHS 111 so people can get the right care at the right place at the right time.

Too many people go into hospital or stay in hospital longer than is necessary. Co-ordinated support early on, focused on a person’s wellbeing as well as their health and social care needs, can reduce their dependency on services in the long run and ensure that admission to hospital only happens when it is really needed. Transformation will require new partnerships with local authorities, communities and employers, with decisive steps being taken to break down the barriers between GPs and hospitals, physical and mental health, health and social care.

New integrated providers will enable the NHS to take a more rounded view of patient care.

We are also committed to developing local payment schemes and supporting leaders creating innovative solutions to local challenges.

Delivering these changes could deliver significant beneficial health outcomes, reduced health inequalities, radically improve patients' experience of interacting with the NHS, improve efficiencies and enable the NHS to manage the expected increase in attendances:

Some activity in GP surgeries can be delivered in pharmacies and by supporting self-

care

Around 180,000 outpatient appointments, can be provided in alternative ways that

are more convenient to patients

92,000 extra attendances expected at Barts Health emergency departments a year

(by 2020) can be accommodated by shifting activity to primary care and improving

pathways and system efficiencies.

To deliver care closer to home, we have prioritised a number of key initiatives:

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Initiatives and the case for change

Proposals What we will deliver in five years

Integrated care Too many people go into hospital or stay there longer than necessary.

Integrated care provides co-ordinated health and social care in patients’ own home or in the community to help them stay well or manage their illness. We want to improve our services and extend integrated care to those at moderate risk of hospitalisation (it is currently only available to those at high risk of hospitalisation).

People with moderate risk of hospitalisation will manage their health better, stay well, be able to live in their own home or the community (rather than have long spells in hospital) and reduce their reliance on urgent care services.

Urgent care People find it difficult and confusing to access urgent care – so they often end up going to emergency departments or calling an ambulance, which diverts attention away from people with more serious and life-threatening issues.

Simplify and integrate urgent care by: - developing a simple online directory of services - integrating NHS 111 with the urgent care system so there is

a single place where people can get advice, book urgent appointments at a primary care hub (see below), their GP or other providers

- replacing standalone walk-in centres with primary care hubs which will provide a greater range of services.

Provide more urgent care appointments in the community (including in the evenings and at weekends). Provide a more comprehensive service in urgent care centres at the front door of emergency departments.

Patients would get the care they need in a timely, easily understood and convenient fashion, helping them get back to health without the need to visit an emergency department. Around one in four patients attending an emergency department will be treated in an urgent care setting, meaning emergency departments are able to provide the best possible care to those most in need.

End of life care One in three people admitted as emergencies to a hospital are receiving end of life care. However most people would like to die in their usual place of residence.

Earlier identification of the need for end of life care, supported conversations and recording and sharing preferences and:

- better sharing of care plans - more community and end of life services - better partnership working across the health, social care and

voluntary sector – including making more use of community facilities such as hospices.

People will be able to make better choices about their end of life care and their experience of end of life will improve. A 30% reduction in bed days during the last year of life. Half the number of emergency hospital admissions.

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Primary care There is an increasing (and ageing) population and a rising burden of disease; a shortage of GPs; and patients find access and quality of care unsatisfactory. The population has some of the poorest public health outcomes in the country (for example survival of cancers and cardiovascular disease and life expectancy).

Improve access to general practice, pharmacies, dentists and optometrists, for instance by providing supportive online tools or Skype appointments. Establish proactive care, by empowering patients to take more control of their health and by offering wellbeing inductions for new patients. Coordinating care. We will make sure 20% of appointments are longer, to suit the needs of patients with complex conditions; we will continue to connect our IT systems. We believe this type of care can only be delivered in:

- primary care practices serving over 10,000 patients - smaller practices working together in networks, or in

collocated facilities at primary care hubs by a broader range of professionals (for example by creating physician associate roles or by having pharmacists working alongside GPs).

The whole population will be healthier. People will find appointments are more convenient, so minor ill health can be resolved quickly and easily. More services will be available in the community, often in the same building so patients will have less need to go to hospital. We will have more primary care staff and patients will be more able to choose a female or male GP. We will reduce patient complaints by 50%.

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Strong sustainable hospitals Even though our focus is to help people stay fit and healthy and to provide care closer to home, we need to make sure that when people do fall seriously ill or need emergency care, there are strong, safe and sustainable services in local hospitals.

We know that there needs to be a continuous focus on quality and safety. Some of our proposals are small and will cost nothing to implement, others require organisations, staff and the public to work together to deliver improvements.

We need to change the way we work if we are to cope with the extra activity expected. The existing emergency departments and maternity units will need to be retained to deliver high quality local care but we need to change the way they work:

Improved local care with specialisation where this improves outcomes and delivers safer care

In order to effectively provide care for the growing populations we need to make sure that Newham and Whipps Cross are able to deliver high quality care for the vast majority of conditions in their local population. We also need the Royal London to function effectively to serve its local community and a wider population in its role as a specialist centre. This doesn’t really happen at the moment as the site is often too busy treating emergency and very unwell patients to cater for the day-to-day needs of local people. This results in large amounts of planned surgery being cancelled and patients staying in hospital longer than they should, affecting local people and patients who have been transferred from further away.

More integration with community and social care

Our hospitals need to be better integrated with the community as well as forming stronger partnerships with charitable and voluntary organisations. We need to work to make sure that local services run as effectively as possible alongside other clinical teams both on and off the hospital sites to deliver the best care.

Working in networks across our sites and more widely

We need to be far better at organising and simplifying the acute and emergency care system and network arrangements. Our proposals will achieve both of these, standardising and improving the system and the standards of care.

The three main acute sites do not consistently meet London quality standards. For example, we know that no site other than the Royal London offers access to emergency interventional radiology in under an hour. Our approach outlines where we need to look across sites and in some cases change configurations to improve arrangements for life- or limb-saving specialist services.

We have prioritised a number of key initiatives to develop strong, sustainable hospitals:

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Initiative and the case for change Proposals What we will deliver in five years

Acute care hubs Too many people are admitted to a hospital ward as this is the only way to access rapid medical specialist opinion and tests. This means that patients who do not need 24/7 nursing care sometimes stay in hospital unnecessarily.

Bring together the clinical areas of the hospital that focus on initial assessment, rapid treatment and recovery at each site to work as ‘acute care hubs’. This would mean that the majority of patients would be treated without needing to be admitted. Only patients needing 24/7 nursing/medical care would be admitted to a specialist ward.

Fewer patients would need a hospital bed – avoiding unnecessary stays in hospital. More emergency consultant cover and quicker treatment. Improved care for adults, young people and children with physical or mental health problems.

Maternity (increase the proportion of natural births) Over the next 10 years the number of births will increase – thousands more births every year. Women report some of the worst experiences of care in London. Too many women don’t have real choice of where they have their baby – often giving birth in an obstetric-led ward which place women at higher risk of interventions and operations compared with planned midwife-led births.

Introduce new ways of working that provide more informed choice and promote more natural delivery. We want to ensure women have real continuity of care so they are supported throughout their pregnancy and can have a more natural birth in midwife-led settings.

Women will feel better supported through their pregnancies with an improved experience of care. Better, safer care and a reduction in unnecessary interventions. A third of women choosing to have a midwifery-led birth rather than an obstetric-led birth. The ability to care for women and their babies without having to build additional hospital capacity.

Surgical hubs The quality of surgery could be improved. Too many people stay longer in hospital than necessary. A lack of coordination means that planned surgery sometimes impacts on emergency surgery and vice versa.

Create surgery centres of excellence (hubs). Newham, Royal London and Whipps Cross would each specialise in a number of specialties. This would:

- reduce waiting times and the number of patients having to go outside of the area to have surgery

- improve emergency and planned surgery

Improved quality of care. Better use of specialist equipment and staff; shorter waiting times for patients; and fewer cancelled operations. Better patient experience, for example a 10% reduction in length of stay for planned admissions.

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Many patients are waiting far too long for operations.

- reduce the number of cancelled operations. New pre-operative pathways will deliver care as locally as possible and focus on recovery and long term health improvement.

Better efficiency, for instance theatre utilisation improved by around 12%. Emergency and maternity services, and less complex surgery at each of the three hospitals would be properly supported.

Case study – surgical hubs Describing surgical services as ‘core’, ‘core plus’, and ‘complex’ provides a way of describing how they could be provided across East London. ‘Core’ services support emergency, medical and maternity care and should be available on all sites.

‘Core plus’ services require a degree of specialisation and/or resources. They require a concentration of the specialist workforce and dedicated capacity in order for care to be delivered safely and sustainably.

‘Complex’ services are required to support the treatment of complex cases, such as complex cancer or trauma. Clinical interdependencies and the input of multiple specialities are crucial to optimise safety and patient outcomes.

Each site would host core services and different combinations of core plus functions. A potential view of what surgical services might look like in East London is shown to the right.

Over the next six months we will test and enhanced this proposal (and other options) through appropriate engagement with the public, staff and local stakeholder groups.

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Working across organisations to continually improve care Many of the initiatives we are taking forward will require organisations to work together more closely than ever before. For example, clinicians from primary, community and secondary care organisations need to work together to agree pathways that speed up patients’ diagnosis and treatment. We also need to work together to increase the number of physician associates, and to define strategies for the future of Mile End Hospital and Whipps Cross Hospital.

Two themes are threaded through all our initiatives: Mental health

A quarter of the population will suffer from a mental health problem in their life. Three quarters of people with mental health problems never receive treatment. People with a serious mental health illness die, on average, 20 years earlier than

people without mental health problems.

We will prioritise improving services for expectant mothers and their partners; children and adolescents; people in crisis; and people with dementia, whilst we review the whole mental health system and develop a five year strategy.

Children and young people We recognise that an investment in the health of our children is an investment in the future. A good, healthy start in life is essential if we are to increase life expectancy and the number of healthy years people live. We need to get better at:

co-ordinating services and joint working. Young people needing healthcare are getting passed between too many people and organisations

identifying when a child or young person’s conditions could be better and more quickly treated in a community setting. There are too many referrals to hospitals

supporting children and their parents/carers to self-care and access services when necessary.

We will involve children and young people in the design and commissioning of services; we will work with schools, children’s centres and youth services which are vital settings for improving health; and we will improve the way young people transition into adult services. We will redesign children’s mental health services to make them less fragmented and work with schools to make sure mental health problems are identified earlier so that young people get the support they need more quickly. We have prioritised a number of key initiatives to improve the East London health economy:

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Initiative and case for change Proposals What we will deliver in five years

Transform the patient pathway and outpatients We are struggling to manage the number of outpatient appointments. However:

- up to 20% of referrals to hospitals are not needed

- up to 20% of patients do not attend their appointments

- the referral process is complicated - the way follow up appointments are arranged

can be ineffective – there are often better ways for patients to access specialist advice

- we don’t always help patients to manage their own conditions.

Redesign the patient pathways for some of the most common:

long-term conditions (for example cardiovascular disease, respiratory disease and type 2 diabetes)

planned care services (for example musculo-skeletal and dermatology).

Make better use of technology. Develop new processes for outpatient treatment and follow up, to improve the quality of referrals.

There will be a 20% reduction in hospital-based outpatient appointments as unnecessary ones are not made and alternative ways of meeting patient needs are developed, for example by using phone, email and Skype clinics. Patients will find the system easier to navigate and be better cared for closer to their home.

Reduce unnecessary testing Around a quarter of tests carried out on patients are unnecessary. Some GPs in East London order over 50% more high-cost tests than other GPs. This is wasteful of resources, delays diagnosis and treatment of patients who need tests, and subjects patients to the inconvenience and worry of unnecessary tests.

Standardise processes and reduce unnecessary testing in the community and in hospitals. Consider enabling GPs to refer straight to tests in hospitals (rather than having to wait to see a hospital specialist first). Improve IT to share tests between GPs and hospitals (rather than have the tests repeated).

Patients will not have to attend (and be subjected to) unnecessary tests and appointments. There will be 20% reduction in spend on the top 20 most costly GP-generated tests by 2020/21.

Shared care records There has been significant progress in sharing patient records but there is still:

Better understand what needs to be shared and how it can be made accessible, secure and useful to staff who need it and to patients.

Our shared care record infrastructure will be in place. There will be quicker, more coordinated care.

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- a lack of connectivity between all care providers

- a need for a more comprehensive system, for example being able to book services through the system, and everyone being able to add information (not just ‘read only’)

- a need to make access intuitive and simple, and to make records up to date and accurate, otherwise health and social care staff will not use them.

Increase the use of shared records. Increase the amount of information available. Increase the number of staff in health and social care organisations who can access shared records. Work with patients to gain their support and consent to view their records.

Patients will not have to keep repeating their ‘story’ and will be better able to self-care or receive care in their own home. Staff will be able to provide better care as they will have a better understanding of the patient history. We will improve efficiency as we remove our reliance on paper.

Physician associates The area needs an extra 125 GPs in five years and almost 200 in ten years – but there is already a national shortage of GPs. Physician associates can perform a large proportion of a doctor’s tasks at a reduced cost – meaning doctors can focus on the patients and illnesses that require their skills.

As well as developing different ways of working and effective ways of recruiting and retaining staff we will introduce more physician associates.

We will have developed the role of physician associate. GPs and other clinicians can spend their time providing high quality healthcare and staff skills will be better aligned with patient needs. This will breathe new life into the workforce, improving staff satisfaction and motivation. Patients will get faster, more effective services.

Mile End hospital The Mile End site offers a range of services from different providers. Barts Health has two acute inpatient wards, but these are separate from the rest of the Royal London site and this makes them difficult to manage and provide high-quality care for patients.

We will continue to provide acute mental health services at Mile End but will seek to change other inpatient services. This would enable Barts and the local health economy to develop a longer term strategy for the site which could include more step-up/step-down facilities, mental health or community service facilities or

A health economy strategy to define the long-term future for the site. Improved efficiencies (for instance reduced clinician travel times and better sharing of facilities). Improved outcomes and patient satisfaction, as clinicians have better

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even sale of underused parts of the site for educational or residential use.

sight of patients, and are able to discharge patients in a timely manner.

Whipps Cross hospital - The buildings are old and require around £80

million just to keep them safe and meeting minimum requirements.

- The buildings are not designed to deliver modern healthcare and have been developed in a piecemeal fashion over many years. For instance the maternity unit is not connected to the main site, so emergencies require an ambulance to transport mothers and babies.

- Whipps Cross has one of the largest sites in London but is used very inefficiently. It is a wasted resource.

We will work with partners across health and social care to develop a robust strategy for the long-term future for the site.

We will have set out a clear strategy, defining the long term future for the site; determined how the transformation will be delivered; and be underway in delivering the changes we need.

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5. Finance

The range of expected net savings and costs for each of the 13 initiatives is shown below.

By year five the annual saving is £48 million.

6. The health economy

Whilst TST initiatives will go a long way towards solving the big strategic challenges we face, there are a number of other initiatives that need to be delivered in partnership if we are to transform the health of our population and the health and social care system. For instance:

better prevention of illness – with local authorities and Public Health England

delivery of other savings. Even if the health and social care economy can achieve the improvements and efficiencies detailed here by 2021 there will still be an historic deficit which will require external investment, as will any rebuilding of Whipps Cross

delivering changes to other health and social care services, for example specialist services.

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7. Next steps

Success in these initiatives will be dependent on the continuation of the strong working relationships we have developed over the past year with all key partners.

Our greatest challenge is in how we develop the enthusiasm, collective responsibility, and clear, achievable plans to implement the solutions that we know people need. From February to May 2016 we will:

engage with staff, stakeholders, patients and the public to test these proposals

further develop our ideas and collate any further data that is required

develop implementation plans with a phased and prioritised programme of change. This will include working on: the interdependencies of the Care Quality Commission improvement plan at Barts Health; the interdependencies between the different workstreams, including IT, estates and workforce; and funding mechanisms/incentives

assess the impact of our proposals on travel, the environment and equalities

strengthen the leadership and capability to support the next phase of the programme

agree how we can measure, monitor and support progress towards the objectives.

We recognise that the content of some of our proposals may have to change, or that external pressures and circumstances will require a refresh of our thinking. It is certain that not every proposal will be able to be developed in the way we describe. The strategy will need to be continually monitored and reviewed as challenges and opportunities present themselves. However we are clear that not taking action now would be catastrophic for the health economy. We believe that the strategy sets the health economy on a path to deliver the changes that are needed to achieve clinical and financial sustainability.

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Questionnaire Questions We welcome your comments on any aspect of our proposals. However you may wish to think particularly about:

1. Overall strategy and scope. Do you think the overall strategy is right? Do the strategy and initiatives focus on where there is most need? Is there anything missing? Are there are proposals you think are not necessary?

2. The specifics. Do you agree or disagree with the proposals?

3. General comments about these proposals

4. Comments about the NHS in general

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About you We would find it useful if you could answer the questions below so we can see what sorts of people are responding and whether they think differently from other groups. We also want to know if any groups are not represented in the responses to this survey. Name: You don’t have to give us your name if you don’t want to and we will still take your views. Would you like to be kept up to date with information about this engagement? Yes / No If yes, please give us your email or postal address (please note that your email and / or postal address will only be used to keep you up to date on this engagement exercise and will not be used for any other purposes) Gender: Male / Female / Other / Prefer not to say How old are you? Under 16 / 16-25 / 26-40 / 41-65 / 66-74 /75 or over / prefer not to say Do you consider yourself to have a disability? Yes/ No / Prefer not to say Do you identify as: Heterosexual / homosexual / other / prefer not to say What is your ethnic background? White: White British/White Irish/Any other white background Mixed: White and Black African/White and Black Caribbean/White and Asian/Any other mixed background Asian: Asian British/Indian/Bangladeshi/Pakistani/Chinese/Any other Asian background Black: Black British/ Black African/Black Caribbean/Any other Black background Any other ethnic group: Prefer not to say Which belief or religion, if any, do you most identify with? Agnosticism / Atheism / Buddhism / Christianity / Hinduism / Islam / Judaism / Sikhism / Other / Prefer not to say Thank you for your time

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Transforming Services Together Strategy and Investment Case

Part 2: Main report

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About Transforming Services Together The Transforming Services Together programme was established in September 2014 by Newham, Tower Hamlets and Waltham Forest Clinical Commissioning Groups to deliver high-quality, safe and sustainable services for the population of East London.

It proposes system-wide transformation and partnership working to a degree not seen before in this region. The CCGs are working with their main hospital services provider, Barts Health NHS Trust and a range of other organisations, as well as members of the public, patient and public representatives and staff are also involved:

Neighbouring CCGs – in particular, City and Hackney CCG, Barking and Dagenham CCG, Havering CCG and Redbridge CCG

Homerton University Hospital NHS Trust

East London NHS Foundation Trust

North East London NHS Foundation Trust

Local authorities (including public health teams) – in particular London Borough of Newham; London Borough Tower Hamlets; London Borough of Waltham Forest; London Borough of Redbridge

NEL Commissioning Support Unit (NEL CSU)

NHS England (NHSE) – responsible for specialised commissioning

Trust Development Authority (TDA)

To find out more, please visit www.transformingservices.org.uk

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About this document This document brings together the collective work of the Transforming Services Together programme. Ambitions and proposals are set out, along with the context to a series of detailed initiatives which are the core of the Transforming Services Together programme.

Over 300 people have been involved in developing this document, including clinicians, nurses, midwives, pharmacists, primary care and social care staff and managers. Over the coming months we will be testing our ideas with staff, local communities, partners and patient representatives, through meetings, workshops and other methods of engagement.

To make your views known, please contact the Transforming Services Together team.

Phone: 020 3688 1540 Email: TransformingServicesTogether@nelcsu.nhs.uk

Website: www.transformingservices.org.uk

Whilst we will continue to engage throughout the development and implementation of any proposals, we will be finalising the Strategy and Investment Case in June 2016, so if you would like to contribute to this, we need your comments back by midnight on 22 May 2016.

There are three parts to this strategy

Part 1: A summary which includes a questionnaire to make your views known

Part 2: The main report (this document)

Part 3: A detailed analysis of each of the 13 proposed initiatives

Assumptions and terms used in this strategy:

Population growth is from the GLA (SHLAA-capped model 2013 release).

The workstreams used the best available local data on current performance and activity from local providers and national sources. Different sources, coding, submission practices and time periods means there are some limitations to this data.

Emergency care is where a patient’s life or limb may be at risk and hospital care may be required; acute care is normally provided in hospital, where the patient requires 24/7 nursing care and it takes place under the care of a hospital consultant; urgent care is where a patient may require treatment for an illness or minor injury rapidly but it is not life or limb threatening.

We use the term emergency department rather than A&E.

East London is the term we use for the boroughs of Newham, Tower Hamlets and Waltham Forest. This is the focus of this strategy. North east London (NEL) is the term we use for the boroughs of Newham, Tower Hamlets and Waltham Forest plus the City of London and the boroughs of Barking and Dagenham, Hackney, Havering, and Redbridge.

The ‘we’ referred to in this document relates to the signatories of the foreword, and the organisations they represent.

We can plan for the future, but political, environmental, economic, social and technological changes make it uncertain. We will continue to discuss and reshape our ideas and proposals in line with new knowledge, policy and developments.

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Contents 1. The case for change ...................................................................................................... 5

1.1 Our population and our services .................................................................................. 5

1.2 The challenge to the estate ......................................................................................... 6

1.3 The IT/informatics case for change ............................................................................ 10

1.4 The workforce case for change .................................................................................. 12

1.5 The financial case for change .................................................................................... 16

1.6 If we don’t change… .................................................................................................. 17

2. Getting the basics right ................................................................................................ 19

2.1 Estates ...................................................................................................................... 19

2.2 IT and informatics ...................................................................................................... 22

2.3 Workforce .................................................................................................................. 23

2.4 Organisational development ...................................................................................... 24

2.5 Working together ....................................................................................................... 26

3. Our strategy (the response to the case for change) ..................................................... 28

3.1 Helping people manage their health better ................................................................ 29

3.2 Care closer to home .................................................................................................. 31

3.3 Strong sustainable hospitals ...................................................................................... 38

3.4 Working across organisations .................................................................................... 40

3.5 Cross cutting themes ................................................................................................. 41

4. The changes we have prioritised and their impact ........................................................ 50

4.1 Expand integrated care to those at medium risk of hospital admission ...................... 52

4.2 Put in place a more integrated urgent care model ...................................................... 53

4.3 Improve end of life care ............................................................................................. 53

4.4 Improving access, capacity and coordination in primary care .................................... 54

4.5 Establish surgical hubs .............................................................................................. 54

4.6 Establish acute care hubs at each site ....................................................................... 57

4.7 Maternity – increase the proportion of natural births .................................................. 57

4.8 Transform the patient pathway and outpatients ......................................................... 58

4.9 Reduce unnecessary testing...................................................................................... 58

4.10 Deliver shared care records across organisations ................................................... 59

4.11 Explore the opportunity that physician associates may bring ................................... 59

4.12 Develop a strategy for the future of Mile End hospital .............................................. 60

4.13 Define a strategy for the future of Whipps Cross ...................................................... 60

5. Financial and activity assessment ................................................................................ 61

6. Next steps .................................................................................................................... 69

6.1 Delivery ..................................................................................................................... 69

6.2 Implementation plan .................................................................................................. 72

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1. The case for change

1.1 Our population and our services The changes described in this document build on national and regional guidance1 and local work to develop the Transforming Services Changing Lives Case for Change2. These document the scale of the challenge facing East London health and social care services.

Over the next 15 years, the population of Newham, Tower Hamlets and Waltham Forest will probably grow by 270,000 – the size of a new London borough. More births are anticipated and there is a need to plan for the increased demand on services. As people live longer, so their health and social care needs also increase. Hospitals and emergency departments already face unprecedented demand for services. Patient expectations are increasing.

There is a high level of population movement into and out of East London boroughs. For example, Tower Hamlets has 281 people moving in and out of the borough each year per 1,000 population3. This can cause difficulty in providing continuity of care. At some emergency departments as many as 30% of those attending are not registered with a GP. The urgent care system needs to be fixed to ensure patients are seen in the right care setting for their needs

Life expectancy in our boroughs is amongst the lowest in England, but that is more to do with environmental factors and deprivation in the area than a reflection on the quality of healthcare. Preventing ill health; better management of conditions by care providers before they become severe (and providing support for patients to selfcare); and treating people holistically by looking at their physical and mental health needs together is essential to the long term future of healthcare

The quality and availability of some services could be improved. Emergency department attendances are high, which indicates issues with access to, or experience of, primary care or other services in the community. Too many patients are being readmitted to hospital as emergencies within a month of being discharged; and we are not meeting all of the London quality standards in our hospitals.

Integrated care for people with long-term conditions needs to be provided and new, more efficient and effective care pathways need to be designed so that patients experience more individual care. More services need to be provided in the community, but some services and specialties also need to be brought together in the same place when there are clear advantages to patients in doing so.

Whipps Cross Hospital was inspected by the Care Quality Commission (CQC) in November 2014 and received a rating of inadequate. As a result, Barts Health NHS Trust was put into special measures. Later inspections of Newham and The Royal London hospitals also resulted in ratings of inadequate in May 2015. The special measures regime is supporting the implementation of improvement plans to address immediate issues across the three main hospital sites. The Transforming Services Together programme aims propose initiatives that support improvement.

1 E.g. the NHS Five Year Forward View and London Health Commission: Better Health for London (2014) 2 www.transformingservices.org.uk 3 Transforming Services Changing Lives Case for Change (2014)

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1.2 The challenge to the estate The Case for Change identified a number of challenges associated with the variable capacity and quality of the current NHS estate across East London. Since then a more comprehensive asset register has been developed in conjunction with NHSE, the CCGs, providers, NHS Property Services and Community Health Partnerships.

Our current estate – the challenge 1. We have a large number of buildings across East London that belong to, or are

occupied by the NHS. In total, we have 164 across primary care of which 66 are in Newham, 50 in Tower Hamlets and 48 in Waltham Forest. Our providers also have a large number of properties, with Barts Health occupying around approximately 450,000 square metres (sqm), North East London NHS Foundation Trust (NELFT) about 30,000 sqm around Waltham Forest4, and East London NHS Foundation Trust (ELFT) about 45,000 sqm around Newham and Tower Hamlets.

Most importantly, we have mapped the sites into the NHS England-prescribed SHAPE tool, which combines various inputs (such as population growth, transport links and other factors) to visually support estate strategy development.

Tower Hamlets Primary and Community Care site profile and estate map5

Site profile 50 sites based on NHS

England Asset Register Approximately 36 GP

practices List size Total (known) list size

across borough of 292,481

Average list size in 2015 of 7,905

4 NELFT Estate Strategy 2014-2019 (page 13) 5 For all three maps, the numbers in circles represent where there is more than one facility in a particular location. This visual presents the majority of NHS sites; we know that some – such as certain individual ELFT and NELFT community sites – are not included in this data

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Newham Primary and Community Care site profile and estate map

Site profile

66 sites on NHS England Asset Register

Approximately 65 GP practices

Significant number (21) of small single handed GP owned sites (average list size of 3,470)

List size Total (known) list

size across borough of 398,113

Average list size in 2015 of 6,125

Waltham Forest Primary and Community Care site profile and estate map

Site profile

48 sites on NHS England Asset Register

Approximately 45 GP practices 5 small single handed GP owned

sites

List size

Total (known) list size across borough of 293,258

Average list size in 2015 of 6,665 Numbers in circles represent where there is more than one facility in a particular location. This visual presents the majority of NHS sites; we know that some – such as certain individual ELFT and NELFT community sites – are not included in the data.

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The secondary care hospital estate6

2. The quality of our buildings varies considerably. We have some leading practice and high-tech facilities which are very new, such as the Royal London Hospital in Whitechapel, and the Sir Ludwig Guttmann Centre which are under five years old and represent significant investment in our region.

But a lot of our estate is of poor quality and needs further investment. Waltham Forest CCG has recently completed a survey7 showing that their premises are in a varying condition across the borough with 63.6% of premises being condition A8 or B9 or above and 35.4% being condition C10. This means that on some sites, a lack of

6 Total bed numbers provided are the current establishment across all Barts sites; outputs of the TST model predict a slightly lower total figure due to the calculations being made on bed occupancy rates 7 The six facet survey forms the ‘core’ estates information required by NHS Estate CODE. The resultant survey will allow condition categories to be allocated to properties on a facet by facet basis together with a summary of remedial costs to bring each facet up to a safe and sound condition 8 Condition A: as new (built within the past two years) and can be expected to perform adequately over its expected shelf life 9 Condition B: sound, operationally safe and exhibits only minor deteriorations 10 Condition C: operational but major repair or replacement will be needed soon, that is, within three years for building elements and one year for engineering elements

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short term investment may lead them to become unsuitable for patient care and some buildings create inefficiencies.

a. We estimate the total cost of critical maintenance across the three boroughs to be around £163 million, of which about £141 million is on Barts Health sites

b. Whipps Cross Hospital represents the majority of Barts’ estates challenges, with about £80 million of critical maintenance needed on the site (70% of which is over 30 years old). In addition, the current location of the maternity suite is separate from the main facility. Any emergencies that arise must be handled by ambulance.

c. The total cost to bring all the primary care premises up to Condition B (and ensure properties in danger of falling into condition C, are retained in condition B) is estimated as £23 million. St James Health Centre, in Waltham Forest, is one of the sites that requires urgent work to rectify maintenance issues. The landlord, NHS Property Services, is planning a programme of £250,000 of essential works to keep the premises going pending a full redevelopment option on a nearby site.

3. We do not use our buildings as effectively as we should. For instance, there is c.3,000 sqm of empty space across the three boroughs’ primary care estate. This costs the CCGs, but is not occupied. We also know there are opportunities to increase the volume of activity that is delivered from the sites that are occupied. More work needs to be done to clarify the precise extent to which we can increase the utilisation of our estate overall (e.g. through increasing the opening hours or number of clinical sessions that are offered).

4. Our infrastructure does not encourage multi-disciplinary use of the same properties. Either providers consider them to be expensive and look elsewhere, or they are not fit for specialist services that would complement the existing care being delivered. For instance, the Sir Ludwig Guttmann Centre’s utilisation could have been increased by providing some of ELFT’s mental health services there, but its lay-out is not considered a safe place for ELFT’s patients to receive care. In addition, The Barkantine Centre has a total annual property charge of over £2 million, creating high service charge costs for providers, which is often unaffordable.

5. Our acute sites are broadly operating at, or close to capacity. Each of the Barts Health hospitals have experienced significant challenges over the past 12-18 months as demand for inpatient beds has continued to grow. This has contributed to poor performance against some key targets (e.g. A&E (emergency department) and 18 week referral to treatment times).

The drivers for change In order to define robust investment strategies, we also need to take account of the factors that will influence how the estate should be configured. The key drivers of change that will impact the estate include:

the population growth. If we don’t change our health system this growth would translate into demand for an additional 550 inpatient beds – the equivalent of an extra hospital, which in addition to the significant capital cost would cost around £250m a year to run. We’d also have to invest heavily in our primary care and

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community estate to ensure the right facilities are available for the population as it grows

changes at King George Hospital emergency department. This will drive additional demand, on top of the population growth, into Whipps Cross and Newham hospitals

funding to deliver major capital programmes is limited. The NHS in north east London is under considerable financial strain, limiting its ability to deliver significant capital programmes. A coordinated, cross-system approach is needed to establish a robust strategy that will drive the right investments that are of benefit to the system as a whole, including any proposals for disposals to reinvest money

delivering outpatient services in the community will require provision of generic (flexible) consultation/examination and treatment rooms, ideally collocated within primary care hubs.

1.3 The IT/informatics case for change Delivering new technology can only be achieved if the underlying infrastructure is capable of supporting it. We have completed a review and have a clear understanding of the existing situation and any deficiencies. We plan to fix the basics before delivering more advanced, interoperable, services.

New ways of working must change the existing ‘diagnose and treat’ regime to ‘predict and prevent’. There is a need to focus on a more personalised and participatory health system, where treatments are based on likelihood of individual response and people are encouraged to take a more active role in managing and maintaining their own health and wellbeing.

Commissioners need to work together to deliver co-ordinated services for the populations they serve, supported by value and outcome-based payment arrangements. This requires information to flow more effectively across health and care.

Without a change to provide interoperable systems which share information and support the delivery of a single electronic health record (EHR) to all parts of the healthcare system at the point of need:

we won’t eliminate waste – data sharing will be by slow and expensive paper records

clinical benefits won’t be realised – the real-time availability of a single, shared (EHR) is essential to support ‘predict and prevent’

financial benefits won’t be realised – integrated care planning and identification of the 20% most at risk of needing hospital admission may not be achievable. Care will remain as ‘diagnose and treat’ and hospital admissions will remain at (high) levels

productivity improvements won’t be met – for example urgent and emergency care pathways will not be supported without integration of systems and the availability of a shared EHR.

In East London, we are already delivering a shared view of patients’ EHR using Cerner’s health information exchange (HIE) in conjunction with HealthCare Gateway’s Medical Interoperability Gateway (MIG). However this provides a limited view of the EHR and is only available to hospital-based clinicians in Barts and GPs using EMIS, the leading primary care IT system. There is no sharing of data for community, mental health or social care; and individual care plans, critically important to our most at-risk patients, remain paper-based.

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Without continued work this shared view will remain limited and read only, and will not be connected to any of our neighbouring providers or across the rest of London. The shared data cannot be used for the systematic review and risk analysis required to support population health and integrated care.

We also need to ensure that new services (such as the shared care record) are viewed and used. This is already a significant problem and will continue as new functions are made available. For example, whilst the functionality is enabled to allow discharge summaries to be sent from Barts Health directly to the GP systems in Waltham Forest, it is only effectively used in 20% of practices.

The drive to deliver a shared care record is supported by NHS England which is advancing the connectedness of EHRs and the interoperability of health information technology. This has been identified as a key aim and articulated in a number of key reports and in the Five Year Forward View which made a commitment that, by 2020, there would be “fully interoperable electronic health records so that patients’ records are paperless”11,12. Achieving this goal will support decision-making, reduce acute admissions and help to transform access to services. It will support more efficient and effective care, enable new models of primary and urgent care and lead to a continuously improving health system that empowers individuals, provides individualised health plans (leading to customised treatment), enable integrated care and accurate risk stratification in real time and support the management of long term conditions.

NHS England has requested all CCGs develop a digital road map to set out their plans for a more connected and paperless system and the TST programme articulates how East London’s health and social care providers will achieve this.

At a London level:

the Healthy London Partnership13 has created a programme of work which focuses on creating the vision for connecting Londoners and health and care providers to allow for real time access to records and information.

NHS England London is working with individual CCGs to define how they can link together to share information outside of their local infrastructure and the East London CCGs need to be part of this wider delivery in order to generate benefit for their patients.

11 National Information Board: Personalised Health and Care 2020: Using Data and Technology to Transform Outcomes for Patients and Citizens. A Framework for Action. Nov 2014 12 National Information Board: Personalised Health and Care 2020: Using Data and Technology to Transform Outcomes for Patients and Citizens. A Framework for Action. Nov 2014 13 www.myhealth.london.nhs.uk/healthy-london/interoperability

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1.4 The workforce case for change There are significant workforce challenges in East London; building a sustainable workforce is a key component of all redesign initiatives. As well as identifying the growing population, increasing population and financial pressures, we know that that around 70% of our budget is spent on staff, meaning that we will need to use our existing workforce more efficiently.

Dealing with future pressures will require the recruitment of a sufficiently skilled and flexible workforce with a strategy to retain and motivate staff to support improvements in quality and patient experience. This should include support of a clinical community that welcomes change and works together to find solutions to difficult problems and the development of new roles and different ways of working.

There needs to be changes to the way the East London workforce is structured and managed. We have to act in a concerted way to ensure the future viability of the workforce and delivery of a high quality service for our population.

The challenge

Providers have retention problems and high turnover rates

The average turnover rate of staff in East London providers is 15%, the equivalent of around 2,800 Full Time Equivalent (FTE)14 staff leaving the hospital providers every year. This proportion is higher than the 10.1% seen across the Health Education North Central and East London (HENCEL) area15. Between 45% and 72% of staff go on to work at another NHS provider, but at least a quarter leave NHS employment.

There is significant variation in turnover across Barts Health sites (amongst medical, nursing, allied health professional (AHP) and scientist roles), ranging from 15% at the Royal London to 31% at Mile End Hospital. 32% turnover rates were seen in Barts Health’s non-hospital workforce in the year to May 2015. As described in the overleaf graph, within our Mental Health and Community providers, turnover rates are 16.4% and 15.6% for East London Foundation Trust and North East London Foundation Trust respectively.

The number of paramedics leaving London Ambulance Service (LAS) increased dramatically between 2011/12 and 2013/14. LAS had around 600 vacancies (particularly paramedics) by April 2014 when turnover was 7.9% and this rate increased to 9.5% by April 2015 (18% for paramedics). LAS identify a range of reasons for the retention problem, but there are common themes of affordable housing, transport costs and the costs of further education.

Providers are not able to recruit to fill their current budgeted establishment, putting pressure on existing staff

All local providers have gaps between their projected staff numbers needed to deliver services, and numbers of staff in post, putting pressure on the workforce and impacting on their ability to deliver high-quality services. Without adequate numbers of staff, providers cannot deliver safe, effective care. For instance there was a 13% gap16 in nursing roles in 2015 across all hospital providers (a shortfall of around 730 FTE nurses). There was a further gap of around 250 FTE in other non-medical roles; predominantly physiotherapy and

14 Full Time Equivalent = full time employees plus part-time employee proportions aggregated together 15 Health and Social Care Information Centre workforce statistics July 2015 www.hscic.gov.uk 16 Shortage of staff compared to the full complement

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occupational therapy roles. At Barts Health there was a gap of 100 FTE in all medical roles (55 short in surgery, 27 short in acute medicine, 10 short in emergency medicine, and eight in other specialties) leading to some hospitals struggling to meet the London quality standards for consultant cover in emergency departments.

East London trust turnover rates at 31 May 2015

Source: HENCEL

Forecast GP retirement rates, coupled with GPs wanting to reduce their workload and a lack of training, means that primary care will struggle to cope in its current form

High proportions of the GP workforce are at, or are approaching, retirement age. In Newham, 38% of male GPs are aged 60 and over. In Waltham Forest the figure is 32% and in Tower Hamlets it is 12%. Many of these GPs want to reduce the hours that they work. Almost 30% of GPs in Newham wanted to reduce their workload over the next five years. To add to the problem, 6% of Newham’s male GPs are single-handed practices, meaning that they do not have direct colleagues to whom they can hand over their workload.

Male GP headcount by age, East London CCGs, 2013

Source: Health and Social Care Information Centre (HSCIC)

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To deliver the forecast increase in activity in the existing workforce model we need an extra 125 GPs in five years’ time and 195 in ten years’ time in addition to today’s GP workforce. This will be impossible given the national shortages and high retirement rates. An additional 30 practice nurses will also be required and there is a recognised workforce shortage.

There are also a number of skills shortages. For example, only 31% of the capital’s GPs believe they have received sufficient training to diagnose and manage dementia17 and only half of all GP associates in training have the opportunity to work in secondary care paediatric services to gain experience of identifying and managing sick children18.

Sickness absence is high in some parts of the NHS and increasing

In our region, sickness rates are similar to pan-London absence rates and vary between 3-4%. However, this masks variations, for instance: a higher level of 6% in clinical service (scientific) roles, 4-5% among nurses and a lower level of around 1% in medical staff (doctors); a 6% sickness rate at Newham Hospital and 3% at the Royal London; and an increasing proportion of staff on long-term sick leave at LAS in 2014/15.

The drivers and opportunities for change

The high cost of living, perceived low pay and work-related stress contribute to high turnover and absenteeism

Assuming the salary needed to live in London is £30,80019 (based on minimum income standard for London), a large proportion of lower band salaries (all staff in posts below a band 5, most staff in band 5 and some in band 6) fall below this threshold.

One consequence of the high cost of living is that people have to live further away from work (40% of the East London workforce live more than ten miles from their place of work and the average travel distance is 15 miles). The average annual travel cost is £2,378.

Dissatisfaction with pay across providers is also a consistent theme20.

This disproportionate effect on low paid staff may explain the reason why the 13% gap in nursing FTEs across the area is not distributed evenly amongst the salary bands. The lower bands are disproportionality hard to recruit – there is an 18% shortage in Band 5 nurses (equivalent to 464 nurses) whilst the

17 National Audit Office (2009) 18 CHIMAT (Child Health and Maternity Partnership Fundamentals of Commissioning Health Services for Children (2011) 19 www.trustforlondon.org.uk/wp-content/uploads/2015/05/MIS-London-full-report.pdf 20 The proportion of staff who are dissatisfied or very dissatisfied with their salary: ELFT 37%, Barts 46%, Homerton 43%, LAS 75% and NELFT 48% (Source: HENCEL)

Band Point

Inner

London

Outer

LondonFringe

Band 1 All 19,217£ 18,583£ 16,051£

Band 2 All 19,217£ 18,583£ 16,051£

Band 3 All 20,750£ 20,116£ 17,584£

Band 4 All 23,144£ 22,510£ 19,978£

Point 16    26,030£ 25,175£ 22,777£

Point 17    26,683£ 25,719£ 23,348£

Point 18    27,758£ 26,615£ 24,289£

Point 19    28,876£ 27,672£ 25,266£

Point 20    30,056£ 28,804£ 26,299£

Point 21    31,249£ 29,947£ 27,343£

Point 22    32,508£ 31,154£ 28,445£

Point 23    33,816£ 32,407£ 29,589£

Point 21    31,249£ 29,947£ 27,343£

Point 22    32,508£ 31,154£ 28,445£

Point 23    33,816£ 32,407£ 29,589£

Point 24    34,852£ 33,399£ 30,495£

Point 25    36,068£ 34,496£ 31,560£

Point 26    37,286£ 35,511£ 32,626£

Point 27    38,428£ 36,525£ 33,690£

Point 28    39,569£ 37,666£ 34,876£

Point 29    41,218£ 39,315£ 36,525£

Band 7 All 37,286£ 35,511£ 32,626£

Band 8a All 45,974£ 44,071£ 41,281£

Band 8b All 52,506£ 50,603£ 47,813£

Band 8c All 61,890£ 59,987£ 57,197£

Band 8d All 72,264£ 70,361£ 67,571£

Band 9 All 84,192£ 82,289£ 79,499£

Band 6

Band 5

15

difference between establishment and staff in post for Band 8a and above is 18 FTEs above the establishment. Establishment vs in post nursing staff (Barts Health, May 2015)

Source: Barts Health Electronic Staff Record (ESR) database

Staff surveys for East London’s acute, mental health and ambulance service workforce reveal significant proportions of staff suffering work-related stress. East London staff suffering work-related stress in the last year

Source: HENCEL

There is an understaffed, stressed workforce, which is rapidly losing skilled workers though retirement, sickness and resignations, and which is simultaneously facing a large increase in workload as those staff are not replaced. The health system has made some remedial interventions but they have proven to be an expensive solution.

Gap 464 FTE

Gap 220FTE

Gap 52 FTE

18 FTE over establishment

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There are significant local and national staff shortages for some specialist roles

GPs: The Kings Fund reported in April 2015 that ‘the rate of increase in the number of GPs has been dramatically outstripped by increases in the medical workforce in secondary care – a trend at odds with the ambition to deliver more care in the community’21.

Emergency Medicine: There are national shortages in the supply of consultants in emergency medicine; theatre nurses; a range of trainees in emergency medicine; non-consultant, non-training medical staff in emergency medicine (including specialty doctors working in A&E); and paramedics22. This means some hospitals struggle to meet the London quality standards for consultant cover in emergency departments.

Paediatrics: There are national shortages in key roles. The Royal College of Paediatrics and Child Health has shown that between 2011 and 2013, the community paediatric workforce declined from 1375 to 1245, a 9.5% drop; their 2013 census showed that the number of paediatric consultants is growing too slowly to meet demand and there are 86 vacancies.

“Despite long-standing ambitions to raise the level and range of community services provided, it is difficult to see any increases among key staff groups. Any such increases have been limited to areas with specific national targets” 23.

There are high levels of spend on agency staff

In order to fill gaps in the permanent workforce, and in the absence of skilled people who want a permanent role, providers use temporary staff. The average substantive salary of staff is £49,000. The average cost of a temporary member of staff is £67,000, a 38% increase. In 2015, temporary staff comprised 12.4% of all FTEs in East London, but 16.3% of the cost. In 2014/15 Barts Health spent around £90 million on agency costs and the total spend on temporary staff across Barts, ELFT and NELFT was £146 million, a £40 million premium over the use of permanent staff. This situation is unsustainable.

1.5 The financial case for change The NHS faces funding constraints and in East London it is estimated that there will be a significant financial gap across all organisations by 2021.

By March 2021:

Commissioners have assumed a level of activity growth sufficient to meet expected demand and this has been estimated at £676 million for all providers.

Cumulative funding allocations have been estimated at £327 million24.

This means that there is the potential for an underlying deficit of around £349 million for the three East London CCGs before the impact of the TST programme.

Currently, the projected financial baseline deficit without implementation of the TST programme is in the region of £655 million for North East London organisations by 2020/21,

21 www.kingsfund.org.uk/publications/workforce-planning-nhs 22www.nhsconfed.org/~/media/Confederation/Files/public%20access/Workforce%20workshop_urgentcare_March%202014/Health%20Education%20England.pdf 23 www.kingsfund.org.uk/publications/workforce-planning-nhs 24 Assessment Nov 2015 ahead of CCG allocations and comprehensive spending review. A refreshed assessment is being conducted in line with allocation guidance.

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of which £398 million is the responsibility of Newham, Tower Hamlets and Waltham Forest CCGs, plus Barts Health.

If we don’t implement the TST programme (and in addition to revenue deficits), the East London health economy would need around £352 million of capital by 2020/21, rising to £1.1 billion by 2025/26. There is limited identified capital funding to support this level of spend.

The main components of the capital requirement are the need to:

extensively reconfigure the Whipps Cross site build facilities on a new site sufficient to accommodate around 550 beds in order to

meet demand growth address known estates backlog maintenance issues across the system

The method by which we have conducted our financial assessment are described in the end note

1.6 If we don’t change…

Patients will wait longer for their operations.

Access to services will become poorer and many residents will continue to receive fragmented care.

Mental health will continue to not have parity of esteem with physical health care.

There will be later presentation of ill health to primary care due to capacity constraints.

More patients will be seen in sub-optimal care settings.

There will be more attendances at emergency departments for urgent care needs.

Those at medium risk of admission to hospital will not be sufficiently supported with symptom control, self-care and secondary prevention.

A high proportion of people will continue to be unable to die in the place of their preference, surrounded by their loved ones.

Unnecessary stays in hospital due to the lack of availability of consultant opinion will continue.

High lengths of stay due to lack of proactive ambulatory care models will continue.

More women than necessary will continue to be cared for in obstetric settings which have higher intervention rates.

Crucial care record information from different providers will not be available to care staff across the health and social care system resulting in sub-optimal clinical decision making.

Patients will continue to be cared for in care settings that are not fit for purpose.

Patients will continue to experience unnecessary trips to hospital.

Patients will continue to experience unnecessary diagnostic testing.

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In summary, the case for change is clear; to continue to provide safe, high quality and sustainable services in the future, organisations will need to work together to redesign care in a very different way.

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2. Getting the basics right

The effective working of our estates, IT systems and workforce are central to delivering TST.

Patients have told us that getting the basics right is just as important as really good clinical care. They want to be seen in well looked after buildings; they don’t want to have to tell their story to every member of staff that they meet because our IT is not joined up; they want staff to talk to each other and coordinate care, be caring as well as competent, to understand that little things make a real difference, and above all to recognise that every person is different.

The investment required to deliver change across these enabling areas will be significant. Recognising our financial constraints, it will be necessary to align closely with the pan-London capital allocation process to ensure sufficient funds are allocated to support the delivery of our strategy.

In addition to these enablers we need to continue to realise opportunities to work together to improve research, digital health and medical technology. This can build on the success of the Clinical Effectiveness Group at Queen Mary’s University of London to support continual improvement and the opportunities that the investments associated with the new Barts Heart Centre bring.

2.1 Estates The ambition of the CCGs regarding the estate is for it to be flexible and fit-for-purpose. The estate will be actively managed and well utilised, with opportunities taken to share space with other services of benefit to the local public.

The Nuffield Trust (2014)25 has clearly stated that the traditional model of small GP surgeries is no longer suitable and plans should be in place to increase the scale of practices. This echoes strong messages in NHS England’s FYFV regarding delivering care in networks, federations and super-partnerships. The development of new infrastructure models can act as an enabler of new models of care by co-locating health, social care and community facilities in a single development.

Each CCG has been tasked with developing local estates strategies which were submitted in draft form, to NHS England at the end of 2015. A common approach has been adopted in each of the three CCGs to ensure the strategies are complementary. In addition to these borough-level strategies, an overarching East London estates strategy is being written that will draw all overlapping considerations together. This will be completed for submission to NHS England by the end of March 2016.

Principles to underpin estates transformation Drawing on input from across the boroughs, we have set out the following principles to underpin the development of our estates strategy:

Maximise the use of space in existing buildings before investing in new builds. Prioritise works to bring the existing estate to minimum condition B requirements. Ensure buildings meet all health and safety and statutory compliance requirements.

25 www.nuffieldtrust.org.uk/our-work/projects/future-of-general-practice

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Review the use of each building and reduce operating costs where possible. Utilise the combined resources and insight to ensure investment benefits the system. Deliver a flexible estate wherever feasible, to enable mixed use, to increase

utilisation and to support changing needs. Actively work to remove factors that inhibit estate diversification (e.g. governance). Ensure good value for money and an efficient use of resources.

Primary and community care estate There are practices of varying quality and suitability in each borough. In alignment with the primary care clinical strategy, our strategy for the estate is to drive towards a consolidation of practices to result in fewer smaller practices and a number of larger ‘hubs’, where a greater range of primary and community care services can be delivered in an efficient and modern setting. The smallest facility offering services will cater for 10-15,000 patients. Larger facilities for over 30,000 patients will host on-site minor surgery units, sexual health clinics, enhanced diagnostic services and community learning environments with access to nutritionists, health coaches and community groups.

A common model for defining hubs has been developed as defined below:

Primary care hub – Consolidated GP practices (estimated 1,500 sqm). Centre Manor Park is a working example.

Primary care hub plus – Consolidated GP practices plus outpatient/integrated social care facilities (estimated 1,500 – 2,500 sqm). These could house additional ‘office based’ specialties such as dermatology, rheumatology, neurology, additional obstetrics outpatient department services or integrated social care.

Multispecialty community hub (estimated 2,500+ sqm). Mixed use centre housing local authority services (e.g. library, drop in centre), leisure facilities and primary care hub (or hub plus). Examples include the Greenwich Centre.

Work has identified potential locations of hubs in each borough (see below). These have been proposed due to their location and the suitability or condition of the premises. More detailed feasibility assessments will need to be conducted on each location to allow for the development of robust costs for any transformation work.

Newham

The under-utilised Vicarage Lane site in the north west of the borough would be a good location for a primary care hub with the potential for a second hub at the Sir Ludwig Guttmann Health Centre. Royal Docks ward could be a location for a third hub. There are discussions around a fourth hub to be considered at Centre Manor Park, and a fifth hub in the Canning Town development opportunity.

Tower Hamlets

The Prime Minister’s Challenge Fund is looking at the development of four locality hubs in Tower Hamlets. One hub in each locality which would provide care 8am-8pm and at the weekends with two GPs, a nurse, a healthcare assistant. The idea is to offer extra appointments. The hubs are likely be based in: St. Andrew’s Health Centre; Barkantine Centre; East One Health Centre; Blithehale Health Centre with an additional potential central hub in Whitechapel.

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Waltham Forest

The under-utilised Wood Street and Comely Bank LIFT properties are adjacent and would provide a good single location for a primary care hub. There is potential for a hub at St James Health Centre; one at Highams Hill ward; another at the adjoining of the Ainslie Therapy/Rehab and Highams Court sites; and one at Thorpe Combe Hospital owned by NELFT.

As the clinical strategies are scrutinised and developed, the estates strategies will be revised, with final version by end March 2016. In particular, the efficiencies planned by the primary care workstream (and the shift to pharmacy and self-care) are not yet fully reflected in the estates analysis.

Acute care estate The Barts Health estate comprises some of the most modern and efficient estate in the region, as well as some of the worst. In some areas, there are significant challenges that will need to be overcome – with the potential need for major capital investment. Integral to these challenges is the limited financial flexibility the Trust has, due to its current circumstances and limited capital budget. Adopting a ‘whole-system’ approach to tackling the most significant challenges is therefore the most pragmatic.

The estates implications defined by each of the initiatives that impact on Barts sites will each need to be developed in more detail to confirm the precise requirements, costs and benefits they will deliver. Any requirements for capital investment will then need to be considered and prioritised against a large number of other requirements for capital across the area (for example, in the resolution of critical estate issues where a risk to patient safety will grow if nothing is done).

As Barts Health works to complete its overall strategy for sustainability, the implications on the estate will be taken into account. There are opportunities to consolidate and dispose of parts of the estate that are not efficient, and/or which are sited in locations where they hold considerable value to a residential or commercial market. Further analysis will be required to define how best this value might be extracted to support the delivery of sustainable and high quality acute patient care. Key issues being addressed at each site are:

St Bartholomew’s Hospital: Complete the phased redevelopment of parts of the site; consider the potential for disposal of poorly utilised or unsuitable parts of the site; develop and preserve elements of the historic, heritage aspects of the site.

Royal London Hospital: Complete the final phase of the New Hospitals programme (set up to deliver the new Royal London PFI building in the Whitechapel area), increasing the density (and therefore efficiency) of clinical services on the site; improve clinical co-location of key services; progress the sale and transfer of the old Royal London hospital to the London Borough of Tower Hamlets; explore opportunities regarding primary care provision on the site; progress plans to develop two further plots of land into a life sciences specialist centre, in collaboration with local education partners.

Mile End Hospital: As described in chapter 4 of this document (and in greater detail in part 3, section 12), there is an opportunity to better integrate acute, community, mental health and primary care services on the site. A system-wide strategy is required to define the most appropriate use of the site.

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Newham University Hospital: Develop the Gateway surgical centre to enable greater volume of activity, in particular orthopaedic surgery.

Whipps Cross University Hospital: As described in chapter 4 of this document (and in greater detail in part 3, section 13), it is clear that there is a growing demand for acute service provision on the site, and a robust strategy is needed that defines how current and emergent challenges can be overcome. Working with local partners, a system-wide long-term strategy is required to define the most appropriate strategy for the site.

2.2 IT and informatics The NHS collects vast amounts of data and we can use this much more intelligently, systematically and transparently. Developing joined-up information systems will support more effective, integrated healthcare.

We have invested significantly as a community in health information exchange(s) to provide early support for integrating care with shared information but also to build trust relationships between care providers. We want people to experience services that are truly seamless, with effective signposting, co-ordination of care and exchange of information supporting every patient’s journey. We want to enable better information exchange so that clinicians have access to key patient data to make decisions and reduce the risk of gaps and duplications in care. There are three broad areas of focus to ensure informatics enables the TST transformational changes:

1. Single systems. Ensuring that all the partners in TST use informatics to build a single approach, identifying and implementing the systems we wish to use to provide greater consistency and potential for information sharing across providers.

2. Connectedness. Utilising electronic information to make sure patients get the right care, from the right clinicians wherever they are managed.

3. Use of big data. The use of real time data to support care at the place and time of need, by providing system alerts and interventions across the care network and to deliver comprehensive analytical reporting, directly into the workflow.

We are delivering these objectives through a focus on four critical areas, which are:

1. Infrastructure reliability and access. To ensure that the infrastructure is up to the job of supporting reliable fast access to systems.

2. Real-time, system-wide, shared electronic health records (EHR). Wherever a patient is seen or a decision made in the health and care system, the appropriate data from every responsible health and care organisation must be available safely in a real-time structured view, embedded into the workflow of the local system

3. Advanced analytics; Insight to prompt changes (in both real time and aggregate form where needed) to treatment or care pathways should be derived by safely combining the data from every responsible organisation into a data service.

4. Patients’ involvement with their own EHR. To ensure that patients get appropriate access to their record to help them interact with it

The development of a real-time, system-wide, shared EHR is one of our specific initiatives described in chapter 4 of this document and part 3, section 10.

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2.3 Workforce TST seeks to address the challenges described in the previous chapter (case for change) through a range of initiatives.

Marketing the attractiveness of East London

It is important that we develop a compelling system-wide vision about East London as an attractive place to live and work to ensure that we can attract the brightest and best candidates. These messages will focus on the professional opportunities, as well as the personal benefits of living in a vibrant and diverse community. This vision and collateral could be used on local, regional and national recruitment drives.

Recruitment

Ensuring a supply of staff: to ensure we have the numbers and variety of staff that we need to deliver our plans, workforce planning should be an ongoing process; reviewing workforce demand and supply, and aligning it to the business planning process. This responsibility can be shared between local providers, as well as regional and national bodies for more specialised roles. As part of this process, we will engage with universities and other education providers to develop and deliver appropriate academic courses to encourage new staff groups (e.g. physician associates and advanced nurse practitioners).

Encouraging young people: in an effort to attract local young people to aspire to work in the NHS, we will work with local schools and education establishments at an early stage in students’ career planning process to build on the positive messages set out in our vision. We can also develop apprenticeships and internships which guarantee employment whilst in the final years(s) of training.

Together these initiatives should help develop a long term supply of local staff, enabling us to drive down the use of temporary staffing.

The development of physician associates is one of our specific initiatives, and is described in chapter 4 of this document and in greater detail in part 3, section 11.

Retention

Training and development opportunities: the development of clear and flexible career paths for various workforce groups will help highlight the career progression and earning opportunities in organisations and across primary, secondary and social care.

Other initiatives to consider include the development of federated training models across primary care, where a number of primary care providers come together for multi-professional placements, which benefit a range of workforce groups and promote MDT working.

Financial incentives: a range of financial benefits could be considered to ensure that we have the appropriate workforce in the face of shortages of particular roles. These could include pure financial incentives such as ‘golden hellos’ or ‘golden handcuffs’, or support with the high costs of London living and transport costs.

We could also consider key worker housing and transport strategies to incentivise hard to fill clinical workforce groups or introduce bursaries, student loans and other financial

24

support for potential graduates entering new or existing clinical professions. We will also explore the removal of perverse incentives such as high pay for bank and agency staff.

Other strategies may need to be considered in areas that are considered unattractive. For example, initiatives that prioritise the funding for doctors and nurses to work in hard to fill areas or initiatives to retain doctors considering retirement.

Flexible working options: offering flexible working could be attractive to candidates. We should investigate flexibility in:

working hours – e.g. develop flexible contractual arrangements in order to accommodate the needs of a range of different groups such as young mothers, people with disabilities, single fathers and carers

working patterns – e.g. develop nurse rotations to include placements in other care settings where appropriate; offer flexible options for those considering retirement, such as different working patterns to facilitate stepped retirement.

local freedom for setting job roles and incentives – e.g. give primary care staff and commissioners flexibility to improve the attractiveness of roles to a workforce from outside of primary and secondary care

Communication: we must endeavour to improve job satisfaction through regular communication with our workforce. The emerging integrated provider networks will be encouraged to support communication, employment, education and training, as well the fostering of clinical leadership.

Improvement of workforce information availability, quality and analysis

There is a gap in workforce information that, if filled, could help the successful delivery of the TST strategy by providing transparency and improved accuracy of capacity forecasting. Initiatives could include a regular collection and analysis of primary care workforce data. Better information sharing about our collective workforce will help us understand staff gaps and help drive up the quality of the information we collect.

Local, regional and national approach

Implementing the workforce initiatives that are required to address recruitment, retention and MDT-working will need input at local, regional and national levels. Locally, it will be on an individual provider basis; regionally we would expect a collaborative approach between healthcare and non-healthcare providers, regulators and commissioners across health sectors to maximise efficiencies and outcomes and to influence national decisions; and nationally, statutory changes will need to occur in order to make some workforce groups and new ways of working attractive to both new staff and those already in post.

2.4 Organisational development All the changes outlined in this document rely on staff co-creating, owning and leading the transformation process so its benefits are realised and sustained across the system. The Five Year Forward View recognised the importance of developing a modern workforce that is aligned with the changing health and social care needs of the population. It is therefore vital that we harness the expertise, skills and energy to transform and deliver care services.

25

Our shared understanding of opportunities and challenges is critical in planning and building readiness for system transformation. This includes supporting our staff community for change and, in particular our leaders at all organisational levels so they feel empowered and have the right resources to enact and sustain changes. Our focus on strengthening the local clinical and staff leadership is underpinned by the recent research and thought leadership by the Kings Fund advocating the move towards place-based systems of care26.

All organisations providing care need to be maximising the opportunities to work together and delivering care across organisational boundaries. We need to learn the lessons from the merger of Barts Health NHS Trust and fully utilising the opportunities that come from the recent strengthening of the leadership on each of the sites. We also need to recognise the opportunities presented by the new emerging models of care such as Primary and Acute Care systems (PACs) or Multispecialty Community Providers (MCPs) signalled by the Five Year Forward View.

Supporting health and care professionals in changing the way they work may require helping them to understand their changing professional identity and providing them with training, tools and resources. Organisations need to work closely with clinicians and the professional bodies representing them to achieve change. For instance:

Primary care is facing unprecedented demand on services and a significant proportion of the services are provided by single-handed GPs nearing retirement age. For transformation to be successful, GPs and other primary care professionals need to be involved and engaged in redesigning the system and implementing new care and operating models in which multidisciplinary teams can operate efficiently.

Transforming maternity services will require the staff to co-create the change to their own working patterns so the care provided is both safe and sustainable. This may challenge their current perceptions of how their roles add value to the expectant and new mothers and how they can facilitate patient-led care.

We have identified the need to train staff across all settings of care in treating patients with dementia which can be done in a more time- and cost-efficient way if developed once for all local organisations.

Creating a safe learning environment, where innovation to create new models of care is encouraged and new ways of working can be tested is critical for staff to effectively contribute and shape the transformation process.

Staff need the skills to support the local population in changing their own behaviour so that people develop and maintain the healthy habits that can keep them well; and to change their approach to treating patients – moving away from paternalistic models of decision-making.

Strong leadership will be fundamental to sustaining our change efforts. Leaders need to be bold and courageous in breaking down organisational barriers so that all health and social care organisations can make best use of the limited resources they have.

Staff, partners, the third sector and all health and social care organisations can only build high quality, safe and sustainable services if we work as one system. The organisational development initiatives underpinning the TST draw on the conceptual framework for the learning healthcare systems and place a particular emphasis on developing a continuous

26 www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Place-based-systems-of-care-Kings-Fund-Nov-2015_0.pdf

26

learning culture27. This will enable the transformation and ensure that the changes result in safe and sustainable services for our communities. A full estimate of organisational costs is contained in the description of each initiative (see part 3).

The learning healthcare system

2.5 Working together Delivering care in hubs across the health economy is central to a number of TST initiatives including surgery, urgent care and primary care (see chapter 4). New ways of working are proposed as part of this transformation:

The MDT skill-mix operating at the front of our emergency departments will be broadened to include at least one registered practitioner and a healthcare practitioner. Where urgent care services are delivered, patients will have access to a prescriber so that they can resolve a much broader range of conditions.

Collaborative working will also operate virtually in the community, with GPs, pharmacies, dental and community health and social care services connected by interoperable IT systems, working together to provide an integrated urgent care response, closer to where people live.

To achieve success will require close alignment of all the described enablers, for instance:

New roles. he integrated care programme has already seen the development and introduction of some new roles, such as the care navigators, who act to co-ordinate the planning and delivery of care to patients most at risk of hospital admission,

27 www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/reforming-the-nhs-from-within-kingsfund-jun14.pdf

27

working with staff from different providers, including primary care, community care and social care.

Good cross-sector financial flexibility in how organisations bear the costs of staff, estates and IT e.g. costs must be shared across patient pathways.

Use of new technologies to make cross-site working and MDT working easier.

New career paths. For instance development of nurse training rotations to include placements in general practice as well as acute, social care and mental health providers. This can be extended to include continuous professional development opportunities across healthcare boundaries.

Enablers work plan

Time Short term

Medium term

Long term

All enablers

Implementation planning

Develop sustainability strategies,

Implementation management

Implement and monitor

sustainability; Review, adapt and update strategies

and systems

EstatesCompletion of CCG Estates Strategies;

delivery of immediate priorities; Strategy

for WXH developed

Estate consolidation and rationalisation; develop hub models

in each borough; business cases for

significant investment (eg

WXH)

Develop new infrastructure

models, collocating health,social care and community facilities; major

capital programmes underway

WorkforceOD

Work with providers to develop

implementation plansIntroduce new roles and MDT working

Ensure long term recruitment, retention

and sustainability

ITFix the basics for

infrastructure, deliver view only shared

care records

Extend sharing of care records to Urgent care,GP OOH and 111

Deliver data sharing supporting structured

data and bookable services

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3. Our strategy (the response to the case for change)

Transforming Services Together (TST) aims to ensure that, over the next five years, all healthcare services in East London become high quality, safe and sustainable.

The whole health system needs to work together to make sure providers are able to consistently meet national and regional quality standards in a financially sustainable way. We will also need to have sufficient capacity to meet demand, working in a different way to meet population needs, for example through earlier intervention, prevention, self-management support and coaching skills for staff. Fundamental national standards are detailed in the NHS Constitution28. These include the:

18 week target from referral to consultant-led treatment for non-urgent conditions

two week target for being seen by a cancer specialist for urgent referrals where cancer is suspected

maximum four-hour wait target in an emergency department from arrival to admission, transfer or discharge.

Clinical sustainability also means providers are able to progress towards meeting the London quality standards for acute emergency and maternity services29 which include that:

all emergency admissions are seen and assessed by a relevant consultant within 12 hours of the decision to admit or within 14 hours of the time of arrival to the hospital

senior decision-making and leadership is available on acute medical/surgical units to cover extended day working, seven days a week

access to key diagnostic services is available in a timely manner, 24 hours a day

providers are able to meet requirements for emergency care medicine staffing, paediatric emergency staffing and obstetric and maternity staffing ratios.

Greater provision of seven day services where it will improve patient care

The following chapter illustrates our response to the case for change. It details our continuing focus on prevention and health promotion and outlines our strategy for the three main areas of the Transforming Services Together programme – care closer to home, strong sustainable hospitals and working across organisations. This chapter also looks at how we are taking forward improvements to mental health care and children and young people’s care, which are embedded in all our work. Specific initiatives are identified and described in more detail both in chapter 4 of this document and in part 3).

28 Patients and the Public: Access to Health Services. Part III. Handbook to the NHS Constitution (2015) 29 Acute Emergency and Maternity Services: London Quality Standards (2013)

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3.1 Helping people manage their health better Encouraging people to invest time in their own health and wellbeing and improving the support the NHS offers will improve people's health and contribute to a reduction in costs30. Better Health for London31 and the NHS Five Year Forward View (FYFV) acknowledge that the future sustainability of the NHS hinges on a radical upgrade in prevention; unless we take prevention and public health seriously, this will adversely affect the future health and wellbeing of Londoners, particularly young Londoners, and the sustainability of the NHS, and tackle the 4% annual increase in demand for health care. The main changes we propose Support people to live healthier lives: Health checks, social prescribing and the establishment of community activity groups all support people to live healthier lives. Social prescribing offers an innovative way for GPs to prescribe alternative community-based support that compliments traditional medicine. For instance people can be referred to local activity groups if it would better meet their health and wellbeing needs.

Organisations also need to help staff in encouraging people to tackle unhealthy behaviours. The Case for Change identified that staff often receive little formal training on behavioural change techniques. Building on the work Barts Health has been conducting with the Centre for Behaviour Change at University College London, work should take place with education providers to equip health professionals with the skills they need to support people to stay well and make every contact count.

Organisations also need to build on existing innovative practice in identifying and supporting people who may be damaging their health through harming behaviour such as excessive alcohol consumption. For example, Barts Health is working towards reviewing all patients who attend emergency departments with alcohol misuse symptoms, to make sure that they always obtain the advice and support they need. The main focus of our improvement is overseen by each of the borough’s Health and Wellbeing Boards, which have many common improvement areas, and have a desire to strengthen collaboration to support prevention. The Healthy London Partnership32 supports London-wide initiatives on engagement, in particular on childhood obesity and improving workplace health.

Make our schools and workplaces healthier: Developing healthy environments in schools and workplaces is one of the most obvious opportunities to support people to live healthier lives. The London Health Commission stated that creating a healthier London requires ‘a new coalition that brings together local government, the health service, the voluntary sector, employers, schools and colleges, transport and the wider public and private sector33’.

In schools, this may involve encouraging greater participation in physical activity. Less than 50% of children in Newham and Tower Hamlets participate in three hours of high quality physical education or extra-curricular sport a week34.

30 Local Government Association. Money well spent: Assessing the cost effectiveness and return on investment of public health interventions. (2013). This report included a review of 200 NICE evaluated public health interventions finding that 15% made a direct cost saving and 70% were good value for money (<£20k/ QALY (Quality Adjusted Life Years) 31 www.londonhealthcommission.org.uk/better-health-for-london 32 www.myhealth.london.nhs.uk/healthy-london/prevention 33 London Health Commission Better health for London (2014) p14 34 London Health Commission. Better health for London (2014) p14

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In workplaces, health and social care organisations need to lead the way in offering healthy environments that encourage good health and wellbeing amongst staff. For example, social marketing campaigns in some NHS organisations have encouraged people to burn excess calories by taking stairs instead of lifts.

Identify physical ill health earlier: Existing screening programmes such as for cancer and health checks, help diagnose illness at an earlier stage, which increases the chances of successful treatments. Analysis of public health information and GP records indicate that up to a quarter of diabetics in East London remain undiagnosed, meaning there are tens of thousands of people who are not receiving the treatment and advice they need to stay well.

The benefits of these changes The expected benefits of making these changes are:

a healthier population, with improved quality of life people with long-term health problems will be better supported to manage their own

illness and will be healthier a reduction in emergency attendances and admissions to hospital a more supportive patient experience of care stronger community infrastructure healthier staff.

Fast food outlets near schools in Newham

Source: London Health Commission (2014) ‘Better health for London’s children’

The diagram illustrates why creating a healthy environment is so important. The London Health Commission identified tackling the number of fast food outlets near schools as a key priority that local authorities could work on together. In close proximity to seven schools in Newham there are 29 fast food outlets.

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3.2 Care closer to home Context: Five Year Forward View The Five Year Forward View (FYFV) sets out a clear vision and direction of travel for the NHS – showing why change is needed and what it will look like. The future will see far more care delivered locally.

Family doctors (GPs) with a registered list of patients will remain as the foundation of NHS care. Over the next five years the NHS will invest more in primary care, while stabilising core funding for general practice nationally over the next two years. 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. The number of GPs in training needs to be increased as fast as possible, with new ways to encourage retention.

Across the NHS, urgent and emergency care services will be redesigned to integrate emergency departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services.

Transformation will require new partnerships with local communities, local authorities and employers, with decisive steps being taken to break down the barriers of how care is provided between family doctors and hospitals, physical and mental health, health and social care.

New integrated provider systems and organisations will enable the NHS to take a more

holistic view of patient care. The NHS is committed to providing meaningful local flexibility in the way payment rules, regulatory requirements and other mechanisms are applied in support of diverse solutions and local leadership, as well as new options for the workforce and technology; and better use of estates.

It is envisaged that delivering on the transformational changes set out in the 5YFV could deliver significant health outcomes and reduced health inequalities, radically improve patients' experience of interacting with the NHS and result in annual efficiencies.

In taking up the gauntlet of the 5YFV, and recognising the significant challenges involved in developing care closer to home in partnership with acute services, we are working on an ambitious and innovative ‘Care Closer to Home’ (CCH)35 strategy, building on the work led by local Health and Wellbeing Boards. This work is focused on creating the right culture, capability and capacity to enable transformation in the community to improve individual and community well-being, manage ill-health and achieve a balanced health and social care economy.

East London is already benefiting from involvement in two national programmes (pioneer and vanguard) established across the UK. This support from pioneer and vanguard contributes to the development of new approaches to service commissioning and delivery, for example, the development of payment reform through Monitor’s National Integrated Care Forum, as well as direct learning from visits to international exemplars.

35 Previously known as ‘Out of Hospital’ services

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Making health a shared value We know that people are happiest and healthiest when they are active, valued members of their communities, supported by a network of family and friends. These people may still require health and social care services, but they generally use services less often, and more appropriately than other people, avoiding crisis situations and improving their quality of life.

Our ambition is to change the prevailing social culture of over reliance on medical/ hospital services to one where people take greater responsibility for their health. This type of culture

change takes years to achieve and requires whole system drive and investment. It is also

important to recognise the determinants of health cannot all be fixed by health services.

Building on the instigation of Better Care Fund (BCF) plans, we must strengthen the relationships between the health, social care and third sectors to achieve health and social care integration and maximise the resource and commitment in the community to create a culture of health where the mindset and expectations for good health include36:

people taking greater responsibility for their own health and actions that influence their health

people staying well in their own homes and communities.

Organisational development that fosters collaboration

Payment reform and incentives

Commissioners intend to reimburse and incentivise providers in ways that reinforce integrated working, with organisations collaborating to deliver quality, value-for-money care for patients in a sustainable local health and social care economy, as summarised in the 2012 Waltham Forest and East London37 Integrated Care Case for Change.

The financial model between commissioners and providers38

36 Although outside the remit of this investment case, the ambition for the whole system would be for other sectors to be included to maximise impact in tackling social and environmental determinants of health: housing, education, safety, food, alcohol and smoking. 37 In this document referred to as East London 38 Purple box indicates proposed strategic option. Green box the proposed interim option

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In line with the Integrated Care Case for Change, and as reflected in the commissioning intentions for 2016/17, East London commissioners are committed to piloting a capitated budget in ‘shadow form’ from April 2016. A simulation exercise between commissioners and local providers is currently taking place. Across East London, CCGs and local authorities are committed to developing a common methodology for calculating a capitated budget, including common approaches to gain and loss sharing and common approaches to outcome-based payments. This work involves Monitor as part of East London’s pioneer relationship.

Provider development

Across East London, there is a commitment to embedding integrated working in the delivery of care, regardless of setting or provider. Each borough is developing its capacity for its various providers to operate collaboratively in networks or partnership arrangements. The diagram illustrates this journey, recognising that the pace of change will vary.

Building on existing work, the CCGs, working with partners in the health and social care system, will take forward the work to achieve mature integrated provider networks by 2021 by drawing on local, national and international knowledge and experience.

Developing new models of care

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Summary: Current provider development

Strengthening integration of health and social care services and systems

Too many people go into hospital or stay in hospital longer than necessary. Co-ordinated support early on, focused on a person’s well-being as well as their health and social care needs, can reduce their dependency on services in the long run and ensure that admission to hospital only happens when it is really needed; existing duplication in the health and social care system otherwise ultimately reduces effectiveness and costs money, which the transformation work being undertaken is mitigating.

Newham

GP networks Primary care provider network is in development. A decision to form a single federation to deliver some integrated care services as part of a local provider partnership is planned for 2016/17.

Integrated provider network

Created in 2014; renamed Sep 2015 as the ‘Newham Integrated Provider Partnership’

Accountable care systems

Developing an establishment plan

New model of care Legal entity formation process underway

Tower Hamlets

GP networks Primary care networks in place since 2009. The GP Care Group (GPCG) is the borough level primary care network

Integrated provider network

The provider forum is the Tower Hamlets Integrated Provider Partnership including Barts Health, ELFT, GPCG and London Borough of Tower Hamlets

Accountable care systems

Awarded integrator function to THIPP following a non-competitive procurement process in March 2014

New model of care THIPP is a national vanguard, awarded 2015, taking forward Multi-specialist Community Provider (MCP) model

Waltham Forest

GP networks Developed a single network of GP practices with 100% population coverage and services from three hubs

Integrated provider network

Provider network in development with the aim of a functioning local provider partnership from April 2016. Plans include: delayed transfers of care; first response/rapid response integration; 75 years+ population cohort/integrated complex care; 0-5 years population cohort; care homes

Accountable care systems

Developed an establishment plan and working with providers on how these initiatives should move forward in an integrated way

New model of care Further to establishment of the provider network, plans for an appropriate legal entity

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Workforce development / new ways of working

Integration and cross-organisational working will require changes to the workforce and ways of working. Staff will be enabled to work more flexibly across organisational boundaries and shared care records will be fully established across providers.

Existing and planned changes to support integrated working include:

Change Detail

Care navigators / coordinators

New roles have been created to support the patients identified in the population most at risk of hospital admission – in the first instance those at Very High Risk (VHR) and High Risk (HR) – working to achieve access to the most appropriate care and support for these patients, at a time and place that suits them.

New staff have received bespoke training so that they can best support patients to navigate the system.

Care navigators provide practical support for patients, (booking appointments and arranging transport), as well as work with the other professionals involved in patients’ care to support coordinated multi-disciplinary team working.

Case Management VHR risk patients receive dedicated, intensive clinical case management to plan and coordinate their health and social care.

Specialist input into the community

Care navigators/coordinators and case managers are underpinned by a MDT that is supported by specialist input e.g. community geriatricians, occupational therapists, physiotherapists and social workers.

The MDTs meet regularly to act as ‘team around the patient’, and to ensure their approach is aligned and coordinated.

Generic workers For example therapy/rehabilitation assistants, working with other health care team members/specialists to improve a patient’s physical and mental health and their quality of life.

Physician Associates

Working in community and primary care (please see chapter 4 of this document and part 3, section 11).

Support for development of MDT/ collaborative working

Structure and process required to deliver MDT approach Organisational development to facilitate culture change Admin support and co-ordination for MDT approach

Care planning Standard template and process for care planning that is accessible by multi providers to enable coordinated care

Informatics Access to the full patient record (shared care records) Access to systems Predictive algorithms and alerts Digital road map

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OD commissioner requirements over the next five years (unless otherwise indicated (specific requirements are shown in each section of part 3)

Key change area Description

Embed the CCH strategy

Workshops and events with stakeholders, to embed the vision, values and deliverables

Develop the commissioning and provider landscape to deliver the strategy

‘New models of care’ workshops to inform development of integrated provider systems/organisations including GP networks, and models of integrated commissioning

Develop MDT/ collaborative working

Programme to strengthen MDT working (for staff with shared responsibility for care)

Support the introduction of new roles

Programmes to support nurses, HCAs, pharmacists, optometrists, practice managers, care navigators etc.

Develop leadership capability

Programme to support future CCH clinical / leaders

Development and empowerment of the community

Involve patient participation groups (PPGs), third sector and Healthwatch in co-design and delivery of the transformation programme and in building capacity in the third sector

Outcomes The CCH strategy is focused on improving individual and community well-being, managing ill-health and reducing health and social care costs.

A summary of the anticipated activity shifts and financial benefits is set out below. The measurements for determining the success of the strategy in achieving targeted improvements to patient experience and health outcomes are described in individual parts of this document and part 3.

Activity shifts

The aim is to reduce the number of acute attendances and admissions by improving earlier intervention and better care coordination, including self-care and prevention initiatives. Activity that is shifted from the acute setting needs to be re-provided via CCH initiatives or new models of provision in primary and community health services. The development of capacity in the third sector and the realisation of a culture of self-care will enable shifts of unnecessary activity from primary and community care.

TST modelling suggests that if we do nothing, about 1.1 million extra primary care attendances would be needed to meet new demand by 2026. With the impact of TST initiatives this figure reduces to c.600,000 extra attendances needed over the same period39.

39 TST Modelled Initiatives Summary Pack (November 2015)

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This reduction incorporates integrated care initiatives where, supported by new care models, patient care is provided in a more appropriate way. For example:

A proportion of primary care activity seen in general practice can be shifted to pharmacy care and self-care, enabling general practice to have more capacity to support the delivery of more complex care.

Approximately140,000 outpatient appointments would be needed to meet extra demand by 2020/21. With the impact of TST initiatives, we may be able to reduce this by 20%, including 5% accommodated by primary and community care.

Without TST, there is likely to be a rise in the numbers of people coming to Barts Health emergency departments of around 80,000 attendances by 2020. With TST initiatives, this is reduced so that attendances are maintained at today’s levels. This can be achieved through a combination of shifting activity; improving pathways and system efficiencies; and providing care in more appropriate settings. ‘Right sizing’ the acute bed base in line with TST strategic projections will be realised from increased capacity commissioned in primary care/ community, through the accountable care system, driving down the demand on the acute bed base.

Our priorities Chapter 4 of this document describes the specific initiatives that require a particular collaborative focus to ensure delivery and have a material impact on the health and social care economy. These are:

1. Primary care 2. Urgent care40 3. Integrated care 4. End of life care.

The full details of these initiatives are detailed in chapter 4 of this document and part 3, sections 1 to 4.

40 NB: does not include urgent care delivered under acute contracts in hospitals

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3.3 Strong sustainable hospitals Even though our focus is to help people stay fit and healthy and to provide care closer to home, we need to make sure that when people do fall seriously ill or need emergency care, there are safe and sustainable services in local hospitals.

The hospitals in East London work together to provide care for the local population. The quality of care in these hospitals is variable, some services are world class and others are poor. To improve this, there needs to be a continuous focus on quality and safety. Some changes are small and will cost nothing to implement, others require organisations, staff and the public to work together to deliver improvements. This chapter outlines how hospitals will change over time, and focuses on the changes we need to make to Newham Hospital, The Royal London Hospital and Whipps Cross Hospital in the next five years to ensure that they are able to provide high quality, safe and sustainable services.

We will not be able to effectively deliver care for our population if we do not change the way hospitals work

Our population is growing rapidly. If we do not change the way we work, we will need to build 550 beds (the equivalent of another hospital) to cope with the growth over the next ten years, with the associated capital and revenue costs. This is not the right thing to do for patients, as people already spend far too long in hospital. Older people in particular become institutionalised and find it difficult to regain their independence in the community after a spell in hospital. Nor do we have the funds to build, staff and maintain this many beds.

If we don’t change, clinical quality will fall, financial problems will become worse and some hospitals may have to stop providing certain types of care. This is unacceptable. We must change the way services work to meet the needs of patients, while using our resources in a sustainable way for the future.

Our strategy We need all of our hospitals to function effectively to serve our growing population but they will have to look and work differently in the future. Each of the existing emergency departments and maternity units will need to be retained to deliver high quality local care. However our changes, in line with national policy, will mean that the way the sites work and the role they play will change in the following ways:

Improved local care with specialisation where this improves outcomes and delivers safer care

In order to effectively provide care for the growing populations we need to make sure that Newham and Whipps Cross are able to deliver high quality care locally and function as strong local hospitals.

We also need the Royal London to function effectively as both a local hospital and a tertiary centre, this doesn’t really happen at the moment. The Royal London Hospital site is often too busy treating emergency and acutely ill patients to function effectively as a tertiary centre or treat patients needing planned surgery in a timely manner. This results in large numbers of planned surgery cancellations and patients staying in hospital longer than they should, affecting not only patients locally but those being transferred from further away.

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Ensuring sufficient local capacity and capability at the Newham and Whipps Cross sites to treat more patients will release some of the pressure on the Royal London and improve both the delivery of tertiary and local services.

Alongside improved local delivery, there are also opportunities for Barts Health as the largest hospital trust in Europe, to better manage its services across sites by taking advantage of opportunities to deliver services at scale. In some cases we need to bring together services and treat larger numbers of patients in one place. This is in line with the NHS Five Year Forward View that outlines that smaller acute hospitals need to work together in collaboration to take advantage of the benefits of scale.

More integration with the community and social care

Our hospitals need to be better integrated with the community and form stronger partnerships with the charitable and voluntary sector. We need to make sure that local services run as effectively as possible alongside other clinical teams both on and off the hospital sites to deliver the highest quality of care in the future.

This will mean changing the way that hospitals work, with local GPs and community teams as well as non-clinical providers. In some cases, this will mean working closely with other provider organisations to deliver care outside of hospital. This might be as part of new integrated models including primary and secondary providers, as set out in the NHS Five Year Forward View - as is happening in Tower Hamlets as part of the vanguard work.

Better network working across our sites and more widely

In line with national guidance, we need to be far better at organising and simplifying the urgent and emergency care system and network arrangements. Our proposals will achieve both of these, standardising and improving both the system and the standards of care.

Currently, the three main acute sites do not consistently meet London quality standards indicating that sometimes we are not delivering the quality of care that we should. For example, we know that no site other than the Royal London Hospital can offer access to emergency interventional radiology in under an hour. Our approach outlines where we need to look across sites and in some cases change configurations to improve network arrangements for life- or limb-saving specialist services.

Changes need to build on, and reinforce, local sustainability plans and improvements

These changes will need to be made alongside the local work that all our hospitals need to make to continue to deliver safe services and improve care. We know that Barts Health has improvement plans to deliver safe and compassionate care as the result of the recent CQC reports. This strategy aims to support, reinforce and build on this work.

We also know that both Barts Health and CCGs are facing financial challenges – the changes outlined in this chapter directly contribute to both the individual organisations and the wider system, improving the financial positon. This is detailed in chapter 5 on financial impact.

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Our approach Chapter 4 of this document (and part 3, sections 5 to 7 for more detail) describe the specific changes that need to be made in the next five years to ensure that Barts Health sites can both serve the local population with high quality care and continue to operate as a tertiary centre providing world class care to the whole of the south of England. These initiatives are:

Establish surgical hubs Establish acute care hubs Maternity – increase the proportion of natural births

Without these changes, or making them in isolation, risks the overall sustainability of both Barts Health and the wider health and social care system. In the next stage of planning, the interdependencies between the changes need to be fully understood to ensure benefits are delivered, and that services remain safe and function correctly during implementation.

3.4 Working across organisations Many of the initiatives we are taking forward will require organisations to work together more closely than ever before. For example, clinicians from across primary, community and secondary care organisations need to work together to agree pathways that speed up the patient journey.

In addition, organisations across east London have agreed to work together to increase the number of physician associates working in primary and secondary care organisations, as well as defining a joint-strategy for the future of Mile End Hospital and Whipps Cross Hospital.

The following six system-wide initiatives need collaborative working to transform care and deliver whole system improvement:

1. Transform the patient pathway and outpatients

2. Reduce unnecessary testing

3. Deliver shared care records across organisations

4. Explore the opportunity that physician associates may bring

5. Develop a strategy for the future of Mile End Hospital

6. Define a strategy for the future of Whipps Cross Hospital

The full details of these initiatives are detailed in chapter 4 of this document and part 3, sections 8 to 13.

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3.5 Cross cutting themes Two themes in particular are found threaded through all the proposed initiatives: mental health and services for children and young people.

Mental health: taking forward transformation Mental health affects us all and has a large impact on society. One in six of the population suffers with a mental health problem at any one time, with one in four suffering at some point in their lifetime41. Of all lifetime mental disorders, 75% will manifest by the age of 1842.

Mental healthcare provision in East London is relatively good – both NHS mental health providers, East London NHS Foundation Trust (ELFT) and North East London NHS Foundation Trust are financially stable, provide good quality care and rank highly in terms of staff satisfaction. However, although mental ill health accounts for 23% of the health burden, it receives only 13% of national NHS spend43.

The government focus on mental health has increased in recent years, with milestones such as the publishing of No Health Without Mental Health44, initiatives such as the Crisis Care Concordat45, and the setting up of the Mental Health Taskforce in 2015. The Five Year Forward View also emphasises the need to improve prevention strategies and bring physical and mental health care together. Additionally, the government has invested in certain areas of mental healthcare, implementing waiting time targets and minimum expectations for services such as Improving Access to Psychological Therapies (IAPT), Child and Adolescent Mental Health services (CAMHS), and early intervention in psychosis. The political landscape is thus primed for mental health services to reach the goal of 'parity of esteem' with those of physical health.

The Case for Change identified a number of mental health-related challenges, predominantly pertaining to Barts Health. For example, it was shown that people with co-morbid dementia spend an average of 10 extra days in hospital when compared to those without. Also, the high incidence of mental health problems in emergency department presentations, and the additional healthcare costs for those with long-term conditions and co-morbid mental health difficulties were also highlighted.

Summary of progress so far

During 2015 we have held several engagement events with clinicians, managers, commissioners and service users. CCGs, local authorities, providers and third sector organisations have had input into the priority areas. These local stakeholders suggested that the TST mental health workstream should build on the challenges posed in the Case for Change, and agreed four service areas for investigation: perinatal (the period from conception up to one year after the birth of a child), CAMHS, crisis care and dementia.

41 NHS Information Centre. McManus, S., Meltzer, H., Brugha, T., Bebbington, P., & Jenkins, R. Adult psychiatric morbidity in England, 2007: Results of a Household Survey. (2009). 42 NHS England. Future in Mind: Promoting, protecting and improving our Children and Young People's Mental Health and Wellbeing. (2015). 43 Centre for Economic Performance Mental Health Policy Group. London School of Economics (2012). How Mental Illness Loses Out in the NHS. 44 Department of Health. (2011). No health without mental health. 45 Department of Health. (2014). Mental Health Crisis Care Concordat: Improving Outcomes for People Experiencing Mental Health Crisis.

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*a comorbid illness refers to cases where a patient has two conditions

The mental health workstream has been building engagement and enthusiasm for change, understanding what services are currently provided, agreeing a high level interim strategy with clinicians and commissioners and more detailed visions and principles for three of the four service areas. Additionally, the CCG commissioners have all developed CAMHS transformation plans, part of an NHS England development to release additional funding to improve the mental health of young people.

The interim strategy highlighted the need to improve services in four key areas, and several key principles for designing new services (shown below). Improvements in mental healthcare will span the whole range of care services, from primary care and secondary care, to social care and universal services. The strategy and supporting initiatives will consider impacts on these different sectors, addressing the capacity and capability to improve mental health care. This may require upskilling the existing primary care and physical care services, and developing additional capacity to address need earlier and reduce the demand for secondary community and inpatient mental health services. An example where this has already occurred is the development of enhanced primary care mental health services.

Of people with a mental health issue 75%

never receive treatment

People with a serious mental illness die on average

20 years earlier

Maternal perinatal depression, anxiety and psychosis costs

the NHS over£2,000 per birth

due to impacts on the child (approx. £8.5m pa. in east

London)

Of the women expected to have mild-to-moderate

affective disorders in the perinatal period,

as few as 2.5%receive psychological

treatment

Patients in east London with co-morbid* dementia spend

on average up to 10 days longer

in hospital than those without the condition

An additional 270,000 population in east London could represent an extra45,000 cases

of mental illness at any one time

Since 2007 there have been13% more children

presenting with self-harm to A&E in east London

People with long-term conditions have

45% higher healthcare costs if they have a

co-morbid* mental illness

Mental health is the third biggest reason for A&E visits,

representing up to 22% of unplanned

admissions

Key areas

1. Perinatal2. CAMHS

3. Crisis care4. Dementia

Prevention and

Resilience

Self-care

Early detection

and intervention

Access

Move to primary care and

community

Involve service users in design

Parity of Esteem

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Key areas of work

1. Perinatal mental health vision

“All expectant and new mothers and their partners will have the knowledge and skills to feel confident in looking after their own and their baby’s emotional wellbeing; should they need additional support, it will be identified early, easy to access, quick, and integrated with their other perinatal care.”

Mental health is everyone’s business – everyone involved in the care of women in the perinatal period will have an active part to play in their mental wellbeing.

Perinatal mental health services will work with universal and antenatal services, good communication, a unified referral process, and information, advice and skill sharing.

Access to services will be easy, with rapid access to psychological therapies where required.

All those involved in perinatal care will have sufficient skills to embed mental health care into existing care.

Mental health and wellbeing support will be available to all mothers, partners and babies, including a range of third sector and community services.

Achieving this vision will require the integration of mental health into all parts of the maternity pathway, from pre-conception through to the end of the first 1,001 days of a child’s life46. This will be achieved through implementation of the perinatal mental health pathway under development by the London Perinatal Strategic Clinical Network (Oct 2015)47.

2. Child and Adolescent Mental Health Services (CAMHS)

All CCGs in the TST programme have developed transformation plans in line with Future in Mind48, as part of NHS England’s programme to improve mental health services for children and young people. These set out how CCGs will invest additional funding from the government over the next five years to make a measureable difference to children and young people. All of the plans set out how the CCGs will achieve the following principles:

Destigmatising mental health.

Focus on resilience and prevention, working with children and parents.

The health and social care system can identify and act on mental health issues earlier.

Integration and streamlining of services that are consistently equitable and easy to access and navigate, removing barriers between services and focusing on the person.

Delivering the outcomes that matter to children and young people, including hard-to-reach groups, and ensuring that transitions to adult services are needs-based and well-managed.

Taking a whole systems approach, working in partnership across primary and secondary care, community and acute providers, education, social care, voluntary sector and the police. Commissioning together and commissioning on outcomes.

46 Durkan, M. et al. The 1001 Critical Days: The Importance of the Conception to Age Two Period. (2013) 47 www.londonscn.nhs.uk/wp-content/uploads/2015/10/mh-care-pathway-231015.pdf 48 NHS England. Future in Mind: Promoting, protecting and improving our Children and Young People's Mental Health and Wellbeing. (2015)

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Reduce the number of self-harm presentations for children and young people.

The local transformation plans will be published following a sign-off process by NHS England. In line with the development of an East London mental health strategy, we will analyse these plans and synthesise them to provide a regional CAMHS strategy, paving the way for increased collaboration on cross-borough challenges such as health promotion and illness prevention, whilst supporting individual CCGs to implement local initiatives.

3. Crisis care

Each CCG, in collaboration with local partners such as local authorities, police, and third sector organisations, has developed a local concordat vision and plan. Achieving improvements in crisis care will involve implementing those plans locally and regionally, integrating delivery with other urgent and emergency care services such as ambulatory care, NHS111, out of hours GPs and emergency departments. These plans are guided by the principles of the Crisis Care Concordat, which are listed below:

Access to support before crisis point – making sure people with mental health problems can get help 24 hours a day and that when they ask for help, they are taken seriously.

Urgent and emergency access to crisis care – making sure that a mental health crisis is treated with the same urgency as a physical health emergency.

Quality of treatment and care when in crisis – making sure that people are treated with dignity and respect, in a therapeutic environment.

Recovery and staying well – preventing future crises by making sure people are referred to appropriate services.

4. Dementia vision

“All those with dementia will receive the support they require to live as independently as possible; they will have been assessed and diagnosed early, and integrated support for them, their families and carers arranged quickly.”

Dementia is everyone’s business – everyone involved in the life of people living with dementia has an active part to play in their wellbeing.

Dementia services will work alongside health and social care services, with good communication, availability of information and advice and skill sharing.

Physical and mental care of dementia sufferers will be joined up in order to reduce the number of presentations to emergency departments and lengths of stay for admissions.

Carers will have access to information, advice, education and support.

We will support the development of dementia-friendly communities.

We will ensure those with dementia have dignity at the end of their life.

CCGs have made large strides in improving dementia diagnosis rates over the last year and their integrated care programmes are expanding to provide coordinated care for those at moderate and high risk of admission to hospital. Whilst these elements are improving care

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for those with dementia, achieving the vision will require greater focus on all parts of the system, within and outside health.

Next steps – system sustainability

The focus to date on the four areas described above only represents a portion of the mental health system (mainly in secondary care mental health services). This focus was derived from, and intended to address, the Case for Change. However the areas do not address the issue of system sustainability for the mental health sector as a whole. The mental health system is under pressure, but it is still relatively resilient. This may change over the coming years as demand increases, and we want to pre-empt where the weaknesses in the system are, beyond that achieved by the Case for Change.

A review of the whole system would provide a foundation for producing a system-wide mental health strategy; this has been a recent focus at a national level in NHS England. We will refresh and build on work done several years ago. This would enable the development of a regional, cross-CCG needs analysis; project prevalence and population growth; and identify potential gaps in service provision and pressure points. It would also answer the following and other questions for the whole system, not just the four areas described above:

How many extra beds will be required in 5-10 years? How could we reduce the need to commission these through community provision instead?

What are the current activity levels for all services in terms of referrals and cluster episodes? How does this compare locally and nationally? How might this change in five to ten years?

What are current waiting times for treatment? How might these change as demand increases or as they system changes?

Children’s and young people's care: taking forward transformation Children and young people aged 0-19, represent 27% of the population in Newham, Tower Hamlets, Redbridge and Waltham Forest – higher than the national average. The Office for National Statistics projects an 8% increase in the group over the next five years (representing an additional 16,000 children and young people)49.

High levels of deprivation, high levels of child poverty, poor nutrition50 and high rates of obesity are also expected to contribute to the demand of health services.

However child and adolescent health services in our area have some excellent assets. For example, the children’s specialist hospital at the Royal London Hospital, which includes a paediatric intensive care unit, and the Newham University Hospital Paediatric Clinical Decision Unit which operates in the emergency department and provides important observation facilities, reducing hospital admissions.

But there are challenges to the system, raised by clinicians and young people including:

a lack of coordination and joint-working

numerous hand-offs between services, resulting in duplication

49 Transforming Services, Changing Lives: Case for Change, Children and Young People Clinical Working Group report (2014) 50 Public Health England. Child Health Profiles (March 2014)

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high numbers of referrals to general paediatrics, orthopaedics and dermatology, and emergency department attendances for conditions better managed in primary care, resulting in large waits and unnecessary use of services

children and young people and their parents/carers not being empowered to support themselves and access age-appropriate services at a location and time that suits them.

In September 2014, the Children and Families Act was enacted, setting out the need for health, social care and education services to work more closely together to provide care that is centred around children and their families. Other recent publications such as the Five Year Forward View and Future in Mind51 have supported this drive.

Summary of strategy

Our strategy aims to place children and young people at the centre of care and services across 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.

The children and young people’s services clinical working group identified four principle concerns: transitions of care, integration of community care, hospital care pathways and urgent care. Central to these are the overarching principles of public health, prevention and safeguarding that are a consistent feature of good care for children and young people; these are summarised in the diagram below.

Transformational changes for children and young people’s services are included across the programme and in many of the individual initiatives (see chapter 4 of this document and part 3).

51 NHS England. Future in Mind: Promoting, protecting and improving our Children and Young People's Mental Health and Wellbeing. (2015)

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Realising the benefits in terms of improved care for children and young people will require collaboration across organisations. The East London CCGs will be able to use the TST governance structure (see chapter 6) to track delivery and progress.

The model of care that we would like to establish over the coming five years is set out in the themes below. This includes information on the changes we will make, the benefits we hope to see and how we intend to take this work forward. We have also described examples of excellent practice which are already beginning to show our vision in action.

Integrated care (working across health systems and with the local authority)

Commissioners and local authorities in each borough will develop local integrated care plans and identify opportunities for joint commissioning. They have developed a joint statement, setting out a commitment to work together to:

develop local integrated care services

jointly commissioning where appropriate

redesign services such as therapies and learning disabilities

introduce and take full advantage of the use of personal health budgets

maximise early intervention.

This will implement the requirements of the Children and Families Act.

Multidisciplinary teams for children with complex needs

Local models of coordinated care have been developed in line with a common set of principles. These models, to be implemented locally by CCGs, will introduce detailed, structured care plans, developed by multidisciplinary teams (MDTs) of health, social care and educational professionals, and available electronically between organisations. A virtual ward is where MDTs are brought together by secure technology to enable health professionals to discuss and coordinate the care and treatment for patients in a community setting. Care will be proactively managed by a care coordinator. Parents, carers and patients will be fully involved in the development of care plans, including regular check-ins prior to virtual ward MDT meetings to assess progress.

Redesigning pathways for long term conditions

As part of the patient pathway and outpatients initiative, evidence-based clinical pathways for conditions that are a priority for our young population will be co-designed. Priority conditions include epilepsy, asthma and diabetes. Children, young people and their families will be central in the design process to ensure pathways are appropriate to their needs and better support them to manage their own conditions. There will be a particular focus on community delivery and transitions to adult pathways.

General paediatric outpatient referrals

There is a need to improve access for primary care to fast specialist advice by phone and email; and investigate use of locality paediatricians. Referral criteria and rules for conditions with a high volume of referrals such as asthma and eczema will be reviewed and guidelines will be standardised collectively by community, primary and secondary

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care clinicians. Access to diagnostics from primary care will also be reviewed to further identify opportunities to provide care in the community. This process will be led by the WEL(C) Paediatric Commissioning Alliance in partnership with the Barts Health Children's Health Network Board. Impact assessments have been included in the ‘transform the patient pathway and outpatients’ (see part 3).

Paediatric urgent care, paediatric emergency care, and paediatric surgery

The systems in place to deliver safe, high quality services for urgent and emergency services will need to change. The new model will involve earlier access to expertise and diagnostics, the development of acute care hubs and better use of ambulatory care. Impact assessments have been included within the acute care hub transformational scheme and urgent care scheme. These changes are detailed in part 3 sections 2, 6 and 9.

Surgery pathways for children and young people also need to be improved in order to reduce waiting times and improve quality and patient experience whilst managing increasing demand. Developing surgery hubs will enable delivery of the appropriate expertise to deliver safe services.

In order to ensure consistency of pathways in urgent care, emergency care and surgery, the models are being developed through the TST programme for all ages, including children and young people; progress is described elsewhere in this document.

Mental health

Future in Mind (2015) set out the need to improve the mental health of children and young people in our population. The TST proposals for improving CAMHS are described in the mental health part of this chapter.

Expected outcomes

CYP

CYP will be more engaged in treatment

Consistent, joined-up

services with a better patient experience of

care

Improved transition to

adult services

Reduction in bed use

Reduced waiting times

Reducing referrals to 2°

care and presentations

to A&E

Care closer to the community

- more self-care and

management in 1° care

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Work in progress

Virtual Wards: Tower Hamlets has extended its virtual ward programme, called the Bridge Pilot, to 2015/16 and has expanded the cohort to 50 patients. This programme is for children and young people with intensive care needs, where care will be proactively managed by a care co-ordinator, between health, social care and education, with input from parents and or carers. Waltham Forest is in the process of recruiting for the coordinated care model. Newham is considering the opportunity for a virtual ward as part of the Children’s Academy integrated care model.

Personal health budgets: Across East London the CCGs and local authorities are working in partnership on the development of personal health budgets (PHBs)

Paediatric emergency care: Development of Paediatric Assessment Unit at Whipps Cross is underway, an initiative aligned with the acute care hubs programme (see part 3, section 6)

Youth commissioners: Delivery of summer workshops focusing on local diabetes services and areas of the care pathway with opportunity for improvement, in particular transition services.

Joint commissioning boards and integrated child health transformation boards have been set up, signing off on initiatives such as personal health budgets

Commissioning Intentions included outpatient redesign (including enabling quicker access to specialist advice, both virtually and face-to-face).

Next steps

Many of the plans are being developed and implemented locally by CCGs and their local authority counterparts. Some of the initiatives are being developed alongside the equivalent adult initiatives (for example, urgent care, acute care hubs and surgery – please see part 3).

The Waltham Forest, East London and the City (WELC) Paediatric Commissioning Alliance will continue to work closely with local authority partners to further support the delivery of holistic and coordinated care. The alliance will also be sending representatives to the Barts Health Children's Health Network Board to ensure progress and planned changes are worked through in coordination with the provider.

Newham CCG, through the diabetes youth project has been engaging with young people in Newham living with diabetes in order to understand their wishes in order to redesign pathways and services. The initiatives proposed at the summer workshops on youth diabetes have been evaluated and prioritised by the youth commissioners. The group has drafted a phased approach, with the first set of changes scheduled to be implemented from April 2016 (with the project informing commissioning intentions in December 2015, and drafting any business cases as appropriate).

As part of sharing good practice across the CCGs, the intention is for the youth diabetes programme to be evaluated and extended to Waltham Forest and Tower Hamlets.

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4. The changes we have prioritised and their impact

Identifying the key initiatives The TST programme has identified over 100 potential improvement schemes. As part of the programme stocktake in August 2015 a set of transformation criteria were agreed by the programme board in order to focus and prioritise the work of the TST programme. Each of the longlist schemes were assessed on whether they:

required whole systems collaboration and financial leverage to ensure delivery

had a material capital requirement which needs external sourcing or sign off

result in a material activity shift in one or more organisations

result in a fundamentally new and innovative service model which has the capability to be of interest to other organisations either locally in East London or nationally.

This resulted in a shortlist of 13 priority initiatives which are the areas of focus in this chapter and (in greater detail) part 3 of the document.

Other schemes that did not meet the criteria were captured, accounted for, and are being progressed through local delivery and ‘business as usual’. The diagram below outlines the process and timelines.

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The 13 prioritised initiatives were grouped into three clusters supported by a range of enablers.

Cluster Description

1. Care closer to home transformation

Focuses on the shift in emphasis to care closer to home and in the community.

2. Strong sustainable hospitals Focuses on change in hospitals.

3. Working across organisations to continually improve care

The transformation that requires whole system working.

It is important to note that whilst children and young people and mental health do not have separate transformational schemes, these are incorporated into all the other schemes as described previously.

Realising the benefits in terms of improved care for children and young people and for mental health will require collaboration across organisations. The East London CCGs will be able to use the TST governance structure to track delivery and progress of this.

The 13 initiatives that satisfied one or more of the transformational criteria (and the criteria they met)

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The 13 initiatives also help achieve the programme strategic outcomes

Transforming Services Together requires whole system working and collaboration to deliver the benefits. Our programme structure and governance is now aligned with these prioritised initiatives (see chapter 6.1 of this document).

4.1 Expand integrated care to those at medium risk of hospital admission

During the last two years, our health and social care services have been working together more closely to ensure those people at the highest risk of admission to hospital experience coordinated case management. This is because our Case for Change showed that around 20% of patients account for 80% of healthcare costs52 and that people’s experience of care is not always as joined up as it could be.

Over the next five to ten years, our integrated care approach will be further developed to ensure that interventions are available for a fully risk stratified east London population. For example:

Case management will be in place for the very high risk and high risk of hospital admission cohorts of patients.

Care coordination and navigation will be in place for the medium risk cohort.

Self-care and self-management approaches will be available for people with low risk and very low risk of admission to hospital.

52 Integrated Care Case for Change – Summary, WELC 2012

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This care model will ensure that care plans are developed around the needs of those people most at risk of admission to hospital, discharge planning is coordinated between health and social care services and people are given the support they need to stay well through prevention and self-care management interventions. Important enablers of this work are the development of shared care records, a workforce that is increasingly able to work across care settings, as well as the organisational development work that will support providers and staff to work together.

Full details of the clinical model, investments and impact can be found in part 3, section 1.

4.2 Put in place a more integrated urgent care model Rising demand due to population growth, combined with the planned reconfiguration of the emergency department at King George Hospital means that without change there is likely to be an increase of 92,000 people visiting our local emergency departments. We know that up to 21% of those who currently attend emergency departments, but who are not admitted, require no significant treatment53 and could have received their treatment in another setting. Our Case for Change also highlighted that people find the urgent care system confusing and hard to navigate.

Our strategy is to simplify the entry into the urgent care system so that people receive the right care, in the right place, first time. We will develop an online directory of services so people can ‘click first’, which will be simple and easy to use to describe where services are and how to access them. The NHS 111 clinical triage service will be integrated with the urgent care system allowing the service to direct people to pharmacies, or book appointments for people directly. We also know that unless people are supported to manage minor illnesses themselves better, the system will not be able to cope with increasing demand. Online resources and applications will be developed that offer advice and the number of people encouraged to use pharmacy services will be increased.

Finally, the urgent care centres at Newham, Whipps Cross and The Royal London will be strengthened and will need to work more closely with hospital services to ensure emergency departments are for emergencies only. This will include the strengthening of the workforce skill-mix and improved access to rapid testing facilities, for example X-ray and bloodtesting, when they are required.

Full details of the clinical model, investments and impact can be found in part 3, section 2.

4.3 Improve end of life care

As a result of the changes we propose, more people will be able to die in accordance with their wishes. Organisations will work together to improve end of life care, focusing on better understanding people’s preferences towards the end of their lives, conducting effective care planning and making sure these care plans are shared between providers. In the future, people will be able to access high quality and responsive care in the community round-the-clock, resulting in fewer people needing to be admitted to hospital during the final months and weeks of their lives. We will also provide better training to staff to help them better

53 SUS data 2014/15

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support people who are dying. This will include training to support staff to start conversations early regarding care preferences.

Full details of the clinical model, investments and impact can be found in part 3, section3.

4.4 Improving access, capacity and coordination in primary care

Without change, by 2020 population growth would necessitate over half a million primary care appointments per year. But because of the age profile of our workforce and national recruitment challenges, we expect there to be 136 fewer GPs working in east London by 2020. This means we need to fundamentally change the model of primary care and diversify the workforce. Whilst we expect the overall number of GPs to reduce, by 2020 we expect there to be 58 more pharmacists, 25 more physician associates, 49 more nurses and 46 more community health service staff working in primary care.

The changes aim to transform, modernise and redesign primary care by focusing on improving access, establishing proactive care models and coordinating care better. For example, access can be improved by allowing people to receive healthcare advice by phone, Skype or email and our workforce challenges will be overcome (for instance) by pharmacists working in primary care, allowing GPs to concentrate on more complex work.

People will be supported to stay healthy and well through better self-care support whilst symptom checkers and online triage systems will also be introduced. In future, to cope with rising demand, up to 24% of current general practice appointments will need to be delivered through services like pharmacies or through supporting patients to manage their own health.

We recognise that primary care has a crucial role to play in providing care coordination and care planning for people with long term conditions. This will require some appointments to be longer, for example for care planning sessions.

In order to transform, primary care will need to be commissioned at greater scale to cope with our future challenges. Given our workforce, capacity and estates challenges, we believe this can only be delivered in primary care practices with patient list sizes over 10,000, or through smaller practices working together at scale in integrated provider networks, or through collocated facilities at primary care hubs.

Full details of the clinical model, investments and impact can be found in part 3, section 4.

4.5 Establish surgical hubs

We want to establish a network of surgical hubs, one at each Barts Health hospital site (Newham, Royal London, Whipps Cross and St Bartholomew’s). These would operate in networks, to provide safer, less variable care delivered by the right person, at the right time.

Surgical hubs allow services to be delivered locally wherever possible and bring services together where this improves outcomes and delivers safer care.

This new model would mean patients only travel when absolutely necessary and would have preoperative appointments and tests at their local hospital.

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Each site will have a ‘core’ surgical offering high quality local care that also backs up maternity and emergency services. This will be combined with a ‘core-plus’ set of services where there are advantages in delivering surgery at scale in terms of quality or safety.

As part of this model, each site would host core services and a different combination of core plus and specialised hub functions. For example, Whipps Cross Hospital could become a specialised hub for urology surgery, whilst Newham Hospital may become the specialist hub for arthroplasty (hip and knee) surgery.

Proposed segmentation of surgical services

Through each site providing a combination of core and core plus surgical services, all sites would maintain the surgical capacity and capability to support emergency and maternity services, safely – see below for details of a potential configuration of services with the sites and specialties. This will need to be further tested and enhanced including through appropriate engagement with the public, staff and local stakeholder groups.

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Potential configuration of surgical services across sites

Over the next six months we will be working to test and enhanced this, as well as other options including through appropriate engagement with the public, staff and local stakeholder groups.

There would be a dedicated emergency surgical service provided around the clock through a network across our hospitals. This would ultimately improve clinical outcomes and improve patients’ quality of life after life- or limb-saving surgery.

This change would also allow:

better networking with other NHS trusts across London through clearer access to strengthened specialist hubs and a world class tertiary centre

surgical services would be safe and sustainable in line with the Royal College of Surgeons guidance and policy on minimum volumes54 allowing surgeons to maintain their skills by treating larger numbers of patients

ensuring adherence to quality standards for safe and optimum care for paediatric surgery

dedicated recovery nursing teams and equipment to enhance recovery and reduce the amount of time patients spend in hospital, getting them home quickly and safely.

The full details of the clinical model, investments and impact are in part 3, section 5.

54 Royal College of Surgeons www.rcseng.ac.uk/healthcare-bodies/clinical-policy/standards-and-policy

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4.6 Establish acute care hubs at each site Too many patients are admitted to hospital because there are not the dedicated facilities to treat them appropriately and send them home safely the same day. Therefore, we want to strengthen emergency departments by establishing acute care hubs at each site where ambulatory55 care is the default option for treatment.

This model, in line with the findings of the Future Hospital Commission, aims to put patients’ needs first and redesign hospital services to meet them56. Acute care hubs bring together the clinical areas of medical divisions that focus on the initial assessment and stabilisation of acutely ill medical patients. Only patients needing care likely to take longer than 48 hours should be admitted to a specialist ward.

This would mean establishing ambulatory care on all three sites and new ways of rapidly accessing specialist medical and surgical assessment through effective use of multi-speciality short stay wards and same day access to clinics.

This would also reduce the demand for hospital beds, allowing the system to serve the growing population without building more capacity.

Full details of the clinical model, investments and impact can be found in part 3, section 6.

4.7 Maternity – increase the proportion of natural births

At its core, the new maternity care model focuses on ensuring that service provision is orientated around providing a good experience of care for women, supporting them through their pregnancy, birth and post-birth journey.

Described by clinicians as the ‘default’ place of birth, 86% of women across Barts Health gave birth in hospital-based, obstetric-led settings in 2013/4, although within this figure there is significant variation across the three sites. This is not safe nor sustainable for the future.

The new continuity of care model aims to encourage more women to choose birth settings appropriate to their risk level. This will mean greater numbers of women will be supported to give birth outside the obstetric unit. As more women are supported to have a natural birth experience across a variety of settings, less medical interventions such as Caesarean section will be required and we will not need to build additional obstetric capacity in the next five years. As part of our ongoing work with our partners in neighbouring areas, we are reviewing the extent to which all providers can meet the growing rate of births over the next 10 years. This will be a key part of the implementation planning.

The full details of the clinical model, investments and impact are in part 3, section 7.

55 Ambulatory care is emergency medical care (diagnosis and treatment) delivered to emergency patients who would have previously been admitted to a bed but are able to visit hospital and depart on the same day (with possible on-going follow up) 56 Future Hospital Commission 2014, Royal College of Physicians www.rcplondon.ac.uk/projects/outputs/future-hospital-commission

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4.8 Transform the patient pathway and outpatients The Case for Change identified that the current model of outpatient care is ineffective and outdated. It suggested that the system is wedded to a 20th century model of service, which is worsened by contracting arrangements and existing custom and practice. In addition to the finding that some appointments fail to add value for patients and clinical staff, without change there are expected to be an additional 141,000 appointments by 2020/2021, due to population growth. Giving the long waiting times that patients currently experience, no change is not an option.

Therefore in response, TST will transform the patient pathway and outpatients. Clinical leads have identified that around 20% of current outpatient activity is either unnecessary or could be provided in a radically different way. The quality of referrals will be improved to reduce unnecessary appointments and all possible pre-work will be completed in primary care. Skype and telephone clinics will become more widespread and in addition, where appropriate, primary care physicians will be given easier access to specialist advice through email and the telephone to help them give the right advice to patients without the need for a specialist consultation.

For the most common long-term condition pathways such as respiratory care and heart disease, we will build on the good work that has already taken place to improve diabetes care and redesign patient pathways in close alignment with each boroughs integrated care plans. In addition, prevention programmes will be strengthened to promote early identification, whilst tele-monitoring systems and patient initiated review (where patients have quick access to specialist opinion, when their symptoms get worse rather than through fixed appointments) will become more widespread.

For the most common planned care patient pathways (those that often result in an attendance at hospital for a procedure), care will be redesigned across East London to reduce waste and duplication. This will mean there will be standardised referral criteria, common standards of care and the widespread sharing of best practice across the region.

Health services should also make it easier for patients to attend appointments when they need to happen. Current ‘did not attend’ (DNA) rates reach 20% in some specialties. Sometimes this happens because patients find it difficult to attend or let staff know that appointments need to be re-arranged. Tackling this problem is an important aspect of our strategy because for every patient who doesn’t attend, another then has to wait longer to get the care they need. The redesign of administrative processes regarding appointment booking is critical.

The full details of the clinical model, investments and impact are in part 3, section 8.

4.9 Reduce unnecessary testing National evidence57 suggests that as much as 25% of pathology testing is unnecessary and recent audit work in City and Hackney CCG has suggested that as many as 20% of primary care initiated MRI requests could have been avoided. Our local analysis suggests that there is as much as 34% variation in the rate of pathology tests undertaken between East London CCGs, something that cannot be explained by population factors alone. Given East London CCGs currently spend around £42.5m per year on testing, as well as the importance of 57 Report of the Review of NHS Pathology Services in England. COI for the Department of Health. August 2008.

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reducing waiting times for cancer testing by 2020, work to strengthen protocols represents a considerable opportunity for improvement.

Over the next five years, we plan to introduce a rolling programme of work focusing on the 20 most requested tests ensuring there are agreed protocols for testing in place between organisations across our health system. This will reduce the amount of instances where people are exposed to unnecessary testing and improve access to testing it is most needed. In addition, where testing is appropriate and it would reduce delays in the patient journey, we will build on the good practice we have already implemented to further enable GPs to book people into tests directly, without having to see a specialist first.

The full details of the clinical model, investments and impact are in part 3, section 9.

4.10 Deliver shared care records across organisations Organisations across East London will further progress their plans to deliver shared care records. Without access to shared information, care professionals often need to repeat tests unnecessarily and ask repeated questions in order to properly diagnose and treat a condition. This is inefficient and leads to a poor patient experience. Access to a shared clinical record also reduces clinical risk as the full patient history (and proposed future appointments) is known; this allows a clinician to provide the most appropriate care.

To provide patients and care professionals with access to the right information, we will ensure that the IT systems that different health and social care organisations use can communicate effectively with each other (interoperability). Often this can be done through software that identifies and shares crucial data fields from the existing system, but it may mean organisations need to make decisions about the systems they would like to use in the future. The security of patients’ confidential information is of the upmost importance to all of us, so organisations will only share information with explicit consent except in an emergency situation (such as if a patient is unconscious). Patients need to have a say in how their data is used and continuing engagement with local residents will be important.

The full details of the clinical model, investments and impact are in part 3, section 10.

4.11 Explore the opportunity that physician associates

may bring Because our future projections show that GPs and specialist staff will be in even more finite supply, we need to diversify our workforce and make sure that we make the best use of the resources we do have.

The UK’s Competence and Curriculum Framework for the Physician Associate (2012) describes a Physician Associate (PA) as a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general medical and/or general practice team under defined levels of supervision. PAs can perform a large proportion of a doctor’s role at a reduced cost freeing up time for trained doctors to concentrate on providing more complex care. In primary care PAs can safely assume up to 83% of visits58.

58 Investigating the contribution of physician assistants to primary care in England, Drennen et al. (2014)

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Because of the challenging recruitment outlook the future brings, exploring the opportunities that new roles can bring is fundamental to our sustainability. By 2025, we hope to have 85 PAs working in East London across both primary and secondary care.

The full details of the clinical model, investments and impact are in part 3, section 11.

4.12 Develop a strategy for the future of Mile End hospital

Barts Health has two acute inpatient wards at the Mile End Hospital (MEH) site which tend to act as overspill wards from the Royal London site. Clinicians have indicated that having these separate geographical locations leads to sub-optimal clinical practice, as it is difficult for consultants to provide the necessary oversight and clinical presence across these two sites.

Specifically, this lack of senior clinical input at MEH can result in patients not being reviewed and safely discharged in a timely way. As a result, patients often stay on the wards for long periods of time and are not always discharged home as soon as it is clinically safe to do so. Following the vacation of the acute inpatient services to the Royal London site there would be subsequent work to understand the opportunity this presents and how vacant ward space and the site as a whole could be better utilised to meet the needs of the rapidly growing local population in East London. Given a large percentage of the site is also used by East London Foundation Trust to provide mental health care, a joint site strategy would be developed for the future of MEH between Barts Health, East London Foundation Trust, Tower Hamlets CCG and other local stakeholders to determine the most appropriate long-term site plan.

The full details of the clinical model, investments and impact are in part 3, section 12.

4.13 Define a strategy for the future of Whipps Cross Defining a strategy for the future of Whipps Cross University Hospital (WX) is crucial to the longer term sustainability of the local NHS. WX has been a pillar of the local community since the beginning of the 20th century, however there are significant challenges to address. Backlog maintenance (the investment Barts Health must provide to keep the current building safe for patient care) is high and the estate is not configured to deliver what is required for efficient, modern healthcare.

With things as they are, doing nothing is no longer an option. We are therefore developing a shared vision with our NHS and local authority partners. We want to write a new chapter in Whipps Cross’ history, where we see it better meet the needs of local people now and into the future, by delivering better integrated services, improved clinical outcomes and a high quality of experience for all our patients.

Over the next six months, we will develop a Strategic Outline Case (SOC), which will set out all the scenarios and make a clear argument to take forward a course of action to deliver change. This may trigger the need for further work to specify how the strategy will be delivered (such as detailed designs for a major investment for example), and clarify how it would be funded. As a result, it may be some time, possibly years, before any change is seen on the ground. But it is important that we take the necessary steps to explore all opportunities and embark on this journey together.

The full details of the clinical model, investments and impact are in part 3, section 13.

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5. Financial and activity assessment

Financial sustainability The TST Finance Steering Group has defined reaching ‘financially sustainability’ as being when each organisation within the north east London health economy can credibly demonstrate a plan to meet statutory financial duties by March 2021. This definition excludes any requirement to repay provider deficits incurred. We recognise that to address the scale of the gap, a focus on new models of care delivery and new payment/commissioning mechanisms will be required for the overall system to reach balance.

For CCGs, financial sustainability means the recurrent delivery of a 1% surplus as required by NHS business rules. For providers, financial sustainability means recurrently delivering a surplus. In addition, because financial and clinical sustainability are intrinsically linked, all organisations in the system need to achieve their financial positions while meeting fundamental national waiting time standards and ensuring sufficient capacity exists in the healthcare system to meet demand.

The repayment of loans and other debts incurred in the process of reaching recurrent surpluses by 2021 has not been allowed for in the definition of financial sustainability. Organisations in north east London recognise that debt repayment is an issue that requires a consistent approach to be agreed.

Financial assessment The TST programme has considered each initiative in the context of its impact on cost, price and activity; for example, initiatives that:

enable a shift in activity from one care setting to another at a cheaper cost and reduced tariff, that also release capacity into the system

increase productivity in the current care setting, thereby increasing capacity in the system, reducing average cost, but not price to the CCG

do not directly impact on activity, but will incur costs/savings and are significant transformational change enablers.

All initiatives are still under development, and discussions regarding how any released capacity in all sectors will be utilised is currently being developed. Net savings and the system financial impact of the TST programme cannot be fully determined until these discussions are resolved. However, projected savings for the TST initiatives are expected to have a net beneficial impact of between £104 million and £165 million over five years to 2020/21, this is net of investment costs. This requires a capital requirement of £72 million (see p65) . The expected annual recurrent net saving by 2020/21 is £43 million.

The table below includes sensitivity analysis, conducted in January 2016, of the changes the system will make. This helped identify the key variables that potentially impact positively or negatively on the net savings position, through a risk assessment of the key assumptions, resulting in upper and lower ranges.

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Revenue impact and capital requirement of TST initiatives to 2020/2159

In order to determine the financial impact of initiatives, the TST programme must consider the potential use of released system capacity. Capacity could potentially be reutilised by providers, enabling them to generate income to match, or improve services. Alternatively, capacity could reduce, freeing up resources and reducing cost within the system. Each option as to the use of capacity has consequences for activity throughput and for waiting lists.

In due course, all TST initiatives should be the subject of a business case before proceeding to approval in line with the governance arrangements agreed by the health system. At that point a decision will be made as to the use of the capacity that each TST initiative will release. This will enable the financial impact of TST initiatives on providers to be more accurately determined.

Activity implications: bed availability

Barts Health is currently running at or near 100% bed occupancy, with the prospect of further pressures as the WEL population grows.

By 2025/26, the local health economy will need an additional 550 beds based on 100% occupancy levels (200,000 bed days); however, this requirement reduces to 26 beds after 2020/21 and 240 beds by 2025/26 after the impact of the TST programme.

59 The expected benefits associated with physician associates have been recorded against primary care transformational change. The acute benefits have not been linked to a specific transformational change, which by 2020/21 could result in net benefit of approximately £0.9 million/year.

5-year net savings

Upper Lower

£m £m

Care Closer to Home

Primary Care 34.5 30.7

Urgent Care 5.8 2.5

Integrated Care 6.6 4.2

End of Life Care 3.4 1.6

50.3 39.0

Strong Sustainable Hospitals

Acute Care Hubs 35.7 22.6

Surgical Hubs, incl. IR 4.3 0.0

Normalising births (13.8) (14.1)

26.3 8.6

Cross cutting themes

Pathway redesign 82.4 64.9

Reduce unnecessary testing 25.5 20.7

Shared Care Records (11.1) (12.3)

Physician Associates (3.2) (11.5)

Mile End Hospital - -

Whipps Cross Hospital (5.1) (5.1)

88.4 56.8

Net TST programme impact 164.9 104.4

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Beds: Barts Health

The table is based on an estimate of 2,019 beds currently available at Barts Health. More work is required to determine how the additional bed requirement will be met beyond 2020/21.

The impact of the TST programme by initiative on Barts Health beds

The above impact is based upon operating at 100% of capacity and shows that 2,045 beds would be needed by 2022 against a current available complement of 2,01960, a 26 bed shortfall. Projecting below 100% occupancy would increase the bed shortfall.

60 Total bed numbers are calculated assuming full bed occupancy

-500

0

500

1000

1500

2000

2500

2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26

Baseline Baseline Adjustments (incl KGH) Growth TST Capacity

Extra 26 Beds

Required

Extra 240 Beds

Required

2019

87

219150

58

2616

30

2045

1800

1900

2000

2100

2200

2300

2400

Baseline Baseline Adjust (inclKGH)

Growth Acute Care Hub +OPAT

Integrated Care EOL Care LoS Reduction Maternity Beds after Growth, TSTetc

5 Year Impact on Bart's Health NHS Trust Beds

Min Max Capacity

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Activity implications: outpatient activity

Although the bed requirement is of critical importance, we know that pressure also exists on outpatient activity as described in the charts below.

Outpatient appointments: Barts Health (all CCGs) ‘000s

A relatively small shortfall remains after the TST programme by 2025/26; however, there is an intervening period where the effect of TST initiatives outstrips growth and by 2020/21 there is a relatively small surplus of capacity compared to the baseline (43,000 outpatient appointments).

Activity implications: primary care

Without the TST programme or increases in capacity, demand growth for primary care creates a shortfall against capacity. This increases steadily so that by 2025/26 there is a shortfall against projected capacity of 24%. Assuming the same case mix, the impact of the TST programme reduces this demand above capacity to surplus capacity of around 560,000 appointments per annum. This ‘released’ capacity will be utilised by GPs spending more time with patients with more complex needs as a result of the projected move from secondary to primary care initiated by a number of the TST schemes.

-400

-200

0

200

400

600

800

1000

1200

1400

1600

2016/17 2017/18 2018/19 2019/20 2020/21

Baseline Growth TST Capacity

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Primary care appointments: capacity released (000’s)

Activity implications: Emergency and urgent care

Emergency demand will outstrip demand without TST, but the shortfall reduces when the effects of the programme are included. The urgent care programme will result in fewer people going to emergency departments.

Barts Health emergency attendances

-3000

-2000

-1000

0

1000

2000

3000

4000

5000

2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26

Baseline Growth TST Additions TST Capacity Release Capacity

-100000

-50000

0

50000

100000

150000

200000

250000

2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26

Impact of TST Baseline Growth Baseline Adjustment (incl KGH) Capacity

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Capital requirements

Capital costs identified as part of this programme are shown below. For comparison, we have also included the expected capital cost that the system would incur if the TST programme were not to be implemented and instead a new 550 bed hospital was built.

Capital funding sources require further consideration and could include national bids or asset disposal across East London, plus a reduction in Barts Health backlog maintenance requirement if we go ahead with a rebuild at Whipps Cross.

The proposed development of Whipps Cross has been included in the list of TST initiatives. This initiative is not to be confused with backlog maintenance work for the site, which is included in the Barts Health baseline position. The Whipps Cross TST initiative involves defining a strategy for the future of the site. Capital design costs are estimated at £41 million and are included in TST initiative costs in the five year timeframe. Rebuild costs are estimated at £412m and are not anticipated until 2022. Should a rebuild be taken forward it is highly likely that the new building and associated flows will support a more productive hospital, these savings have not currently been quantified and would not be realised until well after the new building is operational. Were the redesign initiative to be implemented, we estimate that approximately £40 million of capital costs currently included in baseline calculations for Barts Health backlog maintenance could be removed.

2016 to 2021

2016 to 2025

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Capital impact of TST initiatives until March 2021

The method by which we have conducted our financial assessment are described in the end note.

Conclusions from modelled activity outputs Our conclusions from the financial assessment undertaken so far are:

The TST programme will significantly reduce hospital demand (before impact of population growth) at Barts Health over the next five to ten years.

Inpatient and outpatient activity will reduce due to both preventative initiatives and initiatives that reprovide activity in alternative settings.

The TST programme will reduce average length of stay, which supports the increase of productivity at Barts Health and reduces the need for additional beds at Barts.

The TST programme predominantly impacts on activity for patients registered in East London. Additional capacity is required at Barts Health for other commissioned patients. There is a risk that the capacity released by the TST programme will be used for patients outside of East London.

The TST programme moves us positively towards achieving both financial balance and meeting the need for more capacity to meet demand growth. However the delivery of provider cost improvement programmes, including productivity work, is a critical contribution to overall system financial balance and capacity release.

£m

Care Closer to Home

Primary Care -

Urgent Care 0.4

Integrated Care -

End of Life Care -

0.4

Strong Sustainable Hospitals

Acute Care Hubs 9.3

Surgical Hubs, incl. IR 10.4

Normalising births 0.2

19.9

Cross cutting themes

Pathway redesign 0.7

Reduce unnecessary testing -

Shared Care Records 9.7

Physician Associates -

Mile End Hospital -

Whipps Cross Hospital 41.0

51.3

Net TST programme impact 71.7

Capital

Required

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Further work required In respect of the TST programme:

• We will critically review pricing and explore risk share possibilities and payment innovation. Further refining of investment costs especially in respect of workforce assumptions; estates requirements and delivery risks and phasing will be considered as part of implementation planning to determine that the assumptions for each initiative are robust.

• Providers will review each service line impacted by the TST programme so that the system can ensure that services remain both viable and sustainable, taking into account any payment innovation suggested as part of the TST programme.

• A joint commissioner and provider plan for use of the capacity released by TST programme needs to agreed, aligned with our obligations of clinical and financial sustainability as a system.

• We will endeavour to understand the scale of elective waiting lists at Barts Health and understand how this might impact on the finance and activity projections.

• As part of implementation planning we will assuring that our community and mental health services have sufficient capacity to implement the new models of care.

• We need to agree the process for approving individual initiative investments to be released to proceed to implementation.

Outside of the TST programme:

• Barts Health cost improvement and productivity plans will be finalised and included in a wider five to ten year financial plan inclusive of the TST programme.

• NHS England’s success criteria for strategic plans, including the emerging Sustainability and Transformational Planning requirements, will be reviewed and responded to. The recommendations of the review of the financial assessment will be included in future iterations of financial strategy for East London organisations.

• The 2016/17 national tariff and planning guidance will be used to update plans.

• Specialist commissioning intentions will be obtained and incorporated into post-TST financial positions for the north east London health economy.

• Providers and commissioners will triangulate provider income and commissioner activity forecasts to ensure consistency of forecasting information and robustness of the baseline system financial plan.

• The final estates requirements, including capital investment costs, will be incorporated on the final publication of the Borough and WEL estates strategies, this will mean that the capital plans can be further detailed and funding sources identified

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6. Next steps

6.1 Delivery The TST programme details 13 initiatives which have been grouped into three ‘clusters’:

Care closer to home (CCH), which focuses predominantly on impacts to our community and primary care settings.

Safe, sustainable hospitals (which focuses on acute care transformation). Working across organisations to continually improve care.

These clusters will require different approaches to implementation which are detailed below. It is important to recognise that across all initiatives strong clinical leadership and involvement in delivery is critical. The clusters will all be supported by the enabling work in Informatics, transforming the workforce for the future and estates.

Transformational change of mental health and children and young people’s services sit across clusters, and are involved in many of the individual key initiatives. They will require collaboration across organisations. The East London CCGs will be able to use the TST governance structure (detailed below) to track delivery and progress. A separate mental health strategy will be developed, in particular around the acute mental health services, and enhancing the mental health provision in primary care across the areas covered by four CCGs (Waltham Forest, Newham, Tower Hamlets, and City and Hackney) and two mental health providers (NELFT and ELFT).

There is still a lot of work to do as we move into the next phase of the TST programme. The strategic intent and outline plans laid out in this document must now be detailed for delivery and benefits realisation across the system in line with the Five Year Forward View. The next phase will utilise the working groups for the key initiatives already established by the programme.

Care closer to home This strategy details the CCH outcomes and improvement frameworks, however it is the development of local delivery plans, led by the CCGs that will ensure the realisation of the frameworks.

There will be new contracting models that bring together CCGs and local authorities in the delivery of CCH initiatives. Future ways of working will see these emerging integrated provider organisations managing delivery of patient-centred care through a multi-disciplinary workforce.

CCGs will have responsibility for delivering the strategy through their local, borough-based, implementation plan including agreed outcomes and milestones. Activities that need to take place once across East London will be coordinated. A central team will also track progress and interdependencies of the local implementation plans, thereby providing an assurance function to the CCGs.

The central team will also be responsible for co-ordinating the necessary support for the CCGs from the TST enablers.

70

Increased access to primary care will be delivered through an East London improvement framework that is realised via local delivery. Urgent care will have a similar approach except for some aspects (e.g. NHS 111 procurement) that will require collaboration and governance across not just East London, but the whole of north East London. The end of life care initiative will continue to focus on supporting the implementation of the model of care, working predominantly with Barts Health.

The TST steering groups, detailed later in this chapter, provide the decision-making groups to further develop and deliver the transformational changes.

Strong sustainable hospitals Delivery of the strong sustainable hospitals (SSH) initiatives will be predominantly led by Barts Health, with support and leadership from the across the CCGs. The TST programme will support the identification of required resources and support planning in this next phase. The SSH plans will need to be mainly site-led and managed, with interdependencies identified (including interdependencies with the CQC improvements and cost improvement plans).

The acute care hubs initiative and maternity initiative will see separate site implementation plans as the site reconfiguration and workforce will need individual delivery plans. However the surgical hub implementation plans will work across all the sites, with closely managed interdependencies. The SSH initiatives will sit within Barts Health’s existing governance structures and report to the SSH Steering Group and through to the TST Board, via the Clinical and Academic Strategy Board.

This cluster also needs to include and respond to:

A clear vision and site strategy for Whipps Cross Impact of system changes such as the planned closure of the King George Hospital

emergency department For some changes proposed, or affecting, the SSH cluster (and the potential King George Hospital emergency department closure) the impact is across north east London and therefore the North East London Advisory Group will provide the forum for the wider discussions.

Working across organisations to continually improve care These initiatives impact across organisations and therefore the TST governance is critical to their delivery.

The introduction of physician associates in primary care through the workforce initiative will be coordinated through TST and closely tracked through the workforce working group.

The shared care record requires coordination across East London, with local leads brought together currently by the East London chief informatics officer. An Informatics steering group is in place including multiple organisations.

Local estates strategies are being developed by each CCG and these are responding to the activity projections and TST care closer to home strategy. Making Whipps Cross fit for the future is a key TST initiative and the Whipps Cross strategic outline case is expected to be developed by June 2016. This will respond to the TST strategy and involve the local authority and others through the estates working group which reports to the TST board.

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In addition organisational development and communications are areas of focus that will cut across all the clusters. All the changes required in implementation rely on staff co-creating, owning and leading the overall transformation process so its benefits are realised and sustained across the system. Therefore it is critical to ensure that organisational development is put in place to deliver the necessary change to organisations, clinical leadership and culture. Investment costs have been identified to support this.

Governance of the TST initiative Transforming Services Together requires whole system working and collaboration to deliver the benefits. Our programme structure and governance is now aligned with these prioritised initiatives. This allows regular meetings between key decision makers to ensure rapid progress. The Care Closer to Home and the Strong Sustainable Hospitals clusters meet monthly – including representation from the programme management office, with key individuals attending both clusters to ensure alignment and direction. It is critical that the enabling areas support both clusters, and that the work across organisations is delivered. The TST Board oversees the whole programme.

As described above there will be some initiatives delivered locally through existing CCG governance and by local teams. There will also be initiatives delivered once across East London. For these initiatives the proposed governance structure is below and will be updated to ensure co-ordinated delivery.

For those initiatives that require north east London-wide collaboration and working, the existing forums of north east London advisory group (NELAG) and the clinical senate bring together commissioners and providers. The impact of the potential closure of King George Hospital emergency department and the maternity transformational change are specific examples of initiatives that impact the wider north east London footprint.

72

6.2 Implementation plan These initiatives have been designed to be delivered in a phased and aligned approach over the next five years. As part of the next steps we need to engage and test our proposed changes with a variety of stakeholders ahead of the proposed implementation.

From March to June 2016 we will:

engage with staff, stakeholders, patients and the public to test our proposals and develop our ideas. We also plan to consult on our proposals for surgical hubs

develop implementation plans, identifying interdependencies

strengthen the leadership and capability to deliver the next phase.

We will develop project initiation documents (PIDs) for implementation. PIDs are used to capture the initiatives approach and delivery plan. They will outline the resources, responsibilities and governance for each initiatives; define if business cases are required for funding (and which forum these will go to for approval); and capture key risks and issues for successful delivery.

Next steps

73

NHS England published its planning guidance for 2016/17-2020/21 in December 2015. The guidance asked health and care systems to come together and to create ambitious local Sustainability and Transformation Plans (STP) for accelerating implementation of the Five Year Forward View.

Producing a (STP) plan involves:

Local leaders coming together as a team Developing a shared vision with the local community which also involves local

government where appropriate Programming a coherent set of activities to make it happen Execution against the plan Learning and adapting

Success will be dependent on having an open, engaging and iterative process that harnesses the energies of clinicians, patients, carers, citizen and local community partners.

The TST Strategy and Investment Case is very timely and meets many of these criteria.

Highlights of TST programme phasing

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Communications and engagement

Communications and engagement have been an integral part of our work. During the engagement period we will be talking to overview and scrutiny committees, Healthwatch and our key stakeholders about how to ensure patients, the public and their representatives are involved in future. We will be publishing a summary version of this document, including a questionnaire, for distribution to the wider community across East London.

When we consider the results of the engagement:

if there is general support and no significant, evidence-based challenge (i.e. points that are backed up with firm reasons why our proposals are not the best), we will consider any suggestions on how to improve the plans, and then get on and implement them.

if there are robust, evidence-based challenges to some of the proposals (i.e. points that are backed up with firm reasons why our proposals are not the best, and preferably with sound alternatives) we may incorporate these changes into the plans, look at alternatives or consult on the ideas in order to reach a satisfactory conclusion.

Whatever path is chosen for each element, we will ensure continued engagement of patients, the public and key stakeholders throughout the process. We will continue to test our plans with our patient and public engagement group, with local patient groups and relevant specialty patient groups. We will report back to overview and scrutiny committees and the CCG and Barts Health governing bodies; these bodies include patient representation. We will monitor the engagement plan, and change it if necessary. For instance, if a proposal becomes more contentious whilst we are working up the final plan, then we might consult on the issue.

Engagement and any consultation will be carried out locally where this is most appropriate (for instance primary care proposals) and across the whole of East London when the changes could affect this wider community. We will build our discussions into CCG and Barts Health engagement plans to discuss issues with local people. This will enable the programme to better explain what proposals mean in each borough, reduce confusion and reduce the need for people to respond to multiple questionnaires.

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End Note: Financial assessment methodology

CCG funding allocations have been based on recommendations issued by NHS England over the summer (2015). Funding growth estimates comprise both demographic and non-demographic components. Demographic rises are based on the Greater London Authority’s ward projections1 and non-demographic increases have been modelled at 2% a year. The pace of CCG funding allocations are expected to grow at a slower rate than demand growth. Baseline positions

The financial starting point on which the TST programme has been assessed is based on the following: The expected baseline financial position of all North East London (NEL) organisations having

taking into account estimated CCG funding growth allocations, 2015/16 plans, known local QIPP initiatives, and the impact of demand growth and cost inflation – this is the projected financial position if none of the TST initiatives were implemented.

Any statutory, legislative or essential work that organisations need to carry out to estates, IT and workforce in Barts Health that has a cost requirement over and above that already included in their baseline plans.

A five year financial planning horizon (2016/17 - 2020/21). Inclusion of primary care co-commissioning funding budgets transferring to CCGs.

Quality, Innovation, Productivity and Prevention (QIPP) and Cost Improvement Plans (CIP)

East London CCGs have identified some firm QIPP schemes for 2015/16, but only Waltham Forest CCG has included a small value for defined QIPP schemes beyond that in the baseline positions. This is on the understanding that the TST programme will deliver the bulk of future QIPP savings in future years. Providers have included internal CIPs within their baselines where these are known.

Handling of surpluses and deficits

For CCGs, it is assumed that the TST programme impact on the carried forward surplus/deficit position at the end of each financial year is in accordance with NHS resource accounting and budgeting rules. For providers we have not carried forward in-year surpluses/deficits when calculating the five year local health economy deficit. This is in accordance with the planning guidance provided by North East London CCG Chief Financial Officers.

Modelled TST initiatives

The full range of TST initiatives impacts on a number of care settings, CCGs and providers. To enable a robust calculation of the impact of the TST programme, East London CCGs commissioned an activity-driven model that has the potential to interface with Barts Health modelling components to create a joint commissioner-provider model.

Key other methodological points Where capacity is released within a provider as a result of an initiative, savings have been calculated by estimating the length of stay reduction and determining the number of new patients that could be treated using the number of days saved. At a health economy level, changes between commissioners and providers within the same health system have a neutral financial impact as a tariff reduction is a gain to commissioners, but income loss to providers. Similarly increased income to a provider is a cost to commissioners. It is only when cost changes in an East London provider that there is a real net financial impact to the system as a whole.

1

Transforming Services Together Strategy and investment case

Part 3: High impact changes

2

Contents About this document ............................................................................................................. 3

1: Expand integrated care to those at medium risk of hospital admission .............................. 4

2: Put in place a more integrated urgent care model ........................................................... 16

3: Improve end of life care ................................................................................................... 27

4: Improving access, capacity and coordination in primary care .......................................... 40

5: Establish surgical hubs, including interventional radiology .............................................. 65

6: Establish acute care hubs at each site ............................................................................ 83

7: Increase the proportion of natural births ........................................................................ 103

8: Transform the patient pathway and outpatients ............................................................. 124

9: Reduce unnecessary testing ......................................................................................... 139

10: Deliver shared care records across organisations ....................................................... 148

11: Explore the opportunity that Physician Associates may bring ...................................... 157

12: Developing a strategy for the future of Mile End Hospital ............................................ 162

13: Defining a strategy for the future of Whipps Cross University Hospital ........................ 166

3

About this document

This document is part 3 of the Transforming Services Together Strategy and Investment Case. It contains a detailed analysis of the thirteen initiatives which form the core of the Transforming Services Together programme.

It should be read in conjunction with parts 1 and 2 of the Strategy and Investment Case document. If you do not have a copy, please contact the Transforming Services Together team on:

Phone: 020 3688 1540 Email: TransformingServicesTogether@nelcsu.nhs.uk

Website: www.transformingservices.org.uk

Risk rating methodology The following methodology has been used to score the risks associated with the practical delivery of the changes suggested in sections 1 to 13 of this document.

Ranges and sensitivity analysis As part of the work to understand the financial impact of the proposed changes, we carried out sensitivity analysis of the changes that the system will make.

This helped identify the key variables that potentially impact positively or negatively on the net savings position through a risk assessment of the key assumptions, resulting in upper and lower ranges for the key changes we are making.

4

1: Expand integrated care to those at medium risk of hospital admission

1.1 The case for change Integrated Care initiatives have been designed as part of the Transforming Services Together (TST) five year planned response to the health issues in East London highlighted by the Integrated Care Case for Change, published in December 20121 and the Transforming Services Changing Lives (TSCL) Case for Change, published in December 20142.

Whilst the TSCL Case for Change had a particular focus on hospital services, the diverse nature of the population in East London presents broader health and social care pressures and implications that reach into primary care, social care, community services and the third sector. TST as a programme of work therefore encompasses this broader consideration of issues. More specifically, the TSCL Case for Change identified a need to improve and strengthen our integrated care approach and this is being achieved through redesigning the way services work and by providing improved primary and community care through better care planning.

The proportion of over 65s in East London is expected to grow faster than other age groups

The TSCL Case for Change identified a pressure point in the East London population as it will experience the highest proportional increase in its population among over 65s compared with the rest of London. This group are likely to live longer, and suffer more long-term conditions which would require more complex care3. A more coordinated approach to care is about building a model of care that looks at the whole person, focusing on patients with long-term conditions, the elderly and people with mental health problems. By adopting these principles in a model of care, pressure points on the future East London health system, such as an aging community, can be better responded to.

The East London area continues to be committed to embedding a consistent model of integrated care, with initiatives beginning in 2013. The Integrated Care Case for Change called for “higher-quality, more efficient and joined up care in East London”4. An integrated care model aims to shape care provided around the needs of the patient, rather than organisational, service and borough boundaries. This will improve quality, efficiency and patients’ experience of care as well as achieve the integration across service providers – GPs, hospitals, community services and the third sector – that is necessary to join-up the various components of a patient’s care journey.

Twenty percent of East London patients account for 80% of the healthcare costs

Analysis from the Integrated Care Case for Change integrated dataset (combining data at a patient level across health, social, mental, community and primary care) was risk stratified based on a patient’s likelihood of hospital admission. It showed that around 20% of patients 1 Integrated Care Case for Change - Summary, WELC 2012 2 Case for Change. Transforming Services, Changing Lives. December 2014 3 Case for Change. Transforming Services, Changing Lives. December 2014 4 Integrated Care Case for Change - Summary, WELC 2012

5

account for 80% of healthcare costs5. This top cohort of patients often receive the most fragmented care. Therefore, integrated care services in East London have targeted this part of the population (see diagram below), further divided into very high risk (VHR) and high risk (HR) (c.5% of the population), and have commenced extending the approach to the moderate risk (MR) cohort (c.15%) from 2015:

Risk stratification of the East London population and associated healthcare costs

Some integrated care initiatives have been in place in East London since 2013, and at this stage have targeted the VHR and HR cohorts with plans to ramp up to reaching the full 20% of the population by the end of the five year plan (2020/21).

One of the key findings of the TSCL Case for Change is that hospitals cannot secure high-quality and financially sustainable services on their own; the successful implementation of integrated care is expected to reduce emergency admissions, emergency department attendances, readmissions, and associated elective care provision through better ways to coordinate care6. The potential reduction in non-elective spend is estimated to be 24-40%, based on variability between GP practices across the boroughs, a comparison of East London performance against Office of National Statistics (ONS) top performers and a review of the global evidence base on integrated care7. This reduction in spend will deliver benefits in terms of reducing the number of occupied bed days relating to the integrated care patient cohort. At this stage, as integrated care interventions are implemented and embedded, the estimated impact has been modelled at lower rates. As schemes mature and new ways of working between providers to coordinate care and improve patient outcomes are realised, the potential impact on non-elective spend may be expected to increase.

5 Integrated Care Case for Change - Summary, WELC 2012 6 Case for Change. Transforming Services, Changing Lives. December 2014, p 161 7 Integrated Care Case for Change - Summary, 2012, slide 2

Source: TST Case for Change Summary, 2012

6

Future ambitions

Over the next five to ten years integrated care will reach beyond the 20% of the East London population most at risk of hospital admissions, as we move towards maturing integrated care approach and initiatives across the region with the overall aim to scale up to ‘business as usual’ and whole systems working in line with overarching ambitions, and expanding services in the community as appropriate.

This will be delivered by integrated provider networks that are strengthened by interoperability, improved care pathways and shared care planning – ensuring improved patient experience, improved health outcomes and improved system efficiencies.

We will deliver care that is integrated for a fully risk stratified East London population that would cover:

case management for the VHR and HR cohorts care coordination and navigation for the MR cohort self-care/self-management for Low Risk (LR) and Very Low Risk (VLR) cohorts.

1.2 Model of care Integrated care plays a part in achieving system-wide transformation and partnership. The East London area aspires to build a system of coordinated care that empowers patients, provides more coordinated, proactive and responsive care, and ensures the system operates in an efficient and consistent manner8.

To achieve this, East London has designed a new model of care with nine key interventions for its population, which are underpinned by enablers and components:

Model of integrated care across East London

8 Integrated Care Case for Change - Summary, 2012, slide 1

Enablers

Estates• Capacity in the community

Communications• Whole system• Patient engagement

Workforce• Creation of new roles – case

manager, hybrid health & social worker, health & social care coordinator, discharge coordinator (based in acute wards)

Informatics• Information sharing and decision

support

Organisational Development• GP networks• Clinical leadership • Integrated provider networks (inc.

third sector)• Contracting and reimbursement

modelsEvidenced-based Pathways & Care

Packages(e.g. last years of life,

diabetes, COPD, CHD, falls, alcohol and

substance misuse, social prescribing

Areas of interventions

Self-care, behaviour, and expectation management

Care Planning

Health and social care navigation

Case management

Specialist input in the community

Discharge support for mental health patients from secondary to primary care

Rapid response with short team reablement

Mental health liaison (RAID)

Discharge support from acute to community

Ensuring people are in the most appropriate setting of care

Inte

grat

ed H

ealth

and

Soc

ial C

are

‘Cre

atin

g a

Cul

ture

of H

ealth

’

Self-care

Care Coordination

7

This new model of care9 has been developed as a co-designed approach to ensure that:

care plans are developed around the needs of the patients at highest risk of hospitalisation

discharge planning is coordinated between health and social care services

new ways of working are put in place that join up services and better support people in their own homes

technology is put to better use and information shared securely so that staff have information about the right person at the right time in the right place

commissioning approaches incentivise joint working and preventative care

patients are given the support they need to stay well through prevention and self-care management interventions

all health and social care organisations work together to meet the needs of their patients

Developing integrated care for people at moderate risk of hospital admission

As integrated care is extended to those at moderate risk of admission, the interventions and services required to support patients are expected to diversify, with an increasing focus on secondary prevention and self-care. By building capacity in settings such as primary care (please refer to ‘Model of Care’ in the primary care initiative - part 3, section 4) and in the third sector, the medium risk cohort will be able to access care that will reduce the demand on acute services. This also means service users will experience coordinated, high quality care in community-based settings and be better supported by a well-developed and engaged multi-disciplinary health and social care.

Please see below for diagram of East London Care Closer to Home / Integrated Care programme showing timeline, model of care and intervention against risk-stratified East London population.

Enablers

Integrated care delivery will be supported by several key enablers which are also shared across other workstreams of TST, including care closer to home schemes. In particular, the IT enabler is key to realising care integration via the development and implementation of informatics interoperability and shared care records access across providers to give improved experience of care and coordinated care for service users. Another key enabler is organisational development in regards to facilitating clinician, staff and care provider the necessary culture change for joint and new ways of working to achieve directing care for patients in the most appropriate setting. More details are given in part 2, chapter 3.2 of the Strategy and Investment Case.

9 Model of Care for Integrated Care across WEL, IC Commissioning Intentions 2016/17

8

East London Care Closer to Home / Integrated Care Programme 2012-2021

Source: WEL IC PMO, 2015

WEL CCH/IC Programme 2012-2021

Very High Risk

(0.5%)

High Risk

(4.5%)

ModerateRisk(15%)

LowRisk(30%)

Very Low Risk(50%)

Population Segmentation/Risk

Stratification

Integrated Health &Social Care Approach

• Person-centred care including information personalised advice and education

• Community-based approaches to increase local choice and support, community volunteering for health inc. Social Prescribing

• Enabling approaches e.g. digital engagement and enablement

2012

Maturity reached

over5-10 years

Timeline Developing New Models of Care Areas of Intervention

Care Co-ordination

Ensuring people are in the most appropriate setting of care

Self- Care

• Care planning• Health and social care

navigation• Case Management • Specialist input in the

community• Discharge support from

acute to community• Rapid response with short

team reablement• Discharge support for MH

pts from secondary to primary care

• Mental Health liaison (RAID)• Discharge support from

acute to community

2021

9

1.3 Engagement Engagement has been extensive including clinicians and patient representative groups. The table below lists the examples of engagement across the integrated care themes and the forums in which this has taken place:

Borough level engagement

CCG Governing Body Meetings

Clinicians and patient representatives are present in the three borough CCG Governing Body meetings that occur monthly and include consideration of agenda items on integrated care work/developments at local level.

Integrated Care Committee

Clinicians and patient representatives are present in the three borough Integrated Care Committee Meetings (also named Integrated Care Board and Better Care Fund board) that occur monthly and report on agenda items specific to borough level integrated care development based on this model of care

Waltham Forest Health and Social Care Leadership event (September 2015)

Event included patient, clinical, commissioning, provider and Voluntary and Community Sector (VCS) involvement, and identified the need to take the intent of system-wide working into practice by adopting five key areas of focus; a provider partnership group and leadership project group will be established to take forward work on these key areas.

Integrated care engagement by theme

Care planning and multidisciplinary team working

Three of four workshops have been held on an East London-wide basis, involving service users, GPs, community and acute clinicians, social care professionals and commissioners from across East London. The workshops have developed a collective view of the process of care planning, the content of care plans and the roles and responsibilities required for successful care planning. A fourth workshop is in development following feedback from delegates to deliver an agreed East London-wide care plan template.

Newham CCG ran two workshops with clinical, patient and commissioning involvement to specifically review multidisciplinary team (MDT) meetings – current practices and what they can be in the future. An outcomes paper has identified a new co-designed model detailing a core membership, frequency, objectives and outcomes for MDTs. Tower Hamlets and Waltham Forest had already completed similar review work on their MDTs. Recommendations included adoption of overall MDT principles and approach across East London, with borough-specific details due to the variances in care needed between them.

Capitation Waltham Forest held an engagement event at a Governing Body meeting (June 2015) outlining progress with capitation and

10

requirements of providers in preparation for shadow capitation in April 2016.

Evaluation Interviews were carried out in March and April 2015 by Dr Laura Eyre, Researcher in Residence with the WEL Integrated Care programme which is being deployed in 4 phases. Almost 100 people attended from across East London, including front line staff and clinicians. The event included interpretive discussion sessions with executive and managerial level stakeholders from commissioners (including GPs), NELFT, ELFT, Tower Hamlets Integrated Provider Partnership (THIPP), and Barts Health

Findings from phase 1 have fed into THIPP’s development of Value Proposition strategy; Newham MDT workshops; ELFT’s integrated care strategy; WEL Integrated care project plan; MDT development work in Tower Hamlets and Waltham Forest; care planning work and communications strategies. Findings will also be made available on the East London Integrated care communications web portal10 and have been made available to provider organisations for further sharing and use.

1.4 Outcomes the change will achieve The integrated care model of care is intended to achieve the following outcomes:

Outcome description Outcome by 2020/21 (Metric/impact)

Experience of care A more enabling, person-centred experience of care including more choice and greater satisfaction

Provide personalised care through care navigator/care manager, working with people at higher risk of hospital admission to discuss their needs and care options, and plan their care in order to deliver seamless health and social care

Provide joined-up care through improved IT interoperability, by integrating care providers via the person’s care plan and shared care record, limiting duplication of effort in situations where patient is seen by multiple health and social care providers

Provide people with long-term health problems with better support to manage their own illness

Health outcomes Increase in years of life, reflected in the slope index11

Improvement in long-term condition rates e.g. diabetes, stroke, obesity, coronary heart disease, chronic obstructive

10 http://welccc.nhs.sitekit.net/ 11 http://www.lho.org.uk/LHO_Topics/Analytic_Tools/Slope/SlopeIndexCharts.aspx

11

pulmonary disease, through implementation of self-care and prevention initiatives

Improvement in self-care/self-management (indicated by Patient Activation Measure (PAM)12 for self-care/self-management)

System efficiencies Demand management, including prevention and delayed escalation to higher support or service needs

A reduction in emergency department attendances, and fewer admissions and readmissions to hospital (reduction by 20% in non-elective spend)

Better and more appropriate utilisation of acute services by the VHR and HR cohorts by limiting the number of avoidable hospital admissions overall

More efficient use of services, settings and staff because people would be treated in the best setting for their needs.

Access to IT and information systems and using shared care records will ensure most effective use of clinical time and resources

Outcome improvement trajectories across the three boroughs will be agreed further to a review of the impact of integrated care interventions by stakeholders including commissioners, public health, patients, providers including acute, community, mental health and third sector.

1.5 Investment costs In order to implement the model of care, capital and revenue investment is required. This is a shared investment that is not specific to integrated care, and is captured as part of overall Care Closer to Home costs. Please see Strategy and Investment Case part 2, chapter 3.2 for more details.

1.6 Impact on activity and revenue including sensitivity analysis Integrated care is aimed at reducing unnecessary hospital admissions for those most at risk of requiring acute inpatient care, and will then mature into broader areas encompassed by better coordinated care working across providers in East London. It is a live programme (initiated in 2013) that has seen two/three years of savings already i.e. reductions in acute spend across the identified VHR and HR cohorts. This is a gradual reduction over time. With the extension of the programme to include the MR cohort, this will further reduce acute activity.

Shifting activity

Integrated care initiatives will not entirely remove hospital admissions of VHR and HR groups of the population, as there will always be people in the community that require this 12 http://www.insigniahealth.com/products/pam-survey

12

acute care. Yet the initiatives should ensure that it is patients with the most need of hospital admission that are admitted, rather than those that could receive care in more appropriate places outside of the acute setting.

The extension to include the MR cohort in integrated care initiatives also performs a preventative function whereby care plans are instigated for this group enabling earlier detection and better education around potential long term conditions for those at moderate risk of developing them, and potentially preventing these patients from moving up into the HR and VHR cohorts in the future.

Modelling has shown that the impact of integrated care interventions by 2020/21 results reduction of emergency bed days by 21,053 at Barts Health sites, as set out in the graph below.

Effect of TST integrated care scheme on Barts Health emergency admission bed days

The activity is re-provided via care closer to home schemes e.g. shifts into GP and community health services and the third sector. The capacity would provide Barts Health with the opportunity to tackle its backlog – or to treat other patients on the waiting list more quickly. More work is needed to understand the best use of this capacity for patients and the health system overall.

Financial impact of activity shifts including sensitivity analysis

After conducting financial impact analysis, we undertook sensitivity analysis which suggests a net saving of between £4.2m to £6.6m over a five year period.

Integrated care assumptions

The reductions illustrated in the financial impact commentary are modelled on the basis of the Quality, Innovation, Productivity and Performance (QIPP) submissions for Newham and Tower Hamlets, and reflect a 20% reduction for Waltham Forest (applied to the VHR, HR and MR non-elective admissions)13.

Non-elective Admissions Newham and Tower Hamlets CCGs

o The reductions in activity were based on estimated percentage shifts at diagnosis level

13 TST Modelled Initiatives Summary Pack, V5 Run 7. December 2015, slide 65

13

o The Healthcare Resource Groups (HRG) associated with this activity were identified and the relevant proportions of each HRG were removed from the TST activity/finance model

o The activity shifts were split based on the risk grouping of the patients

Waltham Forest CCG o The number of patients admitted in 2014/15 by HRG and risk category was

identified o A 20% reduction was applied to the VHR, HR and MR non-elective admissions

Emergency departments For all East London CCGs, reductions in emergency department attendances were applied at a ratio of one attendance for each non-elective admission Outpatients For all East London CCGs, reductions in outpatient attendances were applied at a ratio of 0.5 firsts and 0.5 follow ups for each non-elective admission

Integrated care phasing

The reductions for the VHR and HR cohorts have been phased, based on the phasing included in the QIPP returns, which showed a 75% effect in 2015/16 and a 96% effect by 2016/17, before showing a full effect of the reductions from 2017/18 onwards. For the moderate risk cohort, the reductions have been phased to show 50% of the reductions occurring in 2016/17 and 100% occurring from 2017/18 onwards.

1.7 Delivery risks The following risks and issues have been identified as the most critical (red RAG)14 to the overall East London integrated care programme; the actual risk levels vary between boroughs, to reflect local circumstances.

Description of risk Mitigation

Organisational development (OD)

Provider collaborative development does not happen at sufficient pace in each borough

Investment being made in GP networks and provider networks in all three boroughs. Progress at different stages. Further investment through Pioneer and Vanguard national teams. Also, sharing of local, national and international experience/good practice through Programme Management Office (PMO).

Organisational development needs are not prioritised by CCGs and provider partners, including local authorities

CCG sign off on Strategy and Investment Case which includes significant OD investment. Providers, particularly Barts Health to commit to investment in transformation (OD) as part of TST strategy

14 For a definition of risk ratings, please see part 3 ‘About this document’, p3

14

Public, third sector and patient engagement in integrated care is lacking

Rationale for involvement articulated in Strategy and Investment Case in terms of added value and patient/health benefits and mandated to all partner organisations

Lack of clinical engagement and leadership

Programme of investment in clinical leadership included in Strategy and Investment Case. As necessary, external expertise brought in to facilitate development

IC deliverables are not articulated e.g. care co-ordination, patient experience, health outcomes, system efficiencies, preventing effective evaluation of outcomes to demonstrate impact of IC programmes/interventions

Benefits described in Strategy and Investment Case; detailed analysis of anticipated impact of IC care models to be reviewed by clinicians, patients, third sector etc., coordinated by public health

Providers do not have sufficient confidence in other elements of the system to make changes to their own services

Cross boundary collaboration between commissioners and providers in the development and implementation of care closer to home services will increase shared knowledge, trust and confidence. The care closer to home (CCH) governance arrangements will underpin this work and the associated OD programme will help drive the shift away from 'silo' working to collaboration

Informatics

Data quality is insufficient to support proposed contracting and reimbursement changes

The deployment of dedicated analytics staff to work with providers on data capture ensures the continual focus on ensuring quality

Informatics unable to deliver IC priorities including shared care plan enablement

The IT/informatics requirements for the East London IC programme have been identified and shared with the East London informatics team. Next steps include workstream prioritising, including shared care plan enablement.

Contracting and reimbursement

GP federations are not mature enough to enable negotiation with other providers in each borough

Dedicated OD programmes are supporting GP provider network development. The PMO coordinates the sharing of local, national and international knowledge and experience, through East London IC leads and the national pioneer/vanguard support teams

Care planning

Care planning has too many interpretations by clinicians and a common framework cannot be agreed

A task and finish group was established to develop an East London care plan template. Agreed principles and outline content were produced from a series of stakeholder workshops. The template is

15

being finalised with the aim of sign off at a final workshop in January 2016. In parallel, an East London project is being initiated by UCLP to formalise patient centred collaborative working, to ensure effective MDT working re care planning.

1.8 Next steps We expect our proposed care model/changes will be developed and enhanced as a result of further testing and development of the strategy in the following key areas:

1. Engaging with staff and key stakeholders on an ongoing basis to inform development, and a further iteration to develop care models and associated systems and processes e.g. MDT/ collaborative working approach; There is a follow-up leaders’ meeting for Waltham Forest in January 2016 is planned; and an evaluation workshop is planned for February 2016 where we will seek to engage specifically with front line staff and clinicians.

2. Undertaking detailed workforce modelling, capturing all existing workforce information and planned developments, to ensure that the proposed care model is effectively supported by workforce changes, both immediate and planned.

3. Ongoing financial assessment of the activity modelling, costs and savings, including implementation costs and benefits for each initiative, ensuring alignment with each organisation’s own income and expenditure plans, to validate a clear annual benefit.

4. Exploring reimbursement options more broadly so as to identify payment systems and incentive schemes which deliver the desired changes in provider behaviours.

5. Implementation planning to provide an overall phased and prioritised programme of change. Prioritisation and phasing will be completed based on those schemes that are expected to have the most impact on ensuring East London has high quality, safe and sustainable services and will incorporate an assessment of deliverability. This work will also take into account interdependencies with the CQC improvement plan at Barts Health and the different workstreams on each other, including our enabling workstreams (IT, estates, workforce and payment systems).

6. Developing impact assessments for the individual and collective proposals, including travel and equalities.

7. Strengthening the necessary leadership, governance, and system-wide capacity and capability.

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2: Put in place a more integrated urgent care model

2.1 The case for change The need to redesign urgent and emergency care services in England and the new models of care which propose to do this are set out in the Five Year Forward View (5YFV)15. The Urgent and Emergency Care Review proposes a fundamental shift in the way these services are provided, improving out of hospital care so that we deliver more care closer to home and reduce unnecessary hospital attendances and admissions. The 5YFV highlights that we need a system which is safe, sustainable and provides consistently high quality care. The vision of the review is that for those:

people with urgent care needs, a highly responsive service should be delivered as close to home as possible, minimising disruption and inconvenience for patients and their families.

people with more serious or life threatening emergency care needs, the health service should ensure that they are treated in centres with the very best expertise and facilities in order to maximise the chances of survival and a good recovery.

In designing this strategy, the growing and ageing population and the impact that neighbouring borough plans will have on demand for services has been taken into account.

The rising demand from our population, combined with the planned reconfiguration of the emergency department at King George Hospital, means that if we do not change the way we configure our services, by 2020 there is likely to be an increase of 92,000 people per year visiting our local emergency departments.

One of the key objectives therefore in designing this strategy is to ensure that our emergency departments are used for emergencies only. We know from local health data that up to 21% of those who currently attend emergency departments, but who are not admitted, require no significant treatment16, and could have received their treatment in another setting. Of this cohort, up to a third were children and young people. We also know from national evidence that people with a mental health need account directly for approximately 5% of emergency department attendances and most people who frequently re-attend emergency departments do so because of an untreated mental health condition17. In order to ensure that our emergency departments are used for emergencies only we need to therefore offer real alternatives closer to home regardless of age and type of urgent need. For more information on how East London will be redesigning emergency care, please see the acute care hubs transformational scheme, detailed in part 3, section 6.

Work we have completed to date has shown that:

people are not supported sufficiently to manage their own conditions18

15 www.england.nhs.uk/2014/08/15/5yfv/ 16 SUS data 2014/15 17 Transforming urgent & emergency care services in England Urgent & Emergency Care Review Nov 2013 18Case for Change. Transforming Services Changing Lives www.transformingservices.org.uk/downloads/caseforchange/TSCL%20case%20for%20change%20FINAL%20web.pdf

17

around 20% of GP workload is spent treating people with minor ailments which could be treated by visiting one of our 176 local ‘walk in’ pharmacies19 or through self-care

primary care access is currently poor in East London20 and segments of our population are not finding it easy to access our 141 GP Practices in the traditional way. This means that some people choose to attend emergency departments when they are unable to get a GP appointment

there is variation in service provision of our community rapid response services in terms of opening hours21

up to 52% of ambulances arriving at our emergency departments are transporting people who attend but are not admitted to hospital. Of these up to 12% required no significant treatment22

East London urgent care centres do not all meet the urgent care facilities specifications set out in NHS England, London Healthy Partnership23. Currently there is variation in opening hours and available clinical expertise, as well as variable access to diagnostics, which is leading to increased referrals to our emergency departments24

our current payment system does not incentivise or support system working25

our current IT system is not fully interoperable26 which means that clinical records, ‘special notes’, care plans and summary care records (SCR) cannot be easily shared27.

Responding to the above case for change is critical to ensuring that we can continue to offer a sustainable, high quality urgent care service to our growing populations.

2.2 Model of care Our strategy for urgent care closer to home is to simplify the entry into the urgent care system so that people receive the right care, in the right place, first time. Our new urgent care system will recognise the needs of all our age groups – children and young people, adults and older people – and will be able to meet urgent care needs closer to home whether people are presenting with a physical or a mental health need.

Helping people to navigate the system easily ‘click first’: To help people have access to the right service, in the right place, first time we will promote and develop the use of an online directory of services known as My Directory of Services (MiDoS). This is simple and easy to use and describes where services are and how to access them.

The NHS 111 clinical triage service ‘phone first’ will be integrated with the urgent care system. The diagram below shows that the service will be able to direct people to self-care, pharmacies book people into the primary care hubs or, if the level of need necessitates,

19 Transforming urgent and emergency care services in England Urgent and Emergency Care Review Nov 2013 20 GP Patient Survey results 2014/15 21 Urgent care case for change. Transforming Services Together (TST) 22 WEL SUS Data 23 Draft UEC Facilities Specifications. London Healthy Partnership. August 2015 24 Urgent care case for change. TST 25 Urgent care case for change. TST 26 Commissioning Standards Integrated Urgent Care. NHS England. September 2015 27 Commissioning Standards Integrated Urgent Care. NHS England. September 2015

18

within the urgent care centres. The primary care hubs will have a wide range of professionals such as GPs, pharmacists, dental, community health and social care services for people of all ages and for people with a physical and/or mental health need. Where level of need indicates people will be booked into the urgent care centres which will have a multi-professional workforce with access to diagnostics. People requiring ambulatory care28 services will also be able to be booked into these services directly from NHS 111. These changes will ensure that people are seen quickly and conveniently.

Use of NHS 111 as a single point of entry

*Registered patients will be encouraged to contact their own GP first

Increase the confidence in people managing minor illnesses: East London residents are already becoming more confident in managing minor illnesses on their own. To increase this confidence further, online resources will be continuously updated and improved. Digital applications (apps) that offer advice for minor illnesses will be provided and more self-care courses will be offered.

Pharmacies will also play an important role when residents want further support in managing their illnesses. MiDoS will locate local pharmacies and help raise the profile of the support pharmacies can provide. The integrated urgent care system will also be able to direct residents to pharmacies when it is appropriate to do so.

Improve same-day access in primary care: Up to a third of residents are not able to book an appointment at a time that is convenient to them29. Many of these people will have urgent care needs and will, as an alternative, seek help from other services including emergency departments and hospital-based urgent care centres. Many people’s urgent care needs can be met more effectively by primary care. Through the work with primary care GPs will have

28 Ambulatory care is a patient focused service where some conditions are able to be safely treated on the same day which previously have required an overnight stay in hospital 29 GP Patient survey results 2014/15

19

more time to be able to assess and treat people more relevant to their skill sets. Current evaluations are also underway on pilot schemes which are extending GP opening hours within primary care hubs after 18:30 weekdays and at weekends. If these are successful the extended GP hours will form part of local offers.

Improve accessibility to community services: Within primary care hubs there will be collaborative working with GPs, pharmacies, dental and community health and social care services, connected by IT and improved payment mechanisms to work together to provide an integrated urgent care response closer to home. Our current walk-in services will become part of the primary care hub offer with current activity being absorbed by improved access to GPs, pharmacies and self-care.

We will also look at how we can improve current services. This will include improving rapid response teams (adults and children) and mental health crisis teams so that they are able to respond to people’s needs over a 24 hour period. We will also work towards further investing in community ambulance technicians so that more care can be delivered, when appropriate to do so, at the scene in collaboration with our GP’s and community health teams.

The integrated urgent care system will work closely with community nursing staff caring for people with long term health conditions or receiving end of life care in their own homes, including care homes.

Strengthen the urgent care offer at the front of our emergency departments with the right workforce and appropriate access to tests 24 hours a day: If emergency departments are to successfully provide 95% of care within four hours, strengthened urgent care centres are needed at each site.

Within the urgent care centre the workforce skill-mix will be broadened to include multidisciplinary teams, including at least one registered practitioner and at least one healthcare practitioner. Arrangements will also be in place to have access to experienced doctors of at least staff grade 4 registrar level in both adult and paediatric emergency medicine and practitioners with mental health skills will also be available. The urgent care centres will also have access to a medical or non-medical prescriber and access to diagnostic test facilities including X-Ray and bloods so that they can cater for a much broader range of conditions30.

30 Urgent and emergency care facilities specification

20

2.3 Engagement to date In developing this strategy we have been working extensively with our local stakeholders. We have also linked in closely with the work of NHS England and the London Healthy Partnership to ensure that local solutions are aligned with, and will impact positively on work taking place across the city.

Engagement sessions to date:

Newham Urgent Care Working Group

Tower Hamlets Urgent Care Working Group

Waltham Forest Urgent Care Working Group

TST Patient and Public Reference Group

TST Urgent Care Steering Group

Tower Hamlets Patient Focus Group

Newham clinical and engagement patient session

2.4 Outcomes the change will achieve The integrated urgent care system is intended to achieve the following outcomes:

21

Outcome description Outcome by 20/21 (Metric/impact)

Meeting NHS constitution emergency department 95% four hour wait standard

Each emergency care department will consistently meet the 95% four Hour target

Meeting urgent care centre assessment and treatment times

All patients are to be seen and receive an initial clinical assessment by a registered healthcare practitioner within 15 minutes of the time of arrival at the urgent care service

Within 90 minutes of the time of arrival at the urgent care service 95% of all patients are to have a clinical decision made that they will be treated in the urgent care service and discharged or arrangements made to transfer them to another service

At least 95% of patients who present at an urgent care service to be seen, treated if appropriate and discharged in under three hours of the time of arrival at the urgent care service (where clinically appropriate).

Children and adolescents Single call access for children and adolescent mental health (CAMHS) (or adult mental health services with paediatric competencies for children over 12 years old) referrals to be available 24 hours a day, seven days a week with a maximum response time of 30 minutes. Psychiatric assessment to take place within four hours of call

Summary care records 100% of patients have an episode of care summary communicated to the patient’s GP practice by 08:00 the next day. For children the episode of care is also to be communicated to their health visitor or school nurse, where known and appropriate, no later than 08:00 the second day

Proportion of people accessing urgent care system via NHS 111 versus walk in

70% of access to the community based urgent care system is via NHS 111 single point of entry by 2017/18

80% of access to the community based urgent care system is via NHS 111 single point of entry by 2018/19

90% of access to the community based urgent care system via NHS 111 single point of entry by 2019/20

Increase in % of people using pharmacies

50% increase in use of pharmacies for minor ailments

Increase in levels of people being treated closer to home

10% decrease in ambulance conveyances to emergency departments of patients attending but not admitted

Please note this list is not exhaustive

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2.5 Investment costs

2016/17 2017/18 2018/19 2019/20 2020/21 Total

Capital costs inc. capital revenue

£86k £86k £86k £86k £344k

Workforce Modelled as part of tariff

OD costs £60k £200k £120k £380k

Other investment costs

To manage the additional urgent care activity being delivered closer to home, more resource will be required in the new integrated NHS 111, pharmacy, primary care hubs, and the urgent care centres. These resource costs will be further identified as part of the full business case development.

2.6 Impact on activity and revenue Impact on activity

The integrated urgent care system will mean that an increased level of care can be safely carried out away from the hospital setting. This will be achieved through NHS 111 having increased levels of clinicians on the calls, self-care tools accessed on line, increased uptake in pharmacy, improved same day access in primary care and strengthened service offers within primary care hubs and urgent care centres. It is envisaged that the integrated urgent care system will reduce emergency department activity by 26%. The following graphic shows the different care settings in which this 26% of activity will be delivered.

23

Please note it is also assumed that additional call activity will go to NHS 111 and this has been assumed as a 70% of current walk in activity

Impact on finances and sensitivity analysis

After conducting financial impact analysis, we undertook sensitivity analysis which suggests a net saving of between £2.5m to £5.8m over a five year period.

In addition the proposed payment model for the integrated urgent care system is currently being piloted by eight vanguard sites. These sites are reviewing a new three-part payment model which includes the following elements:

% of resourcing at fixed costs % of resourcing at variable cost % outcome based costs and linked to improving quality

It is expected that if the three part payment model is successfully piloted the methodology will be rolled out to all urgent care systems. Waltham Forest, Newham and Tower Hamlets are closely linked into the work of the vanguards through the North East London Network which consists of Barking and Dagenham, Havering, Redbridge, Waltham Forest, Tower Hamlets, Newham and City and Hackney Clinical Commissioning Groups (CCGs). East London CCGs will be evaluating the impact of any new payment models on the urgent care system and will be adapting the financial framework accordingly.

Pharmacy11,556

7%

GP34,73122%

Self-Care9,9716%

Clinical Locality Hubs69,70744%

Co-Located Urgent Care Hub

34,03721%

Activity Closer To Home

24

Further financial validation including the impact on providers will be included as part of the next steps alongside considerations on procurement, financial phasing and payment innovation.

2.7 System commercial considerations and transitional support required

The integrated urgent care procurement group consists of the seven north east London CCGs (Barking and Dagenham, Havering, Redbridge, Waltham Forest, Tower Hamlets, Newham and City and Hackney). The group is planning to re-procure the new NHS 111 clinical triage to ‘go live’ by April 2017.

2.8 Delivery risks The table below outlines the current main risks to delivery

Description of risk Risk likelihood

Risk impact

Risk rating Mitigation

1 Full IT interoperability solutions are not expected to be in place by the anticipated ‘go live’ date April 2017

4 4 16 Work is underway at NHS England and local level to mitigate this risk

2 Lack of clinical engagement 3 3 9 Clinicians have been involved through workshops and 1-1 meetings to ensure that views have been captured

3 Lack of providers available to fulfil service specification criteria for the new integrated urgent care system

4 5 20 Work is underway to assess the market and numbers of providers who will be able to fulfil the remit

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2.9 Next steps Data evidence

The further steps are taking place to add quality to the evidence base

Carrying out validation checks on the database which has been used for modelling and taking corrective action in future modelling where needed

Completing public health work to review the causal factors for emergency department attendances and standardise variations by each GP practice to further add confidence to the assumptions

Completing the linkage work to identify the percentage of people who access the urgent care system through multiple points. This work will add confidence to the assumptions and will also be a good measure of improvement when the new integrated urgent care system is fully implemented

Further financial phasing to include further shifts in activity to for example self-care and pharmacy

Procurement

North east London CCGs are working collaboratively to procure the new NHS 111 clinical triage system. Locally Waltham Forest, Newham and Tower Hamlets are also working on the implementation plans to integrate the rest of the urgent care system with the new NHS 111 and will be reviewing further procurement plans as part of this.

Procurement key milestones

Milestone Dates

Agreement to proceed with preferred timeline including

the NHS England assurance meetings

October 2015

Clinical visioning workshops will be held which will further specify what care is provided within the primary care hubs and how they will be connected through improved IT

October 2015

Arrangements to agree support to develop the service specifications

November 2015

Development of service specification and business case November 2015 – January 2016

Engagement with stakeholders including public engagement

February 2016

Approvals of final specification and procurement process March 2016

Procurement March – August 2016

Award of contract September 2016

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Mobilisation period October 2016 – March 2017

Start of new NHS 111 service contract 1 April 2017

27

3: Improve end of life care 3.1 The case for change “You matter because you are you, and you matter to the end of your life.”

Dame Cicely Saunders, Founder of St Christopher’s Hospice (1918 - 2005)

As highlighted in the Department of Heath End of Life Care Strategy, one in three people admitted as emergencies to a hospital are palliative patients31. The strategy also made clear that 50-70% of patients with progressive illness expressed that they would prefer to die in their usual place of residence. Local data shows that only 22-29% people died in their usual place of residence in East London32.

This evidence, combined with a lack of a standardised local system for conducting end of life care planning means that there is significant opportunity to improve the experience of care towards the end of life for local residents, their families and carers. High quality end of life care should be available to everyone and should be provided in community settings where possible, through health and social care staff who are supported with adequate time, education and training33. The new national framework for action sets out six ‘ambitions’34, principles for how care for those nearing death should be delivered at local level:

1. Each person is seen as an individual

2. Each person gets fair access to care

3. Maximising comfort and wellbeing

4. Care is coordinated

5. All staff are prepared to care

6. Each community is prepared to help.

The diagram overleaf identifies some key areas of improvement and aspiration that health and care professionals from across East London identified as key areas of change35.

31 End of Life Care Strategy: Promoting High-quality Care for All Adults at the End of Life. Department of Health, July 2008 32 SLAM Data, Barts Health 2011-2014, National EoL intelligence network 2014/15 Q2-3 and three year standardised rate 2011-2013 33 Actions for End of Life Care 2014 - 16, NHS England. November 2014 34 Ambitions for Palliative and End of Life Care: A national framework for local action 2015 – 2020, National Palliative and End of Life Care Partnership, September 2015 35 East London workshop on end of life care, March 2015

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Key themes of the case for change

Across East London the key issues in relation of end of life care are:

Inequity of access to high quality care, including 24/7 out of hours support services.

Inconsistencies and inadequacies in the current care model.

Fragmented systems for identifying, conducting and sharing care plans and referring palliative care patients to optimal settings of care.

Poor or unmet patient and carer experience of care and expectations.

Lack of a coordinated approach across organisational boundaries to deliver optimal care.

Workforce challenges including training, recruitment, retention and potential demoralisation of staff providing care to palliative patients.

The engagement conducted to date suggests that the provision of end of life care for adults in East London does not fulfil NICE guidance36. The Transforming Services Changing Lives (TSCL) Case for Change37 highlighted that people’s choices towards their preferred place of death are not always fulfilled. All three boroughs are below the national average for the proportion of patients dying at home (Newham 20%, Waltham Forest 18% and Tower Hamlets 22%) and above the national average of 49% for the proportion dying in hospital 36 End of Life Care for Adults, NICE quality standard (QS13), November 2011. 37 Case for Change. Transforming Services Changing Lives. 2014.

Mental health The end-of-life care principle for long-term condition care should have a strong mental health focus on

emotional support and managing wellbeing in the last years of life.

Pharmacy Improve the provision of 24/7 community pharmacy

services, particularly to support end-of-life care services.

29

(Newham 64%, Waltham Forest 67%, and Tower Hamlets 59%)38. Making sure a patient’s wishes are recorded and shared in order that fewer patients die in hospital (when it is against their wishes) is a key component of Barts Health’s Safe and Compassionate Care Improvement Plan39.

There is currently insufficient capacity to support people to die outside of hospital settings

Enabling more people to die at home, or in a hospice surrounded by their loved ones is also a key enabler for relieving pressure on hospital beds. As the Strategy and Investment Case illustrates, over the next ten years, without changing the way that care is delivered, the local health care system would need to build an additional 505 beds to meet the demand growth expected as a result of our growing population. This is unaffordable and would also mean that care would continue to be delivered in suboptimal care settings.

In order that the needs of a growing population can be met without building further hospital bed capacity, it is important therefore to invest in sufficient care in the community. Currently, despite many palliative care patients spending their last weeks and months in and out of hospital, bed utilisation in facilities suitable for providing hospice care is low. For example, St Joseph’s Hospice has a current bed utilisation of 69% and regularly has up to 19 beds free. If fully utilised, this has the potential of creating approximately 7,000 bed days for palliative hospice care, provided referrals from Barts Health can take place in a timely and supportive way. In addition, engagement conducted to date suggests that there may not be sufficient capacity in community services to support patients to die at home. Further investment in palliative care nursing teams, alongside good care planning is also likely to mean fewer people die in hospital settings.

Capacity also needs to increase in out of hours palliative care services. Across England, 20% of people who die experience three or more emergency admissions in the last year of their life40. Providing consistent 24/7 support services in the community would reduce the need for these admissions. The engagement that has been conducted to date suggests that 24/7 palliative care services that can provide for people in their own homes are not in place locally, with care instead provided either by out of hours GP services, or through local accident and emergency departments, often resulting in emergency admissions.

Identifying palliative care patients and agreeing and sharing care plans is unsystematic across East London

During the end of life care workshop in March 2015, a number of issues were identified within East London related to this area. To support people to die in line with their wishes, health and care professionals agreed that the health system needs to identify those approaching the end of their lives earlier, identify their care preferences more often, and agree care plans that are recorded and shared more systematically between providers.

The sharing of electronic care plans would greatly enhance care, not only between health providers but also across social care and the voluntary sector. For example, in Bedfordshire, an electronic register acted as a single point of care coordination that resulted in a 16% 38 National End of Life Care Intelligence Work, Public Health England, 2015. www.endoflifecare-intelligence.org.uk/data_sources/place_of_death 39 Safe and Compassionate: Our Improvement Plan. Barts Health NHS Trust, 2015. 40 Public Health England. What we know now. National End of Life Care Profiles. 2014.

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reduction of people dying in hospital41. According to Age UK, few care plans have been completed in the boroughs of Tower Hamlets and Newham. It is anticipated that this is also true in Waltham Forest as engagement so far has suggested that there is not a systematic way creating care plans for palliative care patients.

The training and development needs of our workforce

Engagement conducted42 with health, social and voluntary sectors including families and carers has highlighted the urgent need for enhanced training for staff supporting patients towards the end of their lives. This engagement has highlighted that staff often struggle to start conversations early, which results in the care wishes not being recorded and care plans not being recorded. Staff have also highlighted their lack of understanding of agreed pathways and referral mechanisms for palliative care patients. Training and education which empowers staff to discuss options and deliver care with compassion will be crucial to improving end of life care in East London.

3.2 The care pathway and model of care Discussions with key stakeholders including Barts Health, commissioning staff, Marie Curie and St Joseph’s Hospice have suggested that the pathway shown overleaf should be implemented consistently across East London.

41 Detailed in End-of-Life Care, The King’s Fund, 2014. 42 Dying Well event, Newham Community Health Services, November 2015 and End of Life Care Workshop, March 2015.

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End of life care pathway

The key principles associated with the proposed new end of life care model for East London are described in the diagram below. This highlights the importance of defined processes that systematically identify palliative care patients, record their wishes and ensure care plans are shared between providers across the health and care system.

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End of life care model

Implementing the new care model would mean organisations across East London would need to take the following action:

Help people to die in accordance with their wishes. Helping more people to die in accordance with their wishes through tailored and shared care planning is fundamental to improving end of life care in East London. Organisations need to:

work with patients and their families to better understand their preferences towards the end of life

provide enhanced training to care professionals to discuss end of life care preferences

increase capacity in palliative care teams, out of hours services and the voluntary sector to better meet growing demand (see details below)

establish clearer pathways for end of life care support between organisations, including referral mechanisms to hospices and palliative nursing teams from providers

reduce unnecessary hospital admissions by ensuring high quality 24-hour care is available in the community.

Ensure that patients who are towards the end of their life are identified so that care can be planned appropriately. People need to be appropriately identified to ensure that they are able to express their wishes about their care during the last years of life. Although there are identification systems in place across the three boroughs, our engagement suggests relatively few care plans have been recorded to date. Therefore further analysis needs to be undertaken to assess how well these processes work. Whilst primary and community care should be the setting in which care planning takes place, in the short term, identification and care planning processes at Barts Health also need to be improved.

Coordinate care for people towards the end of their life through a shared care plan. Care needs and preferences should be available to patients and all appropriate care givers. Electronic shared care records (see part 3, section 10) will enable this coordination across organisational boundaries. Whilst EMIS does not presently have a care plan functionality in place, it is expected to release this function by September 2016, subject to further technical

Commissioning including ‘more than medicine’

Engaged, informed

individuals and carers

Health and

care professiona

ls committed

to partnership

working

Person centred

co-ordinated

care through care

Organisation and supporting processes

Identity End of Life

Patient

Care

planning and

sharing of care

records

Engaged, involved and compassionate communities

33

assessment. This will be more beneficial than the systems some areas of London use, which are individual word templates held with the patient record but not structured, coded or sharable through the Health Information Exchange. Once the care plan functionality is in place, EMIS will have the ability to support the sharing of end of life care plans across systems connected to the Health Information Exchange i.e. Cerner, EMIS, RiO (for ELFT) and AzusCare (Newham Council). This is expected to provide a high degree of interoperability between providers.

Develop community services enabling more people to die at a place of their choice at home or in a hospice, surrounded by their loved ones. Work needs to take place across health, social and voluntary sectors to develop services which have sufficient capacity to enable people to die at home or at hospices. In order to prevent emergency hospital admissions, the services which are provided at home need to be available 24/7. In addition, referral pathways between hospital, hospice, district nursing and specialist palliative nursing teams need to be defined and properly mapped, including the provision available out of hours. Given occupancy rates are low at facilities that can provide hospice care (69% St Joseph’s Hospice, 50% East Ham Community Centre), commissioners, hospital and hospice staff should quickly act to improve pathways so that the pressure on acute beds can be reduced and patient experience of care towards the end of life can be improved. Organisations should also consider how greater partnership working with the voluntary sector can facilitate the changes we would like to see.

Access to pharmaceutical services 24/7. The provision of out of hours pharmacist support is vital. Engagement with palliative care nursing teams has suggested that access to palliative care medicine has been a constant concern, particularly out of hours when GPs are unavailable to prescribe. This creates a vicious circle which contributes to increasing attendances at emergency departments. As part of extending palliative nursing support to provide 24/7 care, access to pharmacists also need to be offered to aid patients and carers with pain control and symptom management.

Develop the workforce to support patients in the last year of their lives. There are a number of ways in which the workforce needs to develop to implement the new model of care:

Health and social care organisations need to increase the knowledge and skills of staff throughout the pathway. All staff working in the care pathway should be trained to have supportive conversations with patients and their carers about their preferences and needs.

The capacity of palliative care teams and expertise needs to be reviewed to ensure it meets increasing demand so that patients and their families receive prompt access to specialist advice and direct service.

Recruitment and retention of the right staff and appropriate skill mix are crucial factors in the delivery of the new model. Organisations across East London should learn from examples of innovation in this area such as the way in which St Joseph’s Hospice is succession planning to support the potential future skills shortage in this area, through the training of Band 6 palliative care nurses for future, more senior roles.

In addition to the above care model changes, pathways need to ensure that support for families and carers does not end at the time of death. A King’s Fund report identified bereavement care as a key requirement within end of life care43. Appropriate bereavement 43 Community Services – How they can transform care. The Kings Fund. 2014.

34

services should be in place to support the ongoing health needs of those who have lost loved ones44.

3.3 Engagement The following stakeholders or stakeholder groups have been engaged or have helped to shape these proposals:

Barts Health NHS Trust: directors, clinicians and senior managers

Commissioners at Newham, Tower Hamlets and Waltham Forest CCGs

St Joseph’s Hospice

Marie Curie

TST End of Life Care workshop with health and care professionals from across East London (March 2015)

Newham Community Health Services ‘Dying Well Event’ (November 2015), involving carers and families

The above workshop and meetings with key stakeholders help to define the care model and gaps in the service.

3.4 Outcomes the change will achieve The above model of care is intended to achieve the following outcomes45.

Outcome description Outcome by 2020/21 (Metric/impact)

Percentage of practice registered patients on palliative care register

0.6 - 1%

Percentage of patients on palliative care register with an advance care plan

80%

Percentage of palliative patients records which are able to be shared across health providers, social and voluntary sectors (including out of hours providers)

80%

Percentage of deaths in the usual place of residence 80%

Percentage reduction of unplanned hospital admissions for palliative care patients

50%

44 End-of-Life Care. The King’s Fund. 2014. 45 Appropriate data feeds will need to be established as part of implementation planning.

35

3.5 Investment costs Other investment cost assumptions for end of life care will be captured within the overall care closer to home costing (Strategy and Investment Case part 2, chapter 3.2) as they are not mutually exclusive from other schemes e.g. primary care, integrated care, urgent care.

Informatics, training and education costs associated with implementing an EMIS palliative care module are included as part of the shared care records investment requirements (see part 3, section 10).

The organisational development costs estimate what is required for training and education; organisational development costs associated with encouraging organisations and staff to work together across organisational boundaries; and improvement workshops/events.

2016/17 2017/18 2018/19 2019/20 2020/21 Total

Organisational development costs

£220k £200k £420k

Informatics £20k £20k

Workforce costs will need to be identified in greater detail based on community health demand and capacity analysis as part of the submission of a full business case (see 3.9 for more detail).

3.6 Impact on activity and revenue Activity impact

The end of life care project aims to ensure that more care is provided closer to home or in hospice-based settings. This will improve patients’ experience of care in the last weeks of life, help reduce pressure on hospital beds and help the health and care system to be more sustainable.

Whilst further analysis is required, it is anticipated that significant impact can be achieved through building a more proactive, coordinated and responsive system during the next five years. Around 60046 of the c.2,000 patients who currently die following an emergency admission each year at Barts Health, could be cared for in line with their wishes in their usual place of residence or in hospice settings. 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 that are currently operating at 97% capacity; aiding amongst other factors a reduction in cancelled operations.

The average length of stay for patients who die after being admitted via the emergency pathway is 15 days. A more proactive system for those with palliative care needs, including expedited referral pathways between providers, could reduce this to approximately 10 days and therefore move c.6,000 bed days a year to settings that are more appropriate for patients’ needs.

46 Further data validation is required on the percentage of deaths which are palliative in nature. An assumption of 60% has been made, with a further assumption (based on the lower estimate contained within national evidence) that around 50% would prefer to die in their usual place of residence or in hospice based settings.

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Impact on finance and sensitivity analysis

Whilst further work needs to take place to validate the proportion of patients who could be better cared for in their usual place of residence or in hospice settings, the net benefit of improving end of life care is expected to be positive not only for the patients, but also for the health and social care system. In particular system efficiency would be gained from the reduction of length of stay at Barts Health, which would contribute to better use of beds to accommodate elective admissions and the 18 weeks pathway.

After conducting financial impact analysis, we undertook sensitivity analysis which suggests a net saving of between £1.6m to £3.4m over a five year period.

End of life care financial analysis assumptions.

The financial analysis illustrated above has been made in line with the following assumptions.

End of life care model

Better coordination of care and enhanced community palliative care support will support more patients to be managed in their usual place of residence reducing admissions to hospital.

Enhanced protocols and pathways between providers and hospice settings will result in a reduction in acute length of stay for palliative care admissions.

Activity and cost assumptions

c. 2,000 patients died after an emergency admission to Barts Health during 2014/15 with an average length of stay of 15 days and bed day cost to commissioners of £272.

Up to 600 of these deaths were palliative in nature with a minimum of 50% of patients preferring to die in their usual place of residence or in hospice based settings.

Investment costs related to providing the activity in a different care setting over a five year period is estimated at 75% of current cost of acute provision i.e. £2.9m.

Data sources and modelling assumptions for length of stay reductions

Deaths data obtained from Hospital Episode Statistics Admitted Patient Care data via Health and Social Care Information Centre from NEL CSU for Barts Health (all sites)

Data has not been filtered on specialty, Healthcare Resource Group, diagnosis or procedure

An average length of stay was used

Advance care planning is assumed to achieve a 32% reduction in final admission length of stay

Activity group: non-elective admissions only

37

Age group: adults

Cost per bed day: £272 (from SUS 2014/15 extraction)

Assumptions on phasing of achievement of 32% of reduction in final admission length of stay are as follows:

o 2016/17 – 0%

o 2017/18 – 20%

o 2018/19 – 60%

o 2019/20 – 80%

o 2020/21 onwards – 100%

Further validation of these assumptions will be made during December 2015.

Admissions reduction

Evaluation of the opportunity of this scheme to reduce unplanned secondary care admissions through patients being cared for in their usual place of residence or in an alternative preferred care setting will be conducted.

3.7 Delivery risks The table below sets out the risks associated with the delivery of the new care model and any associated mitigations that the East London system will need to manage.

Description of risk Risk Likelihood

Risk Impact

Risk rating Mitigation

1 Insufficient workforce and skill mix to care for the palliative patients in the community

5 4 20 Conduct a full demand and capacity review within community health palliative care teams regarding any investment required (not factored in to date)

Establish a robust recruitment and retention strategy

Ensure that specific training is tailored to provide a skill mix workforce for the boroughs

2 Services are not able to identify palliative patients due to no system in place, coding issues, information is not recorded

4 4 16 Provide enhanced training for health professionals to provide them with training to identify and discuss care needs with palliative care patients and training to ensure they are recorded appropriately on palliative care registers

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3 Lack of care co-ordination and access to care when needed

4 4 16 Establish a strategy for partnership working and ensure there is a robust referral system to transfer palliative patients e.g. from hospital to hospice or from acute hospital to community hospital

4 No shared records and/or they are not able to be accessed among health and social care and other providers

3 4 12 Integrate care records and ensure that care records are reviewed and shared in a timely manner (see part 3, section 10)

5 Insufficient out of hospital investments being available

3 3 9 Consider investment required alongside other care closer to home schemes (see Strategy and Investment Case part 2, chapter 3.2)

3.8 Next steps The table below details the milestones that will form the next steps associated with this transformational scheme

Milestone Description Timescale

Cross organisational workshop to further define the care model

To define and agree end of life care model and actions for implementation

December 15

Validation of associated activity shift financial saving assumptions and investment required

The details in this document represent an initial modelling run only. Further validation is required based on greater clarity of the care model being obtained following a workshop in December 2015.

December 15

Workforce capacity and demand analysis

Mapping and analysis of community capacity and nursing provisions to support the end of life care model

December 15

Stakeholder engagement

Engaging with key stakeholders across all sectors and providers including patient reference group and TST Patient and Public Reference Group on a regular basis to inform development

November 15 to March16

Project working group Establish a project working group with relevant key personnel and decision makers who are engaged and able to take on implementation planning and delivery

January 16

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Clinical validation of interdependencies

Work with clinical leads to rapidly test clinical interdependencies and future model

January 16

Business case for potential community investment

Will require detailed capacity and demand analysis – to understand business case for community investment including bed contracts and the provision of community and palliative nursing capacity to support the new care model

By February 16

Establish baseline data metrics to track improvement (across the boroughs)

Identify % of patients on the palliative registers

Identity % of patients who have their preferred place of death recorded

Identify % of deaths at Barts Health which are palliative in nature

Identify % of palliative patients that have advance care plan in place

By April 16

Implementation plan in place

Including plan to deliver the clinical change, IT, organisational development and workforce aspects of the new care model

By April 16

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4: Improving access, capacity and coordination in primary care

4.1 The case for change Since publishing the Transforming Services Changing Lives Case for Change47 our analysis has demonstrated that transforming primary care is fundamental to creating a high-quality, safe and sustainable health care system in East London. Primary care needs to change in order to meet the needs of the residents we serve, provide for our growing population and deliver more care closer to home and in the community.

Whilst there are examples of excellent practice in East London, often quality is variable, there is variation in patient outcomes48 and service configurations are complex and difficult to navigate. The north east London sector also ranks the highest in the amount of patient complaints in England49, whilst challenges concerning the high level of population movement into and out of London’s boroughs can cause problems in providing continuity of care.

There is also an ageing GP population, working in a variety of ways, sometimes in old estate that is no longer fit for purpose. This is set against a backdrop of a growing population (and subsequent demand), increasing disease prevalence, particularly in mental health and long-term conditions, as well as an ongoing limited financial envelope.

The case for change for primary care services in East London is demonstrated through the following factors:

Growing demand due to population growth and changing demographics

Significant population increases, up to 29% in some boroughs, will create additional demand on primary care services. Overall, our population is expected to rise by 270,000 by 2031; this will mean there will be 1.1 million additional primary care appointments over the next 10 years and 589k over the next five unless the care model is changed.

The rising burden of chronic disease alongside an ageing population50 with increasingly complex care needs51 is increasing the demand for primary care services.

Primary care needs to make better use of the extended-team (pharmacists, optometrists, nurses, care navigators) to cope with an ever-increasing demand for services. The average number of general practice appointments per person per year in England has risen from 3.6 to 5.5 between 1995 and 2008, with the reported current average being 6.1. If this rise in demand continues, because of workforce constraints, the quality of service available will be greatly affected. GPs in the future need to concentrate more of their time on those with long term conditions and complex needs and the wider-primary care team needs to support the treatment of those with minor ailments.

47 Case for Change. Transforming Services Changing Lives (2014) 48 CCG Outcome Indicators, Public Health analysis (2015) 49 Transforming Primary Care in London: general practice a call to action. NHS England (2013) 50 The population of residents over the age of 65 is projected to rise by 60% (37,000) over the next 20 years (Case for Change: Transforming Services Changing Lives (2014) 51 The number of Londoners with complex conditions is expected to rise by a third in the next 10 years

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Generally poor patient experience of access

Around 40% of those asked in the GP National Patient Survey report that they cannot see a GP of their choice and over 30% report finding it difficult getting through on the phone52. Our local analysis to date has confirmed what the London Call to Action53 has highlighted; there is significant variation in access to primary care services in East London. Whilst further analysis will be commissioned, our work so far suggests that supply is not meeting demand and core-hour sessions are not offering enough appointments to meet patient need. For example:

o Local walk-in centre data shows that 70% of demand is in core hours

o Analysis of opening times suggests that up to 50% of practices in some areas of East London shut at lunchtime

o Patients’ experience of GP out of hours services is ranked in the bottom quintile of boroughs in England54 for all East London boroughs.

GP practices across East London are not always able to offer patients a choice of access to a female GP. For example, in some areas in East London the male/female ratio of GPs is 70/30, whereas by 2017 the London average will be 50/50.

Significant workforce shortages and retention and recruitment challenges

There are significant primary care workforce shortages and significant retention and recruitment challenges that need to be addressed. Newham and Waltham Forest already have below average numbers of GPs compared to the rest of London.

GP full time equivalents per 1000 CCG population (London CCGs, 2013)

52 GP National Patient Survey (2014) 53 https://www.england.nhs.uk/london/engmt-consult/ldn-call-to-action/ 54 CCG Outcome Indicators, Public Health analysis (2015)

Source: Health and Social Care Information Centre (2013)

42

A high proportion of the GP workforce are at, or are approaching, retirement age; 38% of male GPs in Newham, 32% of male GPs in Waltham Forest and 12% of male GPs in Tower Hamlets are aged 60 and over, many of whom want to reduce the hours that they work.

Almost 30% of GPs in Newham want to reduce their workload over the next five years.

And 6% of Newham’s male GPs operate as single-handed practices meaning that they do not have direct colleagues to whom they can hand over their workload.

Nationally NHS England reports that by 2021 another 16,000 GPs will be needed.

Male GP headcount by age (East London CCGs, 2013)

Our analysis shows that without changing our model of care, we would require an additional 195 GPs in East London55; something that is a major challenge given this is a national shortage area. We also know there are recruitment and retention challenges associated with primary care nursing staff.

There are also a number of skills shortages in primary care. For example, only 31% of the capital’s GPs believe they have received sufficient training to diagnose and manage dementia and only half of all GP associates in training have the opportunity to work in secondary care paediatric services to gain experience of identifying and managing sick children.

Some GPs and nurses, including those in training, have said they feel dissatisfied with the lack of career and development opportunities available to them. This has led some to consider not working in the area long term. In Newham only three GP Vocational Training Scheme trainees out of 15 obtained salaried positions last year. Focus groups have also highlighted that East London’s nurses are frustrated by the lack of career and pay progression.

55 Excluding expected turnover including through retirement.

Source: Health and Social Care Information Centre (2013)

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Rising costs are making living locally impossible for many nursing and support staff members. This, alongside student debt, means that working in primary care in East London is in danger of being an unaffordable career choice. Few key worker incentives such as affordable housing opportunities are offered.

The combined impact of GP shortages, retirement, reduced hours and skills shortages means that we are not able to deliver the high-quality primary care service that our patients need without significant changes to the workforce profile, ways of working and the ways in which employees are supported throughout their careers.

Many of our challenges can only be overcome by primary care working at greater scale in more multidisciplinary teams. Staff will increasingly need to work across organisational boundaries to provide care for patients closer to home. Significant changes to practice will be required to enable this, with considerable organisational development support needing to be made available to local providers.

Federations or the new provider networks can beneficially assist primary care to work at greater scale, however they are currently operating at different levels of maturity, meaning that the full benefits they could offer have not yet been realised. Much further development needs to take place during the coming years, again enabled by organisational development investment.

Variation in outcomes and patient experience of services

Health inequalities in East London are high. As outlined below, on many public health indicators the local population experience outcomes which fall in the bottom quintile, with some even falling within the bottom 1% nationally. Whilst some of these outcomes can be explained by population and demographic factors, system indicators relating to the extent to which patients with long term conditions feel supported to manage long term conditions are in the bottom 6% of all CCG areas in England.

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CCG Outcome Indicators ranked in the worst quintile in England (2015)56

56 Each CCG, and east London’s position relative to a national ranking is shown in brackets. CCG indicators form part of the CCG Outcomes Indicator Set (CCG OIS), an integral part of NHS England's approach to quality

Domain Priority WEL CCGs Newham CCG Tower Hamlets CCG Waltham Forest CCG Pr

even

ting

peop

le fr

om d

ying

pr

emat

urel

y 1 One-year survival

from all cancers (in bottom 6% nationally)

One-year survival from all cancers (2%)

Myocardial infarction, stroke and stage 5 kidney disease in people with diabetes (5%)

One-year survival from all cancers (4%)

2 One-year survival from breast, lung and colorectal cancers (7%)

Potential years of life lost (PYLL) from causes considered amenable to healthcare – Female (2%)

Under 75 mortality rates from cardiovascular disease - Male (7%)

One-year survival from breast, lung and colorectal cancers (5%)

3 Under 75 mortality rates from cardiovascular disease –Female (21%)

Under 75 mortality rates from cardiovascular disease –Female (3%)

Under 75 mortality rates from respiratory disease –Male (7%)

Potential years of life lost (PYLL) from causes considered amenable to healthcare –Male (35%)

Enha

ncin

g qu

ality

of l

ife fo

r pe

ople

with

LTC

1 Proportion of people who are feeling supported to manage their condition (6%)

Proportion of people who are feeling supported to manage their condition (1%)

Health-related quality of life for carers, aged 18 and above (2%)

People with diabetes diagnosed less than a year referred to structured education (2%)

2 Health-related quality of life for carers, aged 18 and above (8%)

Health-related quality of life for people with a long-term mental health condition (1%)

Health-related quality of life for people with long-term conditions (12%)

Proportion of people who are feeling supported to manage their condition (3%)

3 Health-related quality of life for people with a long-term mental health condition (16%)

Health-related quality of life for carers, aged 18 and above (7%)

Proportion of people who are feeling supported to manage their condition (15%)

Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s -Male (8%)

Hel

ping

peo

ple

to re

cove

r fro

m e

piso

des

of

ill h

ealth

or f

ollo

win

g in

jury

1 Patient reported outcomes measures (PROMS) for elective procedures - Knee replacements (8%)

Patient reported outcomes measures (PROMS) for elective procedures - Knee replacements (7%)

Patient reported outcomes measures (PROMS) for elective procedures - Knee replacements (5%)

Patient reported outcomes measures (PROMS) for elective procedures - Knee replacements (11%)

2 Patient reported outcomes measures (PROMS) for elective procedures - Hip replacements (20%)

Hip fracture: multifactorial falls risk assessment (11%)

Proportion of adults in contact with secondary mental health services in employment (22%)

Emergency readmissions within 30 days of discharge from hospital (12%)

3 Proportion of adults in contact with secondary mental health services in employment (22%)

Proportion of adults in contact with secondary mental health services in employment (12%)

Hip fracture: proportion of patients recovering to their previous levels of mobility/walking ability at 120 days (26%)

Emergency alcohol-specific readmission to any hospital within 30 days of discharge following an alcohol-specific admission (20%)

Ensu

ring

a po

sitiv

e ex

perie

nce

of

car

e

1 Patient experience of GP out of hours services (14%)

Patient experience of hospital care (4%)

Patient experience of GP out of hours services (17%)

Patient experience of GP out of hours services (6%)

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Financial, estates and IT challenges

The financial pressures associated with providing primary care services for a growing population are stark. Newham and Tower Hamlets are experiencing some of the highest rates of population growth in the country. With population growth already being observed and uplifts in primary care funding not increasing in real time, many of our services will become unsustainable. The local health and social care system needs to work with funding bodies to understand whether transformational investment can be provided ahead of further population growth so that the required infrastructure, including any capital investment requirements, can be put in place.

East London has a high number of single handed practices57, 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. For example, surveys58 have highlighted that Waltham Forest’s primary care backlog maintenance costs over the next five years are likely to be £9 million.

Primary care in East London has been relatively slow to embrace digital technology solutions that could support patients to self-care and seek advice in more convenient and cost effective ways.

4.2 Transforming primary care The aim of this workstream is to transform, modernise and redesign primary care in East London by focusing on three areas of change:

1. Improving access: to primary care including general practice, pharmacies, dentists and optometrists

2. Establishing proactive care: empowering and supporting patients to take control of their health and wellbeing through self-care and peer support to manage long-term conditions

3. Coordinating care better: ensuring it is managed, organised and integrated around an individual’s care needs.

In order to achieve these priorities, four key enablers have been identified to support the change. These are workforce, estates, IT, and commissioning/contracting levers.

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 using modern technology.

In addition:

Patients would be supported to take ownership of their own health and therefore have a greater say in their own care.

improvement. The indicators are those that are ranked in the worst quintile/s (1%-40%) in England. Top three priority indicators are shown for all domains within the CCG OIS. 57 NHS England contractual data (2015) 58 Waltham Forest CCG (2015) Six Facet Survey outcome for all primary care premises

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Commissioning decisions would be made with populations in mind in accordance with this strategy. Services would be commissioned at a practice or federation level, ensuring that primary care can operate at scale.

New roles such as physician associates and pharmacists working in primary care practices would be established so that GPs can concentrate on more complex care.

The use of wider primary care services e.g. pharmacists and opticians will be optimised. Some local GPs have reported that up to 40% of their workload is not a good use of their time and skills.

Our proposed care model in relation to each of the three areas

Improving access

Access will be improved through a variety of means including the development of multidisciplinary primary care teams; innovation in the way appointments are conducted; self-care support; and capacity and demand audits.

In the future, care will be provided by primary care teams with a greater variety of health and social care skills. For example, pharmacists working in primary care will be able to advise and treat common ailments allowing GPs to concentrate on more complex work.

Innovative ways of conducting appointments will be expanded in each borough to allow patients to access health care advice by email, Skype and text services. Up to 10% of patients currently accessing primary care services could self-care through supportive online advice and tools.

We will understand and commission for population needs, make it easier to register with a GP, facilitate registration for unregistered patients and provide same day access for unplanned care needs, all of which will be measured routinely by commissioners. Commissioners will then be able to make necessary and timely interventions where capacity does not meet local demand. Extended hours care, the provision of same day access and clinical triage models will be commissioned in line with our urgent care strategy, detailed in part 3, section 2.

Health and wellbeing inductions will be offered to all new patients. As well as being offered health promotion advice, patients will receive information on how to access care appropriately and how to make use of available self-care tools.

Minor ailments services in community pharmacies will be redesigned to encourage patients to seek advice and treatment for minor ailments in these settings.

Establishing proactive care

The single biggest change we can make to improve the sustainability of our health and social care system is to support people to take an active role in managing their own health and staying well.

More consistent and outcome focused care needs to be offered to the ever increasing number of people with chronic conditions. The identification and diagnosis of respiratory disease and diabetes needs to be increased and those on long term conditions registers need to receive proactive care in a more structured way to help them feel supported by the NHS to self-care and stay well. We also will need to strengthen our focus on making

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preventative care a routine part of primary care provision and primary care will need to work collaboratively across boundaries with local authorities, community health services and voluntary sector partners to map services, promote healthier living, and co-design health promotion campaigns that enable improvements in residents’ health.

In the future, patients will have access to tools and information to make healthy lifestyle choices and self-care information and education will be published on GP websites. This will include symptom checkers and online triage systems.

Patients will be able to visit their local pharmacy to obtain advice and be treated for minor ailments. Our plans to create shared care records (see part 3, section 10) will allow providers outside of general practice to view the care needs of patients with long term conditions. We will pilot community pharmacy providers being able to input information directly to our primary care electronic record, EMIS.

Our work to establish proactive care models will again be supported through health and well-being inductions with new patients. Social prescribing also offers an innovative way for GPs to prescribe alternative community-based support that compliments traditional medicine. For instance people can be referred to local activity groups if it would better meet their health and wellbeing needs.

Coordinating care

Approximately 50% of appointments are for people with long-term conditions. By proactively planning care around an individual’s needs, we could significantly reduce the number of unnecessary NHS visits a person has to make. This will enabled by:

a significant investment in technology to ensure there are innovative ways to access advice (phone, Skype, text)

making sure 20% of total appointments are longer, to suit the needs of patients with complex long term conditions. This is especially important for first care planning sessions so that patients are properly supported to self-manage their illness

the establishment of multidisciplinary teams which can proactively plan care around the needs of individuals

investment in organisational development and training to support the workforce in establishing integrated working across the health and social care system.

How the new care model will be supported through the key enablers

Workforce

The new care model cannot be implemented without a fundamental transformation of our workforce, including organisational development support to help providers and teams work better together across organisational boundaries.

Given the workforce challenges associated with skills gaps, recruitment and retention, we will need to find other, sustainable, ways of delivering high quality primary care in East London over the medium and long term future. This can be achieved by using a more varied and multidisciplinary primary care team.

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i) Diversification of the future workforce

In the future it is envisaged that GPs will work alongside physician associates (PAs), nurse practitioners, practice nurses, healthcare assistants, pharmacists and a greater variety of support staff in practices.

Focus groups have suggested that around 30% of the GP workload can be transferred to other health and social care professionals so that GPs can concentrate on those with more complex care needs. National analysis also suggests that around 11% of a GP’s time is taken up by administrative tasks. Our initial aim is to remove 5% of total activity through the widespread establishment of medical assistant administrator roles who will be responsible for call and recall, processing referrals, dealing with consultation outputs that require a level of knowledge of services available across the East London health and social care system.

As highlighted in the graph below, in ten years’ time, it is estimated that in terms of new roles we will require a total of 106 pharmacists and 38 physician associates. In terms of more traditional roles, we will need 238 nurses up from c 175 currently; c.400 GPs down from over 600 currently and 130 administrators (a similar number to the current workforce) to deliver our new model of care to the growing East London population.

Wider primary care workforce (full time equivalents) needed to deliver TST in East London (2014-2015)

ii) New ways of working and organisational development

In the future, hospital and primary care staff will need to work and increase collaboration to meet patients’ care needs as care moves closer to home. Professionals will routinely work across organisational boundaries. Significant investment in organisational development, additional training and the empowerment of the primary and community workforce will be required to enable people to work in this way.

iii) Recruitment and retention

A cross-system recruitment and retention strategy will also be established across the three boroughs, which considers the investment in our workforce that is required to make

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East London a health and social care system of choice for our highly skilled workforce. There needs to be much greater focus on supporting and developing the careers of our health care staff. Federations will be encouraged to support employment, education, and training, as well ensuring leadership roles (clinical and non-clinical) are fostered.

Strategies to improve retention of primary care staff for East London CCGs include:

1. Provision of key worker housing

2. Financial incentives such as support with student loans

3. Flexible working options

4. Offering career development paths

5. Improve job satisfaction through regular communication

Retention of existing skills will need to be supported by the ability to offer flexible options for those considering retirement, such as different working patterns to facilitate stepped retirement. These will need to be managed within the new vision for service provision, and with the aim of promoting and ensuring that the new model of GP facilities and infrastructure, to provide services at scale, is not compromised.

Estates

Whilst this strategy focuses on multidisciplinary team and collaborative working, in Newham 20% of practices are run by single GPs, meaning that it is more difficult to accommodate the new ways of working.

Number of GPs (headcount) per practice by CCG, 2013

Sustainable, larger GP practices that support multidisciplinary working through hub and spoke models and networks collaborations will be crucial in realising our vision. In order for this to happen, investments in facilities such as Centre Manor Park in Newham will be prioritised as part of the borough estates strategies we are completing by March 2016.

Source: Health and Social Care Information Centre (2013)

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In the future, commissioners will invest in buildings which drive economies of scale and are best able to provide the new model of care. This may include the co-location of federated smaller practices in fit-for-purpose buildings. In order to provide capital investment, underutilised assets that are not suitable for the new model of care, or located in areas not experiencing population growth may need to be sold. Wasted space will be proactively reduced and plans will be put in place to maximise the utilisation of the existing estate that could, through service change, meet future requirements sustainably.

National evidence suggests that smaller GP practices struggle to sustainably provide all of the services future models of care will expect. The traditional partnership model, which currently serves an average of 6650 patients per practice, is widely acknowledged to be too small to respond to the financial and demographic challenges facing the NHS59. The London Health Commission’s report Better Health for London also calls for professional isolation in general practice to be addressed60.

This national evidence is in line with our local recommendations for a new model of primary care which is financially sustainable and allows primary care to operate at greater scale, through multidisciplinary working. Given our workforce and estates challenges, we believe this can only be delivered through primary care practices with list sizes over 10,000, through smaller practices working together at scale in integrated provider networks, or through collocating facilities at primary care hubs. General practice will need to adapt in line with this new model of care.

Whilst change is likely to mean that some patients need to travel slightly further for primary care, many more consultations will be provided by telephone or Skype and there will be less requirement for people to travel to a hospital, meaning that a significant proportion of care is provided closer to home. The borough estates plans that will be produced for March 2016 will make specific recommendations on how this element of the strategy is taken forward.

IT and technology

The new model of primary care means creating new and convenient ways in which patient consultations take place, for example by increasing the use of Skype. Increasing connectivity with systems within and across primary and secondary care will also allow faster and more convenient access to patients’ notes and results. This will allow timely diagnosis, and reduce unnecessary testing and appointments. These changes are described in further detail in the appendices on shared care records and diagnostics and will mean that by 2021, staff and organisations will need to use technology in a very different way. Providing sufficient user training and ensuring IT interfaces are user-friendly will be fundamental to success.

Proactive care needs to be encouraged and patients should be able to access their medical records online through an app or via the GP website, which will also be able to offer interactive tools such as symptom checkers. This will allow patients to manage their conditions and health records and to maintain healthier lifestyles.

59Securing the future of general practice: new models of primary care. Smith J et al. Nuffield Trust. (2013) 60 Better Health for London. London Health Commission (2014)

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The following additional investments in IT and technology need to be made in order to implement the new care model and have been accounted for within the financial analysis in part 3, section 4.5:

The establishment of a quality dashboard across the three boroughs with jointly agreed outcomes, including on patient access levels

The piloting of easier methods to populate EMIS (e.g. for flu jabs, minor ailments, smoking advice).

Commissioning and contracting levers

In the future, CCGs will commission care from providers which operate at scale. CCGs will need to develop new contracting models which focus more greatly on improving health outcomes for local residents to support this.

Geographically close groups of practices working together in networks and federations will continue to be part of the commissioning strategy, with the further development of these arrangements being fundamental to reducing variation through peer support; collaboration; sharing of resource; increasing access; and reducing health inequalities. Increasingly, commissioners will invest money across geographical areas rather than in individual practices. This will enable services to be delivered at greater scale and efficiency. For example, call and recall functions for screening and immunisation vaccinations may all be able to be offered more effectively with greater cost benefit through primary care hub arrangements.

The shift to these new care models will be challenging and require significant adjustment and behavioural change from providers, commissioners and patients alike. To support this change to take place the scoping of new contract forms will be a key focus of implementation planning, as will the role of payment innovation and capitated budgets.

The overleaf below illustrates how primary care will be truly coordinated around the patient.

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The future model of primary care

Other significant change initiatives not costed in this strategy

Significant other schemes related to this area of care that may in the future need to be impact assessed and costed:

strategic development of new contract and payment innovations work

a primary care centre as a potential option for the Whipps Cross redevelopment

medicines optimisation initiatives.

4.3 Engagement to date Over the last six months, we have engaged with the following organisational, clinical, stakeholder and patient forums. We have listened and incorporated feedback within this strategy.

The following stakeholders have been engaged

CCG Board Meetings

Primary Care Commissioning Committee at each CCG

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Primary Care Advisory Committee for WEL

Primary Care Board for WEL

Primary Care Development Committee at each CCG

Locality meetings in each borough

Primary care transformation workshops (across WEL and CCG specific)

Primary care clinical leads, CCC chairs, Commissioning leads, workforce leads

Focus groups with practice nurses, vocational training scheme GPs, GPs and practice manager

Expert advice from UCL and Kings, CPENS

Federation dialogues

NHS England - primary care contracting and finance teams

Local authority

Barts Health public health team

TST Urgent Care Programme

TST Integrated Care Programme

Primary care strategic estates groups,

Community Health Partnerships

WEL Pharmacy leads (acute and primary care)

4.4 Outcomes the change will achieve The above model of care is intended to achieve the following outcomes:

Outcome description Outcome by 2020/21 (Metric/impact)

Improved access in line with the London framework standards

e.g.

Getting through on the phone Being able to see a GP Experience of OOH services Choice of healthcare professional Getting through on the phone Registering with a GP

All indicators to have 100% population coverage61

Choice of sex of GP when making an appointment

Improvement trajectory to be set as part of implementation planning

61 Improvement trajectories to be set as part of implementation planning

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Level of patient complaints Reduce level of patient complaints by 50% by 2020/21

All practices to be supported by strong network arrangements/working at scale

100% of practices to have access to working in MDTs

Improvement in retention levels 75% of trainee GPs being retained

Workforce recruitment levels On track to meet the plan (to follow as part of implementation stage) e.g. 25 extra physician associates in primary care by 2021, 58 extra pharmacists working in primary care by 2021

Better use of skill mix To be detailed later62

Reduction of inappropriate use of Urgent Care and Emergency Care

Reduction in the number of registered patients accessing Urgent and Emergency Care services

Increase in the number of patients being signposted to GP registration

Reduction in referrals / per 1,000 made from General Practice

Increase use of specialist advice and alternative support being made within Primary Care

Experience of care

Safe high quality co-ordinated care Available information and links to

community resources Transition between care Environment –estates

To be detailed during implementation planning 63

Workforce satisfaction

Learning and development Health and well being

To be detailed during implementation planning64

62 Improvement trajectories to be set as part of implementation planning 63 Improvement trajectories to be set as part of implementation planning 64 Improvement trajectories to be set as part of implementation planning

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4.5 Investment costs In order to implement the model of care the following investments are required. This includes workforce investment, project implementation costs, organisational development costs and investments in IT. Expected capital costs will be further updated during 2016, as borough based estates strategies near completion.

2016/17 2017/18 2018/19 2019/20 2020/21 Total

Capital costs (estates/ IT infrastructure/equipment) including capital charges

£1.5m £1.5m £1.5m £1.5m £1.5m £7.5m65

Workforce (recruitment process costs and total project management costs)

£1.23m £1.23m £1.23m £1.23m £1.23m £6.16m

Organisational development costs66

£3.47m £3.15m £3.15m £3.15m £3.15m £16.07m

Informatics £1.04m £0.74m £0.74m £0.49m £0.49m £3.5m

Other service investment costs

£300k67 £300k

Systems redesign support, e.g. smart interactive telephones systems, translation services procurement with additional written resources for registering and access pathway.

£2m £2m

Investment in organisational development support

Given that the changes described within this strategy are so significant and require staff and organisations to work in a fundamentally different way, £16 million of investment over five years is required for organisational development work. This is a critical component of the transformation programme which supports the delivery of the wider care closer to home workstream, with the focus areas for investment being:

1. Strengthening multidisciplinary team-working in primary care as part of the care closer to home strategy: to support staff to work together across organisational boundaries to deliver the new care model (includes a diagnostic of need): £800k a year for five years.

65 Expected capital charged: to be finalised following the final publication of borough estates plans in March 2016 66 This relates to improvement work within the Care Closer to Home strategy as a whole but for the purposes of financial assessment has been included within the primary care workstream 67 For minor ailments scheme – anticipated cost of redesign to be further evaluated within implementation stage

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2. Supporting, introducing and embedding new primary care roles as part of the care closer to home strategy: supporting pharmacists, healthcare assistants, optometrists, practice managers, care navigators etc. to successfully deliver the new care model will be crucial to its success: £1.49m a year for five years.

3. Leadership programme: identifying future leaders at all levels of the MDT and supporting them through action learning sets, coaching programmes etc.: £70k a year for five years.

4. Patient development and empowerment programme: programme to support the patient voice to be a fundamental part of commissioning new primary care services as part of the care closer to home strategy, including involvements in the design of self-care models and the provision of Skype/telephone clinics: £820k a year for five years.

Workforce requirements

The table below identifies the additional workforce requirements over the next five years which will enable the new model of care. Given that (due to recruitment challenges and retirements) GPs are likely to make up less of the future workforce68, their higher relative cost means that total workforce cost for primary care is likely to be £32m less expensive by 2021.

Workforce requirements Band (if applicable) WTE

Physician associates 25

Pharmacists 7/6 58

Admin 5 -2

Community staff 5 46

Nurses 7 49

GPs -136

4.6 Impact on activity and finance Impact on activity

The charts below show the extent to which future expected demand is met (depending on whether the proposed model of care is taken forward). Without change there are expected to be an additional 589k appointments required in primary care by 2020/21:

68 Due to the age profile, retirement and recruitment challenges given the national shortage

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Number of primary care appointments, all East London CCGs without TST (in 000’s)69

The new model of care is expected to create additional capacity to ensure primary care can cope with future expected growth. The orange bars highlight the proposed activity shift from general practice to pharmacies, self-care and other primary care providers such as opticians and dentists which acts to reduce demand.

Number of primary care appointments, all East London CCGs with TST (in 000’s)

The proposed 24% shift out of general practice is made up of 14% of activity which will be directed to wider primary care providers (pharmacists, optometrists, counselling and psychology services) and 10% which will be accounted for by patients being better supported to self-care. This shift is necessary because the primary care system needs to

69 TST Activity/Finance model based on data extracted from EMIS and Health Analytics systems

0

1000

2000

3000

4000

5000

6000

2016/17 2017/18 2018/19 2019/20 2020/21

Baseline Growth Capacity

-2000

-1000

0

1000

2000

3000

4000

5000

2016/17 2017/18 2018/19 2019/20 2020/21

Baseline2 Growth TST Additions TST Reductions Capacity

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meet growing demand and anticipated activity shifts from urgent care and hospital based services.

The 24% activity reduction target has been chosen because:

National evidence, guidance and our engagement so far suggests that around 10% of activity can be shifted to self-care by equipping patients with the right advice, health care tools and signposting70.

Around 20%71 of a GP’s workload concerns advice and treatment for common ailments which could be seen by another provider e.g. pharmacists or via self-care. A proportion of appointments are also non-health related queries. It is estimated that primary care signposting to other services would mean an additional 4% shift.

Approximately 20% of current general practice appointments will be longer so that GPs can fully meet the needs of those with complex long term conditions within the high risk integrated care cohort.

There is a need for a 0.5% total increase in activity (96k episodes by 2021) as a result of a necessary shift from hospital or urgent care settings to primary care to aid patients being treated in the most appropriate care setting for their needs.

Impact on financial sustainability including sensitivity analysis

By 2021, it is expected that there will be a more financially sustainable model of primary care in place in East London. After conducting financial impact analysis, we undertook sensitivity analysis which suggests a net saving of between £30.7m to £34.5m over a five year period.

This calculation is driven by the changing profile of the workforce and a more efficient and effective model of primary care being in operation that is working at greater scale. The calculation, for example incorporates the anticipated benefits of physician associates working in primary care. In addition, many of the changes made by primary care in other parts of the country have not been made throughout East London, meaning there is significant scope for improvement. Making the substantial investments that are detailed in part 3, section 4.5, to help transform and redesign services to work at scale will however be crucial to success.

Whilst the financial savings figures include assumptions regarding the future funding growth that is expected, no provision has been made for growth in long term conditions which needs to be better understood as part of next stage financial validation and implementation planning for both pathway redesign and primary care workstreams.

Minor ailments treatment will be more cost-effective under the new care model

The current cost to the system for delivering minor ailments via general practice is estimated to be £76.4 million. If in the future this is delivered by the other primary care providers (pharmacists, optometrists, dentists), the cost to the system is estimated as being £27m. This results in approximately £50 million cost avoidance which can then be reinvested72.

Cost of the future primary care workforce

70 Transforming Primary Care in London: general practice a call to action. NHS England (2013) and Save our NHS: Time for Action on Self Care. Selfcare Forum (2013) 71 Improving Care through Community Pharmacy: a call to action. NHS England (2013) 72 Based on assumptions within ‘Pharmacists could save the NHS 1.1bn by treating common ailments’ 19/10/2014, available at www.rpharms.com

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Using these figures and a range of other assumptions, the cost of the future primary care workforce has been modelled. The workforce needs to diversify:

In ten years, it is estimated that East London will require a total of 106 pharmacists, 38 physician associates, 238 nurses, c.400 GPs and 130 administrators in practices to deliver the new model of care to the growing population.

The overall cost of the primary care workforce is currently around £85 million a year. By implementing the interventions outlined in this strategy we expect this cost to drop to around £78 million whilst delivering roughly an extra 1 million appointments a year by ten years’ time.

As the charts below illustrate, the savings are driven by less expensive roles being introduced under the guidance of GPs. The average salary per full time equivalent (FTE) decreases over ten years from £91k to £75k.

These forecasts show that it is possible to balance the cost of increased numbers of staff needed to deal with the increase in activity with less expensive roles resulting in a reduced cost per full time member of staff overall and a reducing overall cost of a GP-led, but MDT-provided primary care service.

Wider primary care workforce to Wider primary care workforce cost to deliver deliver TST (East London 2014 – 2025) to deliver TST (East London 2014 – 2025)

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The activity and financial analysis has been made in line with the following assumptions:

4.7 System commercial considerations and transitional support required

Whilst there will be a reduction in minor ailments activity, the increased demand associated with a growing population means that income generated by general practice does not decrease.

The transitional costs of creating capacity in general practice by shifting activity such as common ailments, self-care to wider primary care providers needs to be considered.

Finally, the impact of any new national contract for general practice and the wider primary care system will need to be considered once detailed are released.

Assumptions details:

The activity baseline used has been based on the assumption that general practice is currently operating at 100% efficiency (e.g. offering 72 apts. per 1000 registered population/per week)

The proposed shift from hospital and urgent care settings needs to be completed in a phased manner over the next ten years in line with the rate at which general practice is able to transfer activity to self-care and other primary care providers

The current contract will not provide a vehicle by which the new models of care proposed in this document can be delivered.

The following factors affecting future demand have been modelled; TST activity shift from other care settings; activity related to future population growth of 270,000 by 2031

The following factors have not been accounted for within modelling; the rising levels of average attendances that with primary care services are experiencing from patients; the expected 10% rise in LTC during the next ten years; rising life expectancy meaning more people are likely to require managed care for longer; more complex care being shifted into general practice from hospital.

The cost of treating minor ailment in different settings has been assumed to be A&E £147.09, GP £82.30, pharmacy £29.30 (Royal Pharmaceutical Society).

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4.8 Delivery risks The table below sets out the risks associated with the delivery of the new care model and any associated mitigations that the East London system will need to manage.

Description of risk Risk Likelihood

Risk Impact

Risk rating

Mitigation

1 Perverse incentives for change may be observed if the payment for services does not clearly follow the patient

4 4 16 Consider as part of implementation planning in line with payment innovation work

2 Workforce supply will not be sufficient to implement new care model and meet future demand

4 5 20 Launch a joint recruitment strategy across East London health and social care providers

3 Lack of co-ownership, development and co-production of the strategy and implementation plan

2 3 6 Further development of strategy at Board development sessions in December 2015

4 Lack of ownership in the form of a defined clinical lead for primary care improvement within each borough

5 3 15 Consider appointment of a clinical lead/medical director to take forward primary care transformation in each borough

5 Provider development and readiness: 1. Lack of confidence in provider bidding contracts 2. Slow progress in bidding at scale 3. Low levels of network working

4 4 16 CCG led provider OD development programme with appropriate infrastructure, management and governance in place to help them succeed.

6 Potential conflict of interest between CCG Boards and provider networks

4 5 20 Each CCG and provider network to ensure robust governance arrangements are in place

7 Specifics of pathway redesign programme requirements of primary care due to shifts of activity are not yet known

4 2 8 Assumptions of anticipated shift made in modelling assessments. Joint implementation planning post-pathway redesign sessions will be necessary

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4.9 Next steps The table below details the milestones that will form the next steps associated with this transformational scheme

Milestone Description Timescale

Test and agree plans

With Patient and Public Reference Group (November 15) and Governing Body development sessions

December 2015-February 2016

Define local commissioning strategies

Understand what will be delivered at network, local, regional and national level

January 2016

Further finance and activity modelling

To further validate assumptions and incorporate capital costs derived from interim borough estates strategies (December 15).

To include an appointment scheduling workshop

February 2016

Approach to implementation agreed (implementation project initiation document)

Detailing approach to implementation and indicative timescales aligned with local, regional and national requirements

March 2016

Outline business case drafted

To make the case and enable any financial investment required to be signed off

April 2016

Initial workforce impact assessment complete

Initial understanding of complexities scoped including the likelihood of any required workforce consultation related to consequences of change for staff terms and conditions

April 2016

In addition, the following tasks will be carried out by commissioning organisations:

Accessible, proactive and co-ordinated care

CCGs will ensure that robust plans are in place to align local strategies to the London framework with key timeframes for deliverables being agreed and shared.

The scope and outputs of proactive care and co-ordinated care models will be defined in alignment with local integrated care strategies.

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Commissioning

Local commissioners need to explicitly determine their future commissioning plans. This will include what practices/groups of practices will provide what range of services including where economies of scale will be encouraged.

CCGs will work to ensure they support providers/federations to be mature and confident by November 2016 through continued provider development or enabling providers to tender and bid for contracts.

CCGs will use contractual leavers to ensure contractors are abiding by contractual obligations.

CCGs will commission care from practices which work with multidisciplinary teams and practices that give patients a choice of a male or female healthcare professionals.

Enablers

Services will be commissioned from practices that are willing to work collaboratively in networks, operating from fit-for-purpose buildings where IT supports delivery of care and system-wide working.

Commissioners in each borough will determine the optimum number of practices including how many primary care hubs are required and a timescale for implementation.

Estates plan will be informed by the TST commissioning strategy; and any estates investment costs will be calculated and assessed based on the publication of interim borough estates plans in December 2015.

CCG will seek to maximise current resources in terms of access. For example void capacity will be proactively reduced and plans will be put in place to maximise capacity and economies of scale in back office functions.

CCGs will create a joint recruitment strategy across East London to manage the workforce challenges across primary care and the community/hospital interface.

CCGs will identify what level of extended hours coverage is required and commission necessary access to services which aid the implementation of the Urgent Care TST scheme.

CCGs will work with local populations and clinical colleges to promote the opportunities and advantages of working in East London.

Quality

CCGs will agree on a set of outcome and quality metrics that provide the ability to track the successful implementation of this strategy, including a performance dashboard across the three boroughs. This dashboard will focus on clinical pathway improvement, clinical indicators, patient experience and satisfaction, staff satisfaction as well as provider performance metrics.

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Engagement

The need for any public or staff consultation will depend on the number practices that re-locate/merge or new procurements and will be locally led; any shift in employment status.

However further engagement on this strategy will be carried out with:

TST Patient and Public Representative Group CCG Board Meetings Primary Care Commissioning Committees at each CCG Primary Care Advisory Committee for WEL Primary Care Board for WEL Primary Care Development Committee at each CCG Locality meetings within each borough Primary care transformation workshops (across WEL and CCG specific) With partners including NHS England, Local Authorities and Public Health teams,

JOSC, local MPs and Healthwatch, Public Health/LA Local Medical Committees Primary care providers

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5: Establish surgical hubs, including interventional radiology

5.1 The case for change Emergency and elective surgical services are delivered at three Barts Health NHS Hospital Trust sites in East London: Newham Hospital, the Royal London Hospital and Whipps Cross University Hospital. Each of these sites delivers varying levels of secondary care and specialist surgical services. Surgical services are also delivered at St Bartholomew’s Hospital, however, this is dedicated to cancer and cardiac specialised services.

Although there are examples of parts of the system working well, patients are receiving variable standards of care and the current configuration of services is not the most effective use of surgical resources73. For example we know that:

The quality of care can be improved. Currently, because each of the three main sites delivers similar elective services, surgeons in some hospitals see low numbers of patients despite a growing body of evidence showing that higher numbers of patients are associated with better outcomes74

The lack of dedicated short stay surgical facilities with enhanced recovery pathways means that patients are staying longer in hospital than necessary

Emergency surgery across sites is not optimised and this sometimes means delays for non-life threatening emergency surgery

The high bed occupancy and difficulty in separating emergency and elective surgical services (including a lack of ring-fenced beds) contributes to, in some specialities, up to 20% of elective operations being cancelled75

Many patients are waiting too long for operations and performance against referral to treatment times is poor in many specialities at Barts Health

Some people are waiting longer than necessary in hospital before an operation

Not all sites meet the paediatric general emergency surgery standards76

Whipps Cross Hospital and Newham Hospital both fail to meet London Quality Standards targets for access to interventional radiology for critical and near-critical patients77. This is in part due to high bed occupancy at the Royal London Hospital meaning high dependency unite beds are not available.

We also know that a large number of non-complex operations take place at the Royal London Hospital, causing high bed occupancy. These could be delivered more effectively at Whipps Cross Hospital or Newham Hospital and also allow the Royal London Hospital to free up capacity in order to treat more of the sickest patients and most complex cases.

73 Case for Change. East London CCGs Transforming Services Changing Lives programme. 2014 74 2007 A systematic review of the impact of volume of surgery and specialization on patient outcome. M.M. Chowdhury, H. Dagash and A. Pierro www.onlinelibrary.wiley.com/doi/10.1002/bjs.5714/pdf 75 Surgenet data. Barts Health internal performance metrics Jan-Jul 2015 76 Royal College of Surgeons 2015, National Standards for Non-Specialist Emergency Surgical Care for Children https://www.rcseng.ac.uk/surgeons/surgical-standards/working-practices/childrens-surgery/documents/standards-for-non-specialist-emergency-surgical-care-of-children 77 London Quality Standards self-assessment. 2014

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This variation in accessing high quality surgical care across East London is not acceptable.

Given the opportunity to work at scale across the three sites as Barts Health, there is a chance to look at the way services are delivered in order to improve patient safety and improve outcomes, better using capacity to deliver surgery more effectively across East London.

As part of developing a new model of care we have considered how changes to both emergency and elective surgical services can help us ensure we make the most effective, responsible and sustainable use of our limited specialist resources (both people and equipment).

5.2 Model of care Hospitals, such as those within Barts Health, will need to work effectively in networks to deliver safer, more sustainable and higher quality care. Working in networks will mean that most care is delivered locally, with patients only travelling further when it leads to better outcomes. As demonstrated in the Transforming Services Changing Lives Case for Change, changing the configuration of surgical services across East London would maximise patient safety and contribute to making the services more sustainable. A new configuration of services would:

ensure more low risk surgical procedures are taking place at residents’ local hospitals

deliver pre-operative care closer to people’s homes

consolidate some surgical procedures at specialist hubs where it improves outcomes, provides safer services and makes provision more sustainable

strengthen cross-site working and improve inter-hospital transfer arrangements

develop a safer emergency surgery model, strengthening network and triage arrangements across all sites.

For example, in the future, people living in Newham with breast cancer could be able to have all their outpatient and pre-operative assessments with their surgical team at Newham Hospital, before complex surgery taking place at the Barts Cancer Centre using the latest equipment and surgical techniques. This differs from current arrangements which would usually see patients travel all the way to Barts Cancer Centre for each stage of their treatment.

These changes would also allow the Royal London Hospital to free up capacity from less complex cases in order to treat more of the sickest patients and most complex cases.

To do this we want to establish surgical hubs at each Barts Health hospital site that work together in networks.

Enhanced surgical care through surgical hubs and an improved emergency network

These high quality surgical hubs would operate in networks, to provide safer, less variable care by the right person, at the right time.

Describing surgical services as ‘core’, ‘core plus’, and ‘complex’ provides a way of describing how services should be provided across East London.

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For example:

‘Core’ services are surgical services which support emergency, medical and maternity care and should be available on all sites. They also include less complex, elective surgical procedures that can be run in dedicated short stay, day case or outpatient facilities.

‘Core plus’ services are surgical services which require a degree of specialisation and/or resources. They require a concentration of the specialist workforce and dedicated capacity in order for care to be delivered safely and sustainably. All three hospitals will have a core plus service, but it will be different at each hospital.

‘Complex’ services are surgical services which are required to support the treatment of complex cases, such as complex cancer or trauma. Clinical interdependencies and the input of multiple specialities are crucial to optimise safety and patient outcomes.

As part of this model, each site would host core services and different combinations of core plus and specialised hub functions. For example, we have already been piloting Newham Hospital as a core-plus, specialised hub for arthroplasty (hip and knee) surgery.

Proposed segmentation of surgical services

Through a combination of core and core plus services, all sites would maintain the capacity and capability to support emergency and maternity services safely, as well as taking advantage of the appropriate consolidation of services:

Services would see more patients, which would lead to more effective care with dedicated specialist consultant cover

Capacity would be freed up at the Royal London to deliver emergency surgical interventions without delays

There would be more experienced staff with dedicated resources for enhanced recovery and higher day case and outpatient rates (reducing unnecessary stays in hospital)

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Specialist equipment could be used more effectively to deliver higher day case rates e.g. use of interventional radiology for less invasive procedures

Ability to meet royal college and clinical quality standards across sites e.g. Standards for non-specialist emergency surgical care of children78

Higher numbers of procedures enable better consistency of planning and utilisation, and fewer cancellations

The potential to provide dedicated pre- and post-operative care that improves shared decision making and pre-operative quality of care. This also safely reduces length of stay

Larger patient list sizes across the organisation also boost research, learning and teaching opportunities.

Approach to developing surgical hubs: core, core-plus, complex

In order to take this work forward we will need to understand which surgical services can be consolidated in order to deliver care more efficiently and improve patient outcomes.

To do this, surgical specialities have been considered against site-based capabilities, equipment, facilities and capacity; the likelihood of an improvement to outcomes and efficiencies; and to better distribute demand across sites.

The benefits of any consolidation of services will need to be balanced against the following key considerations:

The impact of changes on the way people access services especially vulnerable or frail patients

If consolidation would undermine the delivery of high quality local emergency and maternity services

If there are specialties where patient numbers are relatively low and splitting elective and emergency procedures would result in clinical teams not treating sufficient numbers to maintain their skills; or if there are specialties which require the same specialist equipment or facilities for both elective and emergency activity and patient numbers are too low for a split to be cost-effective

If there are co-dependencies between specialties and, for the above reasons, one of those specialties must be located on one particular site only.

78Royal College of Surgeons 2015, National Standards for Non-Specialist Emergency Surgical Care for Children https://www.rcseng.ac.uk/surgeons/surgical-standards/working-practices/childrens-surgery/documents/standards-for-non-specialist-emergency-surgical-care-of-children

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The potential for consolidating certain types of ‘core plus’ procedures

N.B. The Healthcare for London clinical dependencies framework was used as a framework – see Elective surgical hubs appendix 1

What will this mean for the potential future set up of services?

Over the next six months we will be working with clinicians and patients to develop these plans. This will include detailed understanding of how surgical specialties fit into core; core-plus and complex. We would also be able to understand in more detail the improvements in outcomes we would expect to achieve.

This work will build on work that has already begun in understanding how services may have to be improved and enhanced at sites with regards to new royal college guidance. For example we know that work has taken place to start to understand how we can meet new Royal College of Surgeons guidance on National Standards for Non-Specialist Emergency Surgical Care for Children79.

A potential view of what a future set up of services might look like across sites can be seen overleaf. Over the next six months we will be working to test and enhance this.

Once we have completed this work we would fully engage with patients and the public on these changes.

79 Royal College of Surgeons 2015, National Standards for Non-Specialist Emergency Surgical Care for Children https://www.rcseng.ac.uk/surgeons/surgical-standards/working-practices/childrens-surgery/documents/standards-for-non-specialist-emergency-surgical-care-of-children

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N.B. As St Bartholomew’s Hospital does not have an A&E - it does not have a ‘core’ surgical offer.

In the future we also know that for selected specialties we would also aim to provide additional interventional radiology capacity to undertake interventional radiology in place of traditional surgery. This would enable us to deliver more day-case treatments and improve the patient experience. To do this we would need to invest in more specialist equipment and consider the clinical interdependencies that would bring the most benefits for patients.

We also need to make sure that the new set up of services is suitable for vulnerable and older people. We need to make sure transport issues for frail elderly are fully considered as well as other vulnerable groups.

Formalise the network model for high quality emergency surgery

Our proposal for surgical hubs would also provide each acute site with improved consultant cover to provide effective cross site emergency and on-call cover to deliver 24/7 A&E and maternity services.

Evidence shows that surgery should not be carried out at night unless a patient’s life or limb is threatened. Therefore under these proposals Newham Hospital and Whipps Cross Hospital would carry out onsite emergency surgery for 12-16 hours a day, with emergency surgery for life-threatening conditions outside these hours provided by Royal London Hospital. This will ultimately improve clinical outcomes and save lives.

Therefore, a key ‘core’ requirement at each site is the capacity and capability to surgically triage patients, stabilising them and transferring complex cases to the site that will deliver the best outcome for patients. This represents a strengthening and formalising of how our sites currently work (see also the network emergency care model as outlined in the emergency care initiative - part 3, section 6). Clear protocols would be required for the management of

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patients who need a surgical intervention that cannot be provided on a timely basis onsite, including use of National Confidential Enquiry into Patient Outcome and Death (NCEPOD) lists to improve outcomes. These operating lists differentiate between emergency surgery where patients can be safely stabilised and scheduled into theatre and where immediate surgery must take place to save life or limb. This means hospitals can plan more effectively for scheduled trauma lists surgery. This has been shown to improve outcomes, while ensuring that there is capacity available for life threatening emergency surgery.

Improved emergency care would be enabled by:

redesigning and embedding new surgical on-call rotas, remote and network arrangements to ensure safe and effective cover 24/7 across sites

better use of technology to deliver more effective cross-site specialist on-call arrangements

using NCEPOD lists as effectively as possible to maximise outcomes for patients.

These changes would enable us to effectively increase trauma and emergency theatre capacity at the Royal London Hospital to match demand and complexity to ensure the best outcomes for patients needing emergency surgical intervention.

Improved pathways to improve care

We know we can improve the whole of a patient’s experience of treatment as well as reducing unnecessary cancellations by improving the processes before and after surgery.

As part of developing surgical hubs we need to ensure that pre- and post-operative pathways are improved. This would ensure that we deliver pre-operative care closer to home and coordinated re-ablement and recovery to get people home quickly and safely.

Our proposed model of care includes a single point of referral across Barts Health sites. This aims to ensure timely access to specialist consultant advice while working across site boundaries. The model includes GPs and community nursing staff in the delivery of pre- and post-operative care.

The new model aims to improve local surgical provision and reduce the distance people travel for pre- and post-operative care. Many people would receive more of their care at their local hospital and would be likely to travel less.

We want to deliver pre-operative care closer to home where appropriate, using technology where possible, including straight to test pathways80 where appropriate. We want to develop one-stop multidisciplinary clinics, including social care assessments for higher complexity patients and run these at each site where sustainable. This would mean patients only need to travel for tests when specialist equipment or expertise is required.

There is an opportunity to use this time with patients to deliver important health messages and interventions. Throughout the pathway there will be an improved focus on prevention, ensuring that this is built into clinical models, risk stratification and staff training. This should include effective onward referral and signposting to third sector and social support services that can improve people’s health outcomes.

80 Straight to test pathways allow a fast track service where patients undertake key diagnostic procedures before their appointment with a hospital consultant.

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The proposed perioperative model

We will progress this proposal by:

implementing single points of referral for specialities across site

implementing pre-operative one stop clinics across all sites to deliver care closer to people’s homes and reduce travel

developing multi-agency pre-operative processes for higher risk patients

standardising risk-profiling across sites

developing pre-operative processes closer to home for lower risk patients

maximising the use of straight to test pathways.

Expected benefits of surgical hubs

Changing the configurations of surgical services across East London will maximise patient safety and contribute to making our services more sustainable.

This change will also allow better network working with other NHS trusts across London through clearer access to a strengthened specialist hubs and world class tertiary centres.

The expected benefits of making these changes are:

Improved safety and clinical outcomes

Fewer avoidable cancelled operations

A better experience of care, closer to home wherever possible

More proactive support to recuperate at home and reduced length of stay in hospital

More efficient use of theatres and our specialist workforce

Better team working, support and training opportunities.

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Workforce of the future

The new model of care aims to maximise the use of workforce skills and expertise. Each element of the model requires changes to the way staff work. The key workforce considerations of each of the model’s elements are:

Workforce implications of core services Day case nursing teams need to be re-established as a dedicated resource. It is envisaged that this could be achieved by better utilisation of existing staff; the intention is not to seek new or additional roles for this element of the strategy. The nursing roles would prove attractive as they offer a regular day case-only working pattern. However, Consultants may choose to do day case sessions on a rota basis to ensure that they are also able to maintain their skills and expertise in other, more complex elective procedures.

Key workforce requirements for this element of the model will be the need for revised on-call rotas, adequate numbers of anaesthetists, and a requirement for all sites to have appropriate paediatric capability, as without this all paediatric cases would need to be referred to the Royal London, which is not in line with national standards.

All sites will require training to ensure that they are equally capable of non-complex emergency surgery for both adults and children.

Workforce implications of core plus services There is a recognised shortage of highly qualified specialist staff, and this element of the model seeks to consolidate existing staff onto one site per specialism, with patients streamed appropriately to the correct service in order to access this level of specialist care. This would provide improved patient outcomes and enable throughput of complex cases to be better and more safely managed.

The separation of elective and day case procedures and streaming of complex surgery to core-plus hubs would also enable consultants to have better access to diagnostics and interventional radiology resources for elective procedures, thereby releasing capacity through the improved use of technology. The workforce implications of the sub-specialty hubs are difficult to determine in detail until the configuration of those hubs has been agreed; the priority at this stage is to build the model and system, and the implications for staffing can then be determined as part of the implementation phase. If particular hubs are identified in growth areas, with much higher patient numbers, workforce plans may need to include the development of new roles such as physician’s associates to help meet demand.

Complex and emergency services The reconfiguration of core and core plus surgery should result in increased trauma and emergency theatre capacity to match the growing demand and complexity of cases, and a more sustainable use of skilled expert staff across the system. The provision of intensive care unit recovery support is essential to support the core plus surgical offering81.

The focus on the development of specialist teams and reconfiguration of work flows means that it should be possible to staff the new complex and emergency care model within existing resources and reduce reliance on temporary staffing. However, this

81 LQS standards 1 and 4 will need to be met in such settings; access to a consultant intensivist within one hour on a 24/7 basis. Standard 17 will also be required to be met; a minimum of 70% of nursing staff in ITU to hold a post-graduate intensive care qualification.

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assumes that posts can be filled to establishment levels. Where this is not the case consideration may be given to the development of new and appropriate roles to assist with skill mixing e.g. physician’s associates role in minor and simple surgical services.

Improvements to pre- and post-operative care Integral to the success of the strategy is the requirement to release capacity within surgery by making changes to the way in which pre- and post-operative care and re-ablement are delivered, with this being managed closer to home in community settings instead of via the traditional model of attendance at hospital based clinics. It is estimated that 70% of patients do not require their pre-operative assessment to be carried out in a hospital setting, which could be delivered in the community.

This shift in activity would inevitably have an impact on primary care service configuration and demand; to establish and manage community based pre-operative one-stop multidisciplinary team clinics, and on the wider system in terms of ensuring capability to deliver diagnostic testing via new ‘straight to test’ pathways. It is anticipated that the clinics would have a local authority/social service presence which needs to be quantified to determine the workforce implications for that sector. Community staff would be required to perform a range of test and assessments, and allied health professionals would be required for re-ablement (occupational therapy and physiotherapy). Further work is required to determine the future model, and the workforce implications will depend on mode of delivery and model agreed. It is likely however that there will be a need to transfer some existing staff delivering these services into the community and to recruit and/or upskill some staff to meet the workforce requirements.

Workforce next steps The known additional workforce investment is detailed below. However, more validation work is needed. The next steps in taking forward changes to the workforce are outlined below:

Existing roles: As part of the implementation planning we must have a) a plan to review the current working practices of all our staff groups, based on the need to establish short stay, surgical day case and outpatient provision and b) decisions made about the configuration of ‘core plus’ services to be hosted on specific sites. Where necessary, we will consider changes to working patterns and/or bases in order to deliver high quality services and meet London Quality Standards (LQS) requirements, which may include review of consultant job plans and changes to terms that require further consultation.

Multi-disciplinary working: As part of the implementation planning we aim to have a clear plan to create dedicated specialist teams to deliver ‘core plus’ and ‘complex’ surgical procedures within sub-specialist hubs i.e. consultant-led multidisciplinary teams working together to deliver on moderately or highly complex surgical operations. This will require the consolidation of roles currently aligned to surgery within the existing workforce into a more clearly defined multidisciplinary model. This should improve patient outcomes and enable staff to develop, learn and gain additional experience, which may also support improved recruitment and retention to the teams.

Training: By 2017 we aim to have produced a training and education plan which will undertake to upskill GPs, community nursing, allied health professionals and support staff in the delivery of pre-operative care and assessment and post-operative care and re-ablement support. This will enable patients to maximise opportunities to

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access the care they require closer to home, with only the surgical procedure itself being undertaken in the hospital setting. This will support the provision of additional surgical capacity.

Collaborative working will be required with Health Education England (HEE), Health Education North Central and East London (HENCEL) and our Community Education Providers Networks (CEPNs) and other relevant regional and national agencies to ensure that proposals are developed which are aligned to national, Londonwide and other relevant policies and standards.

Organisational development

We know that there needs to be support provided to staff to work in new ways. This is summarised below, with total costs summarised in part 3, section 5.6:

• Shift current behaviours and attitudes to create flexible pools of high performing teams for each surgical site to enable enhanced recovery (three year programme)

• Supporting consultants in expanding their roles (four year programme)

• Support the design and engagement on interventional radiology model to underpin surgical hubs (one year programme).

5.3 Engagement The pilot of the orthopaedic hub at the Newham Gateway centre was agreed at the clinical strategy group (WEL CCGs) on the 17 September 2014 following work that was reviewed at the clinical services review panel and fully supported following engagement with CCGs. This was presented at the INEL JOSC in early 2015.

Regular meetings and with the clinical lead for surgery at Barts Health, clinical lead for surgery at Newham CCG and the productive theatres lead at Barts Health

Meetings with; general manager for trauma and orthopaedics, acute clinical lead for Newham and Waltham Forest CCGs, lead surgeon at Newham Hospital, consultant urologist at Whipps Cross Hospital, chair of Tower Hamlets CCG (also the clinical lead for TST) and finance and performance teams at Barts Health

Emerging surgery strategy shared with patient representatives at the TST Patient and Public Reference Group (PPRG) in July. Invitees include patient representatives from CCGs and Healthwatch across north east London, Barts Health, Homerton Hospital, ELFT and NELFT.

Attendance at surgical specialty team meetings at Barts Health across the hospital sites (urology, dentistry/maxillo facial, general surgery).

Workshop to develop surgery strategy (15 January) invitees included: o Clinical and managerial leads from Barts Health including representatives

from across the sites, for: breast surgery, colorectal, ear nose and throat, general surgery, orthopaedics, urology and anaesthetics; the surgery clinical academic group lead pharmacist and primary care lead

o Leads for colorectal and orthopaedic surgery from Homerton Hospital o Clinical leads from Newham, Tower Hamlets and Waltham Forest CCGs o Acute care lead from Newham and Waltham Forest CCGs o Two patients, one of whom was also a patient representative

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5.4 Outcomes the change will achieve The above model of care is intended to achieve the following outcomes:

Outcome description Outcome by 2020/21 (Metric/impact)

Elective length of stay (LOS) improvement LOS improvement of 10% across all elective surgical inpatients

Improvement in theatre efficiency Improved efficiency by 12%

Reduction in on-the-day cancellations To top 10% peer performance

Improvement in day case rates (based on the British association of day case surgeons basket of procedures)82

To top 10% peer performance

5.5 Investment costs In order to implement the model of care the following investments are required. This includes capital requirements, workforce investment, project implementation costs, organisational development (OD) costs and investments in IT.

2016/17 2017/18 2018/19 2019/20 2020/21 Total

Capital costs inc. capital revenue

£0.82m £1.4m £1.4m £1.4m £1.4m £6.44m

Workforce

(including project management, procurement etc)

£0.09m £1.25m £1.04m £1.04m £3.41m

OD costs £0.16m £0.15m £0.15m £0.05m £0.51m

5.6 Impact on activity and revenue Improved length of stay

The new model of care will enable o treat many more patients with a small investment in extra staff and one additional theatre (detailed in part 3, section 5.5). The reduction in elective length of stay would lead to a reduction of 8,593 bed days required in the future to deliver a larger amount of surgical activity. This is the equivalent to a reduction of 24 beds that could be used to treat the growing demand.

82 British Association of Day Case Surgeons June 2012. Bads Directory of Procedures ttp://daysurgeryuk.net/en/shop/publications/bads-directory-of-procedures-4th-edition/

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Effect of surgical improvement scheme on Barts Health elective inpatient bed days

• The surgical length of stay reduction scheme will reduce elective length of stay by 10% in 2020/2183

• This scheme only applies to the 3 main sites at Barts Health NHS Trust (Whipps Cross, Newham Hospital and The Royal London)

• In 2020/21 this scheme will reduce elective bed days by 5,812 which equates to approximately 16 beds (assuming 100% occupancy)

• The reduction is slightly greater than the expected increase in bed days due to growth

• This extra capacity would provide Barts Health with the opportunity to tackle its backlog, or to treat other patients on the waiting list more quickly.

More work is needed to understand the best use of this capacity for patients and the health system overall. Using this capacity for elective backlog would reduce the amount of work that Barts Health is outsourcing to other providers and increase the revenue for the trust.

Theatre productivity improvement

The new model of care would improve theatre utilisation over the five years from 45%84 to by 56.8%.

This estimate has been developed through detailed conversations with surgical leads in all specialties by looking at current average surgical lists and practical improvements that could be achieved through the new clinical models, including:

improved scheduling and booking

reduction in late starts

83 Source: TST Activity/Finance Model based on SUS data provided by NEL CSU Trusts included: Bart's Health (3 Sites only Whipp’s Cross, Newham, The Royal London) CCGs included: All commissioners of activity commissioned from Bart’s Health NHS Trust Specialised Commissioned Activity included: Yes PODs included: Elective inpatients only Baseline Adjustments: N/A 84 Current average 2015/16 cross site, cross speciality KTS measure – Barts internal data (Surgnet)

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reduction in patients not attending

improvements in capabilities through specialisation and higher volumes

Using the activity baseline of 2014/15 and improving theatre productivity to 56.8% provides the equivalent of a real terms increase of 26.2% theatre capacity across sites above current activity levels. This increase is more than the aggregate forecast growth in demand over the next five years of 2.8% cumulative growth per year (demographic and non-demographic growth over the five years is the equivalent of 14.8% growth). This means that there would be no need to build new theatre capacity purely to deal with additional population growth.

However, there is a need to do more analysis as additional capacity may be needed for the following reasons:

Capacity across sites not aligned with growth – faster population growth or change in one borough may require a site to boost capacity.

Opportunity to bring in more work – in delivering best in class services, core-plus hubs may treat patients from a wider catchment area than East London CCGs. This is likely to mean extra capacity is needed.

Need to flex capacity to deliver redesign and new models of care – service changes to deliver these new models of care will require some excess capacity in order to double run some services and ensure changes can happen safely, without harm or delays to patients.

Specialist theatres or equipment – there may be a need to develop capacity in certain type of theatres i.e. specialist day care facilities or lead-lined rooms for interventional radiology in order to keep pace with advances in clinical practice and take advantage of the latest techniques.

Due to this uncertainty, and in order to ensure that savings portrayed are not overly optimistic, we have included the investment costs of one theatre alongside the refurbishment of wards requiring urgent maintenance.

To refine this figure, there is a need to conduct a more detailed analysis of theatre demand and capacity; this is a key part of the next steps outlined in part 3, section 5.9.

Financial impact including sensitivity analysis

The changes free up capacity at Barts Health through improved productivity. After conducting financial impact analysis, we undertook sensitivity analysis which suggests a net saving of between £0.2m to £5.7m over a five year period.

This does not take into account the additional revenue benefits to the provider realised through better use of existing capacity.

Additional finance modelling assumptions

With the exception of increasing the interventional radiology workforce and some additional theatre teams, the surgical hubs do not require additional workforce as the assumption is that current teams could deliver the future model of care.

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The exact level of savings to the system and impact on revenue for Barts Health are dependent on decisions of how any freed up capacity is used. Further financial validation will be required as part of the business case stage.

5.7 System commercial considerations and transitional support required

The key commercial considerations in taking this work forward are:

tendering issues around any new build or major works i.e. proposed new theatres/refurbishments

potential investment in community services will be required in order to improve pre-operative and post-operative pathways

new models of care will improve Barts Health’s ability to undertake surgery – and contribute to the 18 week referral backlog – this must be managed in a sustainable way.

5.8 Delivery risks

Description of risk Risk Likelihood

Risk Impact

Risk rating

Mitigation

1 Risk of misalignment with Barts Health (BH) internal improvement work and future capacity planning, which could mean short term changes undermine longer term vision

3 3 9 - Ongoing work with BH productive theatres programme and referral to treatment turnaround - Barts director identified to lead work - Meetings with general managers to be arranged - New BH resource in place to work through next stages of capacity and demand matching and analysis

2 Lack of CCG engagement and support delays or prevents changes

2 4 8 - Ongoing efforts to engage with CCGs. Clinical leads from CCGs involved in planning and strategy development - Continued engagement of topic at stakeholder events

3 Lack of patient engagement delays or prevents changes

3 4 12 - Ongoing work with communications team to engage patients and build narrative for change - Workplan to take into

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account the need to develop high level options appraisal and impact assessment

5 Lack of clarity on capacity and waiting list model slows development of business cases and full benefits to initiatives being articulated

3 3 9 - New BH resource in place to work through next stages of capacity and demand matching and analysis.

6 Development of cross-site working prevented by lack of engagement with clinical staff

2 4 8 - Working with new Surgical CAG on development of cross-site networks to engage sites in cross -working.

5.9 Next Steps In order to take this work forward we want to work with clinicians and patients to develop clear plans to create high performing surgical hubs. This will require:

Phase Outline Time scale

Work to develop detailed clinical plans

Working with clinicians and patients to develop detailed future plans. This will include detailed understanding of how surgical specialties fit into core; core-plus and complex.

Feb – July 2016

Detailed demand and capacity work

Work to develop detailed future plan of theatre capacity across site and by speciality to ensure feasibility of any proposals.

Feb – July 2016

Ongoing public and patient engagement

Work with TST PPRG and Healthwatch to develop proposals that take into account patient perspectives.

Feb – July 2016

Core provision and emergency network

Work to boost local ‘core’ surgical provision and ensure high quality local general surgical provision across site (including non-complex paediatric). Work to formalise emergency surgical network across Barts Health sites.

March 2016 (ongoing)

Further engagement on

Complete impact assessment in line with patient and public concerns and conduct appropriate consultation. July 2016

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detailed proposals

Potential expansion of surgical capacity

Following demand and capacity analysis, potential business cases for expansion of appropriate surgical capacity e.g. refurbishment of Plane Tree Centre85 and potential new build of theatre at Newham.

2016/2017

85 Plane Tree Day Case Surgical centre is at Whipps Cross Hospital and has the capability to act as a stand-alone day case surgical facility

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Acute emergency and obstetric services dependency frameworkNotes:This table combines the individual interdependency frameworks of each service area reviewed as part of the Quality and Safety programme (listed to the right).

For any of the services shown to the right, read down the column to see how dependent they are on the services listed below. Example: Obstetrics is dependent on having the immediate availability of acute medical opinion/assessment.

Acute med

ical o

pinion/ ass

essm

ent (<

48-72

hrs)

Genera

l/ spec

ialist

med

ical in

patients

(>72hrs)

Emergen

cy gen

eral s

urgica

l asse

ssmen

t/ operat

ion

Obstetri

cs

Paediat

ric em

ergen

cy dep

artmen

t

Paediat

ric SSPAU an

d inpati

ent w

ard

Emergen

cy dep

artmen

t

Critica

l care

anaesthetics R+ R+ R+ R+ R+ R+ R+ R

emergency department G G G G G G G

paediatric emergency department G G G G G G

acute medical opinion/ assessment (<72hrs) R R+ R+ G G R+ G

specialist medical opinion A+ A+ R+ G G G A A

general/ specialist medical inpatients (>72hrs) A+ A+ G G G G G

paediatric emergency medical opinion/ assessment G G G G R+ R+ R+ G

paediatric resus G G G G R+ R+ R+ G

paediatric inpatients G G G G A+ A+ G

acute/emergency general surgical opinion/assessment R+ A+ R R R R R

acute/emergency general surgical operation A+ A+ R A+ A+ A+ A+

acute general surgical admission A+ A+ G A+ A+ A+ A

elective inpatient surgery G G G G G G G G

paediatric emergency general surgical opinion G G R+ G A+ A+ R G

paediatric emergency general surgical operation G G R+ G A+ A+ A+ G

emergency surgery specialty opinion (gynae) A+ A+ R R A+ A+ R A

emergency surgery specialty opinion (orthopaedics/trauma) A+ A+ R G A+ A+ R A

emergency surgery specialty opinion (urology) A+ A+ R R A+ A+ R A

emergency surgery specialty opinion (vascular) A+ A+ R R A+ A+ R A

emergency surgery specialty opinion (ENT) A+ A+ R G A+ A+ R A

emergency surgery specialty operation (gynae) A+ A+ R R A+ A+ R A

emergency surgery specialty operation (orthopaedics/trauma) A+ A+ R G A+ A+ A+ A

emergency surgery specialty operation (urology) A+ A+ R A+ A+ A+ A+ A

emergency surgery specialty operation (vascular) A+ A+ R A+ A+ A+ R A

emergency surgery specialty operation (ENT) A+ A+ R G A+ A+ A+ A

paediatric emergency specialty opinion* G G G G A+ A+ R G

paediatric emergency specialty operation* G G G G A+ A+ A+ G

emergency imaging and reporting** R+ R R R+ R R R+ R+

emergency interventional radiology*** R R R R A+ A+ R A+

emergency endoscopy (incl therapeutic) A+ A+ R G A+ A+ A+ A+

acute pathology (laboratory assessment services) R R R R+ A+ A+ R R+

haematology/ transfusion/ blood bank R+ R R+ R+ R+ R+ R+ R+

echocardiography R R R G G G A+ A

cardiac angiography R R R G G G R A+

adult critical care opinion/ intervention (levels 2 and 3) R+ R R+ R+ G G R+

adult critical care admission/access (levels 2 and 3) R A+ R+ R+ G G A+

tertiary critical care access A+ A+ A+ G G G G A+

paediatric critical care opinion and assessment (incl. Anaesthetics) G G G G R+ R+ R+ G

paediatric critical care access G G G G A+ A+ A+ G

neonatal care G G G R+ G G G G

obstetrics G G G G G G G

acute mental health liaison services R R R A+ R R R A

safeguarding level 3 provision R R R G A+ A+ R G

* specialty includes gynae, orthopaedics, vascular and urology

Key

R+

R

A+

A

G No direct dependency

** Emergency imaging includes CT and ultrasound*** Where interventional radiology services are not available onsite, time from decision to transfer to arriving at receiving hospital should be no more than 1 hour.Access for crtical patients, 1 hours. Non-critical, 4 hours.

Needs to be immediately available and co-located

Needs to be available in less than an hour and could be provided in an effective network

Needs to be available/accessible within 4hrs

Needs to be available/accessible within 24hrs

Elective surgery hubs: appendix 1 Acute emergency and obstetric services dependency framework

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6: Establish acute care hubs at each site 6.1 The case for change The Transforming Services Changing Lives (TSCL) Case for Change showed that the current emergency care system is unsustainable. The work we have completed has shown that:

our current system of urgent and emergency care is complex and confusing

people are not well enough supported to manage their own conditions

emergency departments are struggling to meet and maintain the 95% target for patients to be seen and discharged within four hours

too many people are admitted to a hospital ward when they could be better cared for elsewhere. New ways of working such as ambulatory care provide appropriate care to patients without admission. Clinicians have told us that this could be up to 15% of the patients that are currently admitted to a ward

patients often remain in hospital beds longer than they need to or when they could receive appropriate care outside of hospital. The average length of stay of a patient in Barts Health NHS Trust is 0.5 days longer when compared to peers86

two emergency departments do not meet the London Quality Standards87 for consultant cover at the evening or weekend. There are national shortages in supply of emergency medicine clinicians; the specialty shows the highest vacancy rate across England88 (15%).

On top of current operational issues, the challenges are only going to become more severe. We are expecting an additional 270,000 people to be living in East London in the next 20 years89. This rising demand, combined with the planned closure of the emergency department at King George Hospital (KGH), means there is likely to be a rise in the numbers of people coming to Barts Health emergency departments of around 93,000 per year by 2020.

We know that emergency departments should be for emergencies only, yet we know from local health data that up to 21% of those who attend A&E, but who are not admitted, require no significant treatment90. Our confusing urgent care system contributes to this problem. The changes we will make to urgent care (outlined in part 3, section 2) aim to address this challenge.

However, even with the successful delivery of improvements to our urgent care system, our growing population means that in five years our emergency departments will be seeing as many people as they do today. But, if the urgent care system treats more people with minor problems, in future patients who turn up at emergency departments are likely to be sicker

86 CKHS Dataset, last accessed 13/10/2015. Years are July to July calendar years, 11-12 only based on partial data (April – July 2012) 87 London Health Programmes. Quality and Safety Programme Acute medicine and emergency general surgery www.londonhp.nhs.uk/wp-content/uploads/2013/03/Model-of-care-standards-FINAL-Feb2013-v1.11.pdf 88 NHS England. Transforming Urgent and Emergency Care services in England, November 2013 www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%201.EvBase.FV.pdf 89 Transforming Services, Changing Lives. Case for Change www.transformingservices.org.uk/downloads/caseforchange/TSCL%20case%20for%20change%20FINAL%20web.pdf 90 SUS data 2024/15

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and have more complex conditions than they do now. This means that we need to work very differently to use our scare resources in the most effective way to help people stay well, out of hospital and save their lives in an emergency.

The paediatric emergency care system is facing similar challenges; we have a growing young population and limited numbers of specialist staff meaning emergency care provision is variable. There are insufficient paediatric consultants to cover emergency departments at all sites, and consequently there is a reliance on the paediatric acute team to support emergency departments, diverting clinical care away from inpatients. With an estimated 16,000 more children across Newham, Tower Hamlets, Redbridge and Waltham Forest by 2019 there is a clear case for change.

6.2 Model of care In order to deliver safe, sustainable and high quality services for local people, we must radically change the way the emergency care system works:

Three strong local hospitals are needed (Newham University Hospital, Royal London Hospital and Whipps Cross University Hospital), each with an urgent care centre and emergency department. Each of these sites need to be able to provide the vast majority of care for the local population. These will need to work together as a network91 in order to deliver the highest quality care locally, wherever possible, whilst making best use of specialist resources when we know this saves lives and aids recovery92.

The front end urgent care centre offered at local emergency departments must be improved to allow these departments to be used for emergencies only. Please see the part 3, section 2 on plans for an integrated urgent care model for further details.

We need to embed ambulatory care93, models at each site so that hospitals and community services can to treat people who do not need 24-hour nursing care outside of a hospital bed. This will include access to specialist input on the same day, to avoid unnecessary admission to a hospital bed, whilst ensuring best practice treatment and patient experience.

Hospitals must change how they operate. They must change from an outdated model where admission to wards is often required for the patient to gain access to expert staff and equipment, to become local hubs of acute clinical expertise, organised in a way to meet the needs of local people quickly and conveniently. Hospital specialists will need to work closely with each emergency department to treat people in ways that reduce the need for people to be admitted to, or spend unnecessary time in, hospital beds. We need to fully engage with GPs, primary care and community services to establish direct referral pathways and define how follow up treatment is managed.

91 This is a finding of the Keogh review https://www.england.nhs.uk/2013/11/13/keogh-urgent-emergency/ 92 NHS England. Transforming Urgent and Emergency Care services in England. November 2013 http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%201.EvBase.FV.pdf 93 Ambulatory care is emergency medical care (diagnosis and treatment) delivered to emergency patients who visit hospital and depart on the same day (with possible on-going follow up).

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Establishing acute care hubs at each hospital site

The Future Hospital Commission94 was established in 2014 by the Royal College of Physicians with the aim of putting patients’ needs first and redesigning hospital services to meet these needs. One of their recommendations was the concept of ‘acute care hubs’.

These acute care hubs bring together senior clinical expertise from medical and surgical specialties to focus on the initial assessment and stabilisation of acutely ill patients with a view to completing treatment and recovery within 48 hours through a multi-disciplinary team approach.

What this means for our different sites in terms of emergency provision can be seen below:

Newham and Whipps Cross could have: The Royal London could have:

The acute care hub consists of the following teams and functions:

Emergency department

Paediatric emergency department

Ambulatory care unit with hot clinic facilities

94 Royal College of Physicians: Future Hospitals Commission. 2014 www.rcplondon.ac.uk/projects/future-hospital-commission

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Paediatric short stay unit (performing the functions of a clinical decision, assessment, and delivering paediatric ambulatory care).

Short stay unit

Through co-location of the acute medical team alongside emergency care colleagues, the acute care hub creates a clinically-led, collaborative focal point which unites these previously separate areas of clinical care. The hub acts as a central nervous system of the hospital, focusing on emergency and general medicine.

Our proposed changes aim to achieve:

Emergency consultant cover (minimum of 14 hours a day, seven days a week, working towards 16 hours a day within the next three years).

Rapid assessment and triage by senior decision maker in the emergency departments.

Paediatric consultant cover (Between 10:00 and 22:00, seven days a week).

Adherence to the new pan-London mental health crisis standard (see dedicated section on crisis mental health later in this chapter).

24/7 ability to assess, safely stabilise and transfer patients via agreed specialist pathways.

24/7 timely access to high quality diagnostics (imaging and laboratory, endoscopy, echocardiography and physiological testing)95.

Seeing the right specialist as early as possible in the patient journey

The acute care hub model focuses specialist clinicians towards the ‘front door’ of the hospital. Seeing the right specialist as early as possible improves patient care and recovery and reduces length of stay.

Patients will be assessed and receive preliminary diagnosis by a senior doctor, and should see a specialist in their condition as soon as possible. In some cases this might mean seeing multiple specialists for some patients. However, the specialists should be brought to review the patient in the short stay or ambulatory facility rather than the patient moving around the hospital. This will mean patients will be treated in the most appropriate care setting for their needs and will only be admitted to specialist wards when they really need to be.

In order to implement this model, consultant physicians from a wide range of specialities will support colleagues in the emergency care team and will spend sessions providing direct clinical care and specialist opinion in the hub. This will mean spending more time supporting ‘generalists’ so they are able to provide rapid consultation without the need for patients to spend any unnecessary time in the hospital. This will in effect help to increase the skill mix of staff and capability of the workforce in the diagnosis and management of acute, emergency patients.

The acute care hub will bring together the following services within the hospital:

Emergency department

95 Royal College of Physicians: Future Hospitals Commission. 2014 https://www.rcplondon.ac.uk/projects/future-hospital-commission

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Consultant-led general medical ambulatory care service including rapid access to outpatient and clinic services for specialist services – known as hot clinics – where access can be granted on the same day.

Extended outpatient antimicrobial therapy services.

A recovery-focused short stay unit for admissions under 48 hours that provides a central area for coordination of support services.

Handover, transfer and care package services.

This model is aligned across paediatric and adult services with an equivalent offer and purpose.

The beneficial role that ambulatory care will play

Ambulatory care is emergency medical care (diagnosis and treatment) delivered to emergency patients who visit hospital and depart on the same day (with possible on-going follow up). Focusing on ambulatory care as the primary approach to medical clinical care means reducing the treatment provided in the traditional hospital bed base.

Clinicians have told us that up to 15% of the non-elective patients that are currently admitted could be treated in ambulatory care units and we should aim to make ambulatory care the default for patients in the future.

This model would reduce the bed occupancy of specialist wards and protect capacity for the admission of complex patients with severe or acute levels of need.

Currently each site operates a different model of ambulatory care – and this is down to differences in estates and local clinical models. However, in order to deliver the full benefits of this new model of care it must be systematic and standardised. In order to do this we need to provide dedicated, fully resourced ambulatory care units at each site. The investment required for these is detailed later in this section.

Evidence from local pilots and best practice has also shown the following impacts:

Introduction of ambulatory care avoided 90% of admissions with under 1 day length of stay96

Ambulatory care can be used to support an earlier discharge for patients otherwise ready to go home

Delivering care in ambulatory care model can improve emergency departments performance97

When asked about the care they received through ambulatory care models, patients provided extremely positive responses (see below).

96 Presentation: Stepping into the Future, Phase 2 at Newham, June 2015 97 Running a Bigger, Better Ambulatory Care Unit, Whipps Cross Hospital pilot, May 2015

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Our vision in action:

The way we currently work means treatment frequently involves hospital admission when a hospital bed isn’t always the best place for care.

Each of our hospitals run some ambulatory care – but we aren’t doing enough of it. We want to make sure no patient ends up staying in hospital when they could be safe and comfortable at home. This is better for their recovery and the feedback we have had has been great.

Sarah Frankton, consultant in general medicine, Whipps Cross Hospital

Hot clinics

Hot clinics provide rapid access to medical specialist opinion. They are crucial in delivering effective care through this new model as they allow patients rapid access specialist treatment so they can go home safely and then return for treatment or assessment on subsequent days if needed.

This way of working is not new, but does not happen systematically across Barts Health. In order to deliver this model we need to transform outpatient services (see part 3, section 8 on pathways) as well as put in place effective tariff and payment mechanisms.

Introducing hot clinics across our hospital sites will also enable us to support more people to recover safely at home. We will do this by delivering a range of informal outpatient services for a range of conditions requiring treatment with intravenous or intensive courses of antibiotics and anticoagulants (OPAT services). Knowledge gained from recent provision of this type of service at the Royal London (where OPAT is integrated with community and primary care services in Tower Hamlets) suggests that 30% of the patients currently on these treatments in hospital could recover at home safely and return to the hospital for appropriate treatment the next day. Looking further into the future, this model of care has the potential to be introduced across range of conditions currently requiring inpatient treatment.

Recovery focused care

Short stay units focus on accommodating patients for up to 48 hours. The units will need rapid and seven-day access to relevant diagnostic services including rapid access to endoscopy, echocardiography and mental health screening and testing. It will fall under the

Patient experience average response scores from Whipps Cross ambulatory care pilot 2015 (1-5 range)

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care of acute medicine and make use of short stay and rapid treatment pathways with a focus on recovery.

Local pilots (echoing national best practice guidance) demonstrate that the use of focused recovery units in combination with ambulatory care, facilitate an earlier discharge from hospital for up to 75% of patients referred from a hospital ward98.

Support services, such as social care and pharmacy, that are essential to the multi-disciplinary team (MDT) environment will be based within this unit. The concentration of these staff groups, which focus on recovery and re-ablement, in the short stay unit will ensure patients are discharged as soon as possible, in the knowledge they will be stable and safe in their own home.

The new short stay unit will ensure that all patients continue to receive prompt specialist care and support aligned to their needs, maximising alternatives to a longer hospital admission, and improving safety, outcomes and patient experience.

To enable this recovery focussed unit to operate effectively, health and social care services in the community need to be organised and integrated with the teams staffing the short stay unit. This will enable patients to be rapidly discharged on the day they no longer require an acute hospital bed rather than waiting for an assessment and care package to be put in place. The co-location of health and social care staff in the short stay unit will provide the opportunity for MDT team meetings with all professionals able to review each patient’s care plan and their arrangements for recovery and leaving hospital.

Short stay unit proposed staffing groups:

Potential changes to paediatric services

In order to deliver better quality paediatric services we need to adopt a model that focuses on ambulatory care at each hospital site. This mirrors in principles the adult model of actue care set out above. This will bring the paediatric acute physician closer to the front door of emergency departments, and mean only admitting a patient to a traditional ward if necessary.

The creation of paediatric assessment units (PAU) at hospital sites will allow the effective delivery of ambulatory care for children during the day with consultant oversight, without

98 Stepping into the Future, Newham Ambulatory Care Pilot Review, June 2015

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needing to admit the patient for an overnight stay. The PAU would work alongside the functions of a clinical decision unit and mean that fewer patients are admitted to a ward and ward staff have more time to care for the sickest children. It also means that general paediatric consultants are better able to support the emergency departments in caring for any children. The model aims to deliver paediatric consultant cover in emergency departments between 10:00 and 22:00 hrs and appropriate nursing cover 24/7.

In order to deliver this new model of care there will need to be investments in appropriate nursing and medical workforce, as well as changes to the way that consultants currently work across and within hospital sites. This will need to include changing job plans to ensure adequate senior clinical oversight at each site.

Proposed model of peadiatric hospital care and interaction with other teams

As outlined in the Facing the Future Together99 report, the success in improving health care and outcomes for children and young people with acute illness relies on teams inside and outside of the hospital working together. In the case of paediatrics there is a need to ensure appropriate support for GPs and community staff. This is detailed in the model above in the role of the ‘locality paediatrician’. This work is being taken forward in conversations with boroughs.

As part of this model, there would also need to be improved out-of-hours support and transfer arrangements across sites which need to be developed in partnership with London Ambulance Service NHS Trust.

99 Royal College of Paediatric and Child Health, Facing the Future Together for Child Health 2015, http://www.rcpch.ac.uk/facing-future-together-child-health

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Mental health crisis

Creating acute care hubs, as set out in this chapter, aims to make sure our hospitals provide safe and effective care for people experiencing a mental health crisis. They will include:

a dedicated area for mental health assessments which reflects the needs of people experiencing a mental health crisis and is in accordance with Royal College of Psychologists standards

access to on-site liaison psychiatry services 24 hours a day, seven days a week

liaison psychiatry services to see service users within one hour of emergency department referral

arrangements in place to ensure Mental Health Act assessments take place promptly and reflect the needs of the individual concerned

access to all the information required to make decisions regarding crisis management including self-referral.

Similarly for children we will aim to provide:

single call access for children and adolescent mental health (CAMHS) (or adult mental health services with paediatric competencies for children over 12 years old) referrals to be available 24 hours a day, seven days a week with a maximum response time of 30 minutes

access for staff to telephone consultations and an on-site response from a dedicated pool of CAMHS professionals known to the local hospital during, and out-of-hours.

N.B. Full costing and benefits of the mental health changes have not yet been included in the financial modelling. Further work needs to take place to understand if there needs to be any change in investment, above what is currently being planned locally, in order to deliver these changes.

How we will deliver acute care hubs at each site

In order to maximise the benefits of this clinical model we are proposing to put in place a dedicated ambulatory care unit at each site. This will need to be accompanied by changes to existing facilities to enable the other elements of the acute care hubs model to be delivered e.g. hot clinics and dedicated short stay units.

There is a need to focus on embedding the functions of each element of the model of care as each site is set up slightly differently. A focus on pathways will be key to ensuring real change, not simply ‘relabelling’ of units. Newham, Whipps Cross and the Royal London Hospital each has in place some elements of the acute care hub model, however, there is a need for capital investment, as well as changes to working practices in order to realise the benefits and establish this new way of working as standard clinical practice across Barts Health. The grid below summarises the key changes required at each site to deliver this model.

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Time frame Royal London Hospital

Whipps Cross University Hospital

Newham Hospital

Short term / immediate actions

Move to co-locate existing services with emergency department on ground floor (recruitment of additional acute medical workforce complete)

Extended hours of operation for existing unit – moving to an 8am to 8pm model, seven days a week

Additional recruitment of acute medical workforce

Creation of PASSU

Addition of new ambulatory care pathways to current clinical decision unit/short stay unit treatment list.

Additional recruitment of acute medical workforce

Medium term Expansion of services and organisational development and workforce changes

Roll out of Hot Clinics across specialties

Temporary estates changes to provide additional seated treatment areas and changes to workforce

Boost to OPAT services to be consultant-led

Roll out of Hot Clinics across specialties

Temporary estates changes to provide additional seated treatment areas and changes to workforce

Boost to OPAT services to consultant led

Rainbow ward opens – allowing for PASSU working

Roll out of Hot Clinics across specialties

Long term Consolidation of model and addition of exception pathways to enable ‘ambulatory care as default’ for treatment

New capital build to provide purpose built centre

New capital build to refurb mothballed ward for ambulatory care

The key programme milestones are further outlined in the next steps section.

Workforce of the future

Acute care hubs aim to maximise the use of workforce skills and expertise. Each element of the new model will require changes to the way staff work.

We know that there are national shortages of consultants in emergency medicine; theatre nurses; CT3 trainees and ST4 to ST7 trainees in emergency medicine; non-consultant, non-training medical staff in emergency medicine (including specialty doctors working in A&E); and paramedics. In order to address this, significant investment has been made across London into increasing emergency medicine training and developing new roles. It is projected that within three years we shall move from under-recruitment to having the right number of trainees to match existing posts100.

100 Health Education North Central and East London. Education Plan and Workforce Skills and Development Strategy 2013-2018 www.ncel.hee.nhs.uk/files/2013/07/NCEL1592-SDS-Master-Version.pdf

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Given this, in order to deliver the new models of care outlined in this section the emphasis over the next few years needs to be on developing new ways of working across emergency and acute medicine rather than solely recruitment.

The future workforce must meet the needs of patients needing input from across the health and social care system. This will include the expertise to manage frail older patients with dementia, and lead and coordinate the ‘whole care’ of patients in hospital and the community. Across the overall physician workforce there will need to be the right skill mix to deliver appropriate:

specialisation of care (e.g. access to sufficient specialty expertise to deliver diagnosis, treatment and care appropriate to the specific hospital setting)

intensity of care (e.g.. access to sufficient expertise to manage, coordinate and deliver enhanced care to patients with critical illness)

coordination of care (e.g. access to sufficient expertise to coordinate care for patients with complex and multiple comorbidities).

Most physicians, whatever their specialty, will possess and deploy a combination of these skills in their roles. However, structures and roles will need to be designed to support and enhance the delivery of high-quality emergency care, and embed strong clinical leadership.

There will also need to be changes to the way community staff work with on-ward recovery101 nursing, occupational therapy and physiotherapy, together with dementia specialty nursing, local authority social services, ambulance liaison and pharmacy/enhanced prescribing. Some of these resources may present a challenge, given skills shortages within professions both national and locally.

The following organisational development work programmes have been identified, and costed, these are detailed in the section on investment costs.

re-training of staff to perform new roles in acute care hubs including strengthening the MDT working approach across medical specialties.

support for integration of community and social support services.

There are also overarching issues that need to be addressed to attract staff to East London as part of an overall recruitment/ retention and organisational development (OD) strategy, which include:

the high and rising cost of living in London

transport difficulties (particularly for community-based workers who need to use personal rather than public transport to do their work)

availability of low cost/key worker accommodation etc.

The high turnover in specific staff groups in emergency services and also London Ambulance Service, indicates a need to investigate at a local level and develop an appropriate OD strategy designed to improve retention rates.

This [acute care hub] has major implications for the clinical practice of physicians, the training of future generations of physicians, for research and – most importantly of all – for

101 Nurses that focus on the recover and re-ablement of patients but work within a hospital or ward setting

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patients. Its implementation will be a challenge for us all – but implement it we must. Our present and future patients will expect – indeed demand – no less.

Sir Michael Rawlins, Chair, Future Hospital Commission102

6.3 Other significant change initiatives not costed here Below are significant other schemes related to this area of care/change that might in the future need to be fully costed and assessed for level of impact.

Embedded standards of care for frail elderly patients, focusing on mental health needs, including dementia; working with community and social care partners to improve timely supported discharge given the disproportionately high lengths of stay observed within this patient group.

Review capacity of ‘step-down’ rehabilitation beds in the community, including the potential for enhanced contracts with nursing and care homes. An enhanced contract would aim to enhance quality of health care for nursing home residents in association with pharmacy and nursing staff, offering alternatives to admissions to acute hospitals.103

6.4 Engagement The focus of engagement has been on developing and understanding the potential impacts of this clinical model, the benefits for patients and aligning this with current performance and operational improvement initiatives as well as starting to understand the potential impact on future patient flows. The following stakeholders or stakeholder groups have been engaged or have helped to shape these proposals:

Transforming Services Together Clinical Reference Board East London Clinical Strategy Group Barts Health Clinical Academic Strategy Board CCG governing body development sessions board meetings Healthwatch Waltham Forest (involved in Health Foundation bid for ambulatory care

at Whipps Cross Hospital) Barts Health TST Strategy Group TST Children and Young People Working Group, Acute Medicine Working Group and

Emergency Care Working Group CCG governing bodies Programme director representation at North East London Advisory Group and NEL

urgent & emergency care network (covers all seven north east London CCG areas) Regular attendance at TST urgent care steering group, local urgent care working

groups, East London operational resilience group

102 www.rcplondon.ac.uk/press-releases/care-comes-patient-future-hospital 103 Example of a local enhanced service provision for patients in nursing and residential homes www.hscbusiness.hscni.net/pdf/LES_Nursing_Homes_Policy.pdf

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6.5 Outcomes the change will achieve The details below show the high level impact of implementing the acute care hub model:

Outcome description Outcome by 2020/21 (Metric/impact)

Patients treated through ambulatory care as a percentage of non-elective hospital admissions

15%

There would also be an expected Impact on improvement in four hour target performance for the emergency department (95% target). Pilots and evidence suggests this could be up to a 5% improvement. The next steps will are to understand the shifts in more detail. Below are some examples for how this might break down:

Outcome description Outcome by 2020/21 (metric/impact)

GP referrals for emergency admission can be treated and discharged same day

50%104

Reduction in non-elective admissions of less than 24 hours 80%105

Reduction in non-elective admissions of between 24-48 hours 10%

Reduction in non-elective average length of stay 0.1 day

Reduction in treatment costs for patients requiring antimicrobial therapy / infectious disease / anti-coagulation treatment

15%

Agreement on programme outcomes will be agreed as a next step with clinical leads at Barts Health representing the emergency care and acute medicine network and as part of implementation planning.

104 Nottingham University Health Trust, Health and Social Care Journal, Thompson and Connolly May 2014 www.hsj.co.uk/home/innovation-and-efficiency/all-in-a-days-work-the-drive-for-better-ambulatory-care/5070218.article#.VfLbjnmFMuQ Royal London Hospital: Improving Emergency Care. One Version of the Truth, March 2015; HSCIC. Focus on Accident and Emergency, December 2013 www.hscic.gov.uk/catalogue/PUB13040/acci-emer-focu-on-2013-rep-V2.pdf 105 Whipps Cross and Newham Hospital Ambulatory Care pilot data, TST programme May and June 2015

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6.6 Investment costs In order to implement acute care hubs as described in this chapter the following investments are required.

2016/17 2017/18 2018/19 2019/20 2020/21 Total

Capital costs inc. capital revenue

£2.68m £2.68m £2.68m £2.68m £10.72m

Workforce

Including project implementation costs (e.g. project management, procurement etc)

£5.6m £5.8m £5.8m £5.8m £5.6m £28.8m

OD costs £0.21m £0.16m £0.37m

6.7 Impact on activity and revenue The acute care hub model is predicated on senior clinical decision-making and specialist review and treatment delivered as early as possible in each patient journey. The revised service remains focused on the patients that report to the emergency department either by ambulance, walk in or by referral from a GP or other appropriate referring practitioner.

Treating people without admitting them to a hospital bed

The acute care hub model reduces the number of non-elective hospital admissions. To meet the aim of reducing the non-elective admissions by 15% overall, all aspects of the model described in the chapter must be in place. Phasing of the different elements is described at a high level in part 3, section 6.2

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Effect of acute care hub changes on Barts Health non-elective admissions activity

• The charts above show the impact of the acute care hub and OPAT schemes on

non-elective, emergency activity at Barts Health NHS Trust106. (For all CCGs, including specialised commissioning)

• It is anticipated that in 2020/21 there will be an additional 6708 non-elective admissions due to baseline adjustments, including an estimate of the impact of the potential KGH closure

• It is also anticipated that there will be an additional 10,228 non-elective admissions due to growth

• The Acute Care Hub and OPAT schemes are expected to reduce activity by 23,737 admissions in 2020/21

Reduction in admissions results in released capacity equating to bed savings

2015 2016 2017 2018 2019 2020

Bed reduction (cumulative) 0 -118 -142 -145 -147 -150

Bed reduction (yearly) 0 -118 -24 -2 -3 -2

106 Source: TST Activity/Finance Model based on SUS data provided by NEL CSU Trusts included: Barts Health NHS Trust: All Sites (excludes beds in Mid wife led units) CCGs included: All CCGs commissioning activity from Bart’s Health NHS Trust Specialised Commissioned Activity included: Yes PODs included: Non-Elective Activity (excluding non-elective non-emergency) – Codes incl: NEL, NELSD, NELST Baseline Adjustments: Heart hospital move, London Chest closure, KGH closure

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Further work is required to understand what this capacity could be used for in the future but could include:

Support delivery of elective activity.

Change of use.

The utilisation of this capacity should be developed jointly by the provider and relevant CCG.

Re-provision of care

Activity as a result of admissions avoided will be re-provided through ambulatory care units at each site as part of the acute care hub model. This includes follow up patient contacts provided through hot clinics (assumption of 1:1 ratio has been used based on local pilots107).

The activity described in the tables below has been used to develop the workforce requirement. Additional activity will also be provided to ward patients for support in facilitating earlier discharge.

Patient contacts per year in ambulatory care

Site 2016 2017 2018 2019 2020

The Royal London 18,664 23,233 23,760 24,323 24,796

Newham hospital 16,655 21,469 21,775 22,123 22,422

Whipps Cross hospital 19,946 24,892 25,125 25,372 25,648

Barts Health Total 55,265 69,594 70,660 71,817 72,866

Patient contacts per day in ambulatory care (average)

Site 2016 2017 2018 2019 2020

The Royal London 51 64 65 67 68

Newham hospital 46 59 60 61 61

Whipps Cross hospital 55 68 69 70 70

Barts Health Total 151 191 194 197 200

The large number of patient contacts per day demonstrates the need for investment in workforce and estates to enable appropriate delivery of the new service model as described in the investment costs section.

The outputs projected are indicative figures associated with both activity and costs based on current documented assumptions. Further financial management work is required to analyse the impact of this change to the service model moving forward.

107 Stepping into the Future, Newham Ambulatory Care Pilot review, June 2015 and Whipps Cross extended ambulatory care pilot review, June 2015

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Financial impact and sensitivity analysis

After conducting financial impact analysis, we undertook sensitivity analysis which suggests a net saving of between £22.6m to £35.7m over a five year period dependent on the extent and timescale in which acute care hubs are established at each site.

6.8 Commercial considerations and transitional support required The key commercial considerations in taking this work forward are:

Tendering issues around any new build or major works e.g. proposed ambulatory care units.

Managing the released capacity in a sustainable way.

Agreeing appropriate tariff arrangements to incentivise and ensure new models of ambulatory care are embedded and sustainable.

During the period of implementation and transition, support should be provided to facilitate the process and ensure that the system has adequate resource to complete the necessary changes without diminishing quality of service delivery. Consideration should be made for potential additional clinical support staff and ‘double running’ of some nursing and junior doctor roles to sustain quality of service.

6.9 Delivery risks Description of risk Risk

likelihood Risk impact

Risk rating

Mitigation

1 Ability to implement and run existing services concurrently 3 4 12

Invest in project support and possible double running of clinical teams

2 Insufficient stakeholder engagement to deliver large scale change and secure system-wide buy in

3 3 9

Re-focus identification of key stakeholders to engage

3 Need to manage interdependencies across other workstreams i.e. primary care, integrated care, end of life care, community services and discharge.

2 3 6

Managed through ongoing links between project managers

100

4 Lack of emergency and acute general medical workforce

3 3 9

Work with HEE and key workforce partners through TST to ensure long term solutions including suitability of new staff groups such as Physicians Associates.

5 Potentially lack of capital investment available

3 5 15 Need to ensure compelling case for capital as part of TST investment case.

Implementation planning will work to identify suitable source of and route for accessing capital investment

6.10 Next steps Development of the ambulatory care model across three of the acute provider sites has begun in earnest, in part due to the success of site specific trials and the desire to put in place a more sustainable model of care ahead of winter 2015/16. A phased approach will be applied to further implementation to ensure clarity of outcomes, clinical models and investments required:

Phase One Outline Indicative timescale

Clinical validation of new model

Work with clinical leads to test clinical interdependencies and future model and set clear outcomes across sites

January 2016

Public engagement Work with TST PPRG and Healthwatch to test and refine proposals with patient input January 2016

Emergency surgery network

Work to formalise emergency and acute medicine network across Barts Health sites. For details see chapter on surgical changes

January 2016 (ongoing)

Business case for acute care hub at each site

A full business case will be required for full workforce and capital investment of new model March 2016

Implementation Phase one of the implementation allows each

provider an opportunity to invest and crystallise its current service model in line with the

March 2016

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developing strategy supported by the TST programme

Phase Two Outline Indicative timescale

Workforce and OD

Workforce investment including organisational development initiatives

Understand the impact on the nursing and support services workforce and the process of role evaluation and redeployment to meet new service needs

Implementation of best practice methodology Agreement on job planning changes to support

service delivery A workforce consultation will need to accompany this work and should be completed before a final recruitment drive occurs for nursing establishment (if required).

April 2016

Primary care clinical engagement

Engagement programme with GPs, other primary care referral sources and community services to advise and educate on the new model and define how it will interact with (and determine the potential impact on) services outside of hospital as follow up care will also be required

April 2016

Capital works Begin build of agreed estate location for each

acute care hub

September 2016 (Ongoing)

Phase Three Outline Indicative timescale

Workforce and OD

Completion of organisational development initiatives

Completed workforce investment Defined and completed job planning and job

roles in each team

April 2017

Referrer engagement

Engagement programme with GPs, other primary care referral sources and community services to advise and educate on the new model and define how it will interact with (and determine the potential impact on) services outside of hospital as follow up care will also be required.

April 2017

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Capital works Build completion Acute care hub model fully operational at

each site

September 2017

Service relocation Physical co-location of teams to take place into new facility January 2018

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7: Increase the proportion of natural births 7.1 The case for change The Maternity and Newborn Care Clinical Working Group report for the Transforming Services Changing Lives (TSCL) Case for Change108 highlighted a range of issues about the quality of care that women and their families in north east London receive through pregnancy, birth and the postnatal period.

Central to the report was the observation that women in the area consistently reported having some of the worst experiences of care in London109. Care was at times perceived to be unsupportive, fragmented, and provided in places that were hard to reach. In addition, across north east London, the standards of provision and approaches to maternity were seen to vary between organisations, resulting in inequity of service and variable outcomes.

However, within this review there was also recognition that maternity services were struggling with the challenges of a population whose health complexity was increasing, of rising birth rates, staffing levels below recognised standards, and estate that did not meet the needs of users.

The scale of those challenges cannot be underestimated. Over the next ten years it is predicted that there will be another 5,000 births per year across north east London110. The focus of this increase is expected to be around Tower Hamlets and Newham with increases in births of 32% and 22% respectively.

Meeting this future demand through the current model of care is not feasible. Both the Royal London and Newham hospitals’ obstetric-led maternity services are already working at capacity and the Whipps Cross estate is in need of significant redevelopment to meet modern standards in line with the other sites.

Place of birth has been identified as a hugely important issue in improving quality and managing demand, with compelling evidence about the impact it can have on the health of women and babies111.

The current organisation of care is orientated around the majority of women giving birth in obstetric-led labour wards. Described by clinicians as the ‘default’ place of birth, 86% of women across Barts Health gave birth in a labour ward in 2013/14, although in this figure there is significant variation across the three sites.

But national evidence112 has led to the conclusion that women having a straightforward pregnancy should be advised to give birth in places other than obstetric-led settings. Obstetric-led settings place women at higher risk of unnecessary intervention such as caesarean and operative births compared with planned midwife-led births in a birth centre or

108 Transforming Services Changing Lives. Case for Change. Maternity and Newborn Care. 2014 www.transformingservices.org.uk/downloads/reports/MN%20CWG%20Report%20v4-0%20RF%2016122014%20FD.pdf 109 Care Quality Commission Maternity Services Survey. 2013 www.cqc.org.uk/content/maternity-services-survey-2013 110 Transforming Services Changing Lives. Case for Change forecasting methodology. 2014 111 The Birthplace national prospective cohort study: perinatal and maternal outcomes by planned place of birth Birthplace in England research programme. Final report part 4. NIHR. Hollowell J. et al. 2011 http://www.nets.nihr.ac.uk/__data/assets/pdf_file/0006/84948/SDO_FR4_-08-1604-140_V04.pdf 112 Ibid

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at home113. There is also evidence emerging that women with some risk factors (e.g., previous caesarean section) who traditionally would be automatically advised to give birth in a labour ward, may benefit from having their baby at home or in a birth centre114.

Out-of-Obstetric Unit (OoOU) births offer many benefits to all involved in maternity care provision. Women are highly satisfied with births in such settings115, experience less interventions, and are more likely to breastfeed their babies. These types of birth are also a more efficient, less resource intensive way of providing care with significantly cheaper costs per birth4 and are popular with midwives. An additional benefit is that the obstetric unit can focus care on those with the greatest need.

Over many years women have reported their choices being mixed or limited both nationally and locally, despite government commitment that women should be offered choice of place of birth (but recognising that this is something which is not always experienced by women)116.

In recent years Barts Health NHS Trust and other East London maternity service providers have recognised the need for change and moved towards providing more out-of-obstetric unit care. One particular area of focus has been around continuity of midwifery care, a concept that in maternity has been part of government policy in various forms for over 20 years and which itself has the potential to meet women’s needs; decrease intervention rates; improve satisfaction for women; and decrease the rates of pre-term birth, instrumental births and foetal losses before 24 weeks, while increasing rates of normal births and breastfeeding. There is also a statistically significant trend to such models being more cost effective to provide9.

Our strategy recognises the importance of the desire of providers to improve care for women and seeks to work together to create a far-reaching strategy for the benefit of women and families in this area.

7.2 Model of care At its core, the proposed care model focuses on ensuring that service provision is orientated around providing a good experience of care for women, supporting them through their pregnancy, birth and post-birth journey. Several key principles have emerged that support this aim and are described below.

113 Intrapartum care: care of healthy women and their babies during childbirth. NICE guidelines [CG190]. 2014. http://www.nice.org.uk/guidance/cg190/evidence 114 The Birthplace in England national prospective cohort study: further analyses to enhance policy and service delivery decision-making for planned place of birth. NIHR. Hollowell J. et al. 2015 http://www.nets.nihr.ac.uk/projects/hsdr/10100843 115 Alternative versus conventional institutional settings for birth. Hodnett ED, Downe S, Walsh D. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD000012. DOI: 10.1002/14651858.CD000012.pub4. 116 Maternity Matters: Choice, access and continuity of care in a safe service. Department of Health. 2007 http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_074199.pdf

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Increasing the number of births outside of the obstetric unit (OoOU)

In view of the known benefits of birth outside the obstetric unit (OU) this approach is a key strategy focus, with the aim being to encourage a shift 36% of births away to non-OU settings. This work is already in progress with the variation across site seen in the table below. Development of estates is crucial for the Royal London and Whipps Cross sites to fulfil these ambitions. The Royal London is planning to open an alongside midwifery-led unit in spring 2016. For Whipps Cross, widespread improvements are urgently required, including basic provision such as individual bathrooms for women in labour.

Increasing access to birthing centres will also be reliant on ensuring that local guidelines and protocols do not unnecessarily excluding women. For example, at Whipps Cross vigorous review and challenge of the outpatient induction of labour pathway enabled more women to access the birth centre, and also supported a significant reduction in the caesarean section rate. Sites will be reviewing this improvement work in the coming months and undertaking staff training needs analysis to support its implementation.

Continuity of midwifery care

This strategy aims to ensure that all women have continuity of care from a named midwife throughout their pregnancy, starting from their first appointment with the service. Barts Health’s three maternity sites have each been working to identify models of midwifery provision to support continuity of care across the whole pregnancy and birth journey. A

106

review of this work and aspects of the various types of service provision at each site can be seen in the table below.

Variation in current models of community and continuity of midwifery care

Criteria used for comparison

Newham University Hospital

The Royal London Hospital

Whipps Cross

University Hospital

Is there community midwifery team provision?

Can all women be looked after by a community team?

Does the current model of care provide continuity of midwife across pregnancy, birth and postnatal period?

Available to very small group only

Available to very small group only

Does continuity start from booking?

Can all women access all options of out-of-obstetric unit birth at this site

Current numbers of women giving birth outside of the obstetric unit 21% 13% 5%

Key:

Currently the models of maternity care being developed are teams of community midwives providing care for women throughout pregnancy and the postnatal period. By being located in the community, care is delivered closer to home. Some small areas have also started offering continuity of care during labour, but these have been limited; for example women who live in one postcode, have a particular planned place of birth, or a particular risk profile. There is therefore a need for significant expansion to meet our aims.

Moving to midwifery-led models of care orientated towards providing women with continuity of care requires significant organisational development amongst providers and different sites. Services which have experienced this describe the need to support midwives in developing their skill sets to support independent working117. In addition, to effectively monitor activity and quality, and enable efficient working, a significant investment in IT will be required.

117 NHS England (London) Maternity Strategic Clinical network. Increasing the number of women who receive continuity of midwife care: A best practice toolkit. 2015

Not available Available to all women Availability limited

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The range of services across the three Barts Health sites suggests that each site will need to develop its own implementation plan to reach the agreed strategic aims.

7.3 Other significant change initiatives not costed here Transitional care

Transitional care is the provision of care for babies who require more input into their care than the standard advice and guidance offered by clinicians to a normal, well baby. Typically these babies may require prophylactic antibiotics, phototherapy, or intensive feeding support or monitoring. The organisation of care for these babies is approached differently around the country but has a significant impact on maternity services. Generally these babies are cared for with their mothers on the postnatal ward118.

Looking after mother and baby together is good practice and is regarded as the core organising principle of care. However what has emerged in both anecdotal evidence and data sets from Barts Health is that the transitional care is contributing to increased maternal length of stay in maternity beds, when babies require prolonged treatment. The scale of the issue has yet to be defined but all three sites have expressed concern about the impact on the capacity of the unit, in terms of physical space, midwifery workforce and women’s experience.

Further work will need to be undertaken to explore the scale of this issue and potential solutions to this challenge.

Perinatal mental health

Perinatal mental health is an issue of growing concern in maternity services across the UK with increasing recognition of the long term impact on the family and growing child if left untreated. A recent national survey of services for women across the country identified much good practice in north east London. However there is continuing concern amongst clinicians that the provision of services for women with mild to moderate illness remain under developed, with lack of identification being a key issue.

The organisation of care described above will support improved relationships between women and their care providers allowing better recognition of need, communication between agencies, and support for women and their families.

7.4 Engagement Given the inter-related nature of the north east London maternity sector and the need to provide safe maternity care across the area, engagement workshops have included invitees from the whole area, both clinical and commissioner119.

Meetings, briefings and other contact:

Waltham Forest and East London and City maternity commissioners’ alliance monthly meetings. Invitees include commissioners and GP maternity leads from

118 British Association of Perinatal Medicine. Categories of Care. 2011 http://www.bapm.org/publications/documents/guidelines/CatsofcarereportAug11.pdf

119 Discussions take into account the existing models of care in each area.

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Newham, Tower Hamlets, Waltham Forest and City and Hackney; GP maternity lead from Redbridge CCG; contracting representatives from NEL CSU; head of maternity commissioning for north east London (seven CCG areas)

Regular meetings and communication with the consultant obstetric lead, heads of midwifery, midwifery leads and managerial and strategic leads at Barts Health

Briefed ‘Incentives and Levers Working Group’ within National Maternity Review

Email communication with ‘Model of Care Group’ within National Maternity Review

Discussion with executive leads from all seven CCG areas, and medical directors and executive leads from provider organisations in the area, via North East London Advisory Group (NELAG)

Email exchange with Tower Hamlets volunteer home birth advocate and service user

Meeting held arranged with clinical lead directors for maternity across north east London CCGs to discuss impact of potential TST initiatives on primary care role

Site-specific meetings with work stream executive and director, lead consultant, head of midwifery and consultant midwives to discuss and agree OoOU birth aspirations.

Workshops: Five focused workshops (January to September 2015):

1. Developing the maternity and newborn care strategy (27 February)

2. Maternity and neonatal care workshop (17 April)

3. New model for transitional care workshop (12 May)

4. Maternity and newborn care stakeholder workshop (3 June)

5. Joint TST and Barts Health workshop (5 August) on internal efficiency.

Invitees included commissioners and GP maternity leads from Newham, Tower Hamlets, Waltham Forest and Redbridge; consultant obstetricians, heads of midwifery, other midwifery leads, superintendent sonographer, neonatology clinical director, consultant gynaecologist, primary care lead from Barts Health NHS Trust; consultant obstetrician, head of midwifery, consultant neonatologist and other midwifery leads from Homerton hospital; manager for London Neonatal Network (UCLP); interim chief nurse Barking, Havering and Redbridge University Hospital; maternity quality lead for Barking, Havering and Redbridge CCGs; professor of community and family health at UEL, public health advisor, NHS England lead for neonatal care, plus a service user. Pregnant women and new mothers from Newham, Tower Hamlets, Waltham Forest, Redbridge, Barking and Dagenham, City and Hackney invited via Maternity Services Liaison Committee and Healthwatch (13 attended the workshop held on 3 June 2015).

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7.5 Benefits the change will achieve

The high-level impacts of this initiative are:

1. Greater numbers of women will be supported to give birth outside the obstetric unit supporting choice and creating a more sustainable maternity system in the future.

Over the next five years, Barts Health will enable an increase the proportion of births taking place in midwife-led units from 13% to 31% and the number of homebirths from 0.6% to 5%.120

Barts Health Baseline Y5 2020/21 Change

BH total births forecast 17301 18561 1,260

(7.2%)

Obstetric Unit (OU) 14,935

(86%)

11,879

(64%)

3056

(24%)

Midwifery-led unit (MLU)

2,251

(13%)

5754

(31%)

3,503

(18%)

Home birth (HB) 111

(0.6%)

928

(5%)

817

(4.4%)

Site-specific aspirations

Throughout August, September and October 2015, each site agreed their own shift aspirations based on the Birthplace study, birthrate plus audit and the working knowledge of each site’s clinical experts.

Whipps Cross Hospital (WXH): Aim is for OU = 65%; MLU = 27%; HB = 7%

Baseline Y1 16/17 Y3 18/19 Y5 20/21 Change

Births Forecast

4979 5025 5064 5091 112

OU 4680 (94%) 4125 (82%) 3644 (73%) 3301 (65%) 1379

MLU 249 (5%) 800 (16%) 1200 (24%) 1422 (28%) 1173

HB 50 (1%) 100 (2%) 200 (4%) 355 (7%) 305

120 When determining the impact of improving the model of maternity care on shifting Intrapartum activity out of the obstetric units, the activity baseline was 2013/14 SLAM data. This was widely considered to be the most validated data available since the merger of the three trusts in 2013. In addition there was use of the site-specific aspirations in relation to the numbers of women giving birth in Obstetric Units (OU’s), midwifery-led settings such as birth centres and alongside-midwifery units, and at home. This led to Barts Health agreeing that it is clinically appropriate to aim for 64% of births to be within OUs, 31% in MLU settings and 5% in women’s homes.

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Royal London Hospital: Aims is for OU = 70%; MLU = 27%; HB = 3%

Baseline Y1 16/17 Y3 18/19 Y5 20/21 Change

Births Forecast

5477 5737 6045 6328 851

OU 4847 (88.5%) 4474 (78%) 4412 (73%) 4430 (70%) 417

MLU 602 (11%) 1202 (21%) 1516 (25%) 1709 (27%) 1107

HB 27 (0.5%) 57 (1%) 114 (2%) 190 (3%) 163

Newham: OU = 60% MLU = 37% HB = 3%

Baseline Y1 16/17 Y3 18/19 Y5 20/21 Change

Births Forecast

6845 7016 7120 7155 310

OU 5408 (79%) 5246 (75%) 4978 (70%) 4293 (60%) 1115

MLU 1403 (20.5%) 1700 (24%) 2000 (28%) 2647 (37%) 1244

HB 34 (0.5%) 70 (1%) 142 (2%) 215 (3%) 181

2: All women will have access to a model of midwifery care that enables them to experience continuity of care from a named midwife.

The seven core principles of this approach have been agreed by clinicians and leaders at Barts Health.

a. Women should be at the centre of the organisation of care b. Women should be seen close to home/ in the community unless there is a clinical

reason to bring them into hospital c. All women should have access to the same care pathways wherever and however they

intend to give birth and whoever their carer’s are (equity of offer and experience) d. Women should have continuity of care from 2/3 midwives across the antenatal and

postnatal period who work within a team that includes booking e. Women should have continuity of care from her team in the intrapartum period f. The default offer should be out of labour ward births unless clinical reason for

planned birth in an obstetric unit. g. Staff should be enabled to self- manage their workload, feel valued, supported and

well trained to carry out their job.

There is agreement that this approach will support equity of offer and support women’s choices, including around place of birth. In turn it is anticipated that this will improve efficient use of resources in many ways including, better throughput through decreased length of stay, decreased use of equipment and better use of staff. This should then support sustainability within the services in the face of the anticipated increased demand.

3: As more women are supported to give birth across a variety of settings, fewer medical interventions such as Caesarean section will be required.

Evidence nationally3 and locally from Newham strongly suggests that the intended place of birth has significant impact on her mode of birth, with midwifery-led births demonstrating

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lower rates of instrumental birth and caesarean sections for women. In turn this supports quicker recovery times and reduced likelihood of complications for women, with increases in workforce and estate capacity across all settings.

Other work in progress supports this aim, such as outpatient induction of labour (IOL) protocols. (See the figure below). Supporting the sustainability of this work will be critical to prevent slippage such as seen recently in the unexplained rise in caesarean section rates across all sites.

The aim is to reduce the caesarean section rate by approximately 5% by the end of 2021, from the current trust-wide 28% to 23%. This is in line with the best performing acute trust in London.

7.6 Investment costs In order to implement the model of investments will include capital requirements, workforce investment, project implementation costs, organisational development (OD) costs and investments in IT. Further narrative of the workforce and estate investment required is provided below.

2016/17 2017/18 2018/19 2019/20 2020/21 Total

Capital (estates/ IT/ equipment etc)

£0.01m £0.01m £0.01m £0.01m £0.01m £0.05m

Maternity workforce Project implementation costs

£1.86m £2.32m £2.73m £3.04m £3.4m £13.38m

OD costs £0.2m £0.17m £0.07m £0.43m

Informatics £0.2m £0.2m

Newham have reduced caesarean section rates from 33% in 2011 to 27% in 2013. This takes them from the highest rates in East London to among the lowest in just two years.

Normal births have been championed by midwives and obstetricians and began with a multi-professional review of benchmarked data. The DH toolkit helped identify three pathway opportunities to promote vaginal births amongst: first time mothers; women who had previously had a caesarean section birth; and women having induced births.

Training and education and the promotion of a learning culture with monthly audits and reviews has supported consistent, evidence based care. The introduction of a 10 bed alongside midwifery-led unit (AMU) in 2012 and newer technology, such as wireless fetal monitors, has led to improved patient satisfaction, lower intervention rates and lower caesarean section rates.

PROMOTING NATURAL BIRTHS AT NEWHAM HOSPITAL

Improvements in increasing rates of normal deliveries at Newham Hospital

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7.7 Workforce In order for this change programme to be a success, it will need to be supported by a sustainable and highly skilled workforce. Engagement across Barts Health has highlighted the varying approaches to workforce planning, influenced by differing resources and recruitment processes. This variation will directly affect the trust’s ability to provide a universal model of maternity care.

Many improvements in approach have already been made, including a reduction in both vacancy rates and agency spend in relation to midwifery staffing. This is commendable but needs to be complemented by the development and implementation of a strategic trust-wide approach to maternity and newborn care workforce. This will ensure sustainability in meeting future demand for care safely, and address the current concerns raised by the CQC.

In assessing the impact of increased birth numbers on workforce, there has been use of the midwife:birth ratios agreed at each site, as well as the strategic aims of the trust in respect to hours of obstetric consultants on-call. There is a recognition of the important role midwifery care assistants play in the provision of high quality maternity care and this will be developed in future planning.

Consultant obstetricians

Following discussions with the lead obstetrician at Barts it has been concluded that it is reasonable to aspire to 98 hours of consultant cover per week in line with acute trusts across London. This will require a further 6.5 Full Time Equivalent (FTE) obstetric consultants across three sites, as described in the table below. This increase also enable the safe and effective management of the increasing demand expected in antenatal and postnatal clinics over the next five years.

Site FTE obs/gyn

consultants in post 15/16

Obstetric cover (hrs)

15/16

FTE obs/gyn consultants

required

New obstetric FTE

total

Obstetric cover (hrs)

20/21

Barts Health total 40.5 82 7.5 48 98

Whipps Cross 13 80 3 16 98

RLH 12.5 84 3.5 16 98

Newham 15 94 1 16 98

Midwifery workforce

The recent CQC inspections of the service identified concerns regarding staffing on each site and led to Barts Health developing an internal ‘safer staffing’ initiative. This included a review of midwife to birth ratios, which were discussed and agreed with local commissioners and members of each midwifery service liaison committee. The agreed ratios were informed

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by the findings in the Barts Health Birthrate Plus report121 which included acknowledgement of the increased post-natal activity for out of area births at both the Whipps Cross and Newham sites.

The tables below indicate the numbers of midwives each site will need to recruit to meet the safer staffing midwife: birth ratios they have agreed, based on the numbers of births forecast for each year over the next five years.

However, in order to meet the agreed ratios based on the forecasted birth activity for 2015/16, Barts needs to recruit 63 FTE midwives by March 2015/16 which will be before the implementation phase of the OoOU initiative has commenced. It is understood that this funding has been agreed.

From April 2016 onwards, a further 43 FTE midwives will be required to maintain safe staffing levels in relation to the safe staffing ratios agreed phased over the 2016 to 2021. This will require investment in maternity workforce of £11,834,742 (see part 3, section 7.6).

121 Barts Health NHS (2014) Birthrate Plus report.

23

1 1 1 0 1

29

26 26 26 26 26

0

20

40

60

80

100

120

24

25

26

27

28

29

30

Yr 0 15/16 Yr 1 16/17 Yr 2 17/18 Yr 3 18/19 Yr 4 19/20 Yr 5 20/21

FTE midwives required to meet safe staffing ratio Whipps Cross 1:26

Recruitment needed to meet safe midwife staffing levels (right axis)

Births/target midwife ratio (left axis)

Births/actual midwife ratio (left axis)

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Once the required resource has been agreed, the challenges of future recruitment and strategies for sustaining the workforce in safe numbers will reduce if Barts Health moves to capitalise on the predicted over-supply of newly qualified midwives by attracting and supporting staff to work in the East London area. However, this is only if the right conditions can be created to attract new staff to the area and retain those that are already employed. Part of the organisational development resource will be used specifically to engage with midwives, to understand how the model of care can be changed whilst ensuring work-life balance is maintained, if not improved.

166 7 5 5 5

29.3

28.3 28.1 28.0 28.0 28.0

0

20

40

60

80

100

120

25.0

26.0

27.0

28.0

29.0

30.0

31.0

32.0

Yr 0 15/16 Yr 1 16/17 Yr 2 17/18 Yr 3 18/19 Yr 4 19/20 Yr 5 20/21

FTE midwives required to meet safe staffing ratio RLH 1:28

Recruitment needed to meet safe midwife staffing levels (right axis)

Births/target midwife ratio (left axis)

Births/actual midwife ratio (left axis)

24

71 1 1 1

28

2626 26 26 26

0

20

40

60

80

100

120

24

25

26

27

28

29

30

Yr 0 15/16 Yr 1 16/17 Yr 2 17/18 Yr 3 18/19 Yr 4 19/20 Yr 5 20/21

FTE midwives required to meet safe staffing ratioNewham 1:26

Recruitment needed to meet safe midwife staffing levels (right axis)

Births/target midwife ratio (left axis)

Births/actual midwife ratio (left axis)

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Other maternity workforce requirements

As the CQC also identified data quality as an area of concern for Barts Health, resource for three FTE information technology specialist midwives has been included in the costs to deliver the changes described in this document. This is to support improvements in data entry and reporting by ensuring all maternity staff enter data consistently, and maternity information and communications technology requirements are given the necessary priority in the organisation.

Further exploration into how the role of midwifery care assistants (MCAs) will support the implementation of midwifery continuity of care is also required. Both the number of FTE MCAs and future development of the role will need to be considered as the improved model of maternity care is operationalised. Nationally, it is recommended that the number of FTE MCAs required to deliver high quality maternity care is 10% of the midwifery establishment. It has been highlighted that at one Barts site the FTE of MCAs is as high as 30% of the midwifery total and therefore more work is required to understand this variation.

7.8 Estates The capital resource of £218,222 is allocated to the estate requirements explained below. This currently excludes the costs of the new Royal London Hospital alongside midwifery unit (AMU) being refurbished and open by 1 April 2016. If this position changes, the costs associated with developing this unit will need to be factored into the TST 2016/17 year-end financial position.

Whipps Cross

Neither the obstetric unit nor the AMU is currently fit for purpose and this will affect the choices women make about where they wish to deliver their babies. Whilst discussions around the future of the Whipps Cross site development are in progress, it has been recognised that resource is urgently required to ensure that the ambitions of increasing the number of babies born in the AMU are realised. This includes ensuites for all obstetric delivery rooms, the addition of birthing pools in the AMU rooms that are already in use, and the refurbishment of a further two rooms to give the unit the extra capacity it needs to meet future AMU demand. Resource for converting any OU capacity that might be released is not yet available.

Royal London

The capital costs for the development of the AMU at the Royal London Hospital have not been included in these figures as the project started before TST. Should this not form part of Barts Health’s capital plans for 15/16, this figure will then need to be included in the investment costs shown in part 3, section 6. A high level estimate for capital costs is £6 million.

Resource has been included for the addition of equipment at the Barkantine to ensure the birthing pools are fit for purpose.

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Newham

Whilst capacity will be released in the OU, the costs associated with converting this for AMU use is not available.

7.9 Impact on activity and finance: Increasing births outside obstetric unit

Impact on activity

The increase in the number of births being supported outside of obstetric units through the provision of continuity of care creates a more sustainable and efficient maternity system for the future. The ambitions in relation to the shift of activity out of obstetric-led units that have been agreed across settings are set out in part 3, section 7.5. The three tables below articulate the phasing of these shifts across all care settings and the impact of the shifting activity on capacity. Narrative regarding the impact on each setting is provided below.

Obstetric units

The graph shows that over the next five years, intrapartum demand in the obstetric units will move from the current over-capacity (835 births) in 2015/16, to one where demand on the units will be reduced by 2,281 births by 20/21. Some of this capacity released will need to be converted for midwifery-led care, particularly for Newham.

Impact of increasing the number births outside of obstetric units on Barts Health capacity over the next five years

*The capacity of all birth settings have been agreed by BH clinical leads from each site

The reduction in obstetric unit activity will also lead to a reduction in maternity length of stay as there will also be a reduction in both Caesarean-sections and admissions to postnatal wards on acute site. This should create an opportunity for Barts Health to shift some workforce resource currently required to staff obstetric unit demand to other maternity care settings. The rate at which this could be achieved is not yet known.

Phasing/impact of increasing births OoOU on BH obstetric units

BHT OU

Capacity

14,100

15/16 20/21 18/19 16/17 17/18 19/20

14,935

12,654

Birt

h ac

tivity

BH

T 20

14/1

5

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Midwifery-led units (includes birth centres and alongside midwifery units)

Prior to agreeing the ambitions of increasing the number of births outside the obstetric units, it was discussed and agreed to treat capacity of both the alongside midwifery units and the two freestanding birth centres (otherwise known as Freestanding Midwifery-led Units) as one entity. This is in line with recent evidence that suggests the risk profiles of the two cohorts of women who are likely to use these settings are very similar, with a different criteria now set for home births based on the emerging evidence of the birthplace study.

The table below shows the phasing of the increase in births across midwifery-led units, and when they will reach their capacity.

MLU site

Capacity 15/16 (births

p.a.)

No. of MLU births 14/15

(% of all births at each site)

Projected increase of MLU births

Y1

Projected increase of MLU births

Y3

Projected increase of MLU births

Y5

WXH 1000 249 (5%) 800(16%) 1200 (24%) 1422 (28%) **

RLH* 2100 602 (11%) 1202 (21%) 1516 (25%) 1709 (27%)

NUH 2000 1403 (20.5%) 1700 (24%) 2000 (28%) 2647 (37%) *The RLH MLU capacity relies on the new AMU being open in April 2016. **Provided the resource in both workforce and estates are agreed to ensure two birth suites on AMU can be opened by Y3, WXH AMU will not reach capacity until Y5. This assumes further two birth suites increase capacity of the unit to approximately 1400 births p.a. Further analysis to inform future demand and capacity modelling will be taken forward through the North East London Maternity Network (NELM).

With the exception of the Newham midwifery-led settings, all other sites have the physical capacity to absorb the expected shifts in activity from the obstetric unit provided estates and workforce investment is agreed. Newham will need capacity for 647 more births by 2020/21, which could be sourced from the capacity released in the obstetric units over time.

Home birthing team capacity

The capacity of the home birth offer for each site depends on the number of personnel in each team, how they are organised, and whether they are included in the on-call escalation policy for each obstetric unit. The table below describes the capacity of the teams currently, and how these need to grow to ensure the ambitions for increasing the home birth offer to women can be achieved.

Current capacity and HB activity Future home birth aspirations and team growth

Site Capacity

15/16

FTE

15/16

Activity

Y0

Y1

16/17

Capacity

Team size FTE

Y1

Y3

18/19

Team size FTE Y3

Y5

20/21

Team size FTE Y5

WXH 100 4 50 100 4 200 12 355 20

NUH 120 4 34 70 4 142 5 215 7

RLH ?* ?* 27 57 2 114 4 190 8

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*RLH does not have a separate home birth team however may develop this in the future to achieve its ambition of 3% home births in TH.

There are currently eight FTE midwives working in home birth teams across Newham and WXH. Over the next five years, the midwifery workforce will need to be supported to increase to 35 FTEs to achieve the ambition of 5% home births across the Barts Health footprint, based on the current capacity calculations.

Summary: Impact of activity shifts across all sites and settings.

Whipps Cross

Capacity p.a

Activity14/15 Y1 16/17 Y3 18/19 Y5 20/21

Births Forecast 4979 5025 5064 5091

OU 4000 4680 (94%) 4125 (82%) 3646 (72%) 3301 (65%)

MLU 1000 249 (5%) 800 (16%) 1215 (24%) 1422 (28%) (max capacity)

HB 100 50 (1%) 100 (2%) 203 (4%) 355 (7%)

Newham

Capacity p.a

Activity14/15 Y1 16/17 Y3 18/19 Y5 20/21

Births Forecast 6845 7016 7120 7155

OU 5100 5408 (79%) 5246 (75%) 4978 (70%) 4293 (60%)

MLU 2000 1403 (20.5%) 1700 (24%) 2000 (max capacity) (28%) 2647 (37%)

HB 120 34 (0.5%) 70 (1%) 142 (2%) 215 (3%)

Royal London Hospital

Capacity p.a Activity14/15 Y1 16/17 Y3 18/19 Y5 20/21

Births Forecast

5477 5737 6045 6328

OU 5000 4847 (88.5%) 4474 (78%) 4412 (73%) 4430 (70%)

MLU 2100 602 (11%) 1202 (21%) 1516 (25%) 1709 (27%)

HB n.a* 27 (0.5%) 57 (1%) 114 (2%) 190 (3%)

*RLH does not have a separate home birth team however may develop this in the future to achieve its ambition.

Impact on finance and sensitivity analysis

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After conducting financial impact analysis, we undertook sensitivity analysis which suggests a net cost of between £13.7m to £14.1m over a five year period.

Whilst there are some savings in relation to the shift in activity from acute obstetric units to midwifery led settings (approximately £55k - £61k over 5 years), this is negated by the investment required to transform the current model of care being provided to ensure choice in birthplace is fully implemented and staff have the right support in place to work very differently.

Although this scheme results in an increase in costs, this changes proposed are beneficial to the system as a whole. It will ensure more births take place in non-obstetric settings, allowing forecast demand to be absorbed safely and without the need for increasing capacity in obstetric-led units in the future.

7.10 System commercial considerations and transitional support required

Issues around the provision of maternity care in relation to both quality and demand for services are shared by all providers in the wider north east London health economy. The anticipated increase in demand for maternity care is expected to be across the whole of the north east London health economy not simply Barts Health.

This strategy does not diminish the importance of continuing to review and manage demand for services across this wider footprint. This approach must work with the known interdependencies between Trusts to implement solutions that offer mutual support and efficiency across north east London as a whole.

This work will be continued via the clinical senate and maternity network and will require continued engagement by CCGs and providers in a collaborative fashion.

The roles of the North East London Maternity Network (NELMN) and Head of Maternity Commissioning for north east London will be integral to ensuring that there is coherence across the region’s workstreams, allowing Transforming Services Together to continue to align with the ambitions of all north east London providers, as well as the strategic direction of the Pan London Maternity clinical network.

One important example of the need for inter-related thinking is in demand and capacity management. All providers have limited capacity to provide care for women and therefore managing excess demand needs to be a system wide concern.

Any large-scale change to service provision and capital development will need to adhere to NHS procurement guidelines.

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7.11 Delivery risks

The risks described below are associated with the practical delivery of changes to the current provision of maternity care.

Description of risk Likeli-hood

Impact Rating Mitigation

1

Reliable, validated maternity data set across all Barts sites continues to be unavailable due to BH Cerner system configuration and knowledge of users. Lack of reliable data is likely to inhibit accurate measurement of progress against predicted activity shifts for OoOU initiative

3 4 12

Perinatal Network to include informatics within membership, highlighting clear lines of accountability for mitigating risk in relation to ICT

Resource in IT specialist midwives to increase to ensure all staff are supported to use CRS appropriately

2

There is a risk BH will not agree to resource the increase in FTE midwifery staff to meet safer staffing initiative midwife:birth ratios agreed at all BH sites

3 3 9

Project manager to discuss gap in midwifery FTE with programme director for the Maternity work stream and agree process for raising this through new Barts TST governance arrangements

3

There is inconsistency in project management resource across BH sites to ensure effective implementation and delivery of strategic vision for maternity and newborn care. This will impact negatively on the shift of births OoOU

3 3 9

Project management resource for each Barts site requested to support Perinatal Network and clinical leads at each site throughout implementation

4

There is a risk that midwives in Barts may not wish to be on-call for OoOU births. This may restrict the deliverable options of midwifery continuity of care models in the future

3 3 9

Organisational development resource requested to ensure the right level of engagement in development of midwifery continuity of care model to mitigate this risk

Site specific clinical leads identified to ensure messaging around development of midwifery model of care is consistent and effective in

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operationalising continuity of care across all settings.

5

Queens Hospital continues to cap number out of area antenatal bookings. This may increase the number of women booking at BH or Homerton sites which will affect capacity planning in TST strategy

3 3 9

Head of north east London maternity commissioning has raised risk at NEL clinical senate in November and to raise at first meeting of the North East London Maternity Network (NELM) in Jan 2016.

6

The AMU at the RLH and the redevelopment of the new AMU at Whipps Cross (WX) in the Barts strategy have been repeatedly deprioritised. If they are not realised the ambitions for increasing OoOU births will not be realised

3 4 12

Project manager to discuss process for ensuring AMU at RLH remains on track to open April 2016 through BH women and children’s Clinical Academic Group (CAG) with maternity programme director. TST steering group to acknowledge risk of not making WX site fit for purpose in relation to birthing pools at AMU and ensuites in OU rooms.

7

Maternity leadership within BHT has not yet agreed universal standards for continuity of care or commenced staff engagement continuity of care models. This places the timescale for submitting business case for model of care by end of March at significant risk.

3 4 12

Risk has been raised with Work stream executive. Telecall to be arranged with maternity programme director to discuss potential mitigations.

7.12 Next steps In order to take this work forward we want to rapidly build on the strong level of engagement with the lead clinicians at each site to progress this work in the following ways:

Phase Outline Timescale

Development and validation of midwifery continuity of care model (MCOC)

Work with clinical leads to engage with all maternity staff at each site to ensure model develops with their expertise and opinions

Dec 2015- January 2016

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Identification of project delivery leads at each site and associated governance and reporting mechanisms

Work with TST maternity clinical leads to prioritise work plan to ensure streamlined delivery of TST objectives and minimise duplication across sites

Jan 2016

Understand impact of developing new model of transitional care

Support clinical leads to identify benefits of developing a dedicated transitional care ward in terms of reducing inpatient length of stay on maternity units and reduction in demand for special care

Dec 2015 – Jan 2016

Public engagement

Work with TST Patient and Public Reference Group (PPRG) and Healthwatch to develop proposals in line with any patient concerns

Jan 2016

Implementing the improved model of care

Using agreed model working with clinical leads at each site to understand impact of new model on existing midwifery workforce. Identify potential staff consultation requirements

Feb 2016 (ongoing)

Development of maternity networks in primary care

Working with maternity leads identify resource for developing self-sustainable maternity networks for each borough to support shift in culture to one that values normality

Feb 2016

Business case for refurbishment of WXH maternity settings

Detailed capacity and demand analysis – to inform capital expenditure on necessary estates changes

March 2016

Business case for increased FTE maternity staff to meet safe staffing requirements

Detailed workforce modelling to be undertaken to understand FTE required at each site and birth setting and phasing at which this needs to occur

March 2016

7.13 Governance arrangements

Throughout Winter 2015/16, BH will be establishing a new governance structure to take forward the clinical strategy at each site (see figure below). The trust’s maternity and newborn care leaders have identified there is a need to develop a culture that is strongly committed to providing normality for all women, across all sites and professions, as well as within the communities they support. It is also the understanding that these key themes within the BH strategy will be further supported by the recommendations from the National Maternity Review being led by NHS England, due for publication in December 2015.

To ensure the organisation develops in line with its strategic aspirations with regards to the out-of-obstetric unit birth initiative and its quality improvement plans, the Perinatal Network will oversee the delivery of this ambitious change programme. Members of this network and associated site-based working groups will need to be supported to develop both the

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implementation and delivery plans set out in this document via ongoing support from the relevant CCGs and TST programme team over the next five years. Barts Health TST governance structure for delivery of maternity and newborn care initiatives

The first meeting of the Perinatal Network was held on 30 October 2015, where its roles and responsibilities and those of its members were discussed and agreed. It will be a key role of the Barts Health Perinatal Network Board to define further the universal Midwifery Continuity of Care model (MCOC) throughout Winter 2015/16. This will require strong engagement with the midwives at each site who need to recognise the importance of providing an equitable model of maternity care across Barts Health sites, and therefore they may be required to work in different ways to ensure full implementation.

Perinatal Network Board

Women’s & Children’s Health CAG Board

Clinical & Academic Strategy Board

TST Steering Group

Barts Health NHS

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8: Transform the patient pathway and outpatients

8.1 The case for change In 2014/15 hospitals provided 1,406,000 outpatient appointments to East London residents. By 2020/21, if we do nothing, this figure is likely to grow to 1,547,000 due to population growth.

Each appointment represents a patient journey from home to hospital and back again. In many cases this can mean time off work our out of education and training. Standard consultations are short; follow up appointments – not always with the same healthcare professional – are booked far in advance and are not necessarily in sync with developments in the patient’s condition. In addition, patients that need urgent specialist advice are not always able to access it as quickly as they would like. As part of our engagement, many clinicians have told us that outpatient care could be delivered much more effectively.

The Transforming Services Changing Lives (TSCL) Case for Change identified seven key areas for improvement to pathways across primary, community and acute care:

1. We need to focus more on early identification and prevention

For example, in over 90% of cases, the risk of having a first heart attack is related to modifiable risk factors including smoking, insufficient physical activity and obesity. Addressing diet, physical inactivity and smoking to reduce cardiovascular disease also helps to reduce the risk of other chronic conditions, such as type 2 diabetes, liver disease and some types of cancer. Public Health data estimates that 72,310 people in East London are have pre-diabetes, some of the highest levels in the country122. Gaps between expected prevalence rates and those diagnosed need to close so that patients on primary care disease registers can receive the support they need to manage and stay in control of their conditions.

2. A significant number of referrals to secondary care could be managed in a

more effective way

Discussions with specialists have suggested that up to 20% of new patients attending orthopaedic outpatient clinics are discharged after the first appointment with no follow up being required. This indicates that some patients may be better managed by primary and community care services. Quick access to immediate specialist advice for GPs via the telephone has been shown to avoid significant numbers of inappropriate referrals and admissions: a 2012 pilot in Bristol found that referral or admission to hospital could be avoided in 56% of cases123.

3. The referral to treatment process, including diagnostics, could be more

streamlined

The TSCL Case for Change identified that some people wait a long time for their appointments and that some patients have to attend multiple visits before a diagnosis is

122 Public Health England (2015) ‘Fingertips Public Health Profiles) available at http://fingertips.phe.org.uk/ 123 www.pcc-cic.org.uk/article/gps%E2%80%99-hotline-consultants-helps-cut-referrals-and-admissions

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made and treatment begins. Barts Health is currently not meeting 18 week referral-to-treatment (RTT) targets across a number of specialties.

4. Models of outpatient care for follow up can be ineffective

Patient engagement during the development of the Case for Change highlighted people’s frustration at the need to travel and take time away from work for simple and quick outpatient follow-up appointments. In addition, clinicians have expressed concern that standard 10-minute follow up appointments do not always add value.

5. Patients can’t always access specialist advice when they most need it

In some cases the only option for patients suffering an exacerbation of an existing long-term condition or experiencing new symptoms is to attend emergency departments. This can result in avoidable admissions to a hospital bed as this is the default way in which immediate access to specialist opinion is provided in the current system.

6. We don’t always support patients to understand and manage their condition

There is large variation in hospitalisation for people with ambulatory care-sensitive conditions. These are conditions such as diabetes, asthma or congestive heart failure where better management or earlier treatment could prevent admission to hospital.

7. A large number of patients do not attend outpatient appointments

Health services should make it easier for patients to attend appointments when they need to happen. Current ‘did not attend’ (DNA) rates reach 20% in some specialties. Sometimes this happens because patients find it difficult to attend or let staff know that appointments need to be re-arranged. Tackling this problem is important because for every patient who doesn’t attend, another then has to wait longer to get the care they need.

In summary, the message from local clinicians is clear: we need to redesign pathways and be much more ambitious in our future vision of outpatient care.

8.2 Model of care This transformational scheme will build upon existing improvement work and by 2020/21 reduce outpatient appointments by 20% across all pathways so that local providers can meet demand expected due to population growth, whilst improving patient experience and reducing waiting times.

This change will be achieved through two overarching strands of work:

(i) Transforming long term conditions (LTC) pathways: projects that will improve high volume LTC pathways in line with our integrated care vision

(ii) Transforming planned care pathways: projects that will transform high volume planned care pathways such as Musculo-Skeletal and dermatology services.

As highlighted by the diagram below a 10% reduction will come from reducing unnecessary referrals to hospital, whilst a 10% reduction will come through face-to-face appointments being provided in innovative new ways.

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Planned reduction in outpatient activity

The diagram below summarises the changes we are proposing. Clinicians from primary, community and acute services have been involved in determining the approach. Alongside patients, clinical leadership will continue to be integral to the design and development of the new processes and pathways.

Pathway transformation initiatives

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1. We will build prevention and early intervention into each redesign project

In redesigning all high volume specialities, we will:

Learn from and develop the local ‘Making Every Contact Counts124’ strategy with input from public health staff so that we make use of the opportunities arising from everyday contact in each pathway so all clinicians can promote healthy living.

In redesigning long term conditions pathways, we will:

Work with public health to support programmes that prevent or delay the development of cardiovascular disease, respiratory disease and type 2 diabetes, identifying regional programmes that can reduce risk factors.

Making Every Contact Count is a national vision that we will build on with the support of local public health teams. The NHS Future Forum (2012)125 recommended that every health care organisation should implement it and build on the role that the NHS has in health promotion. Every day GPs and practice nurses across the UK see over 800,000 people and therefore have an opportunity to influence healthy living and encourage people to modify their behaviour.

An example of the way we intend to improve prevention is the way in which public health and CCG leads across East London are working together to develop a local approach to the National Diabetes Prevention Programme. This programme offers behavioural support for people with non-diabetic hyperglycaemia, who are at high risk of developing type 2 diabetes. International evidence indicates that a 58% reduction in the risk of developing diabetes can be achieved through this type of intervention126.

To achieve these changes we will need to:

work with public health to develop targeted local prevention strategies for high impact pathways

engage and work with primary and community care providers through new provider models to strengthen preventative care and support.

2. We will increase the quality of referrals and improve access to specialist advice

Providing improved access to specialist advice is important because the clinicians we have spoken to say that primary care teams do not have the support they need from the wider health care system to coordinate care for people with long term conditions. This is backed up by national evidence, with a key Kings Fund paper on referral management recommending the development of opportunities for informal advice from specialists127. Interventions such as these have been shown to work nationally. For example, Imperial College’s Connecting Care for Children (CC4C) email advice evaluation showed that half of queries resulted in advice that enabled GPs to continue patient care and avoid referral; 82% of GPs using the system agreed that it had reduced referrals

124 Making Every Contact Count: (2012), further detail available at http://www.makingeverycontactcount.co.uk/ and https://www.england.nhs.uk/wp-content/uploads/2014/06/mecc-guid-booklet.pdf 125 NHS Future Forum (2012) ‘The NHS’ role in the public’s health: A report from the NHS future forum 126 US Diabetes Prevention Program www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp/Pages/default.aspx

127 The Kings Fund (2010) Referral Management

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Within the East London region, current provision of specialist advice to GPs is variable both by region and specialty. By standardising these services, we are likely to achieve reductions in referrals for high volume conditions. This standardisation should consider implementing single points of access for both phone and email advice which can transfer enquiries to the relevant specialty.

In some cases, telemedicine can be used to support the provision of specialist advice. Telemedicine for in Tower Hamlets is helping us understand how we can improve care for patients. Early indications suggest allowing GPs to access specialist opinion in primary care settings more easily will enable new ways of working. In Scotland, an ophthalmic triage system with digital imaging of the eye led to a reduction of 14% in new referrals.

In addition to providing specialist advice, referral guidelines and processes will be standardised across the region to simplify the system. These referral guidelines will also clarify the diagnostic tests that should be carried out before the first appointment. This will ensure that outpatient referrals add value and that consultants are able to make decisions about treatment sooner.

For appropriate high volume pathways, we will consider the creation of local centres of specialist expertise at primary care hubs to provide extended services to local populations. By creating local centres of expertise we will benefit from economies of scale allowing greater service provision in the community. For example, we will develop community centres of expertise for some MSK services to increase access to physiotherapy, psychological support and pain management in the community.

We plan to develop knowledge and capacity in primary care to enable the management of less complex, high volume conditions without the need for hospital outpatient appointments. This will improve patient experience and enable specialists to focus on more complex cases. Close working with primary care will be vital to rolling out these processes, as well as their involvement at redesign events.

In summary, across all high volume specialties, we will:

(i) provide access to specialist advice for GPs via telephone, email or telemedicine

(ii) agree standardised referral criteria across the region and implement triage rules to ensure adherence

(iii) increase efficiency by ensuring that electronic referral processes are built into the pathway

(iv) enable primary care hubs, through the support of specialists to manage simple conditions in the community. For example, this model will be appropriate for extended MSK and gynaecology services.

To achieve these changes we will need to:

deliver improvements to technology to enable new ways of working

define new referral pathways and strengthen links with community and primary care providers

develop new provider models to enable vertical integration and closer working between acute and community services

develop new payment systems that support organisations and teams to work together and create new clinical practices across boundaries.

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3. We will streamline the referral to treatment process

The referral to treatment process needs to be streamlined in order that waiting times are shorter, waste and duplication is reduced and patient experience of services improves.

Whilst much of this will focus on outpatient transformation work at Barts Health, primary care will also be empowered to care for more patients without the need for a referral through providing quicker access to direct diagnostics (a referral in which GPs only refer to Barts Health diagnostic services and receive the result directly). We will also develop straight-to-test pathways that will allow primary and community practitioners to request tests prior to the first patient appointment with a specialist. This reduces the time patients need to wait for diagnosis and treatment and ensures that the appointment with the specialist is used most effectively.

In some circumstances, we may increase the equipment available in community settings. For example, chronic obstructive pulmonary disease diagnosis requires spirometry assessment, but not all primary care practices have access to the equipment and expertise to take these measurements. Ensuring that future primary care hubs have access to this kind of equipment could reduce unnecessary referrals.

The Barts Health outpatient transformation programme has already achieved a reduction in the time from referral to diagnosis through the implementation of lean principles (a system for service improvement centred on value for patients) and the development of one-stop clinics. For example, a one-stop clinic was established at Barts Health for rheumatology that reduced waiting time from referral to treatment to two weeks. This programme will be accelerated with a focus on high volume specialties where the greatest need to reduce waiting times has been identified.

We will also reduce the number of appointments required before treatment through a cross-cutting programme to reduce multiple pre-operative visits and consider alternative models (such as telephone or internet-based appointment) for these assessments. We are continuing to develop these pathways in collaboration with the TST surgery workstream (see part 3, section 5).

High patient DNA rates need to also be addressed. Musculoskeletal, ophthalmology and cardiology specialties have DNA rates above 20%, as well as provider cancellation rates of 10-15%. A clear improvement strategy will be implemented as this level of DNAs generates inefficiencies in the appointment booking process and leads to unused capacity.

In summary, we will:

develop direct access to diagnostics and straight-to-test pathways ensuring that best practice protocols are built into these pathways to prevent unnecessary testing

expand the Barts Health outpatient transformation programme to reduce unnecessary delays in referral to treatment time

work with the surgery workstream to streamline pre-operative processes. We will seek to incentivise best practice pre-operative assessment through our contracts.

identify and address causes of patient ‘did not attends’ (DNAs) and provider cancellations to increase the proportion of appointments attended and increase ‘right first time’ booking. Technological solutions which allow patients to book and reschedule online should be considered as part of this improvement work.

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4. We will implement new models of care for outpatient follow up

New models of outpatient follow up are required in order to avoid unnecessary trips to hospital and back and improve patient experience of care. Telephone and Skype clinics for conditions such as diabetes have already been trialled in East London, have meant more effective use of clinical time and resulted in good patient feedback. The use of these types of clinics will be expanded to provide more convenient options for patients. Further work will take place to develop payment systems that adequately compensate providers for offering these types of services as this is recognised as an important barrier to widespread adoption. We will utilise allied healthcare practitioners, including physiotherapists, optometrists and pharmacists, to support primary and community care in the treatment and follow-up of patients. In Waltham Forest, community optometrists already carry out long term monitoring of patients with glaucoma. The Royal College of Ophthalmologists indicates that there is also a role for community optometrists in post-operative follow-up of cataract surgery. We will consider opportunities for expanding the primary and community role in monitoring long term medication for patients with long term conditions. In Newham, community pharmacists run a service to monitor anti-coagulant drugs for patients with atrial fibrillation. This service has been running since 2010, and is soon to be extended to enable community initiation of this medication. East London medicines management teams are currently working together to set up a similar primary or community-led service to monitor disease-modifying anti-rheumatic drugs.

In summary, for all high volume specialties, we will:

implement alternative models of outpatient follow-up with appointments available via telephone and internet-based tools, such as Skype

where appropriate, consider alternative workforce groups and approaches that could support primary and community care to treat and follow-up patients.

For long term conditions redesign, we will:

identify long term medications that could be safely and effectively monitored in community or primary care settings to reduce the number of outpatient follow-up appointments that patients with long term conditions need to attend.

To achieve these changes we will need to:

deliver improvements to technology to enable new ways of working for example allowing patients to view their own records and booking or managing appointments

develop payment mechanisms to reward new clinical practice across boundaries.

5. We will better support patients to understand and manage their own conditions

In order to develop patients’ confidence to stay in control of their own long term conditions, staff need to be supported in offering behavioural change approaches that encourage self-care and self-management. For conditions such as diabetes, there are strong networks of specialists, GPs and other health professionals already in place who work together to share best practice and discuss the best approaches to patient management. Networks need to be developed in all high volume specialties over the coming years to facilitate communication and disseminate best practice, including via online portals.

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A 2014 review by Health Education North Central and East London identified several patient self-care support programmes including activities focused on asthma, COPD, diabetes, and pain management128. The recommendations from this review will be considered in the expansion and development of new local education programmes. A King’s Fund report on long term conditions and mental health also highlights the benefits of building psychological support into condition-based education programmes129. Co-morbid mental health problems raise total healthcare costs by at least 45% for each person with a long term condition and co-morbid mental health problem. Therefore, considering this element within the design of future programmes will realise benefits in financial sustainability as well as patient outcomes.

In the Case for Change, patients said that they would be happy to use technology to monitor their condition at home, as this is how many of them manage the rest of their lives. We will increase the use of home monitoring systems for long term conditions where possible, and support record sharing and patients uploading their own results to their health records (e.g. blood pressure monitoring).

Administrative processes also need to change to allow patients to have more control about when they access services, depending on exacerbations in their long term conditions. By supporting them to defer and rebook outpatient appointments that better suit their needs we are likely to reduce DNAs and provide patients with a better experience of care. A six year study by Bristol Royal Infirmary of patient initiated reviews for rheumatoid arthritis showed a reduction in unnecessary follow-up appointments and more efficient use of resources, while maintaining patients’ physical and psychological status130.

In summary for all high volume specialties we will:

develop clinical communities and networks to provide primary and secondary care professionals with more opportunities to share learning and improve patient care

For patients with long term conditions we will:

develop self-care education programmes that support patients to avoid the worsening of cardiovascular conditions, COPD and diabetes

when appropriate, use and develop tele-healthcare monitoring systems that input into shared care records to enable patients to monitor their condition

enable patients to initiate and defer follow-up appointments to reflect their needs.

To achieve these changes we will need to:

work with patients to design new ways of accessing healthcare that work better for them

deliver improvements to technology to enable new ways of working

develop payment systems that reward innovative clinical practice.

128 Supporting the Education and Empowerment of Patients and Carers. Health Education North Central and East London 2014. 129 Long-term conditions and mental health. The King’s Fund 2012. 130 Pope, D. et al (2005) Implementing a patient-led service for chronic conditions. Nursing Times; 101: 49, 28 - 31

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8.3 Engagement The following stakeholders have been engaged to inform this strategy:

Commissioning leads for Newham, Tower Hamlets and Waltham Forest

GP representatives for Newham, Tower Hamlets and Waltham Forest

Barts Health Primary Care Team

Clinical Director for Cancer Improvement, Barts Health NHS Trust

Medical Director, Whipps Cross Hospital

Barts Health Service Improvement Team

Barts Health general management: MSK, diabetes, renal

Public Health Directors at East London Local Authorities and Barts Health

TST Board

TST Clinical Reference Group

TST Workstream Executive

Regular contact and collaboration with key co-dependent TST workstreams

This strategy builds on the patient engagement that took place as part of Transforming Services Changing Lives131. In addition, our approach to pathway redesign will be further tested with the TST Public and Patient Reference Group and we are committed to patients being intrinsically involved in redesign events.

8.4 Outcomes the change will achieve Our proposed model of care is intended to achieve the following outcomes:

Outcome description Outcome by 2020/21 (Metric/impact)

20% Reduction in hospital based outpatient appointments against 2015/16 baseline (excluding population growth) made up of the below initiatives.

Absolute reduction in initial referrals to secondary care Shift to primary/community setting Replacement of physical appointments with Skype or

telephone clinics Absolute reduction in follow up appointments

5% each

Through this work we will release capacity which will contribute to compliance with national waiting time targets and help the East London health system better cope with growing demand.

131 Transforming Services Changing Lives (2014)

133

8.5 Investment costs To implement this change the following investments are required.

2016/17 2017/18 2018/19 2019/20 2020/21 Total

Capital costs (estates / equipment / IT infrastructure)

£0.1m £0.1m £0.1m £0.1m £0.1m £0.47m

Workforce £0.42m £0.32m £0.19m £0.13m £1.06m

Organisational development costs and project management costs

£0.4m £0.4m £0.8m

The table below identifies the additional workforce requirements that will be required to enable the change:

Workforce requirements Band (if applicable) WTE132

Specialist advice for GPs (via email/ telephone)

Consultant - Trauma and orthopaedics 0.21

Specialist advice for GPs (via email/ telephone)

Consultant - Gynaecology 0.21

Specialist advice for GPs (via email/ telephone)

Consultant - Respiratory medicine 0.10

Specialist advice for GPs (via email/ telephone)

Consultant - Cardiology 0.10

Specialist advice for GPs (via email/ telephone)

Consultant - Dermatology 0.10

Specialist advice for GPs (via email/ telephone)

Consultant - Urology 0.10

Specialist advice for GPs (via email/ telephone)

Consultant - ENT 0.10

Specialist advice for GPs (via email/ telephone)

Consultant - General surgery 0.10

Specialist advice for GPs (via email/ telephone)

Consultant - Gastroenterology 0.10

Specialist advice for GPs (via email/ telephone)

Consultant - Paediatrics 0.10

132 Whole Time Equivalent

134

8.6 Impact on activity and revenue Activity impact

Our proposed new model of care will result in a 20% reduction in face to face outpatient appointments taking place at Barts Health over the next five years. This is equivalent to a reduction in 184,000.

This releases valuable clinical capacity for:

hot clinics and other aspects of the acute care hubs model (please see part 3, section 6)

technology based appointments (Skype, email, telephone)

working more closely with GP and community services to improve skills and capability.

Change is necessary because without it, there will need to be an additional 141,000 appointments per year by 2020/21.

Anticipated number of outpatient appointments at without change (in 000’s)

0

200

400

600

800

1000

1200

1400

1600

1800

2016/17 2017/18 2018/19 2019/20 2020/21

Baseline Growth Capacity

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Anticipated impact of TST scheme on future demand (in 000’s)

Financial impact

After conducting financial impact analysis, we undertook sensitivity analysis which suggests a net saving of between £64.9m and £82.3m over a five year period dependent on the timescale and extent to which redesigned pathways are established.

New models of provision such as hot clinics (see part 3, section 6) are likely to provide alternative income for Barts Health, though have not been costed as part of this initial appraisal. Further financial validation is needed as part of the development of a full business case.

8.7 System commercial considerations and transitional support required

Payment innovation is likely to need to be required to support new models of outpatient provision. This includes ensuring acute, primary care and community providers are adequately compensated for care delivered in innovative ways e.g. Skype clinics, quick access to specialist advice by email or over the phone. A reduction in physical outpatient appointments will reduce estate needs and costs for Barts Health, which would allow the trust to use freed up capacity in a different way.

-400

-200

0

200

400

600

800

1000

1200

1400

1600

2016/17 2017/18 2018/19 2019/20 2020/21

Baseline2 Growth TST Capacity

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8.8 Delivery risks

Description of risk Risk likelihood

Risk impact

Risk rating

Mitigation

1 Lack of collaboration across East London. Without agreement on delivery architecture and project management resource, work is unlikely to proceed at pace and in alignment

3 4 12

Implementation plan to be drafted by March 2016

2 Lack of resources to take change programme forward across organisational boundaries.

4 4 16

Resource will need to be reviewed in line with a business case submission

3 Delivery is unlikely without clear focus and prioritisation. 3 12

A prioritisation process has been built into implementation plan. Clinical Reference Board will need to assist with clinical prioritisation

4 Lack of strong leadership could impact delivery of ambitious targets

3 4 12

Agree clinical, finance and management leads in both commissioning and provider organisations as part of implementation planning

5 Failure to deliver IT requirements to planned timescale

3 2 6

Regular contact with IT workstream project manager and East London Chief Information Officer throughout process to date to ensure requirements are fully understood and timeline for implementation plan agreed

6 Lack of alignment with integrated care planning approach for high/medium risk patients

3 4 12

Long term conditions redesign will be taken forward as part of the care closer to home programme

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8.9 Next steps Cross-cutting work and a rolling programme to redesign pathways could begin in 2016.

Given the important of alignment with care planning for ‘high’ and ‘medium’ risk patients, it is proposed that long term conditions redesign is taken forward as part of the Care Closer to Home programme of work.

The diagram below describes the structure of the pathway redesign process, based on the use of proven quality improvement methodologies (Lean and Six Sigma). The redesign phase will be carried out through a redesign workshop involving staff from all relevant organisations as well as patient representatives.

Pathway redesign process

Upcoming milestones

Milestone Description Completion timescale

Resourcing Agree resources within commissioner and provider organisations to take forward implementation planning

December 2015

Agree approach to payment innovation

For Skype/telephone clinics January – March 2016

DNA reduction workshop

Workshop with provider and commissioning staff to agree improvement plan to reduce DNAs in outlying specialties

February 2016

Implementation planning

Draft implementation plan including agreement of which pathways will be redesigned first, the

February 2016

Engagement

• Engage operational and clinical leaders

• Agree roles/ responsibilities

• Agree business and customer metrics

• Understand high level process

• Go and see

Diagnostic

• Analyse key performance indicators

• Analyse best practice

• Map and evaluate current services

• Observation and current state mapping

• Patient and staff engagement

• Share findings and provide opportunity for feedback.

Redesign

• Review current state and best practice

• Design future state process using Lean.

• Understand the supporting flows including information, IT, technology, estates and workforce.

• Agree outcome measures and PMO process.

• Assess risk and benefit.

• Develop business case.

• Design the test and refine phase.

Test and Refine

• Prepare for the trial.

• Communicate and engage with relevant teams.

• Run trial using Six Sigma methods.

• Review and refine process from trial.

• Validate benefits.• Finalise

protocols and other required documents.

• Agree targets.• Create

implementation plan.

Launch

• Engage with broader teams in provider organisations.

• Implement new way following the plan.

• Set up monitoring for the key measures.

• Set up process audit.

Monitor

• Repeat baseline measurements.

• Develop ongoing improvement plans.

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appointment of clinical leads and undertake the diagnostic stage

Mobilisation Set up redesign workshops and pathway improvement working groups March 2016

Redesign events Run first tranche of redesign events that have an East London focus (where appropriate) or borough focus to agree changes to pathways

April - June 16

Implement agreed changes N/A

Post redesign events

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9: Reduce unnecessary testing

9.1 The case for change East London CCGs spent £42.5 million on GP-requested diagnostics in 2014/15: £32m on pathology and £10.5m on imaging. Looking forward, the local demand for pathology and imaging investigations is expected to grow by 10.6% over the next five years.

National evidence133 has suggested that up to 25% of pathology diagnostics carried out are unnecessary. Locally, recent audit work at City and Hackney CCG has found 20% of MRI investigations requested by GPs could have been avoided.

Analysis of local data has revealed significant variation in the number of diagnostic investigations requested by GPs in Newham, Tower Hamlets and Waltham Forest: on average, 54% across the top 20 high-cost imaging diagnostics and 32% across the top 20 pathology diagnostics. National benchmarking has revealed some significant local outliers.

Variation in East London GP-requested ultrasound scans. Tests in each CCG (2014/15)

This data suggests that patients are frequently referred for investigations they don’t need. This is having a negative effect on patient experience and placing an unnecessary burden on resources at a time of growing demand and increasing waiting times for key diagnostics.

Inconsistent referral practice also suggests that we are providing inconsistent care. In some cases, patients may not be referred for investigations when they should be – potentially leading to treatment that is more complex and costly later on.

Reducing unnecessary diagnostics and speeding up the diagnostic process will be even more important with the likely introduction of new four-week cancer targets by 2020, which will require 95% of patients are given a diagnosis or the all-clear within 28 days of GP referral.

133 Report of the Review of NHS Pathology Services in England. COI for the Department of Health. August 2008.

- 5,000 10,000 15,000 20,000

Newham

Tower Hamlets

WalthamForest

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We know from the Transforming Services Changing Lives Case for Change that poor IT connectivity, overly cautious practice and a lack of consistent guidelines contribute to over-investigation locally. We need to drive up outcomes and save money by:

taking a systematic approach to ensure that clear referral guidance and robust pathways of care are in place and that these are followed uniformly

adopting best practice

ensuring information technology is fully exploited

At a time of growing international interest in maximising the value of healthcare interventions and the harms of over-investigation, we have an opportunity to improve local practice and ensure sustainability of the east London health economy for the next generation. Our aim is simple: to ensure patients receive the investigations they need, when they need them.

9.2 Model of care Over the next three years we plan to undertake a rolling programme of work focusing on the top 20134 highest impact in both imaging and pathology diagnostics.

Top 20 high impact GP requested pathology diagnostics in East London

Building on work undertaken by clinicians and management over the past six months to identify initial key lines of enquiry, we plan to undertake a clinically-led programme of work

134 The most costly to the system as calculated by volume x unit cost, 2014/15

141

focusing on the top twenty highest impact imaging and pathology diagnostics in terms of volume and cost. We will:

standardise our approach and roll out clear referral guidance across east London

continue to engage with clinical teams and management to explore, understand and

challenge variation and target outliers

bring together clinicians from across primary and secondary care to identify

opportunities to introduce best practice and share local good practice

consider moving to ‘direct access’ for selected imaging diagnostics, enabling GPs to

refer patients straight to test before they see a hospital specialist (taken forward by

the TST pathway redesign workstream)

challenge behaviour and support GPs to reduce defensive practice

improve IT connectivity to provide clinicians better access to test results, providing a

clear view of the diagnostic pathway and reducing duplicate investigations (image

reports into health information exchange, unification of hospital imaging systems)

implement electronic GP requesting for imaging diagnostics

customise IT systems to give GPs more control over the tests they request

implement ‘pop-up’ notifications to help enforce referral guidance (e.g. to ensure

minimum testing intervals are adhered to) and provide supportive guidance for GPs

(e.g. best practice / investigation cost).

Approach and phasing There are four planned phases to this programme of work.

Summary of planned phasing for programme of work

142

Phase 1 (2016/17)

Quick wins and progression of work based on engagement and analysis (see below) Further focused analysis and engagement to target variation and review guidance

and pathways Implementation of initial IT customisation. Radiology reports uploaded into Cerner

Health Information Exchange, enabling improved sight of the diagnostic pathway for GPs. Electronic requesting for imaging diagnostics rolled out to GPs across WEL, enabling transition away from paper-based requesting.

Target outcome by Q4 16/17: 5% activity reduction across top 20 GP-generated pathology and imaging diagnostics against 2014/15 baseline

Example outputs from clinical workshop in August focusing on pathology

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Phase 2 (2017/18)

Continued work to target variation and review guidance and pathways Increased GP uptake of electronic requesting functionality Further implementation and roll out of IT customisation Further behaviour change work.

Target outcome by end Q4 17/18: cumulative 10% activity reduction across target top

20 GP-generated pathology and imaging diagnostics against 2014/15 baseline

Phase 3 (2018/19)

Complete work to target variation across high impact areas Further IT customisation and adoption.

Target outcome by end Q4 18/19: cumulative 15% activity reduction across target top

20 GP-generated pathology and imaging diagnostics against 2014/15 baseline

Phase 4 (2019/20):

Further benefits realisation.

Target outcome by Q4 19/20: cumulative 20% activity reduction across top 20 GP-generated pathology and imaging diagnostics against 2014/15 baseline

Crossover with TST pathway redesign workstream

When secondary care referral is required, we will develop ‘straight to test’ pathways allowing primary and community practitioners to request tests for patients in advance of consultation with a hospital specialist. This will reduce delays to diagnosis and treatment planning and ensure specialist appointments always add value. Clear referral guidelines and monitoring mechanisms will mitigate the potential risk of over-testing due to ease of access. A review of selected musculoskeletal (MSK), computerised tomography (CT) and ultrasound pathways identified at clinical workshops in 2015 is being taken forward by the TST pathway redesign workstream.

Collaboration across the system

Collaboration across primary and secondary care and across organisations has been central to the development of this work and will be crucial to achieving the planned impact of this scheme.

Workshops to test clinical hypotheses on variation and to develop key lines of enquiry have so far brought together nominated clinical representatives from Newham, Tower Hamlets and Waltham Forest, hospital consultants representing key specialties, senior management from Barts Health and key IT stakeholders representing primary and secondary care.

To provide support and oversight at implementation stage we intend to set up a regular working group with similar representation, plus key contracting and other CCG stakeholders.

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A new GP symposium, organised by Barts Health and bringing together a large group of primary and secondary care clinicians, will help to support some of the wider ambitions of this programme of work (e.g. behaviour change). Both the interface group and symposium will provide vital access to GP networks across WEL.

9.3 Engagement The following key stakeholders have been engaged to help shape these proposals

Nominated GP clinical leads for East London

East London CCG chief officers

Barts Health: Clinical Director of Haematology; Clinical Director of Imaging; Director of Pathology; Director of Imaging Chief Information Officer; Deputy Director of IT; Clinical leads for imaging; Clinical Support Service CAG Director

Acute specialists: biochemistry, haematology, liver, endocrinology, renal, virology

TST GP clinical lead (City & Hackney CCG)

Barts Health Pathology IT Manager

East London Chief Information Officer

We have also engaged with stakeholder groups

TST Clinical Reference Group

WEL Clinical Strategy Group

TST Workstream Executive

Clinical Support Services Clinical Academic Group – Barts Health

TST Board

Workshops:

Diagnostics workshop: 13 January 2015. Chaired by the Clinical Director of Imaging for Barts Health and Newham CCG TST representative. Attended by 20 senior clinicians and managers from Barts Health and WEL CCGs.

Barts Health / East London CCG informatics workshop: 9 February 2015. Chaired by Newham CCG TST representative. Attended by GPs from East London CCGs; Barts Health pathology IT service manager; Barts Health Chief Information Officer; East London Chief Information Officer; and Deputy Director of IT for Barts Health.

Pathology protocols workshop: 8 August 2015. Chaired by Newham CCG TST representative. Attended by Barts Health consultants representing key specialties; GPs and clinical leads from East London CCGs and City and Hackney CCG.

Imaging protocols workshop: 15 August 2015. Chaired by the Clinical Director of Imaging. Attended by eight clinical leads from Barts Health.

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9.4 Outcomes the change will achieve

Outcome description Metric by 2020/21

Reduction in activity across top 20 high-cost GP-generated pathology diagnostics

20%

Reduction in activity across top 20 high-cost GP-generated imaging diagnostics

20%

9.5 Investment costs: In order to implement the model of care the following investment is required. This includes project implementation costs, organisational development (OD) costs and investments in IT.

Phased investment costs over five years 2016/17 2017/18 2018/19 2019/20 2020/21 Total

Workforce £0.2m £0.2m £0.1m £0.5m

Organisational development costs

£0.12m £0.12m £0.02m £0.26m

9.6 Impact on activity and revenue including sensitivity analysis The proposed model of care seeks to reduce activity, resulting in a recurring 20% reduction of the top 20 high-impact GP-requested pathology and imaging diagnostics by 2019/20. This equates to 3.3 million fewer tests over five years.

Anticipated reduction in GP-requested diagnostic activity over five years

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After conducting financial impact analysis, we undertook sensitivity analysis which suggests a net saving of between £20.7m to £25.5m over a five year period.

This net position takes account of investment costs of the £0.8m investment costs which are detailed above. IT investment costs have been excluded as these have been factored into the IT focused initiatives within this programme.

Potential reduction in spend on GP-requested diagnostics over five years

9.7 Delivery risks

Description of risk Likelihood Impact Rating Mitigation

1

Delay to implementation of supporting IT functionality will reduce the impact of this scheme.

3 3 9

Regular contact with IT workstream project manager and WEL Chief Information Officer throughout process to date. Requirements and fully understood and timelines confirmed.

2

Failure to gain necessary traction (i.e. buy-in and time of key stakeholders) would slow progress and reduce the overall impact of this scheme.

2 3 6

Working with CCGs and other key stakeholders to identify nominated clinical and non-clinical leads to drive planning and delivery stage to time, scale and standard. Initiative sits within Care Closer to Home governance arrangements ensuring senior leadership and accountability. Barts Clinical Support Services Clinical Academic Group and WEL

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Clinical Strategy Group engaged early in 2015.

9.8 Next steps Work can progress as soon as funding approved. Key next steps are as follows:

Immediate next steps Action outline Timescales

Business case for funding to progress with phase one of work and subsequent phasing as detailed above

Work with clinical leads to develop detailed business case for March 2016 in line with programme timescale

March 2016

Phase one to commence subject to business case approval

Work to implement changes for quick win areas and commencement of rolling programme to target variation. Detailed phasing

April 2016

Project management resource has been planned to work through areas identified by workshops in 2015. Some of these will be quick wins while others require further analysis and engagement.

Concurrently, systematic work will commence immediately at phase one to continue to target variation across high impact diagnostics and undertake further engagement and analysis to define the streams of work required to tackle variation. High level milestones for the programme of work are set out below.

High level milestones for programme of work

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10: Deliver shared care records across organisations 10.1 The case for change There is a need to make significant changes to the current health system in East London in order to deliver safe, sustainable and effective care. To support these new models of care, information needs to be able to flow more effectively between different health and social care providers.

The development of a shared electronic care record is central to this approach and can help to improve:

patient safety – supporting safer and more informed treatment by providing clinicians with timely access to accurate and up to date information

efficiency – reducing the time, effort and resources required to obtain relevant information regarding patient care

effectiveness – supporting the delivery of appropriate care to patients

patient experience – reducing the need for patients to recall or repeat their medication information and supporting people with difficulties communicating.

There has already been significant progress across East London and the foundations of a resilient, flexible, health IT infrastructure have been established. The standards of the individual systems used by each health and social care provider have advanced and there is now a strong base to develop an interconnected system.

However, there is much work to do to ensure that every patient and their care providers can:

access a complete view of the shared care records they need, in an electronic format, when and where they need it

ensure that care provided across the system is fully integrated, well-coordinated and convenient for patients

support a transition to care away from acute centres and into the community.

Broad adoption of a shared care record across East London will require health information to be easily and appropriately shared to support multiple uses across a wide range of health IT solutions which are well imbedded in the health economy.

Work has already been done by the East London community of CCGs together with their provider organisations – including Barts Health NHS Trust, East London NHS Foundation Trust (ELFT), North East London NHS Foundation Trust (NELFT) and local authorities – to deliver a shared view of patients’ health records using the Cerner’s health information exchange (HIE135) in conjunction with Healthcare Gateway’s Medical Interoperability Gateway (MIG). MIG has been developed to share GP and hospital electronic health records from EMIS (the leading provider of primary care systems) and Cerner. It is visible to all clinicians with proper access and consent. HIE/MIG is now being extended to include other healthcare software providers used locally, including ELFT’s Serverlec Healthcare’s RiO and the Newham social care system, AzeusCare.

135 Cerner HIE is part of the Cerner Millennium solutions which enables the interconnection of health systems through open messaging standards to allow the sharing of electronic health records.

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Without continued work, however, MIG/HIE will remain as a limited, read only view which is not connected to any neighbouring providers or across the rest of London. In read only form, HIE/MIG shared care records could not be used for the systematic review and risk analysis required to support population health and integrated care.

Without the delivery of a two-way, bookable service, the objectives detailed in the urgent care workstream (see part 3, section 2 for more detail) - such as the need to operate across primary and community providers in a more joined up fashion - would also not be possible.

We are also aware that some clinicians are not utilising the existing shared view of health records during consultations with patients. Increasing usage by clinicians would reduce the risk inherent in the provision of emergency care medicine by enabling clinicians to be aware of any allergies, current medication and other health alerts.

The delivery of a structured shared care records has to be delivered to address the needs of the local health economy and to deal with an increasing population and a desire to deliver better, more personal care and improved patient outcomes (including living longer and living healthier) at lower cost.

East London is not operating in isolation. The case for change is being driven not just locally but nationally. NHS England has developed a digital strategy that each CCG is required to emulate and report against to enhance the move towards a paperless working environment and more interoperable IT systems. At a national level the focus is on how systems should interconnect and the standards that need to be adopted to support this.

At a London level, the Healthy London Partnership has created a programme of work which focuses on connecting Londoners and health and care providers to allow for real time access to records and information. According to its vision:

This will be achieved by establishing interoperability standards that allow services provides to seamlessly exchange information across a diverse systems landscape. We will develop universal services such as ‘consent’, ‘identify management’ and ‘role-based access controls’ allowing service providers to overcome common issues that have historically acted as a barrier to true interoperability136.

NHS England (London) is also working with individual CCGs to define how they can link together to share information outside of their local infrastructure. CCGs in East London will need to be part of this wider delivery in order to deliver the full benefits of shared care records for their own patients.

10.2 Model of care Sharing care records and vital information across East London health and social care organisations will be crucial to improving outcomes, reducing waste and improving patients’ experience of care.

As described above, there is work already underway across East London which contributes to the delivery of a shared electronic health record. The integration between Cerner Millennium and EMIS, for example, has delivered proven integration and secure connectivity and has successfully delivered the following functionality:

A GP record summary containing 10 pages of patient data is available to Barts Health clinicians, including real-time medications, current conditions, allergies and

136 https://www.myhealth.london.nhs.uk/healthy-london

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alerts. This is presented by MIG/HIE as a page within Cerner Millennium with tabs for each section of the record

Future appointments and discharge summaries for Barts Health patients are viewable by GPs.

System integration and patient matching between primary and secondary care for practices using EMIS.

Approval and sign-up to data sharing for the majority of GPs across Tower Hamlets, Waltham Forest and Newham, the exception being the GPs using the healthcare system TPP SystmOne.

The electronic transition of discharge summaries and other communications through the BT Spine using Data Transfer Service (DTS), a collection of national applications, services and directories, replacing post and fax.

We are planning on further expanding the current functionality in East London in two ways.

Firstly, we will increase the usage and adoption of what has already been delivered. This work will be centred on the training of GPs and hospital clinicians so that fewer paper discharges are produced and more use is made of the DTS functionality. We will also focus on better communicating the availability of the patient records view so that more clinicians make use of this visibility during patient consultations.

Secondly, we plan to expand the integration of our systems so that electronic health records can be shared between more health and social care providers. This planned work is shown below.

Roadmap for interoperability for East London

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This plan allows for:

sharing of structured data between GPs and the acute care setting. This data can be retained and reused or included into reporting information sources

integrating urgent care systems such that clinical staff within the Urgent Care services who have the correct permissions and consent from the patient can initially view the electronic health record, but within two years provide a bookable, two way service between NHS 111, urgent care, out of hospital services and GP systems

providing further integration for Order Communications (the process for electronic ordering of pathology and radiology tests and the electronic distribution of test results)

integration of community and mental health systems for ELFT and NELFT allowing electronic health records to include these critical components of patients’ health and social care record

expanding the range of information available to include the care plan and crisis plans where required.

Current there is no agreed approach for the integration of Waltham Forest and Tower Hamlets social care systems and work will continue to develop a strategy to determine the feasibility and mechanism for this if supported by the two boroughs.

We will also continue to work with NHS England, which will be defining the standards for interoperability and developing a solution for sharing of patient health and social care information at London and national levels. The standards and plans for this are being developed now and East London is taking an active part in developing the strategy for an interoperable system solution for London. How clinicians will work differently in the future

With the delivery of enhanced interoperability, clinicians and social care workers will have access to patient records whenever they are in contact with a patient, this record will contain all the elements which are relevant to the user and which have been agreed to be shared. Access to this detailed information will mean that diagnosis and treatment are able to be delivered more efficiently and with reduced risk. This improves care for the patient and reduces the cost of delivery of the service.

The electronic shared care record will also enhance risk stratification and enable this to take place in real time (currently this is a monthly process), which supports the development of care plans and helps keep the most at-risk patients out of acute care for as long as possible.

Addressing the case for change

These changes help deliver the end state described in the case for change document, set for us by national, regional and local strategies for interoperability. The integration roadmap for shared care records, shown one the previous page, will deliver an end-to-end view of the patient across most care settings, helping to improve the health of the local population and individual patient care.

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How the new care model will look and feel for service users

In each health and social care system there will be a new view available to display the shared care record information. If a patient has given their consent, their shared care record can be viewed and eventually edited by clinicians. Patients will also be able to book appointments online. The information available within this new view will be the complete record for the patient, restricted only by elements which have been specifically coded for exclusion.

Timeline

The interoperability work to deliver a shared electronic care record has already started and the plan for the next two to three years is shown above.

10.3 Other significant change initiatives not costed here Infrastructure review

The organisations across East London have a variable infrastructure base which reflects their legacy and history, support model and current levels of use. IT support is provided across organisations by NEL CSU. However, this is not a consistent model for all areas. Secondary care, community, mental health and social services add to the diversity mix.

Before we can successfully deliver a new model for population health we must first fix the basics across our existing IT infrastructure in terms of people, processes, support and equipment. As a starting point, we must build a clear understanding of the current situation by establishing a clear baseline position. We will do this by conducting an infrastructure review which will identify the key features of the established base. This review will include:

Hardware

Service Support

Qualification of staff

Service level agreements (SLAs) and monitoring

Service desk support

Disaster recovery

Storage

Network

Training

Applications

Information governance

Data quality

Connectivity

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Once we have established the baseline position we will review this against our overall informatics strategy to identify gaps where we can improve the IT infrastructure. This work has commenced, with the initial investigation reporting produced.

We need to grow the pockets of fledgling capability and move to a single, real time, analytics service that will support East London through the introduction of a single platform. This will build on existing functionality or look at delivering a new service. As the new care delivery organisations described in the Five Year Forward View137 become established, the provider landscape will change very rapidly and we need to engage with our existing suppliers in order to understand current and future plans. This will allow us to reach an informed decision based on consultation. There will be a cost associated with this new technology against which the benefits to the service in East London will need to be carefully assessed.

Advanced informatics

There are pockets of analytical work taking place across East London, for example the analysis of EMIS data by the Clinical Effectiveness Group for Tower Hamlets and Newham and the use of the Health Analytics138 solution in Waltham Forest. These projects provide local level analysis and population stratification to support the development of targeted care plans for the highest risk segments of the population.

Patients’ involvement with their own electronic health record

The service design clearly needs to take account of the patient view of population health and how integrated care is delivered.

How patients want to interact with their data, the consent models they wish us to adopt and the level of information sharing that we make available will provide an invaluable guide to the delivery of population health informatics. We need to consult with our patients to understand this. The model being developed is based on the delivery of patient and service information through available apps.

10.4 Engagement The focus of engagement has been with IT leads in commissioners, providers and local authorities in Newham, Tower Hamlets and Waltham Forest, and with CCGs in surrounding areas (City and Hackney, and BHR).

Informatics programme board and steering group monthly meetings, invitees for both include: IT leads from commissioners (Newham; Tower Hamlets; Waltham Forest; City and Hackney; and BHR CCGs) and providers (Barts Health, Homerton, ELFT and NELFT). IT leads from Newham, Tower Hamlets and Waltham Forest local authorities were also invited. IT leads from Department of Health and UCLP were invited to the programme board.

Regular attendance at Newham, Tower Hamlets and Waltham Forest CCG informatics forums. Invitees include local GPs

Regular meetings with IT leads from NHS England (London)

137 https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf 138 http://www.health-analytics.co.uk/

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Shared care records workshop on 14 May 2015. Attended by 65 members of patients and the public from Newham, Tower Hamlets and Waltham Forest. Invitees sought via CCG patient involvement teams, local Healthwatch organisations, CVS and press releases

Patient and Public Reference Group (PPRG) on 30 June 2015.

10.5 Outcomes the change will achieve The delivery of interoperability and a shared electronic health record will not in itself deliver benefits to the system. However, it will enable the changes in service delivery models across primary, community and acute services, which will in turn transform the provision of care across East London. Some benefits which can be attributed directly to the provision of shared care records are shown in the table below.

Outcome description Outcome by 2020/21 (Metric/impact)

Elimination of paper from the system 95% elimination of orders and requests for radiology and pathology

Care plans available to all clinicians at the point of need

Electronic presentation of patient care plans at the point of need

Shared care record available to all clinicians at the point of need

All areas of the service have access to full electronic health record

10.6 Investment costs including sensitivity analysis In order to implement the model of care the following investments are required.

2016/17 2017/18 2018/19 2019/20 2020/21 Total

Capital charges £2.0m £2.0m £2.0m £2.0m £2.0m £10m

Revenue costs £0.2m £0.75m £0.68m £0.23m £0.09m £1.95m

Following financial impact assessments we have conducted sensitivity analysis which suggests a likely net cost of between £11.1m - £12.3m.

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10.7 Impact on activity and revenue The shared care record will ensure that the models of care defined in TST can facilitate patient shifts. For example, the acute care hub model of care will be underpinned by the use of a patient shared care record, ensuring care closer to home is able to take place.

An example of this is shown in more detail below:

‘Peter has swelling, pain and swelling in his left leg and the skin is red and warm to the touch, and he accesses his local emergency department as a walk-in. He is registered on arrival to the department and is directed for triage by a consultant as part of the Rapid Access Triage service. Based on his symptoms, the consultant suspects he may have deep vein thrombosis.

Peter’s case is discussed by the emergency department and acute medical consultants. Peter is mobile and alert, scores well on the National Early Warning Score (NEWS)139 scale. Checks on his shared record establishes there are no underlying comorbidities or packages of care delivered at home that would necessitate an admission to hospital at this stage. He is referred for focused diagnostic and intervention in the ambulatory care unit.

Blood and urine samples are taken and sent for analysis. Results are stored within the shared record and are accessible to all clinicians with access to this level of patient detail. D dimer results 140indicate that clots may be present in the vein and an ultrasound scan is carried out in the ambulatory care unit. The result confirms detection of a clot. Peter’s shared record is updated with the test results and ultrasound outputs.

Anticoagulation is prescribed by intravenous infusion on a five day course. Through consultation with Peter and checking of his shared record the clinicians are confident that he can receive his heparin intravenously on site in the unit and return for the next five days to receive his daily infusion, rather than be admitted to the ward. Hot clinic appointments are made for Peter and he is registered on the unit’s patient administration system. All of these details are made available via his shared care record. Peter has a dose of heparin delivered intravenously in the unit before he is discharged home to return the following day for his second dose.

A summary of Peter’s visit to the hospital is visible via his emergency department attendance card and the ambulatory care unit’s clinical team. This information is made available to the patient’s GP and is also permanently available via the record should Peter attend again at a later date.’

139 https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news 140 A specialised blood test known as the D-dimer test is used to detect pieces of blood clot that have been broken down and are loose in your bloodstream. The larger the number of fragments found, the more likely it is that you have a blood clot in your vein.

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10.8 Delivery risks

Description of risk Risk Likelihood

Risk Impact

Risk rating

Mitigation

2 There is a risk that the cost of delivery cannot be met through existing funding and thus the work to deliver a shared electronic health record cannot be progressed in the timeline defined

2 5 10 Develop business case for individual projects and seek funding through TST and informatics channels

10.9 Next steps

Action Proposed timescale

Complete individual business cases for system changes delivering shared electronic health records

Start of Q4 2015/16

Confirm funding for individual projects Mid Q4 2015/16

Schedule integration work with development team and complete detailed planning

Q4 2015/16

Commence work on new projects Q1 2016/17

Newham, Tower Hamlets and Waltham Forest CCGs need to work together to confirm the road map for next year and secure funding for the planned delivery activity through the development of a robust business case.

They will also continue to work with NHS England London and NHS England to help define the standards for information exchange and to develop a regional sharing model for London.

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11: Explore the opportunity that Physician Associates may bring

11.1 What are Physician Associates? The UK’s Competence and Curriculum Framework for the Physician Associate (2012) describes a Physician Associate (PA) as a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general medical and/or general practice team under defined levels of supervision.

After the completion of an honours degree in a science or health related discipline and a 2 year PA Postgraduate Diploma programme PAs will be able to undertake the following tasks across all healthcare sectors whilst under supervision:

formulate and document a detailed differential diagnosis on completion of a history and physical examination

work with patients and, where appropriate, carers to agree a comprehensive management plan in light of the individual characteristics, background and circumstances of the patient

maintain and deliver clinical management in collaboration with the patient and on behalf of the supervising physician whilst the patient travels through a complete episode of care

perform diagnostic and therapeutic procedures and prescribe medications (subject to the necessary legislation)

request and interpret diagnostic studies and undertake patient education, counselling and health promotion.

11.2 The case for change As set out in the Strategy and Investment Case (part 2, chapter 2.3), the East London area faces a serious shortfall of GPs in the future (the area will need an extra 125 GPs in five years’ time and 195 in ten years’ time in addition to today’s GP workforce if we don’t change the way we work to deliver forecasted demand), due to an increase in primary care demand and high projected retirement rates in the existing workforce. This is against a backdrop of a national shortage of GPs.

One of the solutions to this problem is the establishment of a flexible workforce which can contribute to multiple specialties across various patient pathways spanning secondary, primary care and social care.

For these reasons (and to create a responsive and safe model of patient care) local primary, secondary, and social care providers may wish to employ PAs who work across all healthcare sectors and a number of patient pathways. They can be used to improve the patient experience and to strengthen multi-professional teams. In addition it is intended that PAs will improve the overall flexibility of our workforce through improving the skill mix. PAs will always work under the supervision of a doctor who will appropriately support them.

There is growing evidence that the introduction of PAs will deliver benefits across a range of areas:

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1. Improved quality of care

Greater continuity of patient care across the whole patient pathway when PAs work across healthcare sectors

A primary care workforce which can support the ageing medical workforce and adapt to new ways of working including co-ordinated care and reducing unplanned admissions.

2. Reduced cost

A reduction in the frequency of use and cost of locum cover, coupled with the fact that introducing PAs is a cost effective solution when other professionals are difficult to recruit such as GPs or Advanced Nurse Practitioners (ANPs). This will result in a more efficient use of trust and practice funds to support the rest of the clinical workforce.

There is a broader recruitment pool from which to pick candidates, giving the NHS a broader of choice of skills and experience.

3. Ability to span traditional divides in the health system

PAs have a holistic/generalist perspective and they provide flexibility, with the potential to work across all healthcare settings and specialties including primary care, secondary acute and mental health care and in some social care environments.

4. Capacity release for training and development of other staff

PAs can free up time for trained doctors to provide training to others and provide backfill of clinical workforce to attend training. This also makes it easier to maintain patient care and patient safety given the loss of clinical workforce through sickness and absence.

5. Support the East London system in meeting service standards

By complementing the work of GPs and ANPs and as a result, releasing their capacity to deliver care, East London organisations will be supported in meeting the European Working Time Directive and ‘seven day services’ requirements.

In addition to these benefits, recent workforce reviews by both the Centre for Workforce Intelligence and the Department of Health-commissioned GP Taskforce (which investigated the current and future GP workforce) have recommended investigating or piloting the use of Physician Associates. In a 2002 BMJ study, 83% of NHS clinicians and service respondents supported the introduction of PAs141.

11.3 Is there NHS specific evidence for the use of PAs? Despite relatively little published evidence in the UK, there are a number of case studies:

Researchers from Kingston University and St George’s University of London reviewed 12 GP practices in England, six of which employed PAs. After controlling for patient age they found that ‘rates of re-consultation after the initial consultation were similar for the physician associates and GPs, as were rates of diagnostic test

141 Can physician assistants be effective in the UK? RCP Journal. 2005

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orders, referrals and prescriptions’. Patient satisfaction was the same between the two groups and although PAs took longer for appointments, the average cost of an appointment was £6 less for the PA cohort142.

A cohort of PAs was employed in primary care in Sandwell. The PAs ‘were reported to have made a positive impact on the workload carried out by other members of the practice teams and to have contributed to improvements in access for patients to primary care service’143.

11.4 Where can PAs be used? Whilst most current PAs in England work in a single organisation (e.g. general practice or acute care NHS trusts) there is potential to consider using them shared across the following settings in combination to accommodate common patient pathways – community, mental health, primary care, acute care, social care.

Where are PAs currently used in East London?

At present only one practice in the East London region employs a PA and three are employed in secondary care. Our research found that each of the current PAs has a very different role and set of responsibilities. As a result of this, the size of the opportunity that comes with introducing and embedding this role is significant.

What is the supply situation?

In terms of supply of the PA workforce, there are now 20 universities in England that are delivering, or intending to deliver, diploma and masters courses by the next academic year – so the level of supply will increase year on year. The UK and Ireland Board of PA Education is forecasting as many as 400 PA diploma graduates by the 2017/18 academic year

UK and Ireland Physician Associate graduates by 2017/18

142 British Journal of General Practice. 2014 143 Can physician assistants be effective in the UK? RCP Journal. 2005

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What and where is the future demand for PAs across East London?

The TST project has identified the following need for PAs across the various workstreams:

Primary care: Forecast modelling based on the likely supply projections has shown a need for 27 PAs in five years and 38 in ten years’ time.

Secondary Care: Based on initially filling 10% of the shortfall in medical roles at Barts Health (the gap between establishment and staff in post), increasing by 20% a year. This would amount to nine PAs in the first year, increasing to 47 in ten years’ time.

11.5 What is the likely return on investment? Although it is difficult to put a cost on improved service quality and patient experience, we can calculate a broad return on investment for PAs in terms of the roles that they can complement. A review of PA productivity in 2000 found that in a mature health and social care system where the role of PAs is well embedded within care models144:

a PA can perform a large proportion of a doctor’s tasks at a reduced cost (as identified by Drennan et al in June 2014145

a PA can safely assume at least 83% of primary care visits without direct physician supervision

cost-benefit analyses of PA-delivered primary care suggest the use of resources is less than physicians, under comparable circumstances

In addition to complementing the current GPs’ and ANPs’ skills, introducing the role of PAs will help to sustain high quality care and patient experience when the recruitment of traditional roles (such as GPs, specialist consultants or nursing staff) is not possible due to national and regional shortages.

Using these assumptions and figures together with our projected demand and annual salary information we can calculate an estimated financial saving from using PAs compared to GPs and acute doctors. Using these assumptions:

• Productivity: Comparing cost of a full time PA with costs of 0.75 FTE GP/acute care doctor

• Salary: PA annual salary of £49,686 per FTE; GP annual salary of £94,800; an average acute sector salary of £60,000

Employing PAs in East London for specific tasks to support GPs and acute doctors could provide an overall annual saving of £1.3m.

In addition to these savings, PAs also attract additional cost benefits related to the cost of training - the cost of training a PA is approximately one fifth that of a doctor146.

144 The economic basis of physician assistant practice. Hooker RS. Physician Assist. 2000; 24:51–54. 57–60, 63–66. 145 Investigating the contribution of physician assistants to primary care in England, Drennen et al, 2014 146 The economic basis of physician assistant practice. Hooker RS. Physician Assist. 2000; 24:51–54. 57–60, 63–66.

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11.6 Next steps We have committed to work with Queen Mary University of London throughout the process on the development of a PA programme.

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12: Developing a strategy for the future of Mile End Hospital 12.1 The case for change Barts Health NHS Trust acquired the freehold of Mile End Hospital (MEH) following the closure of Tower Hamlets Primary Care Trust in 2013. It took over management of the entire hospital site with the exception of Beaumont House, which is a Local Improvement Finance Trust scheme that provides a substance abuse unit for East London Foundation Trust (ELFT).

MEH is a community hospital with services offered by a range of different providers. There is a focus on mental health and primary care, with a strong emphasis on therapies and sports medicine. Barts Health currently has two acute inpatient wards on the Mile End site. These are separate from the acute beds on the Royal London Hospital site and tend to act as overspill wards from the main hospital.

Feedback from clinicians has indicated that having these separate geographical locations leads to sub-optimal clinical practice, as it is difficult for acute consultants to provide the necessary oversight and clinical presence across two sites.

Specifically, this lack of senior clinical input at MEH is one of the main constraints on reviewing and safely discharging patients more effectively and in a timely fashion. As a result, patients often stay on the wards for long periods of time and are not actively discharged home even once it is clinically safe to do so. As well as having a negative impact on patient experience, this also results in a loss of productivity and operational efficiency.

Using the MEH site as an extension of the acute bed base at the Royal London is a false economy. Not only is core clinical time sometimes wasted while consultants travel from site to site, it also takes senior clinical time away from the main site at the Royal London.

In addition, MEH also comes with significant estates challenges. The site is made up of a mixture of old and newer buildings, with the oldest built in 1858 and the newest in 2008.

The site has considerable backlog maintenance requirements as identified in the six facet survey carried out by Capita Symonds in March 2013147. The revised 2015 estimate places these costs at c. £13 million in total. Due to the age of some parts of the site, there are asbestos and potable water legacy issues that require careful management and appropriate investment.

MEH has undergone some redevelopment in recent years including: the construction of the Tower Hamlets Centre for Mental Health (a purpose-built inpatient unit); the refurbishment of Burdett House for mental health outpatient appointments and admin services; the redevelopment of the therapy unit to provide a centre of excellence for sports medicine; and the refurbishment of the Alderney building for office and support accommodation.

In order to improve the quality of acute care provided by Barts Health, the proposal is to relocate the activity currently occupying two acute inpatient wards on the MEH site into the acute bed base already located at the Royal London site.

Following the transition and vacation of the acute inpatient services there would be subsequent work to understand the opportunity this presents and how vacant ward space

147Barts Health backlog update 2015 v13 (Capita Symonds 2013, revised for 2015)

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and the site as a whole could be better utilised to meet the needs of the rapidly growing local population in East London.

12.2 Model of care The relocation of the two acute inpatient wards on the MEH site would:

allow more timely discharge for patients who would previously have been treated at the MEH site

improve clinical quality for patients who would previously have been treated at the MEH site

reduce clinical time spent travelling between the two sites

In order to move these patients, there needs to be a reduction in bed occupancy at the Royal London site. This is the aim of several of the main Transforming Services Together (TST) schemes, such as maternity and pathway redesign, which are also described in this document. Therefore, the changes proposed for acute inpatient wards at MEH, and options discussed for the future use of the site, only become a possibility if these other TST clinical schemes are implemented and realise their benefits.

The transfer of these acute patients to the Royal London would leave two wards vacant at MEH. This will provide the opportunity for longer-term considerations to be made into the future of the site. By developing a strategy involving all core partner organisations (including Barts, Tower Hamlets CCG, ELFT and others), a robust programme of development can be mobilised to lead the site into the future. The strategy would set out how a long-term plan would be delivered following transfer of the acute activity, and define any necessary transitionary arrangements that would need to be put in place.

No decisions have been made on the services that might be provided from the site, but options include:

Use as a step-up / step-down facility, run by Community services.

Use as a rehab specialist unit.

Transfer of occupancy to ELFT for increasing their mental health service provision at the site.

Transfer for use by Barts Health Community Health Services.

Transfer for use by alternative services (for example voluntary sector, non-health services, education or others) where appropriate.

Closure or mothballing of the space to reduce maintenance or upkeep overheads.

Aspects of the site could also be transformed for use in other ways to compliment the local health economy in support of other local objectives. Work conducted by Capita during the summer of 2015 has identified significant opportunities for Barts Health to repurpose aspects of the MEH, such as:

In the development of housing

In the conversion to premises suitable for neighbouring Queen Mary’s University London

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However, there are restrictions on the redevelopment potential of the site due to conditions that were agreed when MEH transferred in ownership to Barts Health. For example the trust would be unlikely to retain the cash receipt of any disposals it makes on the site (including sale to developers, for example). As a result, a broader strategic plan for the site has not yet been considered by the trust. However, the options described remain viable and will be will be considered in due course by the trust.

All the above scenarios would either provide financial benefits through a marginal income by tariff, a service management income to Barts Health, or reduced management costs. The work to complete the strategy will include the completion of feasibility analysis to define the optimum approach whereby the system would gain greatest benefit.

12.3 Engagement Since the changes proposed by this scheme are relatively minor, engagement has been focused on gaining clarity around the clinical requirements of shifting acute inpatient activity to the Royal London and understanding the potential estates implications. Engagement with a broader range of stakeholders will begin following publication of this Strategy and Investment Case.

12.4 Investment costs Due to the low complexity of this scheme there are no material costs in transferring patients from MEH to the Royal London. The benefits will be seen in operational efficiency and patient satisfaction.

There will be investment costs required to deliver the long-term strategy for the site, but these are yet to be calculated. The next phase of work will define strategic options and associate costs with each.

12.5 Impact on activity and revenue Shifting acute inpatient activity from MEH to the Royal London will not have a material impact on revenue and as such is not modelled here. Any material implications will be defined in the next steps, which will develop the strategy for the future of the whole site.

12.6 Delivery risks There are no material risks associated with transferring the existing acute inpatient activity to the Royal London, as the shift will only occur once capacity has been released following implementation of other TST clinical schemes.

Risks associated with delivery of a long term strategy for MEH will be defined in due course.

12.7 Next steps The main next steps to implement the scheme will be:

1. to adapt clinical models of care to reduce, and ultimately remove all transfers to the MEH wards to allow them to be vacated

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2. for the Barts Health estates team to work with partners across the system (including ELFT, Queen Mary University London, Tower Hamlets CCG and others) to develop a strategy for the future of the site

3. for feasibility studies to be completed to further the work completed by Capita, to define opportunities, benefits and risks to the local health economy, to patient safety, and to Barts Health

4. to develop outline and full business cases where necessary, to progress the preferred option(s) into more robust designs and proposals

The full strategy for the future of the site will need to be developed in the context of the overall sustainability strategy that Barts Health will develop, as the financial implications of the preferred changes may be material to the overall economics of the trust.

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13: Defining a strategy for the future of Whipps Cross University Hospital 13.1 The case for change In order to provide safe, sustainable care for the growing population in East London, 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) is therefore crucial to the longer term sustainability of the local NHS.

Barts Health NHS Trust (BH) is working with local NHS partners, together with the London Borough of Waltham Forest, to develop a clear vision for the hospital. Whipps Cross has a long and distinguished history of serving local residents. It has been a pillar of our community since the beginning of the 20th Century and has provided quality healthcare to local families for many generations. But we know there are significant challenges we need to address:

Our buildings are old and require significant investment (c. £80 million in total) to keep them safe and suitable for patient care. Current issues include148:

o water ingress in the basement and problems with flooring structure in places

o mechanical and electrical installations approaching end of their serviceable life

o asbestos in a number of areas of the hospital

o failing lifts, poor doors and other access and safety equipment.

Our buildings are not designed to deliver what is now required in today’s healthcare system, making it hard and expensive to operate efficiently. For example:

o due to the maternity unit’s location, emergencies require the provision of an ambulance, which uses resources that would otherwise be saved if it was physically co-located with the main site149

o Whipps Cross has one of the largest site areas for a hospital in London, at almost 18 hectares, but rates as one of the most inefficient in terms of how the site is used150.

The Care Quality Commission report in March 2015 found that Whipps Cross was delivering inadequate levels of care, with the maintenance of key facilities and equipment (such as theatre ventilation) highlighted as being insufficient151.

We are in financially difficult times and Barts NHS Trust has not been performing well; things need to change to make our services more sustainable in the longer term

148 Barts Health NHS Trust Estates Strategy (draft): 2013-2018 149 Anecdotal evidence: 2015 150 NHS Barts Transformation Plan – Capita Report: 2015 151 www.cqc.org.uk/sites/default/files/new_reports/AAAB8913.pdf

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Our population is growing and getting older, meaning more and more people are in need of treatment to keep them well152. This will place further capacity pressures on Whipps Cross:

o By 2025 we expect the number of local residents over 65 to increase by 25%.

o This increase will be exacerbated by other changes that are occurring across north east London, for example the proposed closure of King George’s emergency department.

Our staff work tirelessly to give the best care to our patients, but we know that they can only go so far with the facilities they have.

With things as they are, doing nothing is no longer an option. We are developing a shared vision with our NHS and local authority partners. We want to write a new chapter in Whipps Cross’ history, where we see it deliver what local people need today and in the future, by delivering better and integrated services, and most importantly through improving clinical outcomes and quality of experience for all our patients.

We are at the start of what may become a long journey, to deliver our vision of improvement in our shared ability to provide good quality health and social care. We will look across the NHS and beyond to learn what works and what doesn’t, including where recent attempts to make major changes at Whipps Cross have failed, to make sure we set up this work to succeed. In particular:

We have all the relevant East London public agencies working together from the outset, including Barts Health NHS Trust, NHS Waltham Forest Clinical Commissioning Group (CCG) and North East London NHS Foundation Trust, as well as the local authority which provides social care services and is also involved in regeneration and planning strategies.

We have begun to involve Barking and Dagenham, Havering and Redbridge CCGs, West Essex CCG as well as their respective local authorities, together with Barking, Havering and Redbridge University Hospital Trust (BHRUT) and Homerton University Hospital as they will also need to contribute to this work to ensure we consider the broader north east London context.

We are looking at different funding models to ensure that we can afford to implement any changes and make them financially sustainable.

We want to involve many different groups in this process to ensure we create a strategy that we all understand and support. This includes clinicians, politicians and decision-makers in the Government – but also, most importantly, the residents and patients who will benefit.

13.2 Model of care We have an exciting vision for the future of Whipps Cross that transforms how services are delivered and fully integrates health and social care to provide better and more sustainable services for residents and patients.

Traditional hospitals provide acute care, but this represents just one part of the patient journey that includes their GP and other primary care services, mental health and community 152 TST Demand Model; population growth data based on GLA Capped SCHLAA 2013

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services, adult social care and wider public health initiatives. We want our patients’ journeys to be defined by their needs rather than by organisational divisions, and to deliver a joined up service across primary, secondary and social care. Effective integration of health and social care services will help us to deliver more efficient and clinically effective services for all. We are therefore looking at how we could adapt our estate to facilitate the integration of different services more effectively.

Alongside health provision, other facilities could also support the way our core services are delivered and help to provide better care for the people we treat and local residents in general. These other facilities could include:

third sector and voluntary services that provide sensitive palliative care

research centres that support advances in treatment

educational and training centres to provide learning and development for our staff

exercise facilities to promote active living

retail outlets for staff and visitors

housing for key workers.

We want to consider all these opportunities in our future strategy for the site.

To help us take steps forward, there are a number of principles we’ve started to frame that help to illustrate our thinking. We want Whipps Cross to:

deliver the basics of care as expected in a 21st century, efficient and effective acute site, whilst also providing exciting ‘leading edge’ care in specialist areas (such as elderly care)

be set up to efficiently and effectively deliver the initiatives articulated elsewhere in the Transforming Services Together (TST) programme, such as acute care (part 3, section 6), primary care (part 3, section 4) and surgical hubs (part 3, section 5)

meet the health, social care and wellbeing needs of our residents (across multiple boroughs) in a coherent and patient-centred integrated campus

be a community asset that is appreciated, valued, flexible to changing needs and used by local residents now and in the future

provide what our local residents need and help them to transform their health outcomes

be fully and sustainably staffed, innovative and flexible, support the access needs of all and be environmentally aware

be appropriately financed and maintained.

We want to learn from, and build upon, examples of health and social care integration from both the UK and further afield, which show what can be done. These include:

The Greenwich Centre in south east London combines a community health facility, new GP health centre, local leisure facilities as well as hundreds of homes. It successfully integrates all these services to create a primary care hub facility that helps a whole range of people, and has become a well-used and popular local asset.

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Jönköping in Sweden is a well-known exemplar of a health authority that successfully integrated medical services with social care and public health to become a national leader in health quality. It is seen as a standard-bearer internationally in the comprehensive delivery of integrated care.

And there are other examples from across the NHS and internationally that we will draw ideas from, to bring the best to Whipps Cross. There is considerable space on the site, enabling us to think widely about what we want to deliver. Only around 30% of the land is currently built on, and many of the buildings are in need of major renovation; we could do a huge amount more with what we have.

Any change we propose will need to be financially affordable and deliver lasting benefits to the local area, so we will need to be creative and look at many options to test what would work best. This is just the start of the journey, but we have big ambitions.

The work will need to consider the implications of a range of different scenarios, to allow us to make the right decisions about where we go next. These scenarios will need to be evaluated to allow us to understand:

how each will impact on the clinical outcomes of our patients and the overall health of our residents

the experience that our patients and residents will get from using these services

the impact on the broader health and social care ‘system’ across north east London

the overall efficiencies of the health and social care system, and how it can demonstrate it will do more with less

the impact on our local economy, in terms of jobs it creates, and investment it will bring for our people

the technical feasibility of each scenario, including the complexity of any transformation, and consideration of any planning or development implications it might bring

the implications on the overall financial position of the local health and social care system, both during the transformation (e.g. the capital funding to make the change happen) and once it’s all complete (e.g. in the cost of operating the transformed facilities, including the cost of servicing any associated debts)

any other risks the transformation will pose, and our ability to control them.

Over the next six months, we will develop a Strategic Outline Case (SOC), which will set out all the scenarios and make a clear argument to take forward a course of action to deliver change. If the SOC determines that a major transformation of the site is required (and affordable), then much more detailed work to develop designs and to test the feasibility of the transformation will be needed. This could take many years to complete. In such a circumstance, we may not see any physical transformation completed for possibly up to 15 years from now, but it is important we take the necessary steps to explore all the opportunities and embark on this journey together.

In parallel to completing the SOC, we will deliver a full review of the current condition of the site and develop a robust short-term investment strategy. The information we have on the current condition needs to be revisited to allow for an effective prioritisation of the investment necessary to keep the site safe in the short term, deliver the critical changes as required by

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CQC, reduce inefficiencies, and deliver what is needed to implement our TST schemes. By aligning with the outputs of the SOC we may then be able to deprioritise and even avoid some back-log requirements as the longer term strategy to transform the site will be clear.

Delivering all of this may require considerable capital investment, and funding any change presents the largest risk to this work. We are already engaging with stakeholders in Government and elsewhere to help us understand and mitigate this however possible.

13.3 Engagement Engagement has so far involved senior individuals from the partner organisations involved, plus selected others. Examples include:

Chief Executive Officer (CEO), Director of Strategy, Director of Estates for Barts Health

Managing Director, Medical Director, Hospital Director, Chief Nurse and senior clinicians at WX

Councillors, the CEO, Deputy CEO, Assistant CEO and management board from London Borough of Waltham Forest

Chair, Chief Officer and Chief Financial Officer, plus management team of Waltham Forest CCG

CEO, Director of Operations, Director of Estates of North East London Foundation Trust

Iain Duncan Smith (MP for Chingford and Woodford); Stella Creasy (MP for Walthamstow); John Cryer (MP for Leyton & Wanstead)

Cabinet Office/Local Government Association individuals who run the One Public Estate programme

There has been some engagement with patient representatives, Healthwatch and other local residents groups, but this will increase considerably as we mobilise to complete the Strategic Outline Case. The outcomes of this work will be best shaped with input from these groups, and we will actively seek to involve them in our plans as they start to take shape.

13.4 Outcomes the change will achieve The Strategic Outline Case (SOC) will articulate the next steps for the preferred option(s). These next steps may involve development of Outline and Full Business Cases. The table below illustrates an indicative timeframe for delivery of these products:

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Outcome description Outcome by 2020/21 (Metric/impact)

Delivery of a robust Strategic Outline Case for the future of the WX site

By summer 2016

Complete prioritisation of the short-term investment requirements (to clear back-log maintenance) and agree capital programme

By summer 2016

Complete works on critical back-log By summer 2018

Delivery of a robust Outline Business Case for physical transformation (if required)

Summer 2018 (TBC)

Delivery of a robust Full Business Case for physical transformation (if required)

Summer 2020 (TBC)

Approval to commence with transformation Autumn 2020 (TBC)

13.5 Investment costs The table below illustrates the level of programme management costs required to deliver the strategy from strategic outline case through to final build.

2016/17 2017/18 2018/19 2019/20 2020/21 Total

Programme costs £8.2m £8.2m £8.2m £8.2m £8.2m £41m

13.6 Impact on activity and revenue There will not be any impact on activity until the Full Business Case has been approved (c.2020) and construction can then commence. The SOC/OBC/FBC process will define the impacts on activity and revenue for the trust and local health economy (including social care).

Revenue impacts will only be on funding the SOC/OBC/FBC programme; costs are likely to be capitalised.

13.7 System commercial considerations and transitional support required

Commercial considerations will be made during the SOC process. Delivering a sustainable funding model for the site may require evaluation of a range of commercial opportunities that could feature on the site, including for example:

Medical research

Leisure activities (e.g., private gymnasium or hotel)

Housing

Retail outlets

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Car parking

Private practice.

13.8 Delivery risks

Description of risk Risk Likelihood

Risk Impact

Risk rating

Mitigation

1 There is insufficient funding available to support delivery of the SOC Barts Health is in special measures and will mean scrutiny by the National Trust Development Agency will be necessary; approval may not be given

2 5 10 BH investigating potential to capitalise spend Contributions from partner organisations being investigated Clear definition of the case for change and the risks to patients of the ‘Do Nothing’ position

2 The WX SOC needs to be written in the context of a broader Barts Health strategy; without this the WX SOC could fail to gain approval

2 5 10 Barts to mobilise a central programme to define the sustainability strategy for the trust; work must proceed in parallel

3 Key posts in Barts Health are still interim; risk that permanence of the outcomes are jeopardised by changing leadership

4 3 12 Developing a cross-system approach will distribute the ownership to a number of system leaders

4 Central Government does not support a major investment in East London

4 5 20 Clear articulation of the system-impact of all strategic options for the site will be necessary Commenced discussions with local MPs;

5 Risk of ‘fall-out’ with staff and local residents if the programme over promises what it can deliver; risk of bad publicity and deterioration in staff morale (already fragile)

4 4 16 Approach must be very carefully managed to ensure messages are always caveated appropriately

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13.9 Next steps The following next steps will govern progress in delivery the SOC:

Barts Health to agree budget to deliver the SOC.

Recruitment of the Programme Director to be completed.

Procurement of Programme Team to deliver the SOC programme.

Planning and mobilisation.

Definition of requirements for technical support (architects, planners, engineers etc) and commence procurement.

Complete SOC for approvals April/May 2016 and plan for OBC phase.

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TST communications and engagement strategy and plan (Approved at TST Board (20/01/16): to be approved at CCG and Barts Health Boards)

January to May 2016

Contents

1. Aims and objectives .................................................................................................. 1 2. Statutory responsibilities ........................................................................................... 2 3. Challenges and opportunities.................................................................................... 2 4. Key messages ........................................................................................................... 4 5. Stakeholders ............................................................................................................. 8 6. Our engagement plan ............................................................................................... 9 7. Alignment with other strategies / policies / issues................................................... 15 8. FAQs ....................................................................................................................... 15 9. Timeline ................................................................................................................... 16 10. Risks and mitigations .............................................................................................. 17 11. Evaluation ................................................................................................................ 18

1. Aims and objectives This communications and engagement plan sets out how Newham, Tower Hamlets, Waltham Forest and neighbouring CCGs, supported by NEL CSU and working with Barts Health NHS Trust, other providers, local authorities and NHS England aim to engage and communicate effectively with patients, the public and relevant stakeholders about transforming healthcare services in east London. Engagement activities will involve local people and stakeholders, particularly those likely to have an interest in these services so that:

Staff, patients, the public and stakeholders: o have the opportunity to make their views known o are clear about any proposed changes o are positive about the changes o are not unnecessarily worried about the changes

The CCGs meet their legal/statutory obligations. We want meaningful engagement with local people and other stakeholders. We will know that we have achieved this if people:

feel informed and listened to have given their views provide feedback that improves the development of the service support the changes.

All communications and engagement will be planned, clear and informative so that stakeholders are reassured and their needs are managed.

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2. Statutory responsibilities Newham, Tower Hamlets and Waltham Forest CCGs (the CCGs) have been responsible for engaging with stakeholders to ensure their views help shape any changes. The CCGs are also responsible for ensuring that public involvement is carried out properly (as outlined in section 14Z2 of The NHS Act 2006, as amended). NHS England’s guidance: Planning and delivering service changes for patients (December 2013) is also relevant. The CCGs will be supported by NEL CSU to plan and deliver:

Phase one: Communications and engagement activities in the period following the publication of the Strategy and Investment Case (SIC) including analysis of feedback from engagement

Phase two: Any required consultation(s) on significant changes arising from the SIC. This will potentially be based on proposals for significant surgery changes, Whipps Cross and Mile End hospitals later in 2016 or in 2017.

The CCGs’ governing bodies are responsible for decision-making regarding the engagement.

3. Challenges and opportunities The key communications challenges, opportunities and risks include: Challenge / opportunity / risk Proposed plan

Engage staff in this transformational change – some may see this as another reorganisation, when many of them are already de-motivated (see CQC report).

Clear internal communication and engagement of leaders and change leaders.

Work with the OD programme and Barts Health. Aim for similar integration and alignment in primary care, integrated care etc.

Ensure the engagement provides the partners with the legal authority to make changes when consultation is not required.

Develop a clear communications action plan, agree with key partners; ensure communications is seen as central and critical to the success of the programme and aligned with workstreams.

Discuss with the inner north east London Joint Overview and Scrutiny Committee (JOSC) and the outer north east London JOSC so there is a unified scrutiny arrangement and/or a unified view.

Ensure changes are not viewed as downgrading by managing public perceptions but are seen as positively taking the NHS forward.

Ensure proposals are discussed and agreed by staff (who have considerable influence on public opinion) and Boards

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Build trust in the NHS; putting clinicians (especially) and managers in front of the public to explain the proposals

Build on the relationships we have in place with our local NHS (members of the Transforming Services Together programme meet regularly with CCG, Barts Health and other colleagues).

Develop lines to describe the benefits for each hospital (and the group of hospitals). Whilst this is a strategic plan, we cannot ignore the fact that the public are interested in their local hospital.

Positively engage with the section of public and stakeholders who are negatively predisposed as they have: o seen reconfigurations (Fit for

the Future, Health for NEL) leading to consultation fatigue and lack of belief that things will change

o seen criticism of existing NHS services (e.g. CQC reports – so they lack trust in the NHS to make good decisions/changes)

o fixed views on finances, PFI, privatisation etc (e.g. 38 degrees, Save our NHS).

Build leadership and change leaders.

Make it clear how change is (and must be) continuous and that proposals build on previous (successful) work.

Explain that TST is part of the solution to the problems.

Recognise failings where they are clear but correct inaccurate criticism.

Brief stakeholders and ensure we understand their aims / objectives. How do we give them what they want?

Recognise that some critics will not change their mind. But we should not distance them from the programme, rather we need to listen to the issues to take them into consideration, amend our plans if necessary, and build a community of supporters around them.

Manage the political sensitivities. E.g. ensure that any proposals are not used as a political football.

It is essential that we engage on the issues and options that are possible. Including all stakeholders in the planning process.

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4. Key messages

We want to make a difference in east London and:

address inequalities. Many of our residents receive excellent care, but the quality and availability of some of our services could be improved. The health of some of our residents is poor, with life expectancy in some parts of east London significantly lower than the England average.

help patients to be in control of their own health and lead longer, healthier lives.

We have a huge challenge in east London and must plan ahead to address it.

Our population is growing and in 15 years it is estimated we will have an additional 270,000 residents – equivalent to another London borough or a city the size of Southampton. If we carry on as we are, the East London organisations will be around £400 million in debt and would need a further 550 hospital beds – the equivalent to another hospital. This would be unaffordable to build and run.

When we published our Case for Change in July 2014, we said that emergency and maternity services would be retained on each of the three main Barts Health sites. Since that time we have established that we face the opposite challenge. We need to maintain these services on each site, and cope with the anticipated increase in healthcare needs – but without having to build a new hospital.

Health and social care budgets are being squeezed.

We are struggling to recruit and retain the numbers of staff we need while many staff, particularly in primary care are nearing or past retirement age.

Some of our buildings and IT are not fit for purpose – Whipps Cross needs more than £80 million of capital investment as a minimum. Much of the primary care estate is also unsuitable for the safe delivery of healthcare.

Whilst CCG finances are currently in balance, Barts Health has the largest deficit in the NHS.

This programme is about a whole-system transformational change, rooted in partnership working. It is bold, ambitious and unprecedented in this area and focuses on changing the social culture of over-reliance on medical services.

This is not the start of the process; there is lots of work already underway to improve healthcare services

Improvements put in place at Barts Health mean it has one of the lowest mortality rates in the UK (4th lowest). For example, performance in stroke and major trauma care are exceptional - these changes are saving lives.

Over the past three years, £21 million has been invested in the Whipps Cross estate and we have some of the most modern and high-tech facilities e.g. the Sir Ludwig Guttmann Health & Wellbeing Centre or The Centre (Manor Park) in Newham.

Integrated care is being provided to thousands of residents across east London, putting them more in control of their health and reducing admissions to hospital

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Our IT systems are getting better and more connected. For example, more hospital clinicians in Barts Health are able to see primary health records, and vice versa, resulting in a quicker and more streamlined service for patients.

Our strategy

Our strategy aims to:

embrace and support the health and wellbeing strategies of each borough;

promote health and well-being by developing the knowledge, skills and confidence to self-manage through collaborative care and support planning

change the culture of how we commission and deliver care and support a learning healthcare system

increase involvement of patients and carers in co-production and shared decision-making

maximise the use of the significant assets in our communities and voluntary sectors

commission activity to be accessed in fit-for-purpose settings of care, often closer to home

help people to stay healthier and manage illnesses; to access high quality, appropriate care earlier and more easily

focus some specialisms in fewer locations to improve patient outcomes and experiences and drive up efficiencies

value the importance of continuity and therapeutic relationships, acknowledging the importance of supporting people’s mental health and well-being needs

ensure the system can respond to the changing demands on our services that we have predicted as part of our Case for Change

help to set our finances on a path of sustainability in an increasingly challenging environment.

Our proposals

Care closer to home

More integrated care for more people at risk of going into hospital, so that they can be cared for at home and stay out of hospital.

A simplified and integrated urgent care system, so that people don’t’ always turn up to emergency departments, but can book GP appointments, get advice and consultations all with one phone call.

Earlier identification of the need for end of life care, supported conversations and recording and sharing preferences. To enable this there needs to be shared care plans and enhanced community and palliative services delivered by better partnership working across the health, social care and voluntary sector.

Making primary care more accessible (with more GP appointments and more convenient times); proactive – helping people to take control of their own health and be healthier; and coordinated (with joined up IT systems so that care givers can

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provide better, quicker advice and services often in the same building). We believe these services can only be delivered in primary care centres with list sizes over 10,000, through smaller practices working together in integrated provider networks, or through collocated facilities.

Strong sustainable hospitals

We need three strong and sustainable hospitals providing emergency and acute care for our growing populations. Each needs a well-functioning emergency department and in the future, they will need to work more closely together and provide different services. We need to address the belief that having all services at a local hospital is a necessary ‘security blanket’.

Develop surgery centres of excellence (surgical hubs) at each of Newham hospital, Whipps Cross hospital and The Royal London. Each site would become specialised to deliver different types of surgery. This would improve patient care (for instance by reducing waiting times, lengths of stay and cancellations), deliver safer and better surgery and improve efficiency

Develop acute care hubs at each hospital site (Newham, Whipps Cross and The Royal London), bringing together more specialists and test facilities to the front door of hospitals so that patients can be diagnosed and treated more quickly and fewer patients will need to be admitted to a hospital ward.

Introduce care that promotes normal delivery of babies. Providing better continuity of care will support more women to have more natural birth in midwife-led settings. This will contribute to us being able to cope with the expected 5,000 more births a year across north east London in the next 10 years.

Working across organisations

Reduce the number of hospital-based outpatient appointments by improving the quality of referrals and improving Skype, telephone and other access.

Reduce unnecessary testing and sharing care records, for instance by ensuring care givers can see a patient’s tests. This will reduce the inconvenience to patients and save money.

Develop new roles, different ways of working and effective ways of recruiting and retaining staff. For example, we will introduce more physician associates, health coaches and other roles who will be able to take on much of the day to day work of a GP. This will free up GPs (who are in short supply) to concentrate their expertise where it is needed most.

Develop a strategy for making better use of Mile End Hospital. This could include more step-up/step-down facilities, mental health or community service facilities or even sale of underused parts of the site for educational or residential use

Develop a strategy with partners, for the long-term future of Whipps Cross.

We must improve the health, life expectancy and care of people with mental health difficulties, particularly focusing on rapid treatment early in life when the majority of symptoms first appear.

We will work with schools, children’s centres and youth services which are vital settings for improving the health of young people; and we will improve the way young people transition into adult services. We will redesign children’s mental health

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services to make them less fragmented and work with schools to make sure mental health problems are identified earlier, leading to young people getting the support they need more quickly.

The expected outcomes

The combined impact of these initiatives, if they are all delivered through a coordinated, integrated delivery plan over the next five years, alongside productivity improvements, will be:

a significant increase in activity being delivered closer to home, in more efficient care settings

a healthier population, and patients who experience better care

a workforce that is more appropriate for delivery of efficient and effective modern healthcare; staff who better understand their role, who feel supported and who are enthused about their job, healthcare and the NHS

that hospitals are able to relieve the existing pressure on beds; can cope with the increase in population and long term conditions; and help to reduce waiting times, or create opportunities for new income streams

improvements in the clinical quality of services and the physical and mental health of the whole population. We expect these proposals to directly support the Safe and Compassionate improvement programme and the transition of Barts Health out of special measures

net savings from the TST programme of between £104 million and £165 million over five years to 2020/21. The expected annual recurrent net saving by 2020/21 is £48 million. The most likely position if we deliver the changes described in this document; internal cost improvement programmes (CIPs); and quality, innovation, productivity and prevention (QIPP) programmes, is one of overall health economy balance with some organisations being in surplus and some in deficit.

a significant reduction in the capital spend required. The TST programme proposes a budget for buildings and infrastructure of £72 million by 2021 (excluding essential estates and IT works), but the requirement if TST is not put into action is £250 million.

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5. Stakeholders There are a number of people and organisations who/which are involved, or interested in proposed changes to healthcare services in east London. They key external and internal audiences include:

NHS England Neighbouring CCGs - in particular, City and Hackney, Barking and Dagenham,

Havering, Redbridge and where appropriate, north central London CCGs NEL Commissioning Support Unit Homerton University Hospital NHS Trust East London NHS Foundation Trust North East London NHS Foundation Trust Third sector organisations Local authorities and public health teams; City of London; London Borough of

Hackney; London Borough of Newham; London Borough Tower Hamlets; London Borough of Waltham Forest; London Borough of Redbridge; London Borough of Barking and Dagenham; London Borough of Havering

3. Health partners

1. Staff mployee

4. Community

5. Influencers 2. Patients and carers

Professional/representative bodies (e.g. LMC), Royal Colleges and Unions

Local GPs, pharmacists and opticians

Secondary care clinicians and staff

Community and mental health services clinicians and staff

Staff in local and neighbouring CCGs

Carers, families etc

Patient support groups

Public

Community groups

Campaign groups, including Save our NHS

Patient consultative groups

Health Scrutiny Committees

Healthwatch

Media

Health sector voluntary and charitable sector (e.g. Age Concern)

Health and wellbeing boards

Service providers

Patient reference groups

6. Represent & regulate

MPs, MEPs

Local councillors

Local councils (CEs, Directors of Adult Social Services, Children’s Services)

Faith groups

NHS England, TDA, Monitor

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6. Our engagement plan

The Strategy and Investment Case (SIC) will to go to the CCG governing body meetings in Tower Hamlets (26 January), Waltham Forest (27 January) and Newham (10 February). It will also go to the Barts Health board on 3 February.

Following any amendments to be incorporated into the documents, the engagement process will run for 12 weeks from 29 February 2016 to midnight on 22 May 2016.

There are three documents:

o Part 1: a summary to be tested with the Patient and Public Reference Group o Part 2: the main report o Part 3: the detail of the proposed high impact initiatives

We have already received and welcomed feedback as the document has been drafted. Once the full document is publically available we will continue to invite comments from interested parties.

By engaging with stakeholders, we will be able to ensure commissioning decisions take into account public, patient and clinical views to ensure a safe service and excellent patient experience.

All engagement will build on links and relationships developed during previous engagement programmes (in particular Transforming Services, Changing Lives Case for Change (2014)). Activity

The engagement plan includes: Drop-in sessions in each hospital Meetings in each borough with staff and public to ask for their views Media releases and adverts to be placed in the local press Attend Overview and Scrutiny Committee meetings in each borough Meetings with Healthwatch, LMC and other stakeholders in each borough Monthly meetings with the Patient and Public Reference Group (PPRG) Production of a newsletter providing monthly updates on the programme Mail outs to all interested parties asking for their views and the offer of a meeting

Collateral A number of materials will be available throughout the engagement process to inform the public about the programme. These will include this engagement plan and:

The Strategy and Investment Case o Part 1 – the summary o Part 2 – the main document o Part 3 – detail of the high impact initiatives

Core presentation Advertisements and media releases Website Newsletter Questionnaire on the website and in the summary version to encourage feedback Posters for patient/public areas.

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Group Engagement Objectives Responsibilities Timescale 1. Staff CCG engagement:

The CCGs and the three chief officers will lead on the engagement in each borough. This will include updates at staff meetings and briefings in staff newsletters and other internal communication channels.

Ensure any engagement that is already happening locally in the CCGs is aligned to the TST strategy. This will be achieved through regular contact with the communications and other staff at the CCGs.

Some of the changes will increase activity in primary care (e.g. moving some hospital appointments for patients with long-term conditions into primary care, where appropriate and where it will benefit the patient). The changes will occur at a time when primary care staff are already feeling overworked and demoralised. We will attend LMC meetings in each CCG area to engage with GPs

Barts Health engagement:

Communicating with Barts Health staff is the responsibility of the trust; however the TST programme needs to work closely with communications and other staff at

To hear staff views Ensure a sense of ownership in each CCG about the TST programme so the proposals can be taken forward Ensure staff feel they have been involved in the programme and that TST is not just ‘another thing’ Develop NHS staff as potential ambassadors and drivers for change Help staff understand the impact of the proposals and allay fears they may have fears about the their jobs and understand the benefits for their future careers Ensure a sense of ownership within the Trust about the TST programme so the

CCG/TST/Comms CCG/Comms GPs/TST/Comms BH/TST/Comms

Ongoing Ongoing Ongoing Ongoing

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Barts Health to ensure their staff are informed about the programme and have the opportunity to engage. This will include providing materials and information for use within their internal channels, and working with them to arrange events and briefings.

Drop-in sessions will be held at each hospital site to inform staff, patients and carers about the programme

proposals can be taken forward Ensure staff feel they have been involved in the programme and that TST is not just ‘another thing’ Allay fears staff may have about the their jobs and understand the benefits for their future careers Align key message with BH’s safe and compassionate plan

BH/TST/Comms

During engagement process

2. Patients and carers Regular meetings of the TST patient and

public reference group (PPRG)

Drop- in sessions at each hospital site to inform patients and carers about the programme

Drop-in sessions in each borough. These will be hosted by staff and clinicians involved in the TST programme and will be an opportunity for the public to have their questions

Hear the views of patients and carers Emphasise the message that this is not another NHS case of ‘change for change’s sake’ Allay fears over potential extra travel to different sites for treatment Provide reassurance of the NHS commitment to clinical quality and patient care Help prevent ill health and improve the health of residents

TST/Comms BH/TST/Comms CCG/TST/Comms

Every month During engagement process During engagement process

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3. Health Partners (local authorities, health and wellbeing board, charity and voluntary sectors)

Regular updates through meetings and other communication channels

Attendance at key events

Ensure any impact on health partners are fully explored Utilise specialist knowledge of issues and opportunities Ensure synergy with partners’ developments and announcements

Comms/TST Comms/TST

Ongoing Throughout engagement process

4. Community Drop-in sessions for the public. These will

be hosted by staff and clinicians involved in the TST programme and will be an opportunity for the public to have their questions answered. One session will be held in each of the three boroughs and at each Barts Health site

Workstreams and additional events and workshops as necessary which will be focused on particular areas of the programme

Newsletter – several editions of a newsletter have been produced which provides updates on the TST programme. This will continue throughout the engagement process

Take out adverts in local papers

Website – the website http://www.transformingservices.org.uk/

Encourage members of the public to attend events to understand their needs Build trust in the NHS as effective caretakers of the health of the local population Help the public understand how the NHS works and the different services on offer Understand the needs of the residents Ensure their views are listened to

TST/Comms TST/Comms Comms Comms

Throughout engagement process Throughout engagement process Monthly Start and end of engagement process

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will be updated and continue to be a source of information for anyone with an interest in the TST programme

Literature and posters to be mailed out to

Healthwatch and other stakeholders asking them to distribute and advertise in public areas

Media release to inform members of the

public

Provide updates to CCG meetings with the public

Comms Comms Comms CCG/Comms

29 February Start and throughout Throughout (see below) Ongoing

5. Influencers (media, Mayor’s office and London Assembly members, borough councillors)

Adverts will be taken out in local papers

A reactive statement will be agreed to respond to any questions on publication of the SIC on 20 January 2016

A further, proactive release will be prepared which will outline the programme and the engagement in more detail

Another proactive release (half way through the engagement) will encourage people to get involved

A final media release will be issued immediately following the closure of the

Ensure their views are listened to Facilitate them into providing reliable information to their readers/constituents

Comms Comms Comms Comms Comms

29 February 20 January 2016 29 February Half way through engagement process End of engagement process

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engagement period

Documents will be emailed to MPs and we will offer to meet with them to discuss further

Meetings with campaign groups such as Save our NHS

Details of the programme will be emailed to voluntary organisations and charities and we will offer to meet with them

Comms TST/Comms TST/Comms

29 May Throughout engagement process Throughout engagement process

6. Represent and regulate

Attend meetings with the LMCs, NHS England, Royal Colleges, scrutiny committees and Healthwatch

Provide information as required under the NHS Act (OSCs) Receive independent endorsement for proposals and provide reassurance for relevant audiences Receive critical challenge and objective examination

TST/Comms Throughout engagement process

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7. Alignment with other strategies / policies / issues

a) This communications and engagement strategy will need to align closely with the organisational development and clinical leadership strategy, to ensure the impact of both strategies is maximised

An example of how this could work in practice is that the organisational development and clinical leadership strategy will need to take ownership of the programme to ensure it is delivered and implemented effectively. This will help to meet the aim of engaging CCG and Barts Health staff in the programme.

b) This implementation of this strategy will need to align with the communications and engagement strategies of Newham, Tower Hamlets and Waltham Forest CCGs.

c) All three CCGs (Newham, Tower Hamlets and Waltham Forest) have been approved to take on fully delegated commissioning of local GP services. The three CCGs have agreed to work together and will be developing a joint advisory board to oversee commissioning decisions. This should provide opportunities to better integrate care across the whole east London population – but will need to be explained.

d) CQC inspections of Barts Health. The trust is in special measures. The essential focus on these immediate issues may detract and/or complicate the focus on TST. The messaging has been (and continues to be) that TST addresses some of the underlying problems in the system and therefore has to be seen as part of the long term solution. It will also be important to highlight the positive aspects of Barts’ care e.g. low mortality rates; some of the best stroke and major trauma care in the world; the Barts Heart Centre. Maintaining staff morale will be critical to the success of the trust and to the programme as a whole.

8. FAQs Q: Is this about closing hospitals? A: No. Closing hospitals can save money and improve the quality of services but in East

London, because of the expected extra 270,000 people, this would not be appropriate. Nor would opening a new hospital. We need to live within our means and reduce our reliance on hospital-based care.

Q: Will the Transforming Services Together programme solve the funding gap in

this area? A: Not completely – but it would play an important part in restoring balance. Q: Will people have to travel further if you are proposing to consolidate some

surgery? A: Some people may have to travel further for their operation. However pre and post-

operative assessments would mainly be done at the patient’s local hospital. The proposals would reduce the number of cancelled operations and bring many services (such as outpatient) closer to home. So for most patients there will be a reduction in the need to travel. Patients would also benefit from shorter waiting times for surgery and improved outcomes.

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9. Timeline

The engagement process will begin on the 29th February and last for 12 weeks. Analysis of the engagement period will then be incorporated into an engagement report for 17th June.

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10. Risks and mitigations Risk Mitigation 1. Any proposed service moves

from one hospital to another will be seen as ‘downgrading’

Lines to take will be developed to make it clear that all moves strengthen the offer at each site

2. Not all decision-makers fully understand the requirements for engagement and consultation, so services are changed prior to approval

NEL CSU communications team attend programme meetings to advise decision-makers and others (as appropriate) on legislation, guidance and best practice in relation to service change

3. Everything focuses on small contentious changes when most of the programme is about being more efficient; making small-scale changes to streamline services and improve patient care

Develop narrative around the smaller scale changes (such as new protocols) and the benefits they will bring, and emphasise in all communications to stakeholders

4. Impact of Barts Health being put into special measures, following publication of the CQC report on Whipps Cross Hospital. The need to address immediate issues may detract from the longer-term vision

Continue to emphasise that action to address the immediate issues is crucial, but so is developing the longer term strategy, as this will address some of the root causes of the current challenges.

5. That ONEL/INEL JOSC do not support the proposals

Send the documentation and plans to the JOSCs prior to engagement asking for comment; offer to meet with chairs and/or committees in advance; offer to meet with committees during the engagement

6. Risk of loss of momentum Ensure ownership of programme through engagement and getting staff members to present/discuss at every opportunity

As phase two of this programme may involve consultation on service changes, it is important to be mindful of the reasons why proposals for health service change in England are contested. The Independent Reconfiguration Panel advises that one of the most common reasons why proposals are referred is: 8. Health agencies caught on the back foot about the three issues most likely to excite local opinion – money, transport and emergency care

The financial implications will be clearly laid out The clinical workstreams are asked to consider

implications for travel in their impact analysis There is an urgent and emergency care

coordination workstream in place. There is clear consensus within this group that emergency care needs to be retained on all sites.

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11. Evaluation The success of the formal engagement will be measured by:

Meeting milestones and adherence to action plan Key stakeholders (including patients) are aware and understand the issues Respondents’ views on quality of proposals and of the process Relevance of views expressed and the improvements made on the proposals Processes are sound and do not allow successful legal/quasi-legal challenge.

These align with the aims and objectives outlined in part 2 of the Strategy and Investment Case.