1. health and fitness

LONDON BOROUGH OF WALTHAM FOREST
HEALTH OVERVIEW
AND SCRUTINY COMMITTEE
Item No.
18th March 2015
Report Title: Transforming Services Together
Presented by:
Classification:
Terry Huff, Chief Officer, Waltham Forest CCG
Senior Responsible Officer, Transforming
For Scrutiny
Services Together programme
Report Author:
Status:
Claire Lynch Tel. No. 020 3688 1540
[email protected]
Communications Directorate, NEL CSU
Open
1.
SUMMARY
1.1
Purpose
We met with Waltham Forest Health Scrutiny Committee members on 9 September 2014 to
provide a briefing on the interim Transforming Services, Changing Lives Case for Change.
The purpose of this report is to:
 Share with the Waltham Forest Health Scrutiny Committee the final Transforming Services,
Changing Lives Case for Change
 Introduce a broader programme of work called Transforming Services Together, which is the
delivery programme of the joint 5-Year Commissioning Strategic Plan for Newham, Tower
Hamlets and Waltham Forest CCGs.
1.2
Accessing the Case for Change
The Case for Change document will be circulated with this report, and can be accessed via our
website www.transformingservices.org.uk
2.
BACKGROUND
2.1
Outcomes of the Transforming Services, Changing Lives programme
We engaged with around 2,800 clinicians, patients and members of the public. We tested our ideas
and sought views in a number of ways; we analysed feedback from over 90 meetings and events;
64 questionnaires; focus groups and interviews:
The case for change is clear
 Our population is growing and the local NHS needs to respond to increased demand, for
example in maternity and children’s services
 We need to better care for the increasing number of people with long-term conditions
 We and our partners need to work together more closely to strengthen our prevention
approaches, supporting people to live healthier lives and improving physical and mental
wellbeing
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2.2
The local NHS needs to invest time and effort in tackling inefficiencies. Estates, IT systems and
care pathways sometimes do not work for the greatest benefit of patients or staff
We need to fix our urgent-care system, ensuring patients are seen in the right care setting for
their needs
We need a transformed workforce for 21st-century care – with different skills and roles, working
in different settings
Changes will need to be made to local services if they are to be safe and sustainable. More
services need to be provided in the community, closer to people’s homes
The local NHS and partners will need to work together to secure high-quality and financially
sustainable services in east London
How did Transforming Services Together come about?
Organisations need to work together to create change across the whole health care system.
Newham, Tower Hamlets and Waltham Forest CCGs have produced a Five-year Commissioning
Strategic Plan which seeks to resolve strategic issues facing the region and to create a sustainable
health economy.
The Transforming Services Together programme was launched in September 2014 to deliver the
five-year plan.
The findings of Transforming Services, Changing Lives will form the basis of work to improve
hospital-based services through the relevant clinical and enabler workstreams of the Transforming
Services Together programme.
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2.4
Brief timeline (to date)
Summer 2014: Newham, Tower Hamlets and Waltham Forest CCGs finalised their joint 5Year Strategic Commissioning Plan
September 2014: Transforming Services Together programme launched and began
‘mobilisation’ to deliver the 5-Year Strategic Commissioning Plan
December 2014: Case for Change published, the outputs of which are being incorporated into
the Transforming Services Together programme
Jan 2015 onwards: implementation of Transforming Services Together programme
What is the scope of the Transforming Services Together programme?
The Transforming Services Together programme currently has 14 workstreams: nine clinical
workstreams, and five enabler workstreams (which support all the clinical workstreams.) More
information about these workstreams is available in Appendix 3.
Clinical workstreams
 Diagnostic services
 Maternity and newborn
 Children and young people
 Surgery
 Pathway redesign
 Urgent and emergency care coordination
 Primary care
 Integrated care
 Mental health
Enabler workstreams
 Population health informatics
 Workforce
 Organisational development/clinical
leadership
 Estates
 Long-term financial management
2
(Item X)
2.5 Who is involved?
NHS England was involved in the development of the plan and will continue to be involved in its
delivery. The three CCGs will work closely with their main acute provider, Barts Health NHS Trust,
to deliver many of the aims of the five-year strategic plan. The three CCGs will also work with:
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Neighbouring CCGs - in particular, City and Hackney, Barking and Dagenham, Havering,
Redbridge and north central London CCGs
NEL Commissioning Support Unit
Homerton University Hospital NHS Trust
East London NHS Foundation Trust
North East London NHS Foundation Trust
3rd sector organisations
Local authorities and public health teams in City of London, Hackney, Newham, Tower
Hamlets, Waltham Forest, Redbridge, Havering, Barking and Dagenham
Engagement with health and wellbeing boards, overview and scrutiny committees and other
stakeholders will be crucial as the programme progresses, and an engagement plan is being
developed. We are in the process of establishing a Transforming Services Together Patient and
Public Reference Group (PPRG.)
2.6 What are the aims of Transforming Services Together?
2.6.1 We have a range of challenges we need to address across east London:
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We need to make significant savings in our health economy
We are seeing a rising demand in our services
Our population has particular needs, including high levels of deprivation
The health of our residents is poor
The quality and availability of some of our services could be improved
Patient experience is often poor
A whole system change, rooted in partnership working, is required; piecemeal changes alone
will not address the root causes of the problems we face.
2.6.2 We want to:
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Help patients to be in control of their own health so they lead longer and healthier lives
Provide more co-ordinated health, social and mental health care in our communities
Improve hospital services and primary care services, including GPs
Ensure our budget is spent in the best way to provide a more sustainable health service
2.6.3 To do this we will:
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Be bold and ‘think big’
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This is whole-system, transformational change. The breadth and scale of the proposed
change is unprecedented in this region
Develop our partnership working to a degree not seen before in east London
o This will include developing new roles working across organisational and borough
boundaries
o We are starting from a good base. The integrated care programme, which involves
health and social care professionals collaborating across the NHS and local authority,
has been running in east London since 2013 and is seeing real results
Work at a pace that supports whole-system, transformational change
o As would be expected of a programme of this size, the 14 workstreams are at different
stages of development
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3.
Some of the changes needed are complex, involve a number of stakeholders and
organisations, and must account for future demand (for example, maternity care.) This
will take time and detailed planning.
o Other changes are about ‘fixing the basics’ in the current system – making immediate
changes to improve patient care and experience (for example, improving our IT
systems)
Engage our whole workforce in this system transformation
o It is our aim that the work of Transforming Services Together becomes ‘business as
usual’ for staff
o The people involved in our programme include clinicians, nurses, managers, local
authority colleagues - these are the people who know best where change is needed,
and can make it happen
Develop and shape a compelling vision that is shared by our staff, partners and patients
o We have been talking to and sharing our plans with many of our partners, through
formal and informal settings. We will continue to do so.
IMPLICATIONS PARAGRAPHS
3.1 Human resources implications
The Transforming Services Together programme will involve new roles and changes in roles. A
workforce workstream is in place, one of their roles will be to look at this area in more detail.
3.2 Financial implications
The Case for Change is clear that there are serious financial challenges facing both providers and
commissioners which will need to be addressed collectively. The Case for Change outlines
ambitions, not specific service proposals to address the financial challenge.
3.3 Health Impact Assessment / Equalities Impact Assessment
Reducing health inequalities was a key theme in the Case for Change. Any future service changes
arising through the Transforming Services Together programme will be subject to Equality Impact
Assessments
4.
CONCLUSION
The Waltham Forest Health Scrutiny Committee is asked to note the aims of and next steps for the
Transforming Services Together programme.
5.
APPENDICES
The appendices are at the end of this document and are:
Appendix One: timeline for the programme
Appendix Two: governance arrangements
Appendix Three: aims of the nine clinical and five enabler workstreams
6.
BACKGROUND PAPERS
The Transforming Services, Changing Lives Case for Change document will be circulated with this
report, and can be accessed via our website www.transformingservices.org.uk
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Appendix One – timeline for the programme
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Appendix Two – governance arrangements
To strengthen local governance arrangements to ensure north east London wide issues are addressed, and given the interdependencies across
systems, the North East London Advisory Group has been established. This group is predominantly focused on the strategic business challenges
facing the entire health economy.
At the November review of arrangements with NHS England, a proposal was agreed to establish a new North East London Clinical Senate, and to
agree clinical redesign and transformation proposals from a clinical perspective, ensuring a north east London system wide view is taken
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Appendix Three – aims of the nine clinical and five enabler workstreams
Clinical workstreams:
Diagnostic services
Overall aim:
The diagnostics workstream aims to:
To ensure high Understand and plan for growth in demand for diagnostics
quality and
 Transform diagnostic pathways to reduce ‘bottlenecks’ in the system
sustainable
 Ensure consistent 24/7 access to diagnostics across the patch
diagnostic services  Agree and implement best practice diagnostic protocols across primary and
across the health
secondary care to reduce over-investigation
system in east
 Share results across the system better, providing an end-to-end view of the pathway
London
We will know if we have been successful if we see:
 Patients receive timely diagnostics based only on clinical need, without duplication
occurring when care settings change
 Better patient experience; better access, tests appropriately available at the right
time and outside ‘office hours’
We plan to achieve by July 2015:
 A list of high impact protocols to work on, based on a review of local and national
data, best practice and existing guidelines
 A process in place to review and sign off best practice protocols, endorsed by
primary and secondary care
 A first set of protocols signed off, with a second set under review
 Plans for a local model for interventional radiology to tackle capacity issues and
improve outcomes (access to interventional radiology has been identified as a
significant system ‘bottleneck’)
 Work underway with population health and informatics to improve sharing of
diagnostic results between primary and secondary care
Maternity and newborn care
Overall aim:
The maternity and newborn care workstream aims to:
To improve the
 Prepare for the increase in births forecast across north east London over the next
quality of care for
10 years
women, their
 Provide antenatal care closer to home
families and
 Provide proactive postnatal care closer to home
newborns and to
 Promote normal deliveries in maternity care
plan for the future
 Increase the opportunities for women to give birth in local birthing centres or at
growth in demand
home
 Better support new mothers with mild and moderate mental health needs
 Move towards a named midwife model
 Enhance training for staff working in maternity services across all professions
 Understand the demand for neonatal transitional care1
 Understand future transitional and neonatal care capacity requirements
We will know if we have been successful if we see:
 More care available closer to home for pregnant women and new mothers, with
more women accessing that care
 A better patient experience, with fewer women having medical intervention during
birth
 Real choice for women, with an increase in births at birthing centres and at home
 A maternity service able to cope with the increased birth rate.
We plan to achieve by July 2015:
 Strengthen the existing north east London maternity network to enable it to take
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Where babies need treatment from specialist neonatal staff, for example on a postnatal ward, but do not need to be admitted to
a specialist neonatal unit.
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forward the work to determine future demand and capacity requirements given the
increasing number of births
 Understand the barriers to increasing the number of out of hospital births across the
system – this will include reviewing the capacity and usage of birthing centres and
the use of home birthing teams across north east London
 Understand how we can support our workforce to cope with extra demand and
provide a better patient experience
Children and young people
Overall aim:
The children and young people’s workstream aims to:
To ensure high Better coordinate and integrate care for children and young people
quality, integrated
 Boost paediatric expertise in urgent and emergency care settings
and sustainable
 Improve access to mental health services for children and young people, including
services for
in urgent and emergency care settings
children and young  Ensure age appropriate care is in place for children and young people
people across east  Improve the transition between young people’s and adult’s services
London
 Join up local authority/NHS work to maximise early interventions for children and
young people
 Optimise referrals from primary care to children and young people’s services
 Redesign hospital networks for children and young people
We will know if we have been successful if we see:
 A better patient experience for children and young people; where care is
coordinated, timely and appropriate to their age and clinical need.
We plan to achieve by July 2015:
 ‘Task and finish’ groups underway following workshops on paediatric expertise in
urgent and emergency care settings, integrated care and hospital-based networks
 Early drafts of standard guidelines of care provision for adolescents written
regarding age-appropriate care settings
 Pilots underway of virtual community ward support for children and young people
with intensive continuing care needs in some boroughs
 A proposed new diabetes pathway for children and young people with type 1
diabetes
Surgery
Overall aim:
The surgery workstream aims to:
To ensure a high Develop high-quality surgical services across sites;
quality, safe and
o Deliver a strengthened local surgical offer of core services; and
sustainable surgery
o Consolidate surgery where appropriate into specialist hubs to achieve safer
service for all
and better outcomes for patients and the wider health economy
patients
 Reduce the number of cancelled operations
 Deliver preoperative care closer to home
 Reduce the number of people having to stay in hospital overnight unnecessarily
 Ensure emergency surgery services are delivered in the most effective way
 Develop and map the elective paediatric surgery services available at each hospital
 Improve patient outcomes after surgery and speed-up recovery, through developing
enhanced recovery models
 Develop planned surgery teams that can work across hospital sites
We will know if we have been successful if we see:
 A better experience for all surgical patients; with treatment given by specialist teams
and fewer cancellations of planned operations
 Patients only staying in hospital if they need to
 More people going home from hospital quickly and safely
 Better clinical outcomes
We plan to achieve by July 2015:
 A plan in place that describes the ‘surgical offer’ for a range of specialties on each of
the three main Barts Health sites, segmented into:
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(Item X)
o
o
o
Pathway redesign
Overall aim:
To provide better,
more efficient and
sustainable care
for patients within
‘high-volume’
specialties across
east London
Primary care
Overall aim:
To provide
coordinated,
proactive and
accessible care
for all patients
Core services: surgical services which support the delivery of emergency,
medical and maternity services, available on all three sites
Core plus services: surgical services which require some specialisation,
available on one or two sites
Complex services: surgical services required to support the treatment of
complex cases, available on one site
The pathway redesign workstream aims to:
 Redesign long-term condition care pathways across primary, community and acute
care
 Implement new models of outpatient care to provide more effective, sustainable
care to patients when they need it
 Re-establish the GP’s role as an ‘expert generalist’ so that care for patients with
long-term conditions is co-ordinated through them
 Maximise the use of technology and innovation (e.g. telephone and Skype clinics)
 Increase service provision in the community, closer to home
 Increase efficiency by removing duplication and other waste
 Improve patient experience, ensuring they are seen by the right clinician, first time
We will know if we have been successful if we see:
 A better patient experience across primary, community and secondary care
 Better quality and more sustainable services
 Patients treated closer to home where appropriate and reduced attendance by
patients with long-term conditions at A&E or urgent care facilities
 Improved clinical outcomes
We plan to achieve by July 2015:
 A workplan to agree the high impact pathways to improve first
 First redesign workshops on pathway improvement in chosen specialities held
The primary care workstream aims to (through co-commissioning - see page 17):
 Develop and agree a service model that enables more high quality care to be
delivered closer to patients’ homes in a way that does not duplicate but integrates
with other services and is tailored to the needs of the community.
 Support the delivery of primary care at scale through GP networks or other
emerging formations that are fit for purpose and are able to bid for and hold NHS
contracts
 Enables patients to be cared for within a primary care setting where safe and
appropriate to do so therefore reducing the reliance upon acute and urgent care
services.
We will know if we have been successful if we see:
 A better patient experience of primary care services
 Long-term conditions diagnosed early
 People supported to be more in control of their condition
 Less people requiring unscheduled care.
 Services delivered through GP provider networks or other ‘at scale’ formations.
 A bigger multidisciplinary primary care workforce, where all staff are developed and
the best staff are retained.
We plan to achieve by July 2015:
 A review of the extended hours arrangements across WEL
 A plan for delivering multi-channel access (example, online, telephone or videoconferencing)
 A consistent WEL wide approach for GP provider network development
 A clear vision for how co-commissioning can support the development of our
objectives.
Integrated care
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Overall aim:
A local NHS that is
shaped around the
needs of the
patient, rather than
organisational and
borough
boundaries
The integrated care workstream aims to ensure:
 Care plans are developed around the needs of the patient at the 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 support people in
their own homes better
 Technology is put to better use and information shared securely to ensure staff have
information about the right person at the right time in the right place
 Commissioning approaches incentivise joint working and preventative care
 All organisations work together to meet the needs of their patients
We will know if we have been successful if we see:
 People supported to manage their health at home and treated in the most
appropriate setting when needed
 A better patient experience, where patients feel supported to be more in control of
their health
 Information sharing across organisational and borough boundaries
 People having to repeat information about their condition becomes a thing of the
past
 Care resources are used efficiently getting the maximum possible benefit for the
money we spend on care
We plan to achieve by July 2015:
 Integrated care service in place aimed at the top 5% of people identified as being at
high
risk of being admitted to hospital. This includes for these patients:
o Rapid Response Service - where patients are assessed, treated and
supported in their own home avoiding an unnecessary and costly admission
into hospital or residential care
o Process for care planning developed
Mental health
Overall aim:
To provide a better
mental health
service in
prevention and
recovery
The mental health workstream aims to:
 Improve the mental health of all patients, through prevention, early identification and
intervention, with a particular focus on people with long-term conditions and
complex co-morbidities
 Improve the physical health of people with a serious mental health illness
 Reduce stigma and discrimination and improve preventative approaches to mental
health for at risk groups
 Improve the recovery of people with common mental health problems
 Also focus on the mental health needs of the workforce.
We will know if we have been successful if we see:
 Improved service user experience for patients and staff, where the impact of mental
health conditions is lessened due to prevention and early intervention
 Parity of esteem between physical and mental health.
We plan to achieve by July 2015:
 A clear strategy, aligning mental and physical health professionals, that defines how
to deliver parity of esteem, transform urgent mental health support for young people
and adults and improve dementia care
 A plan to deliver the London Health Commission recommendations around crisis
care, perinatal mental health and others
Urgent and emergency care coordination
Overall aim:
The urgent and emergency care coordination workstream aims to:
To provide a
 Deliver a safe, sustainable and whole-system model of urgent and emergency care
whole-system,
across east London
consistent and
 Support people with urgent care needs to get the right advice, in the right place, first
high-quality urgent
time
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(Item X)
and emergency
care across east
London.
Right advice, in the
right place, first
time, 24/7.
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Ensure services for urgent, non-life threatening needs are delivered at or as close to
home as possible
 Provide the best expertise and facilities to reduce risk and maximise survival and
good recovery
 Deliver strong and consistent patient experience
 Provide an operationally resilient system
A key part of this approach will be to ensure a whole-system approach, ensuring
primary and secondary care are joined up
We will know if we have been successful if we see:
 Improved patient experience
 Better care, services and advice in the community: reducing the number of people
going to A&E; reducing the need for people to spend time in hospital; and reducing
the time they spend in hospital
 Better care and systems in A&E and hospitals: reducing the time ambulances wait
to handover patients and the time patients wait in A&E
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Better and simpler processes to support the improvements and make them
sustainable.
We plan to achieve by July 2015:
 Using findings from the Sir Bruce Keogh’s Urgent and Emergency Care Review and
the Barts Health ‘Stepping into the future’ initiative (Jan - Feb), where senior staff
are released from other duties to be available in A&E and on wards:
o Understand what the changes are that will have the biggest impact and how
quickly they can begin
o Understand how ambulatory care (treating patients in hospital without the
need for overnight stays) can be used to treat more patients
o Shape a clinically-led vision for sustainable emergency care across east
London
 Define a consistent approach and strategy for out-of-hospital urgent care across
east London, working to deliver the right care to patients in the right place at the
right time, to help better manage referrals through to secondary care. This will
include work to:
o Design consistent urgent care pathways, aligned across 111, urgent care
centres, walk-in centres, GP out-of-hours services and others
o Identify ways to improve urgent care delivery for mental health patients
o Develop safe and robust processes for admissions avoidance and
ambulatory care
Enabler workstreams:
Workforce
Overall aim:
Develop an east London
approach to workforce
issues, rather than a local
approach, which fails to
address our shared
requirements.
The workforce workstream aims to:
 Ensure sufficient skilled staff are recruited to meet future demand
 Improve staff retention across the system
 Support the overall improvement of quality and patient experience
 Enhance the flexibility of our current workforce and create roles that will
respond to future demand
A key part of this approach will be to develop an east London approach to
workforce issues, rather than a local approach (which fails to address our shared
requirements.)
We plan to achieve by July 2015:
 A map of the NHS workforce across east London, which will give a profile of
the workforce, including unfilled positions and the age of employees
 Work underway for workforce modelling to support the clinical workstreams in
their planning
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A plan in development with both providers and commissioners to retain and
recruit staff in east London, which includes aligning bank and agency
arrangements across hospital and community trusts
Organisational development and clinical leadership
Overall aim:
The organisational development and clinical leadership workstream aims
to:
Ensure the changes
proposed by Transforming  Develop a framework that enables all of the workstreams to achieve their
Services Together are
goals and outcomes
embedded into the local
 Establish and implement a model of clinical leadership for the Transforming
health system, and the
Services Together programme
long-term objectives of the  Build a sustainable network of ‘change agents’ that supports Transforming
programme can be
Services Together for the next five years
realised.
 Ensure the vision, objectives and benefits of Transforming Services Together
are clearly articulated and understood by all stakeholder groups
A key part of this approach will be to ensure the changes proposed by
Transforming Services Together are embedded into the local health economy,
and the long-term objectives of the programme can be realised.
We plan to achieve by July 2015:
Note: in development. This workstream is at an earlier stage, as it needs to link
closely with and respond to, the emerging aspirations of the clinical workstreams
Estates
Overall aim:
The estates workstream aims to:
Ensure there is an
 Coordinate day-to-day and longer-term initiatives to improve the NHS estate
appropriate balance
 Have a good understanding of the demand for and supply of, NHS estate
between the need to make  Provide information about estates to clinical workstreams, to inform their
progress in the short-term,
plans
whilst developing a longer-  To develop a strategic estates plan
term plan for providing
A key part of this approach will be ensure there is an appropriate balance
high-quality, well-utilised,
between the need to make progress in the short-term, whilst developing a
NHS estate
longer-term plan.
We plan to achieve by July 2015:
 A map of all NHS buildings across north east London - across primary,
community and hospital care
 Use the map to support and advise all the clinical workstreams in their
discussions regarding service changes, particularly around moving hospital
services closer to people’s homes
Population health informatics
Overall aim:
The population health informatics workstream aims to:
Act as a coordinating
 Ensure real time, system wide, shared electronic health record; wherever a
function for all the
patient is seen or a decision made in the health and care system, the
informatics projects taking
appropriate data from every responsible (health and care) organisation must
place across east London
be available safely in a real time structured view, embedded into the
to improve patient
workflow of the local system
healthcare
 Offer 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. Insights should be fed back to individual patient records.
 Involve patients with their own electronic health record
 Enhance infrastructure reliability and access
Key to this are three themes;
 Single systems; where all partners use informatics to build a single approach
in identifying and implementing the systems we want to use, to provide
greater consistency and potential for information sharing across providers
 Connectedness; use electronic information to make sure patients get the
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(Item X)
right care, from the right clinicians wherever they are managed
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
We plan to achieve by July 2015:
• A baseline of the infrastructure for informatics and a plan to fix identified gaps
• Make further progress in real-time sharing of patient records
• Conclude the process for identifying how patients will collaborate
Long-term financial management
Overall aim:
The long-term financial management workstream aims to:
To support financial
 Have oversight of the delivery of all financial activity modelling for
sustainability across the
Transforming Services Together in support of the Transforming Services
east London health
Together investment case
economy, for
 Produce an improved financial management tool to support local long-term
commissioners and
financial planning that enhances the commissioners financial planning
providers, by the end of
capability
year 5 of the Transforming  Construct a system wide consolidated commissioner and provider financial
Services Together
model to support a robust and analytical basis for assessing the long term
programme.
financial viability of the whole health economy
 Agree and sign-off all financial communication and information disclosure for
Transforming Services Together
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