1. No category

Part: Public
Paper 6.2
Cover Sheet: Governing Body
Date
15th January 2014
Title of paper
Ealing CCG Out of Hospital Delivery Strategy
Presenter &
Organisation
Mohini Parmar, Ealing CCG Chair
Author
Kathryn Magson, Ealing CCG MD
Responsible director/ Name and Role
Clinical Lead
Confidential
Yes
No
The Governing body is asked to:
Approve the draft Ealing out of Hospital strategy including the OOH model of care and services that could
potentially be delivered in each of the settings
Summary of purpose and scope of report
This delivery strategy builds upon and progresses the commitments made in Ealing’s 2012 out of hospital
strategy, Better Care, Closer to Home. Specifically this document sets out:
How health services delivered outside of hospital will be organised in the future
Our plans for increasing the amount of services delivered outside of hospital
How the services will meet the needs of patients across the whole of Ealing and what
these changes will mean for residents.
Our plans to establish the infrastructure and workforce required to help deliver the out
of hospital care outlined.
This strategy supports the reconfiguration of acute services across North West London set out within
Shaping a Healthier Future.
Lastly, this document will directly inform Ealing CCG’s Out of Hospital Strategic Service Delivery Plan (SSDP)
which will include the investment in infrastructure and workforce needed to deliver transformations in out
of hospital care.
Quality & Safety/ Patient Engagement/ Impact on patient services:
This strategy will ensure that there is reduced variability in quality of delivery across Ealing and also
increase the range of services locally. It is anticipated that full implementation of this strategy will lead to
improved access to services, increased range of service delivered locally and less services delivered in an
acute setting.
Equality / Human Rights / Privacy impact analysis
This strategy aims to improve access to improve services for all groups. As the SSDP and OBC is delivered
specific activities will take into consideration the needs of different groups. This includes assessing estates
based on accessibility and mapping different needs across the borough.
Financial and resource implications
There are no direct, immediate legal or financial implications arising from this report for either Ealing CCG
or London Borough of Ealing.
Across North West London, an additional £190m of investment is being made available for the
strengthening of Out of Hospital services. This has already been fully accounted for through the CCG’s
financial plan and QIPP planning.
Ealing CCG has formulated its Out of Hospital Delivery Strategy, with the clear objective of discharging all
its obligations whilst not exceeding its resource limits. All schemes which involve new investments will be
subject to business case approval through the CCG’s Executive Committee and Governing Body. All
schemes which require the investment of capital will be subject to the usual approval process, with
additional oversight by NHS England and Her Majesty’s Treasury.
Risk
By their very nature, large scale transformational programmes carry an element of inherent risk,
which vary according to the local delivery environment at the point in time each element is
implemented. This strategy sets out a number of plans, goals, targets and aims.
All schemes which involve new investments and/or a significant change to care pathways or
patient experience, will be subject to business case approval through the CCG’s Executive
Committee and Governing Body as regulations and authority requirements so stipulate. Where
initiatives interface with the Local Authority the CCG is committed to working with the Council in
the re-design of specific services and will report these to the Health and Well Being Board as and
when appropriate.
A significant and robust governance structure is in place across North West London where Boards
such as the CCG Chairs Collaboration Board regularly review risk, safety and patient experience
to ensure this is well managed.
Governance and reporting (list committees, groups, or other bodies that have discussed the paper)
Committee name
Date discussed
th
Outcome
Ealing CCG Executive Innovation
Committee
18 December
Discussed and feedback provided
Ealing CCG Executive Innovation
Committee
8th January
Discussed and approved
Ealing Health & Well Being Board
14th January
TBC
Ealing CCG Governing Body
Ealing CCG Council of Members
th
TBC
th
TBC
15 January
15 January
Draft Out of Hospital Delivery
Strategy
Ealing Clinical Commissioning Group
Edition: 8.1
Date: 09 January 2014
Approved by:
Page 1 of 41
Executive Summary
Purpose of this document
This delivery strategy builds upon and progresses the commitments made in Ealing’s 2012
out of hospital strategy, Better Care, Closer to Home. Specifically this document sets out:
How health services delivered outside of hospital will be organised in the future
Our plans for increasing the amount of services delivered outside of hospital
How the services will meet the needs of patients across the whole of Ealing and
what these changes will mean for residents.
Our plans to establish the infrastructure and workforce required to help deliver
the out of hospital care outlined.
This strategy supports the reconfiguration of acute services across North West London set
out within Shaping a Healthier Future.
Lastly, this document will directly inform Ealing CCG’s Out of Hospital Strategic Service
Delivery Plan (SSDP) which will include the investment in infrastructure and workforce
needed to deliver transformations in out of hospital care.
The need to improve Out of Hospital Care
Population and health needs
Ealing is a large London Borough with a unique set of challenges. Ealing’s demographics are
changing and, as a result, the health and care system needs to respond. In addition Ealing
has a number of specific health challenges which include:
The main causes of death in the borough are; Cardiovascular disease – 31% of all
deaths, Cancers – 30% and Respiratory disease – 14%
High rates of emergency admissions for heart attacks, strokes, and mental health
problems
High prevalence of diabetes – 20,000 patients diagnosed, set to double in the next
ten years
High rates of substance misuse and alcohol-related hospital admissions
Access to and quality of care is variable
At present, access to care and the quality of care are variable across the borough. For
example;
Too often our care is fragmented and we have an over-reliance on hospital care.
Many hospital admissions could be prevented or treated in a community setting that is
better for patients.
People can end up staying in hospital longer than they need or wish to, due to a lack
of adequate supported discharge. We need to have more planned care and earlier
interventions outside of hospital, and access to and quality of care that people receive
can be variable.
Developing and investing in Out of Hospital care will help us meet the changing requirements
of Ealing’s population and enable them to access the care they need in the most appropriate
setting.
2
Vision for our care from now to the next five years
We have a vision of reform which moves the system from a responsive to a proactive system
that delivers care in a planned and coordinated way. At the heart is the empowerment of
individuals, carers and families. We have also set out a number of strategic goals that we are
working to deliver and standards against which we will measure our success.
What patients have told us
Through the development of this strategy we have listened to the needs of patients across
Ealing to understand their preferences for out of hospital services. The key themes arising
from our engagement to date include:
Patients want the ability to ‘take control of their own health and care needs
Accessible services is a consistent theme and include; transport, language and the
availability of appointments
Patients want to experience care that is co-ordinated and joined up
Throughout this document we have set out what this means for patients across Ealing.
Integrated and Co-ordinated Care
We want Ealing residents using community health and care to experience coordinated,
seamless and integrated services using evidence-based care pathways, case management
and personalised care planning. Integrated care will underpin our approach to the delivery of
all services across all settings of care.
Over the last year we have begun to develop an emerging vision for care across Ealing and
have worked with our partners to develop a set of design principles and success factors. We
are now working to implement our plans to improve the integration and co-ordination of
health and care for patients across Ealing.
Delivering care across a number of settings
We want to provide care as close to home as possible so that people can get easier and
earlier access to care. To achieve this will deliver health and care services from a number of
different settings that will be located across the borough.
Each setting of care will play a different, complimentary role, in delivering our out of
hospital care.
Our plans to deliver services out of hospital
As outlined above we plan to increase the number of services delivered outside of hospital.
This section sets out the services we intend to deliver across the different settings outside of
hospital. This will allow patients in Ealing to:
Have easy access to high quality and responsive primary care
Receive high-quality planned care out of hospital
3
Experience responsive urgent care
Receive the appropriate mental health care locally
In the future, more services, particularly for planned care, will be delivered within out of
hospital settings. The diagram below shows that the majority of support will be delivered in
an out of hospital setting. This is supported by the acute and tertiary care settings which will
provide support to those patients who are most ill.
Infrastructure required to support delivery
To support the delivery of our OOH strategy we need to develop the way we will work
together with patients and our partners, how we need to develop our staff to deliver the
change, improvements in our IT and other infrastructure. In particular:
Ways of working
Workforce
Information technology
Patient Transport
4
Estates Baseline
Delivering our strategy will have a number of important implications for our estate across
Ealing. The impact of OOH delivery will be felt at two levels: Impact on GP estates and
Impact on hubs.
To enable the improvements in OOH care appropriate investment is required in estates
across Ealing. The CCG in is in the process of identifying potential locations and estates for
local hubs. This document will inform the development of the SSDP which will set out a
number of options to be assessed using an agreed set of criteria.
Next steps
To receive investment for improvements in OOH estates the CCG must complete a number
of steps which generate a number of outputs. These will ultimately result in an Outline
Business Case for priority investment.
What this means for patients:
GPs will continue to provide core GP services and will act as the named point of
contact for co-ordinating the care for their patients
Patients will continue to be registered with their GP and use them as their main
point of access to the health system
Improved access to GP appointments with local GP practices and hubs and will
have access to an increased range of services
A greater number of services will be delivered locally across four main settings;
GP Practices, within a network or at a hub and at the Local Hospital.
Responsive urgent care when needed to keep patients out of hospital settings
Patients with the most complex cases will continue to be seen in a major or
specialist hospital as they will have access to more specialist services
5
Contents
Executive Summary ............................................................................................................................................. 2
Purpose of this document .................................................................................................................................. 2
The need to improve Out of Hospital Care ....................................................................................................... 2
Vision for our care from now to the next five years .......................................................................................... 3
What patients have told us ................................................................................................................................ 3
Integrated and Co-ordinated Care .................................................................................................................... 3
Delivering care across a number of settings ..................................................................................................... 3
Our plans to deliver services out of hospital ..................................................................................................... 3
Infrastructure required to support delivery....................................................................................................... 4
Estates Baseline................................................................................................................................................. 5
Next steps .......................................................................................................................................................... 5
1. Purpose of this document .............................................................................................................................. 8
2. The need to improve Out of Hospital Care ................................................................................................... 8
3. Vision for our care from now to the next five years .................................................................................. 10
Our vision for out of hospital care .................................................................................................................. 10
Expected outcomes .......................................................................................................................................... 10
Strategic Goals ................................................................................................................................................ 11
Out of Hospital Standards ............................................................................................................................... 11
4. What patients have told us .......................................................................................................................... 13
5. Integrated and Co-ordinated Care ............................................................................................................... 14
6. Delivering care across at number of settings ............................................................................................ 16
The role of GP Practices ................................................................................................................................. 16
The role of GP Networks ................................................................................................................................. 16
The role of Local Hubs: .................................................................................................................................. 17
The role of the Local Hospital......................................................................................................................... 17
7. Our plans to deliver services out of hospital ............................................................................................. 18
Ealing CCGs model for Out of Hospital Care ................................................................................................ 18
Delivering high-quality Planned Care out of hospital .................................................................................... 20
Mental Health.................................................................................................................................................. 24
8. How will our initiatives deliver our standards ........................................................................................... 25
Outcome-based measures of success ............................................................................................................... 25
9. Infrastructure required to support delivery ................................................................................................ 26
Ways of working .............................................................................................................................................. 26
Workforce ........................................................................................................................................................ 26
6
Information technology ................................................................................................................................... 28
Patient and Community Transport .................................................................................................................. 28
10.Estates ........................................................................................................................................................... 30
Impact of our Out of Hospital Strategy on Estates ......................................................................................... 30
Estates baseline ............................................................................................................................................... 30
11.Next steps ...................................................................................................................................................... 31
Strategic Service Delivery Plan ...................................................................................................................... 31
Site Service Specification ................................................................................................................................ 31
Site options development and assessment ....................................................................................................... 32
Outline business case ...................................................................................................................................... 32
12.Appendices .................................................................................................................................................... 33
Appendix 1: Health of Ealing Population ....................................................................................................... 33
Appendix 2: GP Practices and Networks in Ealing ........................................................................................ 34
Appendix 3: GP Location and indicative list size ........................................................................................... 36
Appendix 4: Case for Change ......................................................................................................................... 37
Appendix 6: Delivering our national expectations.......................................................................................... 38
Appendix 7: Initial list of services for inclusion in the Local Hospital and hubs ........................................... 39
Appendix 8: Draft criteria for the evaluation and prioritisation of investment .............................................. 41
7
1. Purpose of this document
This delivery strategy builds upon and progresses the commitments made in Ealing’s 2012
out of hospital strategy, Better Care, Closer to Home. Specifically this document sets out:
How health services delivered outside of hospital will be organised in the future
Our plans for increasing the amount of services delivered outside of hospital
How the services will meet the needs of patients across the whole of Ealing and
what these changes will mean for residents.
Our plans to establish the infrastructure and workforce required to help deliver
the out of hospital care outlined.
This strategy supports the reconfiguration of acute services across North West London set
out within Shaping a Healthier Future.
Lastly, this document will directly inform Ealing CCG’s Out of Hospital Strategic Service
Delivery Plan (SSDP) which will include the investment in infrastructure and workforce
needed to deliver transformations in out of hospital care.
2. The need to improve Out of Hospital Care
Ealing faces a number of demographic and health challenges
Ealing is a large London Borough with a unique set of challenges. Ealing’s demographics are
changing and, as a result, the health and care system needs to respond:
Ealing’s population: set to rise to 372,000 by 2020
A predicted increase of 48% in over-85s
A quarter of our population is aged under 20
High proportion of children living in poverty
Significantly increasing demands on and need for carers of children and older people
Increasing prevalence of long term conditions in deprived areas
In addition Ealing has a number of specific health challenges which include
The main causes of death in the borough are; Cardiovascular disease – 31% of all
deaths, Cancers – 30% and Respiratory disease – 14%
High rates of emergency admissions for heart attacks, strokes, and mental health
problems
High prevalence of diabetes – 20,000 patients diagnosed, set to double in the next
ten years
High rates of substance misuse and alcohol-related hospital admissions
Access to and quality of care is variable
At present, access to care and the quality of care are variable across the borough. For
example;
Too often our care is fragmented and we have an over-reliance on hospital care.
Many hospital admissions could be prevented or treated in a community setting that is
better for patients.
People can end up staying in hospital longer than they need or wish to, due to a lack
of adequate supported discharge. We need to have more planned care and earlier
interventions outside of hospital, and access to and quality of care that people receive
can be variable.
8
Developing and investing in Out of Hospital care will help us meet the changing requirements
of Ealing’s population and enable them to access the care they need in the most appropriate
setting.
Financial case for change
We have used existing data to develop a picture of total spend across Acute, Community,
Mental Health and Continuing Care across the borough.
Ealing CCG - Project spend for Acute, Community, Mental Health and
Continuing Care 2013/14 to 2017/18
400,000
350,000
300,000
CCG Spend
£'000
250,000
200,000
150,000
100,000
Community
(exluding Primary
Care LES)
Continuing Care
Mental Health
Acute
50,000
-
Source: Ealing CCG Initial Budget and Financial Plan 2013/14. Assumptions for change in spend based on projections applied
in the SaHF DMBC,
The above chart shows that planned spend for FY13/14 for Acute Care, Mental Health,
Continuing Care and Community Care. Changes in population coupled with expected
change in prevalence rates are predicted to increase the cost of delivering these services
14% by 2017/18. These levels of change create a financially unsustainable position along
with increased pressure on current infrastructure and workforce.
In order to maintain a financially sustainable health economy that meets the changing patient
needs and continues to deliver quality care a fundamental change is required. To deliver this
change Ealing CCG plan to implement a range of new models of care. The planned net
saving across theses selected services to 2017/18 is £65m with 87% of this net saving from
reduced Acute spend.
Significant investment in Out of Hospital Care will be essential to ensure these plans can be
achieved and Ealing residents are able to receive the level of care they require in a local
setting.
Further analysis using the baseline data will be developed in the SSDP.
9
What this means for patients:
A larger range of services will be delivered closer to patients homes
Improved access to primary care across Ealing at times convenient to patients
Ealing residents will continue to receive high quality services
3. Vision for our care from now to the next five years
We have a vision of reform which moves the system from a responsive to a proactive system
that delivers care in a planned and coordinated way. At the heart is the empowerment of
individuals, carers and families. We have also set out a number of strategic goals that we are
working to deliver and standards against which we will measure our success.
Our vision for out of hospital care
We will work in partnership with patients, public, community and hospital clinicians and
managers, out-of-hours services, social care and the voluntary sector to provide
integrated care pathways for people with a LTC). This will include changing the way we
fund healthcare services to ensure different providers work together better.
We want to provide more care closer to home so people can get easier and earlier access
to care. This will mean we can help people stay healthy and potentially life threatening
diseases can be picked up at an earlier stage – when treatment is much more likely to be
successful and can avoid patients ending up in hospital
Expected outcomes
In addition to supporting us achieve wider outcomes and strategic aims the main areas of
benefit expected to be delivered as described by the “Shaping a healthier future”1 are:
Improved clinical
outcomes for
patients
Reduced mortality through better access to senior doctors
Reduced complications and poor outcomes for people with long-term
conditions by providing more coordinated care and specialist services in
the community
Quicker access to treatment by more senior doctors
Improved
experiences for
patients and their
care
Increased ability to take control of their own health conditions
Improved access to GPs and other services so patients can be seen
quicker and at a time convenient to them
Less time spent in hospital as services are provided in a broader range of
settings
Improved
experiences for
staff
Improvements in patient care
Improved team and multi-disciplinary working
Improved integration across out of hospital and acute care
Increased opportunities to maintain and enhance skills such as allowing
doctors to develop their specialist skills
Operating services
with improved
financial
sustainability
Reduced admission and readmission rates
Reduced GP appointments
Reduced number of did not attend appointments
Improved efficiency of services
1
http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/SaHF%20DMBC%20Executive%20Sum
mary%20(extract%20from%20Volume%201).pdf
10
Strategic Goals
Better Care, Closer to Home set the vision and strategic goals for out of hospital care. Each
of our strategic goals below represents a specific commitment that patients can expect from
out of hospital care.
OOH Strategic Goals
We will deliver these goals in three ways:
• Accessible care: care that is responsive to patients’ needs and preferences, timely
and accessible.
• Proactive care: proactive planned care that is easy to access, convenient and able to
utilise specialist skills where appropriate.
• Co-ordinated care (including rapid response and supported discharge): care that is
patient-centred, co-ordinated and offers continuity of care to high need patients.
Out of Hospital Standards
We have agreed a number of clinical standards, applicable across all North London CCGs, to
ensure that quality is maintained and improved as our services change. They apply to both
core primary care delivered by GP practices and, more broadly, care delivered outside of
hospital.
Since 2012, we have become both more ambitious, and more specific, about the standards
we expect from different parts of the system. We have since added two further standards –
“Population and Prevention-orientated” and “Safe and High Quality”.
11
Revised OOH Delivery Standards
What this means for patients:
A more extensive range of services closer to patients homes
Improved access to primary care across Ealing at times convenient to patients
Greater co-ordination of patients care across different providers with named
healthcare professionals supporting them
Patients will be supported to manage their own care through the provision of relevant
and accessible information
12
4. What patients have told us
Ealing CCG has made an on-going commitment to capturing public feedback and patient
experiences. This information is gathered through a number of conduits, including public
stakeholder meetings, the four local community networks, local voluntary sector forums,
partnership boards, a range of patient and carer-led groups, Healthwatch, complaints, Patient
Participation Groups at local GP practices, and via patient representatives.
Community transport, interpreting services and
support for carers have been frequently raised
through our PPE work.
Patient feedback and research shows that
patients expect a health system that delivers
better quality, more accessible and more coordinated healthcare in and out of hospital.
Patients have told us what they want from all out
of hospital services and from primary care their
feedback is important in building our plans to
deliver out of hospital care.
Patient Expectations of Care
We have also undertaken a range of engagement activities to support the development of
our Out of Hospital Strategy and Specification for the Local Hospital. The key events and
findings are set out below and these themes have been addressed throughout the document.
Summary of engagement events to develop the OOH Strategy and Local Hospital Specification
What this means for patients:
Patients want the ability to ‘take control of their own health and care needs
Accessible services is a consistent theme and include; transport, language and the
availability of appointments
Patients want to experience care that is co-ordinated and joined up
13
5. Integrated and Co-ordinated Care
We want Ealing residents using community health and care to experience coordinated,
seamless and integrated services using evidence-based care pathways, case management
and personalised care planning. Integrated care will underpin our approach to the delivery of
all services across all settings of care.
Progress to date
Scheme
Roll out the Integrated Care
Pilot
Progress to date
Integrated Care Pilot (ICP) operating since 2012 has demonstrated
clear benefits by using risk stratification, care plans, case
conferences and multi-disciplinary teams to improve the coordination of care.
The Health and Wellbeing Board in Ealing has agreed a shared
commitment to implement integrated care at scale and pace, building
on existing partnerships. Our approach to health and social care
integration is based on the registered GP list, organised around the 7
GP Networks based in 3 localities.
Our future plans
Over the last year we have begun to develop an emerging vision for integrated care in
Ealing:
In Ealing care organisations will work seamlessly to promote and deliver healthier
communities to deliver positive experiences and improved health outcomes.
Patients, service users and their carers will be at the heart of decisions about their
health and wellbeing.
We have also worked with our partners to develop a set of design principles and what we
consider to be success factors.
Our approach will focus on patients with complex health and social care needs, such as
the frail elderly, patients with long term conditions and frequent users of health and
social care services. We will work across organisational and professional boundaries to
ensure that we deliver health and social care interventions in a coordinated patient-centred
way to the most vulnerable patients in our communities. A process of stratification will be
used to group patients, and from this most appropriate care services will targeted.
14
GPs will be at the centre of organising and coordinating people’s care and will act as
the people’s champion; ensuring people receive high quality integrated care that helps
them achieve their own goals. GPs will work with other providers in integrated networks and
will be able to draw upon all the services and resource they need to meet people’s care
goals. Whilst not all care or coordination has to be delivered by individual GPs, the GP’s
patient register will be the organising principle that guides how care is co-ordinated between
agencies.
Care co-ordinators will be accountable for ensuring that all of our out of hospital
standards relating to care planning and co-ordination are met. They will ensure that
patients always know who to turn to, without having to worry about which agency is
responsible for any particular need, or which budget it might relate to. They will be based in
our seven care networks, allowing them to align with our existing multi-disciplinary groups
(MDGs) and support the virtual ward networks, but will build and maintain very strong links
with practices.
Local Hubs and the Local Hospital will support multi-disciplinary groups and care
networks who will provide a number of services across all settings of care. Multi-disciplinary
teams, aligned with our networks will provide holistic care for patients with Long-Term
Conditions (LTCs) or complex health needs. These teams will be comprised of local GPs
working with community health and social care practitioners such as district nurses,
community psychiatric nurses, and social workers.
Systems will enable and not hinder the provision of integrated care. The financial model
will pay for people’s health and social care needs on a basis that rewards outcomes not
contacts. Commissioning budgets will also be pooled where this would be beneficial for the
population. To enable seamless delivery, information about people’s care will be shared with
them and, with their permission, across the organisations that are responsible for providing
their care. Leaders will no longer accept ways of working that are silo-based and do not
consider the needs of people beyond their own part of the pathway of care. Providers will be
responsible for taking joint accountability for achieving a person’s outcomes and goals and
will be required to show how this delivers efficiencies across the system.
We are already working with the London Borough of Ealing to commission a range of
service for children and young people. Our main initiative are set out in the following
sections.
What this means for patients:
GPs will be at the centre of organising and coordinating people’s care and will act
as the people’s champion
Patients with complex needs will have care co-ordinators who will be accountable
for ensuring that the standards relating to care planning and co-ordination are met
Multi-disciplinary teams will be aligned to networks and support the delivery of
holistic care for patients with LTCs or complex needs
15
6. Delivering care across at number of settings
We want to provide care as close to home as possible so that people can get easier and
earlier access to care. To achieve this will deliver health and care services from a number of
different settings that will be located across the borough.
Our aim is to provide services as locally possible where it is both safe and affordable to do
so. To support the assessment about where services should be located we have
considered the following factors:
Quality of Care
Clinical quality
Patient safety
Patient experience
Affordability
Level of activity
Cost of provision
Deliverability
Workforce
Estates
Equipment
Clinical and Non-Clinical Dependencies
Accessibility
Ability and need to access services
Patient choice
Out of Hospital Services within Ealing be delivered at one of the following settings:
The role of GP Practices:
Patients will continue to be registered with their GP and use them as their main
point of access to the health system.
GP practices will continue to deliver the full range of core services and will offer a
variety of systems for walk-in access, telephone triage, same day and pre-booked
appointments.
Where appropriate GP practices will also provide a range of services including
procedures such as minor surgery. GPs will also have access to services
commissioned on a borough wide basis in order to reduce variability and achieve
value for money such as access to pathology services.
The role of GP Networks
GP Practices across Ealing are structured into seven health networks covering
populations between 50,000 and 70,000 each (Appendix 2).
By working in health networks we will be able to offer a wide range of Out of
Hospital Services in each area. These services will be delivered in a number of
local settings within a network, including GP surgeries, however they will not be
16
provided by all GP surgeries. This means that patients may receive care from a different
location than their registered practice.
GP networks are central to collaborative and integrated community-based services. To
support network development further and faster we will appoint a network relationship
manager for each of the localities
GP Networks in Ealing
The role of Local Hubs:
Hubs will enable and support the delivery of a wider range of services locally. It will
achieve this by:
o Localising the most common services people need for everyday illnesses
and injuries
o Integrating and joining-up clinical services with others such as social care
to intervene earlier along the patient pathway and reduce hospital admissions
over the longer term
o Centralising services currently delivered locally, where access allows,
achieving economies of scale.
o Providing the appropriate infrastructure so that some services currently
delivered in hospital can be delivered locally.
Hubs will include a range of services including out-patient appointments, diagnostic
and rehabilitation services.
There will be a number of hubs located across Ealing. The size and location of these
services is currently being determined
The role of the Local Hospital
Shaping a Healthier Future agreed that Ealing Hospital will become a Local
Hospital from 2017 meaning that it will provide a different range of services that
at present.
The Local Hospital will act as an intermediary and point of transition between
primary and community care settings and specialist and acute care settings. As
such the Local Hospital will form part of the wider Out of Hospital service provision
and will be interconnected with GP practices and other providers.
The Local Hospital will also act as a hub. As a result patients will also be able
access services delivered from the Hospital at the hubs across the borough. In
addition the Local Hospital will also provide a greater range of diagnostics and
services in order to realise value for money.
Services specific to the Local Hospital are included in the Local Hospital specification
and are therefore not set out in this document.
17
What this means for patients:
Patients will continue to be registered with their GP and use them as their main
point of access to the health system
GP networks and Local Hubs will allow patients to access a wider range of
services locally rather than in a hospital setting
The Local Hospital will act as an intermediary and point of transition between
primary and community care settings and specialist and acute care settings. As
such the Local Hospital will form part of the wider Out of Hospital service provision and
will be interconnected with GP practices and other providers. The Local Hospital will
also operate as a hub.
7. Our plans to deliver services out of hospital
As outlined above we plan to increase the number of services delivered outside of hospital.
This section sets out the services we intend to deliver across the different settings outside of
hospital. This will allow patients in Ealing to:
Have easy access to high quality and responsive primary care
Receive high-quality planned care out of hospital
Experience responsive urgent care
Receive the appropriate mental health care locally
Ealing CCGs model for Out of Hospital Care
Each setting will provide a range of services that will allow residents across Ealing to access
the full range of health and care support.
In the future, more services, particularly for planned care, will be delivered within out of
hospital settings. The diagram below shows that the majority of support will be delivered in
an out of hospital setting. This is supported by the acute and tertiary care settings which will
provide support to those patients who are most ill.
18
What this means for patients:
GPs will continue to provide core GP services and will act as the named point of
contact for co-ordinating the care for their patients
Improved access to GP appointments with local GP practices and hubs and will
have access to an increased range of services
A greater number of planned care services locally
Responsive urgent care when needed to keep patients out of hospital settings
Patients with the most complex cases will continue to be seen in a major or
specialist hospital as they will have access to more specialist services
Easy Access to High Quality and Responsive Primary Care
We are committed to improving access to primary care so it meets patients’ expectations.
Improving access will mean opening at convenient times, offering a wider-range of services
and being located in the right places. We also want to improve quality which means ensuring
that care is being delivered to the right clinical standards, in good facilities.
Progress we have made since 2012
Since our original OOH strategy was published in 2012 we have made significant progress
improving the way patients are able to access services. These include:
Scheme
Development of
Health Networks
Urgent Care Centre
at Ealing Hospital
Nursing Homes
Progress to date
Establishment of networks has continued across the borough. Practices
have been organised into 7 networks across Ealing,
Networks are supported by Clinical CCG Executive leads and Network
Relationship Managers
The Urgent Care Centre at Ealing Hospital provides 24/7 urgent care services
to residents across Ealing.
Ealing CCG has commissioned a new service for Nursing Home Residents.
This service is an Enhanced Primary Care Service offering proactive case
management, 7 days a week from 8 am- 8pm.
Since going live in July 2013 more than 600 nursing home residents have
chosen to register with this scheme.
Our future plans
Services provided at GP practices
We aim to support patients to self-manage as much as possible. We know that a
significant proportion of service users would value an increased role in the management of
their own care, but that the current system does not provide patients with the information,
advice and support they need to self-manage.
Practices remain the centre for most routine primary care. GPs will act as the named point
of contact for co-ordinating care for their patients.
Every practice will continue to offer core primary care services, as well as working with
other practices in their care network to provide additional services. GP practices will also
continue to have access to and provide the diagnostics and tests that they do currently such
as blood tests.
19
In line with national expectations and work taking place across NW London we are working
to identify ways of delivering services more flexibly and innovatively with extended
hours, 7-days a week. 7-day working is expected to have a number of benefits:
De-risking for patients accessing health services outside of ‘core hours’, leading to
better outcomes
Improved patient experience
Greater access to out of hospital services outside of ‘core hours
Services provided at a hub or across a GP Network
GP networks will support GPs in Ealing to provide extended hours services so that
patients can access services within a GP practice from 08:00 to 20:00. Specific
practices in each locality will offer appointments during extended hours on behalf of their
locality. An agreed number of practices per network will also be open on Saturdays,
Sundays and Bank Holidays to provide extended care on non-working days. Patients will also
be able to access GP services extended hours GP services at Hubs. .
Patients will also be able to access a broader range of primary care services than is
available in their practice. Practices will collaborate at network level to share staff
resources and skills, referring between practices so that all of our patients can access a wide
range of ‘enhanced’ services in primary care.
What this means for patients:
GPs will continue to provide core GP services and will act as the named point of
contact for co-ordinating the care for their patients
Improved access to GP appointments with local GP practices and hubs and will
have access to an increased range of services
Delivering high-quality Planned Care out of hospital
Our vision is for an increasing number of patients to be seen in community facilities and
settings so they do not have to travel to hospital for outpatients. These will be underpinned
by robust and clear care pathways.
Progress we have made since 2012
Since our original OOH strategy was published in 2012 we have made significant progress
improving the way patients are able to access services. These include:
Scheme
Outpatient and
elective procedures
will be moved out
of hospital
Pulmonary Rehab
Progress to date
Diabetes: We have invested in new care pathways and clinics to enable
Ealing patients with diabetes to access specialist diabetes experts in a wider
range of settings. This year we have moved over 100 patients from a
traditional hospital setting to new locations closer to home
MSK: Our investment in MSK services has improved quality, reduced waiting
times for patients and lowered the requirement for hospital based care. This
service now has waiting times near four weeks and we are seeking to
expand it further.
Pulmonary Rehabilitation: This service, provided by Ealing ICO, has been
in operation for over a year now and has enabled over 400 patient contacts
for the delivery of an enhanced model of care
This service is run by Physiotherapists for people with a diagnosis of Chronic
Obstructive Pulmonary Disease (COPD) in 3 different venues across the
20
borough.
So far 269 people have been assessment and 108 have completed the full
rehabilitation programme. At the end of the programme over 75% of patients
have shown a measurable physical improvement and patient feedback is very
positive feedback.
Our future plans
Services provided by a GP
Individual GPs will retain responsibility for referring patients to specialist services and
are expected to ensure that all referrals are clinically necessary and appropriate to patient
need.
Before making a referral, GPs will have access to relevant consultants via email and
telephone and will be further supported by services delivered across a network or hub.
This will offer the GP a specialist opinion before they make a referral, to ensure that all
referrals are appropriate, and that patients receive the right care in the right setting.
The continued expansion of the referral facilitation service will continue to work with GP
practices in Ealing to ensure that patients are directed to the most appropriate setting in
which to receive on-going treatment and management of their conditions. As new care
pathways and services are developed the RFS will be involved in ensuring that these are
delivered.
Services provided at a hub or across a GP Network
Hubs and networks will enable a wider range of services to be delivered locally. These will
include various diagnostic and outpatient services. It also means that within networks,
patients will be referred between practices as well as to secondary care.
Patients currently receive a number of services at their own, or at another local GP
Surgery. We are currently reviewing the services that are currently commissioned using an
agreed framework2. The aim of this review has been to improve the quality and reduce the
known variation while ensuring a thriving and successful primary care service which best
meets the needs of our local population. These services will be commissioned and delivered
at either at a practice or at a network level and include:
Ambulatory Blood Pressure Monitoring
Anti-coagulation and NOAC
Diabetes support
ECG Scheme1
Insulin Initiation
Minor Surgery
Near Patient Testing
Phlebotomy
Post Discharge Procedures
Gynaecology - Ring Pessary
2
From April 2014 CCGs will no longer have the ability to commission local enhanced services from primary care providers;
providers; instead CCGs will be required to commission any out of hospital services required using an appropriate and
proportionate procurement process and the NHS Standard Contract as the contracting mechanism. As a consequence CCGs
have reviewed all the local enhanced services that have been commissioned have concluded which services they wish to retain.
This paper sets out the process by which CCGs in the Collaboration will re-commission enhanced services
21
We plan to extend the current range of planned care services as well as introduce new
services that can be accessed from the appropriate out of hospital settings. These
include:
Dermatology Assessment and Outpatient Services
Musculoskeletal Services including physiotherapy
Cardiology Outpatient and Simple Diagnostics
Anticoagulation outpatient and monitoring
Comprehensive Community based Diabetes Service
Non-complex Gynaecology and Sexual Health
Those patients with the most complex cases will continue to be seen in a major or
specialist hospital as they will have access to the largest range of services.
The provision of these services in each hub will require access to the appropriate
diagnostics facilities. Hubs will host some diagnostic equipment such as ultrasound and
ECG. Where additional or more specialist diagnostics are required they will be
delivered from the relevant hospital of your choice. Diagnostic results will be shared
electronically between care providers, to ensure continuity between different settings,
especially when a patient is referred between providers or services
The transition of these services will support the wider changes taking place across NWL and
will ensure that patients across the borough have equality of access to a range of
services.
During the development of this strategy, CWHHE collaboration CCGs have been working
closely with Imperial Hospital to review improvements and transform planned care. This has
been supported by the NHS IQ development programme. The aims of this programme are
to:
Align clinical systems across primary and secondary care
Increased communication between clinicians to manage patient care plans
Reduction in the need for multiple appointments
Direct access to specialists for urgent reviews to avoid A&E presentations
Expansion of referral facilitation services: patients treated in most appropriate settings
We are working closely with the London Borough of Ealing to commission a range of
services for young people. These include; integrated services for children and young
people with additional needs, Home based care and, Community health care for children.
What this means for patients:
A greater number of planned care services locally
Patients with the most complex cases will continue to be seen in a major or
specialist hospital as they will have access to the largest range of services.
in each hub will require access to the appropriate diagnostics facilities. Hubs will
host some diagnostic equipment such as ultrasound and ECG. Where additional or
more specialist diagnostics are required they will be delivered from the relevant
hospital of your choice.
The transition of these services will support the wider changes taking place across
NWL and will ensure that patients across the borough have equality of access to
a range of services
22
Responsive Urgent Care
Our aim is to respond rapidly to urgent needs so that fewer patients have to access hospital
based emergency care. If a patient has an urgent need that requires a clinical response we
aim to commission services that will respond within two hours.
Progress we have made since 2012
Since our original OOH strategy was published in 2012 we have made significant progress
improving the way patients are able to access services. These include:
Scheme
Progress to date
Intermediate Care
Ealing (ICE) and
rapid response
team
This service has enabled us to make great progress with the delivery of our Out
of Hospital strategy and has prevented more than 1,000 hospital admissions in
the short time it has been in operation. We are currently reviewing this service to
continue its development and help it deliver the full range of benefits required.
Our future plans
We will continue to work with GPs to address frequent users of emergency services
(FUES) including Ambulatory, Mental Health, Social Services and ICE. GPs will monitor lists
and take appropriate action, in conjunction with our partners, in order to reduce admissions.
Ealing CCG has commissioned a comprehensive intermediate care service known as the
Intermediate Care Service Ealing (ICE). We intend to continue the development of the
service which will:
Work from multiple sites to maximise working relationships with the A&E departments
of all local acute hospitals, and proactively seek referrals for patients who require
intermediate care.
Extend direct referrals to all clinicians, including nurse practitioners and practice
nurses
Share electronic patient information
Continue working with GP practices and raise the profile of the service with primary
care.
Extend the acceptance criteria for referrals from the proposed emergency department
frailty unit.
Close working links with the proposed re-designed cardiology services and ICP for
whole systems integrated approach to care, responding rapidly to needs of patients
with acute exacerbation of chronic conditions
We are also considering a rapid response service that will work closely with social
services so that the patients’ needs can be met rapidly in a time of acute deterioration. The
aim is to provide safe care at home when appropriate. It will also have close links with the
cardiology services and ICP, allowing an integrated approach to care, and have the ability to
respond rapidly to needs of patients with acute exacerbation of chronic conditions.
As supported discharge is an essential service that GPs need to provide; we will be
commissioning supported discharge for patients discharged from the hospitals (bedded and
non- bedded) from 2014.
We are also developing our approach to supported nursing and rehabilitation in an out
of hospital setting. This is short-term support for certain patients who are able to return
home following an acute episode but need additional rehabilitation and care. The aim of this
service is to reduce the likelihood of these patients experiencing an acute episode in the
short-medium term.
23
Community bed-based care services are an important element of our strategic plans to
improve care response and support the shift from hospital to community-based care. We are
currently looking to procure Multi-disciplinary Therapy and Nurse Led Rehabilitation
Beds that will generally be used by those over the age of 65 who have been in hospital for
an acute spell, but require a longer period of in-patient rehabilitation. The provision of these
beds will help reduce inappropriate admissions to acute care by proving access to step-up
beds, increase timely discharge from acute care by ensuring patients receive the right care in
a local setting and, support patients remain out of hospital following an acute episode.
The Local Hospital will include an Emergency Care Centre that will be open 24 hours a
day, 7 Days a week. Patients needing urgent care will be able to access this service directly
or will be referred by the 111 service or their GP
When GP surgeries are closed it is important that patients are able to access responsive Out of
Hours services if they become unwell. A responsive out of hours services supports patients
stay out of hospital. We are in the process of re-tendering our GP out of hours service.
This piece of work will be informed by a review of current arrangements and take account the
interdependences between the NHS 111 and urgent care services.
What this means for patients:
Responsive urgent care when needed to keep patients out of hospital settings by
providing them with alternatives settings or the appropriate care package to keep them
at home
Improved access to Out of Hours GP services
Patients who regularly use urgent and emergency care services will be
supported by GPs to reduce the need for them to use urgent care services
Mental Health
We are continuing Shifting settings of care project to clinically manage patients via primary
rather than secondary care.
This programme will create more effective pathways between acute mental health in-patient
and community services, and identify and support those patients whose care can be
transferred to less intensive settings. To support this we are developing both primary care
and mental health services by:
Establishing discharge managers in every borough and increasing specialist
community and home treatment levels, to support the discharge of patients from
acute mental health in-patient wards across NWL
Creating a support system in primary care involving GPs, community
psychiatric nurses and support workers, to support the discharge of stable and
low-complexity patients from specialist community mental health care to primary
care. Community-based staffing levels and GP capabilities will also be increased and
enhanced
Creating a “primary care plus” support system for GPs to enhance primary
care treatment of mental health conditions. This will include access to consultant
advice and rapid referral back into secondary care mental health services if the
patient’s condition deteriorates rapidly
24
What this means for patients:
Patients who can be will be cared for outside of hospital
Settings will promote independence and provide a more supportive community
setting
GPs will be able to take a more holistic view of patient needs
8. How will our initiatives deliver our standards
Outcome-based measures of success
As well as meeting our standards, the ultimate test of our changes is whether we are
improving the health and wellbeing of residents, and whether we are delivering services more
efficiently and effectively.
We will know this by monitoring improvement against three domains of outcomes. Under
each of these are a number of measures that will tell us if our changes are improving patient
health, experience and value for money:
Area
Clinical Quality
Patient
experience
Value for money
Outcomes
Improved clinical outcomes
Reduced mortality rates
Reduced morbidity rates
Improved patient satisfaction and confidence in treatment
Improved patient choice
Increased ability to treat and support patients in a community
setting
Reduced admission and readmission rates
Reduced number of unnecessary investigations or duplication of
assessment
Improved efficiency of service delivery through streamline patient
pathways
As we put these changes in place, we will develop detailed metrics that track these
outcomes. We will monitor these to ensure that the same quality and consistency of care is
being delivered across the borough.
25
9. Infrastructure required to support delivery
To support the delivery of our OOH strategy we need to develop the way we will work
together with patients and our partners, how we need to develop our staff to deliver the
change, improvements in our IT and other infrastructure.
Ways of working
Co-design and co-production
In developing our plans in more detail, we will continue to engage and work with patients and
their carers, providers and local authority colleagues to ensure services are integrated and
effective.
We will work with patient representatives and others as these changes are implemented to
ensure that we communicate effectively about what to expect, and what this will mean for
people’s care.
New contracting models
To facilitate integrated care, we will be exploring new contractual mechanisms for community
services, including contracting with alliances of providers or lead providers managing a
complex pathway, and developing outcome-based contracts to align incentives for providers
to manage patients more effectively.
How we will work together
Our new ways of working will require us to collaborate differently in the future, for example:
Working across organisational boundaries through networks and multi-disciplinary
group working.
Inter-referrals between GP practices and to GPs with specialist skills intra- and internetworks.
Staffing some services for extended hours and/or seven days a week to ensure access.
Differentiating roles for different patients, with some individuals focusing on long-term
conditions and others on episodic care.
Workforce
The workforce strategy for North West London, From Good to Great, identified that these
changes will require new ways of working, new roles, repurposed and enhanced roles, and
significant investment and training for our existing workforce. Some of these are outlined
below.
New roles
Examples of new roles we expect to see in future include:
Case managers (which may be a GP or another professional) acting as the first point
of contact for care and care planning with patients a higher risk of hospital admission.
Care navigators (which may be volunteers) will support patients to navigate between
services
Health and Social Care Co-ordinators (HSCC) will need to develop relationships and
work closely with a range of professional groups to ensure patients receive joined-up
care. The care co-ordinator role will require knowledge and skills in relation to social
care and wider public services, as well as healthcare.
26
Ealing CCG Network Relationship Managers have been employed to support the
development of GP networks in Ealing.
Case management
Home based rapid response
A range of new and enhanced roles have been identified
▪
Patient /
User
▪
Clinical
case
managers
▪
▪
▪
Provides psychological and/or personal care and
support to individuals
▪
Provide supervision to nurses/case managers for
motivational interviewing and deliver higher level CBT
CBT Mental
Health
Supervisor
▪
▪
▪
Coordinate health and social care packages according to
the care plan agreed by the case manager, individual and
carers; Support individuals’ maintenance of goals
Coordinate early supported discharge from acute to home
and on-going care prior to discharge from rapid response,
including liaising with primary care team, individual, carers,
and social care
Perform specialist assessments / interventions when
requested by Case Manager or Health and Social Care
Coordinator
Provides specialist input into care plans
Shared across both
▪
Carers
Intensive
Home Care
Clinicians
(Nurses &
Therapists)
▪
▪
▪
Intensive
Home Care
Administrator
▪
▪
Health &
Social Care
Worker
Community
Health
Medic
(sessions)
Provides psychological and/or
personal care and support to
individuals
Perform face to face assessment and rapid
interventions at individual’s home for defined
period
Provide on-going care and monitoring,
support reablement or care of the dying,
including using other team members as
appropriate
Provide clinical support for HSCC for
determining appropriate response or referral
Act as a single point of
access for referrers, taking calls from GPs,
ambulance service, and carers (in the case of
palliative care)
Refer individuals to rapid response team or to
most suitable provider
▪
Perform specific moving and handling tasks,
installation of equipment, etc. as needed by
team to support the patient / user
▪
Perform on-going health care, reablement, and
personal care and monitoring, including support
for mental health
Conduct observations and report deviations
Support equipping and liaise with HSCC to
secure health, social care and voluntary
services when unable to provide directly
Handyman
▪
Social
Worker
Act as first point of contact for very high risk individuals
and carers
Perform holistic assessments and initial diagnostics of
individuals’ health and social care needs
Co-create care plan with individuals and carers, using
low-level cognitive behavioural therapy techniques, e.g.,
motivational interviewing
Provide on-going care and monitoring, drawing in
specialist input as needed
▪
Community
Health
Worker
Health &
Social Care
Coordinator
Self-manages care with support
from health and social care
professionals and carers
▪
▪
▪
▪
Provides medical cover to team and specialist
input
Works directly with case managers to monitor
very-high risk LTC individuals
SOURCE: Community workf orce project design group meetings – November 2012, team analysis
1: It is assumed that the teams will in addition have access to condition-specific specialist opinion, and to regular care already provided by in the
community, e.g., primary care, pharmacist support as needed
Examples of new roles required
Repurposed and enhanced roles
As well as new roles, we will require our existing healthcare professionals to work differently
in the future, for example:
GPs will find their role enhanced, with a greater role in care planning and care coordination. Those with specialist skills may also act as specialists in their local area.
Specialist, community and district nurses and other health professionals (including
health visitors and therapists) will provide more community and home-based care,
and will be aligned with our locality.
Social care teams will begin to align with our locality, working closely with health
colleagues.
Consultants will provide clinics in our hubs, ensuring patients receive all the care they
need in a community setting.
111 will be transformed to provide an increasing amount of care and advice remotely,
requiring a significant increase in both the numbers and skills of 111 staff.
Shifting diagnostics, clinics and planned care procedures from hospitals to community
settings will require an increase in community staffing, including some staff moving
from hospital settings.
Establishing learning hubs
We know that these changes will require changes in the skill-mix of our workforce, both for
newly trained staff and for existing staff, which in turn means we need to re-think training. In
order to facilitate these changes, we will need to provide training to our workforce, for
example in:
Multi-disciplinary team collaboration
Referrals standardisation and peer review to manage referrals
27
Administering tele-care and tele-health
Supported discharge pathways
Mental health care training for primary care staff
Records sharing as new systems are introduced
In addition, practices will work together to improve their services. This will include supporting
each other to benchmark, audit, review and improve their services. Sharing patients across
practices will give all practices an incentive to maintain and improve quality across the
borough.
Information technology
Effective information sharing will reduce duplication across the system and facilitate effective
care in community and primary care settings.
Some of the initiatives within NWL include:
Single IT System across Ealing and CWHHE CCGs
Our GPs recently voted to adopt a single IT platform, the preferred system being SystmOne.
This is the same system that the other CCGs in the CWHHE collaborative have chosen to
use. This means that the vast majority of practices and potentially all community healthcare
providers in and around Ealing will use the same system. Not only will this enable everyone
to share a clinical record but also will ensure far better communication between providers
and practices. In addition the CCG is working with the CWHHE collaborative to develop a
share patient record which will support the delivery of whole systems integrated care.
Shared Care Planning
We will support the development of the next phase of the ICP care planning tool, intended to
be a universal shared care plan. This solution enables GPs and other social care and health
professionals to input to a care plan on their own system.
Agreed sections of that data are then extracted and presented in a composite care plan
made available to any health or social care professional involved in that patient’s care. The
underlying data warehouse enables monitoring of care planning activity to support the lead
clinician in ensuring care is provided and recorded for the patient.
Virtual Ward monitoring systems
Staff in the virtual ward will require information systems, which quickly display the patients
they are responsible for in the virtual community ward. We will develop IT systems based on
ward monitoring systems in hospitals to manage packages of care for patients in the
community and in real time provide data about patients admitted to hospital and their
progress towards discharge.
Patient and Community Transport
This document sets out our intention to shift a significant volume of activity from hospitalbased care to a range of additional settings in primary care, community services and
patients’ homes. This should lessen reliance on transport services to reach appointments.
However, we do recognise that the least mobile patients will require additional transport
services to reach local services.
Through Ealing CCG’s Patient and Public Engagement Committee, we have received
significant feedback from patient groups on the range and quality of patient transport services
in Ealing for non-hospital based care.
28
Many patients have reported that they face barriers to both community and primary care
settings because of the lack of transport for people with mobility or other health problems, in
some cases leading to people presenting at A&E / UCC because they have not been able to
attend appointments elsewhere. Therefore, Ealing CCG recognises that there may be
greater need in the borough for community-based transport as out of hospital activity
increases over the coming years.
We also acknowledge that there is a diversity of need in relation to transport. Carers, for
example, have highlighted parking restrictions as a barrier for them to attend their own
medical appointments, particularly as their caring commitments place restrictions on their
own time and flexibility. Patients with learning disabilities, on the other hand, have requested
training as they would prefer to develop the skills and independence to use public transport,
rather than relying on taxicard or dial-a-ride schemes.
Ealing CCG intends to identify options in this area across the borough of Ealing in 2014/15.
We will examine a range of schemes and suppliers to understand what is feasibly affordable
and could be made available to Ealing residents in order to strengthen transport and access
options in the borough. Transport options will be rigorously tested for affordability and value
for money.
We recognise that strengthening patient transport for community services may require us to
work with a number of new organisations such as social enterprises, community and
voluntary services, private companies and individuals. We will ensure that, when we
undertake this work, we will draw on the expertise of groups and individuals through our
Patient and Public Engagement Committee.
A significant amount of work is already underway across North West London to examine
issues and options in this area. The SaHF programme has a fully established transport and
access group (TAG), chaired by an Ealing GP CCG clinical lead. Ealing CCG will feed into
this group and use its outputs to strengthen our own work and understanding in this area
What this means for patients:
Patients will be more involved in shaping their care and will experience greater levels of
co-ordination across the health and care system
Patients with complex needs will have health and care professionals who can support
them to navigate services across the system
Patients will receive services from highly trained staff in a local setting such as a hub
Health and care professionals will be able to share information more easily meaning
patients will experience more joined up care. This means that patients may need fewer
repeat tests and different
Services will be as accessible as possible so that patients easily travel to appointments
29
10. Estates
Impact of our Out of Hospital Strategy on Estates
Delivering our strategy will have a number of important implications for our estate across
Ealing. The impact of OOH delivery will be felt at two levels:
Impact on GP estates
Practices providing care on behalf of their network (for either enhanced primary care or
extended hours care) must be fully accessible in terms of both buildings (e.g. wheelchair
accessibility) and location (e.g. accessible by public transport).
Impact on hubs
As services, equipment and teams are moved to community settings the appropriate
accommodation with be required. For example, diagnostic equipment will require the
appropriate space, health and social care teams will require a base within our networks.
Hubs will also need to be flexible and accessible to accommodate a range of services,
activities and patients.
In the first instance, we will focus on utilising any spare capacity we currently have. Where
possible, our existing estate will be improved to offer the capacity we need and to meet
relevant standards. Only once these options have been exhausted will we explore new
capacity; investment in new estate will only be considered where suitable existing premises
cannot be identified.
Estates baseline
To enable the improvements in OOH care appropriate investment is required in estates
across Ealing. The CCG in is in the process of identifying potential locations and estates for
local hubs. This document will inform the development of the SSDP and OBC which will set
out a number of options to be assessed using an agreed set of criteria.
An audit of the healthcare estate within Ealing is current underway using existing data
collated from a range of sources in order to identify appropriate locations for hubs across the
borough.
30
11. Next steps
To receive investment for improvements in OOH estates the CCG must complete a number
of steps which generate a number of outputs. Steps 1-3 are in development and near
completion.
The chart below details the process that is required to develop an outline business case for
specific sites
Strategic Service Delivery Plan
This document will inform Ealing CCGs Strategic Service Delivery Plan (SSDP). The SSDP
develops our strategic intentions by including the investment in infrastructure and workforce
needed to deliver transformations in out of hospital care.
It will include a significant number of sections within this document along with the following
additional sections:
Model of Care
This section builds on the model of care presented above to include:
Catchment: Describes the geography or list over which the services will need to be
delivered making assumption about what is acceptable or workable
Menu of services for potential hubs: describes what services will be delivered and
how they will be delivered
Future activity: What will be done in the future across the borough based on the
strategy and proposed model of care
Options for delivering the future OOH model
This section moves from the overall targets for change to the narrowed list of options that
could enable delivery of the future model.
This will be informed by going through an exercise to identify services delivered in the Local
Hospitals, then remaining services in the hubs with the rest delivered by in different estates in
the borough. The overall outcome will be a shortlist of options.
Site Service Specification
For the CCGs’ priority site, this describes the services that will provided by the site, how they
will operate and be integrated into the full spectrum of OOH care. This deliverable will be the
key input to NHSPS’s options development and assessment
31
Site options development and assessment
NHSPS uses the site service specification to develop site options and assess options against
agreed scoring criteria to develop a preferred site option .
Outline business case
The OBC must be in accordance with Treasury Green Book Guidance (five case model) to
demonstrate the case for development of the hub.
GP premises investment strategy
S&T develops the GP premises investment strategy, outlining the planned investment in GP
premises required to achieve the principles for OOH service delivery
32
12. Appendices
Appendix 1: Health of Ealing Population
The chart below compares health of people in the Ealing area with rest of England. Ealing’s
result for each indicator shown as circle. The average rate for England is shown by the black
line, which is always at the centre of the chart. The range of results for all local areas in
England is shown as a grey bar. A red circle means that Ealing is significantly worse than
England for that indicator; however, a green circle may still indicate an important public
health problem.
33
Appendix 2: GP Practices and Networks in Ealing
Network
Acton
Central Ealing
North North
North Southall
GP Practice Name
Acton Health Centre
Acton Lane Medical Centre
Acton Town Medical Centre
Chiswick Family Practice (Dr Webber)
Chiswick Family Practice (Dr Bhatt)
Churchfield Surgery
Cloister Road Surgery
Crown St Surgery
Hillcrest surgery
Horn Lane Surgery
Mill Hill Surgery
The Bedford Park Surgery
Boileau Road Surgery
The Burlington Gardens Surgery
The Vale Surgery
Western Avenue Surgery
Corfton Road Surgery
Cuckoo Lane Surgery
Dr K K Gyi & Partner
Gordon House Surgery
Lynwood Surgery
Pitshanger family practice
Queen Walk Practice
Brunswick Road Medical Centre
The Argyle Surgery
The Surgery
Barnabas Medical Centre
The Medical Centre (Balachandran) (Doncaster Drive Medical Centre)
Elm Trees Surgery
Greenford Road Medical Centre
Hillview Surgery
Islip Manor Medical Centre
Mandeville Medical Centre
Meadow View Surgery
Perivale Medical Clinic
Allendale Road
The Grove Medical Practice
Chepstow Gardens Medical Centre
Dormers Wells Medical Centre
Jubilee Gardens Medical Centre
K S Medical Centre
Lady Margarat Road Medical Centre
THE NORTHCOTE AVENUE PRACTICE
Saluja Clinic
Somerset Family Health Practice
Somerset Medical Centre
Southall Medical Centre - main branch
St George's Medical Centre
The Town Surgery
South Central Ealing
Woodbridge Medical Centre
The MWH Practice
Ealing Park Health Centre
Elthorne Park Surgery
Grosvenor House Surgery
Northfields Surgery
The Florence Road Surgery
34
South North
South Southall
Allenby Clinic
Broadmead Surgery
Eastmead Surgery
Elmbank surgery
Goodcare Practice
Greenford Avenue Family Health Practice
Hanwell Family Health Practice
Hanwell Health Centre (Dr R Naish)
Mansell Rd Practice
Northolt Family Practice
Oldfield Family Practice
Ribchester Medical Centre
West End Surgery
Westseven GP
Yeading Medical Centre
Belmont Medical Centre
Featherstone Road Health Centre (Bondcare)
Guru Nanak Medical Centre
Hammond Road Surgery
Sunrise Medical Centre
Medical Centre (mangat)
The Welcome Practice
Waterside Medical Centre
35
Appendix 3: GP Location and indicative list size
36
Appendix 4: Case for Change
Better Care, Closer to Home set out a clear case for change:
“We need to do this because demographic changes are increasing demand on healthcare
services and the resources available are not increasing at the same rate. As the population
ages and the number of chronic illnesses rises, the way we currently deliver care is
becoming unsustainable.
Improving our out of hospital services will make care better and less expensive. By
intervening earlier, joining up care and supporting patients at home, we will be able to
improve outcomes and patient satisfaction, whilst delivering greater value for money. Better
care, closer to home is an essential way to maintain the quality of care in the face of
increasing demand and limited resources”.
The case for change is now even stronger:
As the population ages and the number of people with a long term conditions (LTCs)
increases; the way we currently use hospital is becoming unsustainable3.
Under our current model of care, we can’t afford to meet future demand. Hospital is
too often seen as the answer and we need to have more planned care, earlier, outside
of hospital.
Improving our out of hospital services will make care better and will cost less. By
intervening earlier, joining up care better and supporting patients at home who are
currently being admitted to hospital, we will be able to improve outcomes, and patient
satisfaction while spending less. Better care, closer to home is our way to maintain the
quality of care in the face of increasing demand and limited resources. In particular,
there is a growing role for primary care.
Continuing financial pressures means we need to achieve longer-term financial
sustainability for our health economy; a growing elderly population is increasing
demands on our healthcare through rising rates of dementia and frailty in the elderly
population, as well as increases in “lifestyle” conditions of childhood obesity and
alcohol related hospital admissions; patients and their families now have greater
expectations of quality and safety; an since we published Better Care, Closer to Home,
we have moved towards integrated care and joint delivery as organising principles of
how we deliver care in the future.
More must be done to address variability in access, Patients across London report
feeling less able to book appointments or order repeat prescriptions online, or make next
day appointments with their GP4.
The NHS “A Call for action5” demands that the NHS must change if services are to
remain free at the point of access. It details a focus on preventative rather than
reactive care services matched more closely to individuals’ circumstances instead of a
one size fits all approach; people better equipped to manage their own health and
healthcare, particularly those with long term conditions; and more done to reduce
inappropriate admissions to hospital and avoidable readmissions, particularly amongst
older people.
3
Better Care, Closer to Home, 2012-2015
Primary Care in London: General Practice, A Case for Change?, NHS England, November 2013
5
http://www.england.nhs.uk/wp-content/uploads/2013/07/nhs_belongs.pdf
4
37
Appendix 6: Delivering our national expectations
5.2.1 NHS Call to Action
The NHS’s Call to Action and NHS England’s case for change for primary care in London
have both made it clear that in future we must shift away from a system of reactive, episodic
treatment and towards co-ordinated, long-term care, with GPs increasing operating as the
central point of continuity across the system.
Central to delivering this is integration. By 2015/16 the whole NHS will pool £3.8bn through
Integrated Transformation Funds, which are “a single pooled budget for health and social
care services to work more closely together in local areas, based on a plan agreed between
the NHS and local authorities”.
5.2.2 Integrated Care
The Department of Health is also supporting fourteen ‘pioneer’ sites, which will lead the
integration of health and social care. As outlined in Section 6, we – together with all the
CCGs in North West London – have committed to developing pioneer whole system plans as
part of this transformation.
5.3.3 7-day working
Improved and transformed access to primary care has also been recognised as a critical
improvement needed across the system. The £50m Challenge Fund announced in October
2013 has challenged GP practices to identify ways of delivering services more flexibly and
innovatively with extended hours, 7-days a week. This aligns with our commitment, through
Shaping a Healthier Future, to 7-day working across the system and points to an enhanced
and modernised role for primary care in future.
7-day working supports our OOH vision and is expected to have a number of benefits:
De-risking for patients accessing health services outside of ‘core hours’, leading to
better outcomes
Improved patient experience
Greater access to out of hospital services outside of ‘core hours
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Appendix 7: Initial list of services for inclusion in the Local Hospital and
hubs
All services subject to activity and affordability
Where services are delivered in a hub they will also be delivered from the Local Hospital
Service Category
Potential Services for inclusion
Assessment unit
Step Up beds (Enhanced monitoring and assessment)
Cancer care services
Outpatient clinic (including Ambulatory care)
Chemotherapy (Ambulatory) and Oncology (no head and Neck or other specialised)
One-stop diagnostic (including 2-week referrals)
Cardiology
Full Outpatient and Diagnostics clinic
Electrocardiogram (ECG) and Echo - specialist / complex in LH/MH
Risk Assessment - complex patients
Community Services
Community Zone
Dermatology
Diabetes (link to
cardio vascular centre,
diabetes,
ophthalmology)
Emergency Care
Centre
ENT
Ealing LH
Y
Y
Y
Y
Y
Y
Y
Community based cardiac rehabilitation (nurse led)
Y
Space for networks of community-based professionals to coordinate cases and
training
Y
Complementary Voluntary Sector Providers e.g. carer support, respite , patient advice
and liaison pals, peer support groups
Y
Civic space e.g. retail, library, technology and internet access
Y
Healing skin care rehab
Y
Outpatient clinic - Tele-health and minor procedures in community
Phototherapy or other simple but intensive treatment (3 days a week)
Y
Young adult diabetes services (transitional adolescent service)
Y
Y
Insulin pump
Complex Patients (Type 1 + 2) including foot clinic
Paediatric diabetes services
Outpatient clinic
Y
Y
Y
Y
Education for all diabetes patients (elements of this should be delivered across all
settings)
Urgent care centre (adults and children)
Y
Minor injuries unit
Y
Outpatients (dependent on activity)
Y
Y
Microsuction
Frail and Elderly
Network
or Hub
Y
Frail and Elderly Assessment Unit that includes: Rapid access, Neurology, epilepsy,
Parkinson, Stroke outpatient work
Y
Rehabilitation e.g. stroke
Y
Home visits (community liaison nurse, occupational therapist and/or physiotherapist)
Memory Management and Dementia
Gastroenterology and
Colorectal Clinic (GI)
Y
Therapeutic and diagnostic endoscopy (to be scoped)
Y
Rectal Screening
Y
One stop clinic which includes full outpatient, upper/lower GI, rectal bleeding
Y
GP Practice
Space for GP practices and GP rooms for shared clinics
GP practices, GP rooms for shared clinics
Haematology
Specialist Outpatient clinic
General outpatient Clinic
Y
Therapeutic Haematology (e.g. sickle cell)
Y
Patients with LTC and
Cancers e.g.
Respiratory, Cardiac,
failure, Cancer care
Maternity
Mental Health
Y
Y
Y
Educating patients and carers and providing access for minor exacerbations of chronic
disease. Preventative care e.g. smoking cessation, conditions support groups
Y
Antenatal, postnatal advice & complimentary support
Y
Antenatal and postnatal outpatient
Y
Midwife led day assessment with link to consultant
Y
Early pregnancy unit
Y
Mental well-being for non-formal psychiatric condition e.g. psychiatric liaison services
supporting and coordinated with other clinical assessments (IAPT)
Y
Outpatients
Assessment & Liaison (community MH)
Y
Y
Y
39
MSK and orthopaedics
Neurology
Ophthalmology
Outpatient clinics including Trauma and Orthopaedics, pain clinic. The majority of
outpatients seen in hubs (see CCG MSK interface spec)
Rehabilitation (depending on volume and dependencies)
Eye Clinic (outpatient and day case) - Specialist Satellite Unit
Y
Y
Y
Community based services
Paediatrics
Emergency and Urgent Care Access
Y
Y
Outpatient clinic (depends on activity)
Y
Palliative care
Care to include last 7 days, heart failure and COPD
Y
Radiology
CT scanning (to include Urograms)
X-Ray (Inc. Swallow Test)
Y
Ultrasound
Y
MRI
Y
Rehabilitation
Renal
Respiratory
Rheumatology
Y
Psychology
Physiotherapy
Occupational therapy
Speech and language therapy
Dietetics
Step Down (Integrated Rehabilitation) - Beds to be available across the borough
Satellite renal dialysis unit
Outpatient clinic, Specialist nurse-led clinics in asthma, COPD and TB, pulmonary
rehab, MDT's Vitrual link
Assessments for domiciliary oxygen and nebuliser use
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Diagnostic clinic
Full rheumatology services linking with MSK, Diabetes. Includes joint injections,
podiatry - the majority of these services would be delivered in a hub
Y
Outpatient clinic including Joint Injections and Nurse-led clinic (majority in hub)
Y
Podiatry
Y
Sensitive Conditions
Ambulatory Care for Sensitive Conditions e.g. Cellulitus, DVT, Pyelonephritis
Sexual health and HIV
Health advisers
Y
Psychosexual counselling
Y
Outpatients (includes GUM Clinic, specialised clinics, contraception, HIV and general
Gynaecology)
Y
HIV and STD testing
Y
Y
Social Care
Assessment / Liaison
Urology
Outpatients
Y
Vascular
Outpatients
Y
Y
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Appendix 8: Draft criteria for the evaluation and prioritisation of investment
As part of our delivery of improved OOH care, there will be capital investment in
infrastructure across Ealing, which will cover both hubs and GP premises. This will enable
Ealing CCG to deliver their visions for improved OOH care.
Investment will be supported by business cases for each site, which will demonstrate the
strategic, financial and managerial logic of investment. As investment is finite, these business
cases need to prioritise different options for OOH delivery, including different sites.
In support of this, it has been agreed that we should have principles to support decisionmaking. These principles and criteria have been developed to apply across all settings of
OOH delivery.
The criteria will be used to:



Evaluate whether investment plans meet a minimum threshold.
Prioritise different investment plans.
Articulate consistent expectations of OOH service providers.
The collaboration board agreed that a common set of criteria should be develop and
employed across NW L but weighted by each CCG through their application. As such
proposed criteria were considered by the collaboration board on 12 December. We will adopt
the outputs from this when considering investment in estates across Ealing.
41