COMMISSIONING STRATEGY PLAN ( ) WELCOME FROM CHIEF EXECUTIVE, CHAIRMAN AND CHAIR OF THE PEC

Transcription

1 COMMISSIONING STRATEGY PLAN ( ) Contents Section 1 Welcome & Introduction Section 2 Vision & Values Section 3 Local Context Section 4 Strategy Section 5 Performance & Delivery Section 6 Declaration of Board Approval SECTION 1 WELCOME FROM CHIEF EXECUTIVE, CHAIRMAN AND CHAIR OF THE PEC Welcome to NHS Lewisham s Commissioning Strategy Plan for This is year two of a six year strategic plan and sets out how we plan to deliver our ambitious and challenging proposals for achieving our vision of the best possible health and well being for people in Lewisham. At NHS Lewisham, we aim to provide the best possible health and well being for people in Lewisham, reduce inequalities and improve health outcomes. Specifically, over the next five years we plan to drive improvements in stroke, trauma care, children s services, maternity services, mental health and primary and community care services. This plan analyses the health needs of the local population, describes our vision and values for the future, highlights our strategic goals and initiatives that underpin the vision and lays out high-level implementation plans for future investment. It also describes how we will make significant investments in partnership working over the next five years at regional, sector and local levels in order to deliver our vision. NHS Lewisham Commissioning Strategy Plan Page 1 of 94

2 Over the last year we have sought the views on the healthcare issues of our local population on a scale never seen before. Through the London wide Healthcare for London and A Picture of Health consultations, we listened when local people told us what they want to see from their health services and Six People s Principles of accessibility, patient focus, standards of care, increased focus on prevention, information and promotion and increased focus on mental health, have become important principles guiding our approach and are reflected throughout this plan. Local people and other partners have also been involved in our strategic planning process and have contributed to this plan by helping us to prioritise which health outcomes or goals need to be improved for and with people in Lewisham. Our work is informed by our vision and values which help us to create a local NHS that helps people to stay healthy, receive appropriate treatment and care, and brings a focus on well being and prevention. We have an ambitious plan for the next five years at Lewisham one which sets out how we will make recognisable reductions in inequality of health and healthcare and significant improvements in the health of our local population.. This plan describes how we plan to get there and ultimately deliver the best possible health and well being for people in Lewisham. Michael Richardson Gill Galliano Magda Moorey Chairman CB Chief Executive Chair of the PEC NHS Lewisham Commissioning Strategy Plan Page 2 of 94

3 SECTION 2 VISION & VALUES The vision for Lewisham is: The best possible health and well-being for people in Lewisham By 2013 there will be a greater focus on health prevention and we will have made a recognisable reduction in inequality of health and healthcare across Lewisham and in comparison with the rest of the UK. In particular our population will be able to recognise significant improvement in the following areas: Provision of primary care will be significantly improved and overall provision of services will be consistent in quality across Lewisham. It will provide 24/7 care to those that need it and our population will be confident in its ability to access it. Patients will be confident that all care they receive will be coherent across all providers involved, whether these are in primary, secondary, mental health, social or voluntary care providers evidenced by effective transfer of information, communications, and understanding between our providers. Patients and our residents will be more involved in shaping healthcare in Lewisham, resulting in our services being more focused around their needs rather than our providers and we will treat everyone with respect. Individuals will be better informed about their health needs, resulting in better understanding of how to improve their health and well-being and have greater expectations on our services. People from diverse communities will recognise that services will better meet their needs through increased choice of the types of care available, the services available, and the locations where they can be accessed. Delivery of this vision is underpinned by our values which will govern the way in which we develop our organisation. Outcome focused: we will be uncompromising in achieving safe, consistent, high quality services that deliver the best possible outcomes and in ensuring that the decisions we take are based on the best available evidence. NHS Lewisham Commissioning Strategy Plan Page 3 of 94

4 Reducing inequalities: we will strive to reduce inequalities across our population and to reduce the gap with the best in the UK. We will ensure that everyone we deal with is treated with dignity and respect, regardless of their circumstances. Good stewardship of resources: the PCT will be an efficient and effective steward of its resources by investing in care that delivers the best outcomes for our population whilst living within our means. Patient and public centric: we will always put the public and patients at the centre of all we do. We will ensure that our services are designed and delivered to achieve the best outcomes for people that we are responsive to their needs and concerns, and that deliver the best possible customer experience. Spirit of partnership: we will value our partners and recognise we need the widest collaboration across the community. We will actively seek views from our partners and seek agreement on the best solutions. Honesty and realism: we will expect our people always to act in an honest and transparent manner and be realistic in the promises they make and to be prepared to adapt to the changing needs of our population. 2.1 DELIVERING OUR VISION Our vision is aligned with a set of goals which are set out in section 4. NHS Lewisham will work with a range of partners to deliver our vision as set out in the diagram below: The Architecture for Delivery Our Vision for 2013 What we will achieve by 2013 what will be different by then Strategic Goals How we will measure success and progress towards achievement of our vision Initiatives to Deliver the Goals - an integrated programme for delivery What we need to do to deliver our goals Healthcare for London Pan-London priority initiatives CCI initiatives SE London Sector based initiatives Local Lewisham PCT Initiatives Local priority initiatives NHS Lewisham Commissioning Strategy Plan Page 4 of 94

5 2.1.1 Healthcare for London Healthcare for London (HfL) focuses on issues of improving acute services across London, general improvement in health and changing care pathways to improve outcomes for patients. The Joint Committee of Primary Care Trusts (JCPCT) approved the overall strategy in September 2008, and across London work has begun on implementation of some of the key elements of the strategy. A selection process in underway for specialist trauma services, which will be focused in the centre of London. These centres will manage the most critically ill patients with multiple injuries, and a significant improvement in mortality is anticipated through focusing expert skills and facilities. Lewisham Hospital will work closely with the appointed centre as part of a managed pathway. A selection process is underway for hyper acute stroke centres which will provide the initial acute intervention for stroke patients. Again Lewisham Hospital will form part of a clinical pathway which ensures that the acute part of the treatment takes place in an expert centre, recovery takes place more locally, and rehabilitation takes place as far as possible in the community. The success of both these developments requires active and progressive clinical networks. NHS Lewisham will build on the success already achieved with other South East London PCTs in the development of clinical networks for cancer, stroke and heart disease. A programme for the procurement and establishment of Polyclinics and a GP led Health Centre is underway, and NHS Lewisham will be developing the Waldron Health Centre as the first part of its hub and spoke system, as set out in the Primary & Community Services Strategy A Picture of Health NHS Lewisham has taken an active and influential role in the A Picture of Health (APOH) programme. The delivery of APOH is critical to the transformation of Lewisham s local acute providers, to work towards a sound financial platform which will underpin the development and expansion of high quality services, consistent with the framework set out in Healthcare for London. Lewisham, in common with the other South East London PCTs, has recognised that the solution for its local health economy lies in working together to address the underlying structural problems. Since the JCPCT decision taken on 21 July 2008, work has been underway to plan the implementation and engage with a wide spectrum of clinicians. On 10 September 2008 the Joint Overview and Scrutiny Committee (JHOSC) voted to refer the decision to the Secretary of State. An Independent Review Panel has completed their collection of evidence and will make recommendations to the Secretary of State in the early part of NHS Lewisham Commissioning Strategy Plan Page 5 of 94

6 The APOH programme seeks to create a more stable, service driven and financially viable acute hospital platform, by re-organising acute services in outer South East London. This clinically led programme will help to ensure that acute services meet national standards and are financially sustainable. The major drivers for re-organising acute services are as follows: Within urgent and emergency services, we need to: Ensure there are sufficient numbers of patients being seen in each service to enable expertise to be maintained. Ensure that sufficient numbers of specialist staff are available to form strong clinical teams. Enable elective and emergency care to be better managed by separate rotas to ensure that elective care does not suffer unduly when there are emergency pressures, and to maintain specialist experience. Provide choice and better access for patients through the development of Urgent Care Centres. Provide Older People Assessment Centres. Maternity and Newborn Care services must strive to make childbirth as normal an experience as possible for most women, but also enable fast, high quality care to be delivered to women who need it. We must: Ensure 98 hour consultant cover on labour wards. Ensure each pregnant woman has an experienced midwife available throughout pregnancy and birth. Achieve the best possible outcomes for the mother and the newborn baby. Paediatric services must: Concentrate specialised and intensive care on fewer sites. Manage very complex cases in appropriately staffed centres. Develop assessment centres. Separate neonatal and paediatric care in accordance with Royal College guidelines. Manage elective surgery: So that it is not subject to continued disruption by emergency surgery. To reduce the risks of hospital associated infections. NHS Lewisham Commissioning Strategy Plan Page 6 of 94

7 A key component of the APOH approach has been the recognition that the acute bed base cannot be expanded further to accommodate the improved and growing services. This will necessitate a significant shift of non acute activity out of hospital, either by ensuring that admission only takes place when appropriate, or by ensuring that patients are moved more quickly to a non acute setting, or discharged home with appropriate support. The Integrated Impact Assessment undertaken as part of APOH has shown that acute service re-organisation has the potential to reduce inequalities if implementation of change is managed so that care is brought closer to people s homes. As part of the consultation process it was determined that it is acceptable that some patients travel slightly greater distances if this results in improvements in pathways of care and health outcomes. APOH has been the vehicle through which we have engaged the public in discussing the broader policy changes and our local strategic plans. Through APOH, we are providing local residents with the opportunity to comment on and help shape Lewisham s future health and care services. We are committed to providing greater choice about services and access to a greater range of services Strenghtening our Collaborative Commissioning South East London (SEL) is made up of the six London PCTs of Bexley, Bromley, Greenwich, Lewisham, Lambeth and Southwark. Collaborative Commissioning Groups were established last year across London to lead on strategic and commissioning issues that require a collective approach across a number of PCTs locally and ensure that effective lead commissioning arrangements are in place. They are accountable to the constituent PCTs. To ensure effective decision making, the SEL Collaborative Commissioning Group (CCG) membership has Chief Executive representation from across the collaborating PCTs. The terms of reference of the CCG are: To steer the sector wide commissioning process. To develop and guide the sector wide commissioning strategic direction. To ensure a single integrated and aligned commissioning agenda across NHS London and London PCTs. To establish clear roles and accountabilities for local commissioning bodies. To ensure the effective operation of lead commissioning. The SEL CCG meets monthly and has agreed that their key responsibilities will include: NHS Lewisham Commissioning Strategy Plan Page 7 of 94

8 Ensuring alignment of PCT commissioning strategies across the sector and with overall London-wide commissioning strategies. Providing input and ensuring alignment in the development of the provider market. Setting objectives and performance managing local clinical networks, e.g. cardiac, cancer. Leading local strategic change and reconfiguration programmes. Ensuring consistent application of the London wide commissioning business process. Ensuring that lead commissioning arrangements are operating effectively across PCTs, including the performance management of key commissioned targets, eg 18 week wait, cancer access targets, London Ambulance Service. Co-ordination of practice based commissioning plans where appropriate to feed into lead commissioning arrangements. Local oversight/management of national programmes e.g. independent sector treatment centres, Connecting for Health. Co-ordinate local specialised services commissioning services across region. Sharing good commissioning practice. From April 2009, these arrangements are being strengthened through the establishment of a Joint Committee of PCTs across the six PCTs and a Sector Strategic Commissioning Vehicle to pool expertise and resources to inform and undertake commissioning activities. The sector level partnership will be supported by two local commissioning alliances, one consisting of the commissioners who collaborated for APOH - Bexley, Bromley and Greenwich working the newly formed South London Healthcare NHS Trust (which brings together Bromley Hospitals, Queen Elizabeth and Queen Mary s Sidcup NHS Trusts under a single Trust management structure) and the other consisting of the Academic Health Sciences Centre (AHSC) commissioners in Lambeth and Southwark. Lewisham will play a part in both of the alliances initially, though primarily with the AHSC alliance. The alliance will closely link with the PCT s borough-based commissioning arrangements to ensure strong public health and clinician input, effective patient and public engagement and a meaningful interface with Practice Based Commissioners. The diagram overleaf shows how these strengthened arrangements will work: NHS Lewisham Commissioning Strategy Plan Page 8 of 94

9 South East London Collaborative Commissioning BBG LSL GSTT KCH AHSC UHL Merged Trust The PCTs in SEL have a track record of working collaboratively with their partner organisations (both health and social care) over a number of years to successfully deliver a range of initiatives and service developments, many targeted to deliver tangible health and well-being benefits for the various communities living and working in South East London. Working within a framework of well established Clinical Networks, commissioners have worked with clinical teams to support the design of consistently high quality clinical services. Collaborative Commissioning Intentions for which set out the key initiatives to be delivered across South East London are available on our website Local Initiatives NHS Lewisham must also take into account a range of further strategic drivers at a local level. Borough Partnerships Work with the London Borough of Lewisham and other strategic partners in delivery of the Sustainable Communities Strategy (SCS) through targets set in the Local Area Agreement and proactive work to improve health and tackle health inequalities which is an underpinning principle of the SCS. NHS Lewisham Commissioning Strategy Plan Page 9 of 94

10 The development of closer and more integrated arrangements with the London Borough of Lewisham in both public health and joint commissioning. Taking forward and developing joint commissioning plans for services covering Children and Young People, Mental Health, Learning Disabilities, and Older People. The framework for this partnership working is shown below: Joint Strategic Needs Assessment Sustainable Community Strategy Shaping our Future Local Area Agreement Other Partnership Strategies e.g. Safer Lewisham Sustainable Development Adult Joint Commissioning Plan Children and Young Peoples Plan Framework for addressing Health Inequalities (ref. Initiative 1) Commissioning Strategy Plan Organisational Development Plan Initiative 1 Health Improvement Market Management Strategy Initiative 2 Children and Young People Comms and Engagement Strategy Initiative 3 Maternity IM&T Strategy Initiative 4 Polyclinics and Primary Care Risk Strategy Initiative 5 Mental Health Primary Care & Community Strategy Initiative 6 Care Closer to Home / ERM Estates Strategy Initiative 7 Long Term Conditions PCT Programmes A range of work programmes led by the PCT to meet our strategic goals. These are detailed in Section 4. NHS Lewisham Commissioning Strategy Plan Page 10 of 94

11 2.2 EQUALITY IMPACT ASSESSMENT NHS Lewisham is fully committed to the promotion of equality and its impact on the reduction of health inequalities. Our Single Equality Scheme outlines the Trust s seven strategic equalities priorities, which are: 1. Supporting targeted action on health inequalities 2. Embedding Equality Impact Assessment 3. Commissioning for equity 4. Improving equalities data collection 5. Ensuring equality in recruitment, retention and progression 6. Building staff capacity 7. Consulting and engaging our communities A key tool in delivering equality in a systematic way is through conducting Equality Impact Assessments (EIA) on the Trust s policies, strategies and services, in order to identify and mitigate any possible negative impacts with respect to race, disability, gender, age, sexual orientation or religion and belief. As NHS Lewisham s principal planning document, it is important that the Trust considers the impacts of its overall Strategy Plan, its programmes and the constituent services on the health and well-being of specific populations. Initial impact assessment screenings for each of the programmes have been completed. These are available separately. Although there were differences in the equality and diversity issues for each programme, there were some common themes: Age: From improving service outcomes during maternity and via services for children and young people, to ensuring that older people can receive care closer to home, the strategy will lead to service improvements and better health outcomes from birth to the end of life for all those who live and work in Lewisham Disability: The strategy includes the assurance that the Trust will strive to ensure accessibility for all new services, in line with the DDA, and to deliver quality monitoring of good employment practices (with particular emphasis on improving the accessibility of services for those with Learning disabilities). Gender: Better access to primary care and psychological therapies are just two areas where the strategy aims to promote gender equality (includes promoting equality for individuals who are transgender). EIA 1 NHS Lewisham Commissioning Strategy Plan Page 11 of 94

12 screenings of each service area will be able to better identify the impact of the CSP on promoting gender equality Race: The current needs assessments being completed in relation to mental health and children & young people, coupled with improvements to services related to Long Term Conditions, Access to Psychological Therapies and access to Primary Care mean that the strategy will have a high positive impact in regards to promoting race equality Religion & belief: The strategy includes actions for the Trust to ensure that services can meet the needs of members of the population who have specific needs linked to religious and cultural beliefs, as well as ensuring that such needs are recognised, via the provision of space for reflection and prayer for example. The strategy shows the Trusts commitment to ensure that service leads strive to understand the differences of culture, religion and belief that all require flexible approaches to both health promotion and service delivery. Sexual Orientation: We recognise that there are very few official statistics relating to lesbian, gay, bisexual and transgender populations of the United Kingdom, however recent studies and consultations have highlighted access to appropriate sexual and mental health services as areas of particular concern to LGB communities 2. The strategy highlights the need for both improved access to psychological therapies and better targeted health improvement messages for this population e.g. relating to cancer, CVD, mental health etc Deprivation: Recognising that negative health outcomes are very much linked to high levels of deprivation the strategy focuses on tackling this wider determinant of health, not only by ensuring that services are concentrated in areas with most need, but also through fostering wider collaboration and partnership working across the borough. There are challenges in screening programmes of this magnitude, for example, long term conditions. However, we recognise that over time, each service area or pathway will need to be screened for their equalities impacts, in order to have a true sense of any emerging inequalities or possible discriminatory practices. This will also ensure the Trust reaches its potential to promote equality across all six strands, as well as tackling health inequalities relating to deprivation. The Department of Health have recently published their retrospective EIA of the World Class Commissioning assurance framework, which includes recommendations for PCTs working towards world class commissioner status 3. NHS Lewisham is committed to taking forward these recommendations, and the table below outlines the progress we have made to date towards implementing these actions: 2 See Single Equality Scheme DH_ NHS Lewisham Commissioning Strategy Plan Page 12 of 94

13 DH Recommendation Performance data should be disaggregated by ethnicity, disability and gender wherever possible, in order for PCTs to monitor the impact of its commissioned services on the corresponding population groups PCTs should ensure that they have sufficient equality and diversity capacity to support the commissioning function The criteria used by PCTs to prioritise investment should encourage the equitable allocation of resources according to need and avoid exacerbating existing health inequalities Promotion of equality and diversity should be considered throughout Local Action to Date Programme managers are expected to include their arrangements for collecting disaggregated data within their EIA reports. NHS Lewisham has a named Equalities Board Champion and Strategic Equality Lead. A part-time Equality and Diversity Coordinator has been employed to support staff in delivering on this agenda and to advise on undertaking impact assessments A series of training sessions on equality, diversity and EIA will be held early in 2009 for both staff teams and managers Areas where Lewisham s population experiences significant health inequalities directly informed the selection of the health outcome areas. The criteria for selection also included alignment with the Local Area Agreement and the Annual Public Health Report, both of which have a clear focus on addressing health inequalities. The impact assessments on each programme area will further assist in highlighting any possible negative impacts, so that inequalities are not further exacerbated while reducing others. Through the annual operating plan, decisions will be needed to allocate investment to prioritised needs. The Trust has agreed to develop a priority setting framework for this function, one of the stated underpinning principles being equity prioritising on the basis of need. Factors that we would need to take into account include the need to address inequalities and inequities of access, accessibility and legislation and directives (which would includes equality legislation) The tender document for the Musculoskeletal Services contract is NHS Lewisham Commissioning Strategy Plan Page 13 of 94

14 the procurement process The equalities duties relevant to the provider need to be explicit and clearly stated within PCT contract conditions PCTs should consider the unique strengths of third sector providers when developing strategies to increase choice of healthcare provision PCTs are strongly encouraged to assess the impacts of their strategic plans and programmes of work ( initiatives ) on key equality groups Board support: PCTs should ensure that training and development providers possess the necessary expertise to deliver in this area being used as an exemplar for contract development. This service was one of the first to be impact assessed and has also incorporated the Trust s guidance on collecting disaggregated equalities data for service users. The Strategic Equalities Lead will be working with the Procurement Project Manager to ensure that this good practice is embedded into the forthcoming procurement policy. Building on a primary and community providers event in October attended by voluntary sector representatives, the PCT will be working with the local authority to agree a joint voluntary sector commissioning framework, based on the principles of the local and national Compact and the recommendations of the Audit Commission report, Hearts and minds: commissioning from the voluntary sector Leads have outlined the key impacts on outcomes and inequalities within each programme (screening). These will be analysed by the Strategic Equalities Lead to form a high-level viewpoint of the overall impact of the programme. Individual service heads will still be expected to carry out EIA on individual services and policies as required. Reports are screened for their equality impacts, and the findings of the screening reported to the PCT Board. The Trust plans to carry out an evaluation and diagnostic exercise with board members between April and June We will use this opportunity to assess the Board s training and development needs with respect to equality and diversity Providers will be questioned directly on the skills and experience they have to deliver on the areas identified above. NHS Lewisham Commissioning Strategy Plan Page 14 of 94

15 SECTION 3 LOCAL CONTEXT This section provides context about the health needs of Lewisham; insights from our patients, carers and local residents; the current provider landscape and the key changes by providers envisaged, details of NHS Lewisham s finance and activity positions and outline of the local Primary and Community Services Strategy. 3.1 Local health needs Section 3.1 provides an overview of the intelligence we have about the health needs of our local population, which has informed the choice of goals and programmes described in this Strategy. Further information about how we are addressing these needs is provided in the appendices of the programmes. The health needs are described more fully in the Joint Strategic Needs Assessment, produced jointly with the London Borough of Lewisham. The demographic profile of Lewisham and the increasing levels of deprivation present a significant challenge to health and social care providers Key messages Lewisham has high levels of deprivation. It is a Spearhead Group authority because it is in the worst 20% of areas nationally for deprivation, life expectancy, and premature deaths from cancer and cardiovascular disease. Levels of deprivation have increased. Lewisham was ranked the 39 th most deprived borough in England in 2007 on the Index of Multiple Deprivation compared to the 57 th in In the next five years an increasing proportion of the middle aged and older population of Lewisham will be from Black and Minority ethnic communities., This will lead to an expected increase in the prevalence of some long term conditions such as, diabetes, hypertension, stroke, heart failure and chronic kidney disease. Lewisham has a relatively younger population compared to nationally. The population is growing, with an increase of 4% in children and young people and 3% among adults under 65 over the next five years, which will place an increased demand on services. NHS Lewisham Commissioning Strategy Plan Page 15 of 94

16 Lewisham has high rates of smoking, alcohol use and obesity, which contribute to the high rates of morbidity and premature mortality, especially in cardiovascular disease and cancer. One of the risks to the health of children in Lewisham is the lack of herd immunity, which can be established with increased coverage of immunisation. Young women in Lewisham have high conception rates Lewisham has high levels of communicable disease including HIV, sexually transmitted infections and tuberculosis Mental health is an important area of need in Lewisham as we have high rates of severe and enduring mental and common mental health problems Population There are various estimates of Lewisham population: Census 2001: 248,922 (ONS) 2007 mid-year estimate (MYE): 258,500 (ONS) 2008 mid-year estimate (MYE): 262,522 (GLA 2007 Low) For the purposes of this Section, the GLA 2008 MYE is used. Lewisham has a population of over a quarter of a million people and projected to rise over the next 5 years. The birth rate is increasing and between 2006 and 2007 about 3,000 people migrated to Lewisham. The projections from the Greater London Authority (GLA) estimate that Lewisham s population will increase overall by 3% between 2008 and The greatest increase will be in young people aged 0-15 by 4%. There will also be an increase among of 3% among adults aged 18 to 65. The numbers of those aged 65 and over is expected to decrease by 1% over the same time frame. The proportion of those aged 65 and over from Black and Minority Ethnic (BME) groups is estimated to rise from 14% in 2001 to 27% by NHS Lewisham Commissioning Strategy Plan Page 16 of 94

17 Table 4: Population growth Year baseline year %compound growth population segment ,401 51,661 52,165 52,660 53,203 53,595 % growth 1% 1% 1% 1% 1% 4% , , , , , ,600 % growth 1% 1% 1% 1% 0% 3% >65 23,706 23,509 23,295 23,184 23,252 23,438 % growth -1% -1% 0% 0% 1% -1% Male 128, , , , , ,096 % growth 1% 1% 1% 1% 1% 3% Female 134, , , , , ,537 % growth 1% 1% 1% 1% 1% 3% Persons 262, , , , , ,633 % growth 1% 1% 1% 1% 1% 3% White 158, , , , , ,774 % growth 0% 0% 0% 0% 0% 0% Black % growth 2% 2% 2% 2% 1% 8% Asian subcontinen t % growth 2% 2% 2% 2% 1% 9% Other ethnic % growth 2% 2% 2% 2% 1% 9% Source: GLA 2007 PLP Low There is relatively high mobility within the Lewisham population compared to inner London boroughs. The Strategy has taken account of the projected increase in the population, which will particularly impact on maternity services and services for children and young people, and those at increased risk of vascular disease and cancer in their middle years in addition to the relatively high level of mobility within the population. NHS Lewisham Commissioning Strategy Plan Page 17 of 94

18 Age Figure 1: Lewisham Age Profile by age and sex Lewisham Age Profile - GLA 2008 mid-year estimate Percent Lewisham males England males Lewisham females England females Lewisham has a relatively younger population compared to nationally. Gender The GLA 2008 MYE shows that there are 49.6% males and 50.4 % females in Lewisham. Ethnicity Lewisham is the 15 th most ethnically diverse local authority in England. Black and minority ethnic (BME) groups account for almost 40% of the total population, with the largest groups being Black African and Black Caribbean. It is estimated that 60.4% of the population is white. Black Caribbean (13.3%) and Black African (11.1%) are the next largest groups. NHS Lewisham Commissioning Strategy Plan Page 18 of 94

19 Figure 2: Ethnicity breakdown in Lewisham. Lewisham Population Percentages by Ethnic group (GLA Low) White Black Caribbean Black African Black Other Indian Pakistani Bangladeshi Chinese Other Asian Other The relatively large Black African and African Caribbean population have a higher vulnerability to diabetes and hypertension, and the conditions that these are risk factors for e.g. chronic kidney disease, stroke, heart failure, retinopathy etc. As this population both increases in size and age we may see a marked increase in these conditions. This population also has higher rates of HIV and sexually transmitted infections than the general population Deprivation The Index of Multiple Deprivation (IMD 2007) ranked Lewisham as the 39 th most deprived borough in England and the 11th most deprived in London. High levels of deprivation are associated with poor health outcomes. Lewisham is a Spearhead Group authority because it is in the worst 20% of areas nationally for deprivation, life expectancy, and premature deaths from cancer and cardiovascular disease. As well as achieving poor health outcomes, compared to the England average, there are significant health inequalities within the borough. The wards with the worst health outcomes overall are Evelyn and New Cross. Other wards such as Rushey Green, Lewisham Central, Bellingham NHS Lewisham Commissioning Strategy Plan Page 19 of 94

20 and Downham also have poor health outcomes in some areas and there are pockets of deprivation in other wards too. The number of children and older people living in poverty is also high. The following map shows Super Output Areas (SOA) in Lewisham by national quintile of deprivation. Quintile 1 is most deprived, quintile 5 least deprived. Lewisham has no SOA in the nationally least deprived quintile, and over a third of its SOAs in the most deprived quintile. Figure 3: Deprivation levels by Ward Based on 2001 Census data, 36% of the population lived in social housing. More recent local survey data from 2007 suggests there has been an increase in the number of private tenants with corresponding reductions in home ownership and social rented sector. Recent data suggests that over 32% of all households are one-person households, a third of which are pensioners living alone. Lewisham has high levels of unemployment compared to London and the overall proportion of people in employment has fallen over the last two years. The current credit crunch and downturn in the economy is likely to make this situation worse. The numbers of people claiming incapacity and other income- NHS Lewisham Commissioning Strategy Plan Page 20 of 94

21 related benefits continues to be high. There is also considerable variation in average income levels across Lewisham Life Expectancy For the population of Lewisham, life expectancy is significantly lower than the England average. In recent years, however, life expectancy has been rising faster than the England average, so the gap is closing. Life expectancy for men in Lewisham has been improving; however it is lower than that for England. Since it has increased by 3.8 years. In the period men in Lewisham could expect to live to 76.0 years, 1.2 years less than the England average of years. Life Expectancy for women in Lewisham is also improving however it is lower than that for England. Since it has increased by 2.4 years. In the period women in Lewisham could expect to live to 80.8 years, 0.74 of a year less than the England average of years. There are also significant inequalities across the Borough for example, between 2002 and 2006 there was up to a 6-year difference between the wards with the lowest and highest life expectancy for men Health conditions and diseases Deaths In common with the rest of England, the three main causes of death in Lewisham in were circulatory disease (32.1%), cancer (12.6%) and respiratory disease (13%). NHS Lewisham Commissioning Strategy Plan Page 21 of 94

22 Figure 4: Top 10 underlying causes of death in Lewisham Premature Mortality (under 75 years of age) A key concern for Lewisham is the high premature mortality rate compared with England. Early deaths are significantly higher than expected for a range of causes, including cancer, heart disease, stroke, circulatory disease, respiratory diseases and overall deaths linked to smoking. For deaths linked to causes amenable to healthcare interventions, the mortality rate for Lewisham is approximately 20% higher than the rate for London. Infant mortality is reducing and is now comparable with the rate for England. As with life expectancy, there are particular parts of the Borough where premature mortality rates are significantly higher than others which present challenges to health services; for example, between 2004 and 2006, New Cross and Ladywell had the highest cancer mortality rates in Lewisham; Lewisham Central and Evelyn have the highest rates within Lewisham for circulatory disease for the same period. 4 Emergency hospitalisation rates Lewisham s emergency hospitalisation rates for acute conditions usually managed in primary care* (defined by NCHOD), chronic conditions usually 4 Mortality data needs to be interpreted with an understanding of its limitations there are relatively small numbers of deaths in each year and also considerable fluctuations from year to year particularly at ward level. NHS Lewisham Commissioning Strategy Plan Page 22 of 94

23 managed in primary care and all conditions are significantly higher than the national rate (the 95% confidence intervals do not overlap). The following charts and tables show comparative emergency hospitalisation rates for Lewisham and England. Data is presented for 2006/7, the most recent available, using indirect age standardisation rates per 100,000 persons (i.e., male and female combined), from which standardised hospitalisation ratios have been calculated. The source was NCHOD, which analysed data from the HES database. The charts also include the position for London as a whole. Acute conditions including hypertensive heart disease and heart failure usually managed in primary care 2006/7 Label Indirectly age and sex standardised rate per 100,000 Lower limit of 95% confidence interval Upper limit of 95% confidence interval SHR Observed Number of Admissions Expected number of Admissions ENGLAND London Lewisham LB Lewisham s emergency hospitalisation rate for Acute conditions usually managed in primary care* (defined by NCHOD) is significantly higher than the national rate (the 95% confidence intervals do not overlap). NHS Lewisham Commissioning Strategy Plan Page 23 of 94

24 Emergency admissions for Chronic conditions (diabetes, asthma) usually managed in primary care 2006/7 Indirectly age and sex standardised rate per 100,000 Lower limit of 95% confidence interval Upper limit of 95% confidence interval SHR Observed Number of Admissions Expected number of Admissions ENGLAND London Lewisham LB Emergency admissions, chronic conditions usually managed in primary care, 2006/7 indirectly age standarised rates with 95% confidence intervals (source: Compendium) Age standardised rates Upper limit of 95% confidence interval Low er limit of 95% confidence interval Indirectly age and sex standardised rate per 100, ENGLAND LONDON Lew isham LB Area Lewisham s hospitalisation rate for these conditions is significantly higher than the national rate (the 95% confidence intervals do not overlap). Emergency admissions all conditions 2006/7 Indirectly age and sex standardised rate per 100,000 Lower limit of 95% confidence interval Upper limit of 95% confidence interval ENGLAND SHR Observed Number of Admissions Expected number of Admissions London Lewisham LB NHS Lewisham Commissioning Strategy Plan Page 24 of 94

25 Lewisham s hospitalisation rate for these conditions is significantly higher than the national rate (the 95% confidence intervals do not overlap). Vascular Disease The premature mortality (under 75 years) rate from all circulatory disease (CVD) for men and women in Lewisham is above the rate for England and London. The following graph and table present rolling 3-year averages for Directly Age Standardised Rates for the 10-year period to 2007 (the most recent data available at the time of writing) for all persons. Data is shown for Lewisham PCT, England, London, the average for London Spearhead PCTs, and the London Cosmopolitan Cluster of the Census Area Classifications. (This represents a group of PCTs whose populations most closely resembles that of Lewisham across a wide range of 2001 Census variables. The methodology for this is complex, and can be found on the NCHOD website). NHS Lewisham Commissioning Strategy Plan Page 25 of 94

26 Three years to Spearhead average DSR Lewisham LB DSR LONDON COSMOPOLITAN DSR LONDON DSR ENGLAND DSR In Lewisham had significantly higher admission rates compared to the England average for stroke, coronary heart disease and diabetes. In March 2008 there were 5,694 people with diagnosed chronic heart disease (CHD), 1,957 people with atrial fibrillation, 1,495 people with heart failure, and 3,016 people with diagnosed transient ischaemic attack (TIA) or stroke and 4,239 people aged 18 and over with chronic kidney disease. Smoking Smoking is the leading preventable cause of ill health and early death in the UK. In the period the rate of deaths attributable to smoking for those aged 35 and over in Lewisham was significantly worse than that of England, (284.5 per 100,000 deaths compared to England at per 100,000 deaths). It is estimated that 26.8% of people over 16 years of age smoke in Lewisham, These rates are well above the England average for smoking which is 22%. Alcohol In the period alcohol-specific mortality in Lewisham for males and females is not significantly different than that of England. Compared to other London boroughs, Lewisham ranks the fourth highest for male alcohol-specific mortality and third highest for females. However during , in terms of hospital admissions for alcohol specific and alcohol related admissions for females, Lewisham had significantly less admissions than England. Admissions rates for males are the same as that for England. Obesity It is estimated that there are 40,000 people who are obese in Lewisham in There are almost 20,000 people classified as obese on GP registers in Lewisham in the same year. Diabetes The prevalence of diabetes in Lewisham is very high compared with the England population. There are 11,266 aged 17 and over with a diagnosis of diabetes. Hypertension Hypertension is the most common long term health condition both in Lewisham and nationally. It is a highly modifiable risk factor for stroke, heart disease, and kidney failure. There is a strong association between undetected and uncontrolled hypertension and deprivation and inequalities. 30,321 people with diagnosed hypertension. It is estimated that only half of the expected number of people with hypertension in Lewisham are diagnosed. NHS Lewisham Commissioning Strategy Plan Page 26 of 94

27 Cancer Premature mortality (under 75 years) from cancer in Lewisham is above the rate for England and London. The following graph and table present rolling 3-year averages for Directly Age Standardised Rates for the 10-year period to 2007 (the most recent data available at the time of writing) for all persons 19. Data is shown for Lewisham PCT, England, London, the average for London Spearhead PCTs, and the London Cosmopolitan Cluster of the Census Area Classifications. (This represents a group of PCTs whose populations most closely resembles that of Lewisham across a wide range of 2001 Census variables. The methodology for this is complex, and can be found on the NCHOD website.) Three years to Spearhead average DSR Lewisham LB DSR LONDON COSMOPOLITAN DSR LONDON DSR ENGLAND DSR Tuberculosis The annual report of tuberculosis (TB) in South East London in 2007 was published in November 2008, and provides an overview of the epidemiology of the disease locally. In total, 485 cases of TB were notified in South East London in 2007, a decrease of 4% (n=20) compared with The overall incidence in the sector was 31.5 per 100,000 population in The number of notifications increased in Lewisham in 2007, by 16%. Patients of Black African ethnicity continued to be disproportionately affected by TB in 2007, and this ethnic group accounted for 48% of all South East London notifications during this year. Country of birth was noted in 91% notifications (n=443) and a total of 59 countries of birth were recorded (including the UK). As in previous years, the highest numbers of notifications were in patients who were born in the UK, NHS Lewisham Commissioning Strategy Plan Page 27 of 94

28 Somalia and Nigeria. The number of paediatric cases (ie: in patients below the age of 16 years) increased by 26% (n=10), compared to the previous year, and accounted for 10% of all sector notifications in Ongoing monitoring of paediatric cases within the sector continues to be important, as they are an important proxy indicator of ongoing transmission in the community. The proportion of notifications with pulmonary TB (which is important from a public health point-of-view, as it is this form of TB which may be infectious to others) remained largely stable in 2007, and pulmonary TB was diagnosed in 46% of all reported cases in that year. Figure: TB incidence rates by borough, Incidence per 100,000 population Bexley Bromley Greenwich Lambeth Lewisham Southwark South East London Year Children s and Young people s health Maternity There were 4,132 births to Lewisham women in 2007/8. Around 40% of births were to women from Black and Minority Ethnic (BME) groups. 10% of births were to women aged under 20 or over 40. Births in Lewisham have increased by 12% since 2002/3 and the total number of births to Lewisham women is projected to increase by 13% by Infant Mortality Infant mortality rates in Lewisham have improved and since 2002 the rate for Lewisham has been lower than the London and England rate. For the period the Lewisham rate was 4.7 per 1,000 births compared to 5 per 1,000 births for London and England. NHS Lewisham Commissioning Strategy Plan Page 28 of 94

29 Since 2003 the rate for stillbirths has been reduced to 5.2 per 1,000 (2006) which is lower than the England rate, at 5.3 and London at 6.3. Low Birthweight Lewisham has a higher percentage of low birth weight babies than both London and England. These are infants who weigh less then 2500 grams expressed as a percentage of all live births in the borough. The most common reason for very low birth weight is extreme prematurity. In the period , Lewisham had a significantly higher rate of low birth weight babies, 9.5 compared to that of England (8) and London (8.5). The latest data (2006) shows that the situation is improving with a Lewisham rate of 8.5 compared to the London rate of 8.3 and an England rate of 7.9. Immunisation There is a low uptake of childhood immunisation such as Mumps, Rubella and Measles (MMR) in Lewisham. The World Health Organisation recommends that 95% of children receive a vaccine such as MMR at age months. In in Lewisham the percentage of children immunised with MMR vaccine by their 2 nd birthday was 61% compared to 85% in England. Improving MMR uptake in Lewisham is a high priority in improving children and young people s health. Obesity Obesity is a particular problem for children in Lewisham. For reception aged children; rates of obesity are significantly higher than that of England and London, 14.4 % compared to 9.9% and 11.3% respectively. Teenage pregnancy Lewisham has the second highest rate of teenage (15-17) conceptions in London. The teenage pregnancy rate in Lewisham is declining with a 15% reduction since In 2006 the rate was 68 per 1,000. It is unlikely that the PCT will meet the 2010 target of reducing teen conceptions by 50% from the 1998 baseline. Sexual Health Lewisham has high rates of sexually transmitted infections (STIs) including Chlamydia, Gonorrhoea, and HIV. In 2007 there were 1,158 people aged 15 and over who have been diagnosed with HIV living in Lewisham. Mental Health In March 2008, there were 3,132 people with schizophrenia, bipolar disorder and other psychosis on GP registers in Lewisham. Within the South London and Maudsley (SLaM) Foundation Trust there are 3,132 Lewisham residents on the Care Programme Approach (CPA) of which 1,398 are enhanced CPA. NHS Lewisham Commissioning Strategy Plan Page 29 of 94

30 Among Lewisham s population (aged 16-74) it is estimated that 37,757 will experience a common mental illness (e.g. depression, anxiety, panic, phobia and compulsive behaviour). In 2008 of the 12,410 people in Lewisham claiming Incapacity benefit, 46% had mental and behavioural disorders. Carers The 2001 census identified 19,675 people in Lewisham providing unpaid care (7.8% of the population). 81% are between 18 and 65 and 4,243 care for more than 50 hours per week. There are at least 1,200 young carers (under 18) within the borough and 33% of those caring for children with disabilities are lone parents. Approximately 50% of carers supported by Carers Organisations within Lewisham are from BME communities. References: Maternity Health Needs Assessment: 2008 Lewisham PCT Office National Statistics 2007 National Centre for Health Outcomes Development: Low birthweight births 2006 NHS Immunisation Statistics National Child Measurement Programme ( results) Department of Health Under 18 Conception data for top-tier Local Authorities (LAD1), final 2006 HPA SOPHID 2007 Increasing Access to Psychological Therapies: Care Services Improvement Partnership - London Development Centre 2008 The Health and Social Care Information Centre: Statistics on Smoking: England, 2008 North West Public Health Observatory: Local Alcohol Profiles for England 2007 The Health and Social Care Information Centre and National Centre for Social Research 2007: Healthy Lifestyle Behaviours: Model Based Estimates for Middle Layer Super Output Areas and Local Authorities in England, SE London Health Protection Agency November 2008, Annual Report of Tuberculosis in SE London in 2007 The Quality Management System (QMAS) data from Lewisham GP practices for March 2008 provides the following information on the numbers of people on disease registers: (This is a snapshot as QMAS is a dynamic database, with new information being added as patients are seen in primary care). NHS Lewisham Commissioning Strategy Plan Page 30 of 94

31 3.2 Insights from Patients, Carers, Residents and Key Local Partners A large stakeholder event with 85 members of the local community (including 50 randomly selected members of the public) was held to help prioritise the health outcomes for Lewisham. Views from the event were used alongside other evidence on local health needs to determine the ten priority health outcomes. Key themes that emerged during the event were: The overlapping nature of many of the emerging health priorities. All the priorities were considered of equal importance. Some participants felt some priorities to be substantively different to one another and therefore incomparable. There needs to be a focus on prevention. Priorities need to encompass broader health, wellbeing and community needs. The event led to the list of priority health outcomes being adjusted for example mental health was added and improvement in children s health was ranked the top priority. Over the last year, a key part of engagement with patients, carers, public, clinicians and stakeholders has been through the APOH and HfL consultations held December 2007 to April HfL is focused on tackling health inequalities and developing world-class services for Londoners over a 10 year period. The outcome of the public consultation was agreement that work needed to focus on six priority areas - stroke, major trauma, polyclinics, unscheduled care, local hospitals and diabetes. A public consultation on stroke and trauma was launched in February 2009 which aims to ensure that Londoners are no more than 30 minutes from a specialist stroke unit and no more than 45 minutes from a major trauma centre. APOH is focused on delivering improved and sustainable acute services, supported by developments in out of hospital care closer to people s homes. The consultation provided three different options for change. A criteria setting workshop was held after the consultation with the general public, community and voluntary groups, clinicians and managers to review and rank the criteria for assessing the options. The highest priority for all groups was clinical quality and safety, with skilled staff and capacity to meet demand coming next for members of the public. NHS Lewisham are finalising their Communication and Engagement Plan by March 2009 with the explicit aim of being the most responsive PCT in England. This plan sets out how the PCT intends to deliver this aim in its public and patient NHS Lewisham Commissioning Strategy Plan Page 31 of 94

32 involvement activities over the next 5 years and will be available through Provider landscape The table below describes the current providers commissioned by NHS Lewisham to provide services to the local population. The table includes commentary on the priorities for configuration, provider or market development. Primary care - GPs, dentistry, and optometry Provider/Number of providers GPs 49 practices Pharmacy - 55 Community Pharmacies Dentistry - 36 Dentists Optometry - 18 Mandatory Opticians 21 Domiciliary 2008/9 value of activity commissioned 000s Providerspecific commentary 89, GMS Contract 34 PMS Contract 10 single handed 15 pharmacies provide emergency contraception 6 pharmacies provide anticoagulation services 1 practice provides orthodontics 7 offer sedation 7 offer domiciliary care Key Changes Needed Improved access Better quality and consistency of care and patient experience Enhanced range of services both through individual schemes and development of 4 Polyclinics Premises development to ensure fit for purpose. Robust succession planning needed to maintain numbers of skilled practitioners. Increased practice nurse development and recruitment Use of APMS contracts to commission services NHS Lewisham Commissioning Strategy Plan Page 32 of 94

33 Community and intermediate services Children & Young Peoples Services (PCT) 11,655 The provider arm of the PCT delivers health visiting, school nursing, community paediatrics, and children s community nursing, safeguarding and paediatric therapy. These services are commissioned by a joint commissioner (PCT and LBL). Review options for future provision March Sept 09 Implement April 2010 Development of detailed service specifications Integration of services around Children s Centres including review of HV role Children & Young Peoples Services (Southwark PCT) Paediatric Audiology Newborn Hearing Screening Programme CAMHS 291 Commissioned from South London & The Maudsley Foundation Trust Review of SN, Children s Community Nursing Team, Special Needs Team and Safeguarding and Paediatrics Dermatology Review service specifications Develop full range of early intervention support services in both universal and targeted settings Develop full range of CAMHS services for children and young people with learning disabilities NHS Lewisham Commissioning Strategy Plan Page 33 of 94

34 Independent or other statutory providers Adult Services (PCT) 955 A range of services commissioned form independent and statutory providers in relation to children with ongoing care needs. 15,565 PCT Provider arm provide District nursing, community matrons, specialist nursing services, podiatry, therapies, Walkin-Centre, sexual and reproductive health services and intermediate care. Review options for future provision March Sept 09 Implement April 2010 Relocation of Walk-in Centre to GP led Health Centre/Urgent Care Centre subject to consultation by end 2009 BPAS (Independent provider) Provision of vasectomy and other related family planning services Review of Phlebotomy and MSK foot services Development of Care Closer to Home plans jointly with LBL, including review of LINC, LATT and Hip Team Review of vasectomy commissioning to implement MRSA Screening requirements from April NHS Lewisham Commissioning Strategy Plan Page 34 of 94

35 Learning Disability Specialist Healthcare Provision Social Care Provision Southwark PCT 6 Main provider organisations commissioned under a common framework to ensure best value for money. Some specialist out of borough placements. A range of Learning Disability specific professional services (nurses, SALT, physio, OT etc). Review of supported living services Development of individual budgets Changes in the health support needs of the younger cohort of people with learning disabilities are likely in this next 3 8 year period to require the commissioning of more acute, intensive home support services. NHS Lewisham SLaM Pharmacy support to commissioned services Psychology support for adults with learning disabilities including specialist behavioral intervention. Other specialist mental health services are commissioned as part of the main SLaM contract. Review Adult Mental Health/LD care pathways. NHS Lewisham Commissioning Strategy Plan Page 35 of 94

36 Total Spend 9,821 Mental health South London & The Maudsley NHS Trust Other NHS: Oxleas Central & NW London SW London & St Georges Joint Working & Voluntary Sector 60,167 These figures Development of the Working for Wellness project by improving access to Physiological Therapies 5, ,828 include the commissioning contribution from London Borough of Lewisham as part of the section 31 joint commissioning agreement. (NB. The contract figure for SLaM includes CAMHS, MHOA, Learning Disability, Addictions and Specialist services as well as Adult Mental Health Services) Ongoing service specification reviews and changing tripartite S31 agreement to bilateral s75 agreement Mental Health Older Adults - emphasis on delivering care closer to home and early intervention, specifically for clients with dementia. Review of effectiveness and cost effectiveness of medium secure contracts Extending advocacy support Development of the Working for Wellness project NHS Lewisham Commissioning Strategy Plan Page 36 of 94

37 High Secure 3,250 Review of care pathways and service provision to ensure effective moveon through system Secondary care Guys & St Thomas NHS Foundation Trust Kings College Hospital NHS Trust 36,236 25,365 Greater provider collaboration with University Hospital Lewisham and SLAM via Academic Health Sciences Centre (including APOH decision for complex paediatrics and maternity) The Lewisham Hospital NHS Trust Bromley Hospital Trust Queen Elizabeth Hospital Queen Mary s Sidcup Development of Primary Care Oral surgery services impacting on Kings 86,441 Awaiting outcome of APOH IPR on emergency surgery. Development of Urgent Care Centre and Medical Assessment Service 2,799 2, Merging into single Trust 2009/10 NHS Lewisham Commissioning Strategy Plan Page 37 of 94

38 London Ambulance Service (LAS) 7,628 Provides emergency 999 transport and treatment Development of alternative pathways rather than conveyance to an A&E Integration into emergency prevention activities Workforce development Health Promotion & Prevention Voluntary and community sector, SLAM, LBL, C&YP Services, PCT, Adult Services, PCT, Stop Smoking Service and Health Improvement Team, PCT, Hospices, Marie Curie, Stroke Association, and Crossroads. A range of services including a focus on mental health promotion, sexual health, tobacco control, community development, CVD and cancer prevention, screening, physical activity, healthy eating and obesity. Review of local mental health promotion strategy Pilot in collaborative commissioning in the North of the borough Women s health intervention to tackle premature death St Christopher s Hospice 1,077 Inpatient, day care, home care. Marie Curie 60 Nursing Care mainly nightshifts Range of health improvement initiatives physical activity, childhood obesity Engagement in review of local end of life strategy Stroke Association 37 Family Support Worker Engagement in integrated care work for stroke rehabilitation NHS Lewisham Commissioning Strategy Plan Page 38 of 94

39 Lewisham Crossroads Macmillan Palliative Care Scheme 24 Respite/sitting service for carers. Engagement in review of local end of life strategy 3.5 Financial Situation NHS Lewisham has a history of meeting its financial objectives with the exception of the financial year For the financial year 2008/09 the PCT is forecasting a break even position. The latest financial results available at the time of publication show that the PCT has an under spend of 191,000 for the seven month period to October Summary Financial Position Month 7 (October 2008) Annual Allocation Year to Date Budget Year to Date Spend Year to Date Variance 000s 000s 000s 000s Acute Commissioning Acute 150,019 87,980 92,715 (4,735) Other External Trusts 21,716 12,668 12, Specialist 13,088 7,642 7, Sub Total 184, , ,783 (4,493) Health Client Group Commissioning Mental Health 73,698 42,990 42, Learning Disabilities 9,821 5,729 5, Other Health Client Groups 22,669 13,223 12, PCT Provider 28,386 16,538 15,130 1,408 Premises 3,612 2,163 2,564 (401) Prescribing 36,320 21,393 20, Primary Care 53,529 31,225 31,218 7 Corporate Budgets 11,799 6,719 6, Shared Services 3,474 2,027 2,093 (66) Other PCT Budgets 4,854 2,984 2, Reserves & Contingency 16,999 2, ,464 Total 449, , , NHS Lewisham Commissioning Strategy Plan Page 39 of 94

40 3.5.1 Forecast financial results for 2009/10 to 2012/13 The finance and activity templates (separate document) set out in detail the forecast financial results for financial years 2009/10 to 2012/13. The underlying assumptions used are as follows: FY FY FY FY 2009/ / / /13 % % % % PCT Allocation Uplift 5.8 % 5.8 % 4.0 % 4.0 % GP Contract Inflation 1.5 % 1.5 % 1.5 % 1.5 % Dentist Contract Inflation 1.5 % 1.5 % 1.5 % 1.5 % Community Services Wage Inflation 2.4 % 2.3 % 2.3 % 2.3 % PBR Tariff Inflation 2.8 % 2.8 % 1.0 % 1.0 % Non PBR Tariff Inflation 2.8 % 2.8 % 1.0 % 1.0 % Prescribing Inflation (before new drugs) 4.0 % 4.0 % 4.0 % 4.0 % In addition, in accordance with guidance from NHS London the allocation for financial years 2009/10 and 2010/11 have been reduced by 1% for the London investment fund. The financial position for the five year plan is detailed in the table below: FY FY FY FY 2009/ / / /13 000s 000s 000s 000s Income 471, , , ,874 Expenditure Primary and Community 161, , , ,261 Mental Health, Learning Disabilities/Continuing Care 86,946 89,126 91,092 93,041 Secondary or Tertiary Care 202, , , ,823 Other PCT Commissioning Spends 18,404 21,113 23,715 24,327 Contingencies 2,351 2,489 2,592 2,697 Total Expenditure 471, , , ,149 PCT Surplus (Deficit) ,725 Aspects of the finance and activity templates are described in more detail below. NHS Lewisham Commissioning Strategy Plan Page 40 of 94

41 3.5.2 Finance and Activity Templates The finance and activity templates have been completed and submitted to London NHS in accordance with the details required and the assumptions set out by NHS London and other assumptions contained within Health and Wellbeing The templates need refinement in terms of analysis of current spend and future developments but at this time includes an uplift to reflect demographic change and price inflation, plus increases in investment each year to reflect the PCT's intention to invest in the health and well being of its population. More information is available in Appendix 1B Programme 1 Health Inequalities and Health Improvement Acute An acute activity model has been set up to populate the acute fields by specialty. Acute activity is assigned to grouped specialties based on the mapping table supplied by NHS London. NHSL conditions are based on mapping particular HRG s /ICD10/OPCS codes. The model starts with a detailed download of 2007/08 activity and costs from the PCT s information system for full year 2007/08 and year to date 2008/09. The cumulative position to month /09 has been adjusted to give a full year forecast outturn position for 08/09. The full year forecast 2008/09 position forms the basis of projections for the next four years. The model includes fields to account for tariff changes, demographic changes by specialty, and allows for adjustments on a yearly basis to activity, for example, the implications of APOH, Effective Referral Management Programmes to move activity from the acute sector into primary and community care settings, and a number of investment initiatives to meet health outcome priorities. Two particular initiatives are in maternity services and cancer services and are service quality related rather than activity related. The projection for acute expenditure also makes an estimated allowance for the effects of the introduction of HRG4 but this is very difficult to forecast accurately. Additional activity categories have been created under Other where necessary to cover areas not currently identified in template, for example Critical Care Mental Health NHS Lewisham Commissioning Strategy Plan Page 41 of 94

42 The majority of mental health services are currently commissioned via a block contract. Significant work has taken place in 2007/08 and 2008/09 to develop a robust contractual agreement with the main provider, South London and Maudsley (SLaM). Foundation NHS Trust This has involved developing clear service specifications against which activity is monitored. The quality and scope of the activity reporting has developed and is facilitating more targeted commissioning discussions. Over the next five years, it is anticipated that there will be significant change in the information available to commissioners as work on Service Line Management comes to fruition, and national pilots on Payment by Results (PbR) through activity based clusters are developed in Mental Health. NHS Lewisham will make full use of this information in order to more closely plan and align commissioning intentions against activity levels. This financial model will therefore be refined year on year as further information becomes available Primary Care / Community / Prescribing / Corporate The general NHS London planning assumptions have been applied to future years. Given 2008/09 forecast outturn, prescribing expenditure has been uplifted by 4%. Dental expenditure includes investment to increase access in line with the recently submitted dental toolkit. A provision has been made for additional services operating from Polyclinics. 3.6 Activity Commissioned Acute activity The PCT s largest contract is with The Lewisham Hospital (c. 88 million) but it also has significant contracts with Guy s and St Thomas (GSTT c. 36 million) and Kings (c. 25 million). There are 4/5 other contracts in the range of 1 million to 4 million and around 15 contracts in the 200k to 950k range. The last 4 years (2005/06 to 2008/09) have seen material growth in acute activity and spend with full year outturn exceeding contracts by significant amounts. There have been particular increases in inpatient elective, inpatient non elective and outpatient follow up activity and costs in these years, and also in the area of critical care and high costs drugs and devices. In terms of providers the most significant increases (proportionately) have been at GSTT and Kings. The tables below illustrate this: NHS Lewisham Commissioning Strategy Plan Page 42 of 94

43 Acute Spend -Main Providers 2004/5 Actual 000s 2005/6 Actual 000s 2006/7 Actual 000s 2007/8 Actual 000s 2008/9 Budget 000s 2008/9 Forecast 000s Main Providers University Hospital Lewisham 91,133 95,819 86,618 96,229 86,441 89,728 Kings College Hospital 17,665 19,630 19,478 23,623 25,365 29,165 Guys and St Thomas Hospital 26,575 28,523 28,810 36,582 36,236 39,349 PCT TOTAL 135, , , , , ,242 Note UHL 0708 includes certain one off payments Activity - Main Providers 3 Main Providers 2005/6 Actual 2006/7 Actual 2007/8 Actual Elective 22,039 24,583 27,509 Non Elective 6,716 7,696 8,038 Emergency 21,862 20,889 19,925 PCT TOTAL 50,617 53,168 55,472 Guys 2005/6 Actual 2006/7 Actual 2007/8 Actual Elective 5,512 5,567 6,226 Non Elective Emergency 1,805 1,835 2,117 PCT TOTAL 7,635 7,758 8,703 Kings 2005/6 Actual 2006/7 Actual 2007/8 Actual Elective 4,792 5,450 7,107 Non Elective ,113 Emergency 1,276 1,561 1,599 PCT TOTAL 6,623 7,796 9,819 UHL 2005/6 Actual 2006/7 Actual 2007/8 Actual Elective 11,735 13,566 14,176 Non Elective 5,843 6,555 6,565 Emergency 18,781 17,493 16,209 PCT TOTAL 36,359 37,614 36,950 NHS Lewisham Commissioning Strategy Plan Page 43 of 94

44 In moving forward the PCT is seeking to arrest these upwards trends through a number of plans and processes, many through Practice Based Commissioners. There is investment in Acute services in specific areas, namely maternity services, cardiac services and renal services but there are a number of projects to move appropriate services into the community. In addition plans are in place to reduce unnecessary A&E attendances though provision of an Urgent Care Centre. It is generally recognised that meaningful community activity data is an issue and therefore it is difficult at this stage to demonstrate the above in activity terms. Health Client Groups The PCT has commissioned a block contract with SLaM for the majority of secondary mental health services, of which adult mental health has the most significant financial value. Adult Mental Health services are commissioned jointly with LBL, currently via a Section 31 Agreement. It is intended that this agreement will be refined and updated, with the subsequent section 75 agreement being a bilateral arrangement between commissioning organisations (SLaM is currently party to the S31 agreement). There is a cost and volume contract in place for specialist and tertiary services provided by SLaM. A contract for 34.5 Medium Secure beds/units is held with Oxleas NHS Foundation Trust. Lewisham PCT is seeking to ensure that service specifications are developed to enable greater specificity on these services contracted. The development of PbR in Mental Health will be closely monitored by the PCT to reduce any adverse financial risk as the contractual climate changes. Continuing Care and Learning Disability services will be commissioned at underlying levels of performance. Staying within budget will require a range of commissioning activities to limit in-year cost pressures. The impact of capping the PCT contribution to the Learning Disability budget, and the preparatory work to support the transfer of budget at source from the PCT to the council, may result in a sudden shift in the pattern of spend on the continuing care budget which will be closely monitored and risks mitigated. Commissioning plans for other service areas mental health, children s services, substance misuse, physical disability services and sexual health will be closely managed so that investment portfolios deliver effectively to achieve commissioning plans and stay within budget. Effective commissioning of PCT provider services will support the achievement of the ERM Programme. PBC will be developed in partnership to support delivery of the ERM Programme. NHS Lewisham Commissioning Strategy Plan Page 44 of 94

45 3.7 Primary and Community Services Strategy NHS Lewisham is developing a comprehensive Primary and Community Services Strategy (PCSS). The overall strategic aim of the strategy is to improve the quality of, access to and scope of primary and community health care services in order to improve health outcomes for the whole population of Lewisham. The PCSS aims to create an understanding and ownership of the strategic direction for primary care and sets out our plan for the commissioning of primary care services in Lewisham until During the time period covered by this strategy NHS Lewisham expect to see radical changes in the primary care landscape. Whilst embracing both national and local changes in order to support improved health outcomes for patients, NHS Lewisham also recognises the importance of the high quality service provided by many of the existing primary care service providers. It is essential that these are developed further as an integral part of the changing landscape. Examples of the imminent changes include the implementation of the A Picture for Health (APOH) and Healthcare for London (HfL) proposals. These include the: introduction of new providers through Equitable Access to Primary Care (DOH 2007) using detailed procurement processes; development of Polyclinics; creation of at least one GP led Health Centre; extended opening hours; redesigned roles delivering care closer to home and the development of an Urgent Care Centre at University Hospital Lewisham (UHL). An arms length community health service provider organisation will be created to fulfil the requirement to separate the commissioning and provision of community services. All of the above developments will contribute towards the transformation of primary care as we know it. The key headlines for primary care from the document are; Equity: Develop an approach to establishing equity in the levels of primary health care delivered to practice populations based on per capita expenditure (Doctors and Dentists). Workforce: Plan for the replacement of retiring staff and training and development of staff into new responsive roles. Mental Health: Implement the Working for Wellness programme (Improving Access to Psychological Therapies IAPT) and the associated redesign of the psychological therapy enhanced service. Equitable Access: Commission at least one GP led Health Centre and roll out extended hours of access to all providers. NHS Lewisham Commissioning Strategy Plan Page 45 of 94

46 Care closer to Home: Develop the service specification and commission services in the Waldron Health Centre as a polyclinic. Develop a further four polyclinics, using hub and spoke models to provide access for the rest of Lewisham. Urgent Care: Develop an urgent care centre at UHL in response to the outcomes of APOH. Estates: Bring premises up to standard to meet the PCT Estates Strategy and the Disability Discrimination Act. Service Redesign: Develop service redesigns in endodontics and periodontics to improve dental health care, move care closer to home and impact on secondary care referrals. Service Development: Ensure Optometry service redesigns are developed in accordance with best practice guidelines. Practice Based Commissioning: Develop practice based commissioning to further re-design services and to become multi organisational, incorporating other clinicians and their staff in addition to GPs and practice nurses. Development of both existing and new enhanced services linked to the National Contracts to maximise their impact on patient care including for Adults with Learning Disabilities. Communication: Improve communication with patients, carers and voluntary sector providers. Performance: Development of a robust performance management framework for all primary care providers. In order to deliver integrated primary care services, the PCT aims to commission services that deliver: A high quality, cost effective, best value for money contracts for service provision, which are based on local needs. A primary focus on reducing health inequalities that underpins all commissioning decisions. Increased primary care capacity, in fit for purpose settings, to meet the identified needs of patients and to support the appropriate re-provision of services historically provided in hospital. Equitable access to the same core primary care service for all patients. The development of, and engagement with, Practice Based Commissioning (PBC) and other primary care initiatives. NHS Lewisham Commissioning Strategy Plan Page 46 of 94

47 Re-shaped primary care services and new roles to facilitate the redesign of patient pathways, including the introduction of new providers/provision to fill identified service gaps and deliver Choice. Closer liaison between primary care and partner agencies when complex and special needs cannot be met solely in primary care. Comprehensive, robust and appropriate systems of accountability and performance management are in place. An environment that places a high priority on commissioning learning and development for all stakeholders whatever their role and responsibilities in order to develop a modern accredited, sustainable workforce where transferable skills and innovative practice are supported. An empowered population which takes an informed interest and responsibility for their health needs and promotion of well being, including them in the development of this strategy and subsequent changes in health care provision. The PCSS will be available from June 2009 on our website at Development of Polyclinics to deliver strategic goals The development of a number of polyclinics across Lewisham underpins the delivery of Equitable Access to a wide range of high quality health services in Lewisham. These centres will ensure that care closer to home is available to people in all parts of the borough and that this is accompanied by the development of a seamless pathway of care for patients between the different services on offer. Our plans, as documented here and in the Primary and Community Services Strategy (PCSS), are to have a minimum of four polyclinics in Lewisham. Given the pre-existing pattern of services, premises and patient needs within the four cluster areas in Lewisham, it is envisaged that both the physical model (single site / hub and spoke model) and the services offered at each of the four sites will need to vary in order to meet the needs of the catchment population. The following services will be at the core of all of the polyclinics: GP Services Full range of Core and Enhanced GP Services Access 8am 8pm daily for both registered and unregistered patients, walk-in and bookable appointments NHS Lewisham Commissioning Strategy Plan Page 47 of 94

48 Access to Primary Healthcare Team including Practice Nursing services Community Services District Nursing Health Visiting Community Matrons Podiatry Children s Therapy services Adult Therapy Services Midwifery Specialist nursing services incl LTC, TB etc Sexual and Reproductive Health services Community dentistry IAPT talking therapies Pharmacy Services Dispensing services Stop Smoking services Medicines Usage Review Anticoagulation services Drug and Alcohol services Emergency Hormonal Contraception Minor Procedures Phlebotomy MSK Joint injections Diagnostics Ultrasound Spirometry ECG Secondary care outpatient consultations Health promotion and prevention and well-being Health screening programmes E-based information and lifestyle support Benefits and welfare advice services In addition to this core group of services there may be other high priority areas identified through a local needs assessment and consultation process that will ensure that the services and the way that they are provided, address the needs of the local population. For example, this would include the details of which secondary care outpatient consultations should be carried out in any one area, NHS Lewisham Commissioning Strategy Plan Page 48 of 94

49 In the north of the borough with the high number of non-english speaking residents there may be a greater focus on interpreting and language specific services. In addition, one of the potential sites (Downham) includes swimming and library facilities already because of the previously identified need for healthy living and recreation services for the population it serves. The full range of services and speed with which these come on stream will reflect local health priorities and patterns of pre-existing facilities and services in each location. The agreed site identified as Lewisham s first polyclinic is the Waldron Health Centre in the North of the Borough. A consultation, running from January to April, has been undertaken primarily to inform the development of a GP led health centre (location and services) but has also informed local planning about the range of services that residents would like to see being offered from a polyclinic site. We will use focus groups and stakeholder meetings to inform decisions about the services that should be made available, in addition to the core services, as each of the polyclinic sites is developed. Programme Planning for the phased development of polyclinics A minimum of four polyclinics are planned for Lewisham. The first polyclinic has been agreed as being the Waldron Health Centre in Deptford. A health needs assessment is currently being undertaken to inform planning for our second polyclinic in the South of the Borough. It is envisaged that the Downham Healthy Living Centre will be the hub to support the health system in that area. Following economic modelling being undertaken across London, NHS Lewisham will review space utilisation in the health facilities of Downham Healthy Living Centre to determine what support if any is required across the cluster to meet the extended polyclinic services. In the remaining two areas, Central and South West, the PCT has been meeting with local primary care stakeholders to explore the development of two multi site polyclinics in each area. Each of these areas has well established health centre and GP premises with additional capacity built in to the current infrastructure in anticipation of developments such as these. There are well developed models in each of these areas for shared access to services on a relatively small scale e.g. dietetics services. In each of the two areas it would again be proposed that some further development of specific sites would take place and feasibility studies in relation to some of the proposed sites that would be included have already been commissioned. NHS Lewisham Commissioning Strategy Plan Page 49 of 94

50 The table below details the proposed phasing of polyclinic development in Lewisham in and Cluster Location Centre/hub Consultation target date Board decision target date On stream target date 1 Waldron Centre Q Q Q Downham Centre Q Q Q Central hub Q Q Q South-west hub Q Q Q The timescales for development of polyclinics in clusters 2 and 4 are not dependent on major capital development programmes and therefore early indications are that the target dates shown in the table above are the latest that services would become operational. The PCT is considering the provision of a fifth polyclinic site incorporating an Urgent Care Centre, located on the Lewisham Hospital site. The PCT is committed to promoting each polyclinic to the public and stakeholders as it comes on stream using the HfL Polyclinic Communications Toolkit. Capital investment programme The funding for the Waldron Polyclinic development is committed (as a national commitment) in this CSP. Outline provision has been made for , which will be subject to a full assessment in 2010/11 CSP. The PCT 5 year capital investment programme includes allocations in ( 100,000) and ( 4,200,000). NHS Lewisham Commissioning Strategy Plan Page 50 of 94

51 SECTION 4 STRATEGY 4.1 Goals NHS Lewisham has identified its 10 priority health outcomes following analysis of local health needs and priorities identified in a wide range of strategic documents, including the Lewisham Health Profiles 2008, the draft Joint Strategic Needs Assessment (JSNA) 2008 and the Local Area Agreement In 2008/9 there was also discussion and ranking undertaken at the Professional Executive Committee and Trust Board seminar and discussion at the Adult Strategic Partnership Board (ASPB) and the Children and Young People s Strategic Partnership Board (CYSBP). A stakeholder deliberative event was held on the 20 th October 2008 with 85 members of the local community to prioritise the health outcomes for Lewisham. These 10 outcomes therefore represent a consensus view of the strategic goals or priorities for Lewisham. As illustrated in the section below, significant progress is needed against each of these goals. NHS Lewisham will measure its progress and success against delivery of these goals Strategic Goal 1 Reducing Health Inequalities Where are we now? 0 th Percentile Worst Best Time STRATEGIC GOAL Value Value Period 100 METRIC 1. Health inequalities 48 8 CY 2007 Current Previous Upper Quartile Average IMD (Indix of Multiple Deprivation) What is our current goal? By 2014, the average index of multiple deprivation (IMD) score will have improved significantly and be closer to the national average and this will continue to improve. Assumptions That this is a joint strategic goal for Lewisham as a whole. Lewisham is the 39 th most deprived borough in England. NHS Lewisham Commissioning Strategy Plan Page 51 of 94

52 Actions to achieve progress NHS Lewisham will continue to work with Local Strategic Partnership to deliver the Local Area Agreement programme and its wide range of targets. Delivery monitored through the six themed Partnership Boards Strategic Goal 2 Life Expectancy Where are we now 0 th Percentile Worst Best Time STRATEGIC GOAL Value Value Period M 2. Life Expectancy 73 F 87 CY 2004/06 M F Current Previous Upper Quartile 100 METRIC Life Expectancy at Birth (years) What is our current goal? In 2014 life expectancy for men and women will have increased by an extra 1 year 3 months compared with that for 2009 and will continue improving. What are our trajectories? Life Expectancy at birth, trajectory to 2014, Males Years of life expectancy Calendar year Gap in years ENGLAND Lew isham LB gap NHS Lewisham Commissioning Strategy Plan Page 52 of 94

53 Assumptions That a downward trend continues to That primary care and health improvement programmes deliver additional impacts. Specific short term interventions will be required for early impact against a background of preventive work for longer term gain. Actions to achieve progress Secondary prevention project to support primary care received by less well served populations, communities and people until primary care strategy is fully implemented. Interventions include CVD, cancer and diabetes interventions for over 50s especially Strategic Goal 3 Improving children and young people s health Where are we now? 0 th Percentile Worst Best Time STRATEGIC GOAL Value Value Period 100 METRIC 3. Improving children FY 2007/08 and young people's health Current Previous Upper Quartile Proportion of children completing MMR immunisation by age 2 What s our current goal? In 2014, children in Lewisham will have reached the target levels of uptake of immunisation (90%) so that outbreaks of vaccine preventable disease will be much less of a risk. NHS Lewisham Commissioning Strategy Plan Page 53 of 94