GOVERNING BODY PAPER

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1 Enclosure: E Agenda item: 7 GOVERNING BODY PAPER Title of paper: To approve South London Commissioning Strategy Programme Case for change Date of meeting: Wednesday 26 th March 2014 Presented by: Dr Hany Wahba Chair, Governing Body Prepared by: Annabel Burn Chief Officer Summary of Strategic Objectives Supported by this Report (X) Improve health outcomes x To assure and drive improvements in quality x Ensure access to high quality primary x Meet statutory obligations care services Ensure access to high quality x Take a long term approach to the health x secondary care services needs of the local population Building a new Clinical Commissioning Group Enhance communications with practices and patients Enhance the use of information Please provide brief executive summary:- 1. The six CCGs in South East London and their co-commissioners from NHS England (London region) are working together to develop a South East London five year commissioning strategy. The South East London strategy is commissioner-led and clinically-driven and will continue to be shaped and developed to incorporate the views of all the partners and stakeholders. 2. The South East London strategy will establish a collaborative approach to tackling the major strategic challenges within the area s health economy over the course of the next five years. The strategy aims to improve health outcomes for our local population, take action to reduce health inequalities; ensure providers consistently deliver safe and high quality care; and support a financially sustainable health economy. 3. Commissioners of health services across south east London are working to develop the strategic plan for South East London in partnership with local councils, hospitals, community services, mental health services, patients, carers and local people to identify and address the most significant issues associated with local health and care services. 4. Local CCGs are also working to develop borough-specific strategic plans that will be reflected in and respond to the content of the South East London plan. 5. An initial stage in the development of the South East London strategy is to prepare a case for change for local health services. The purpose of the case for change is to clearly articulate the main reasons that the local health economy requires transformation so that services can continue to deliver optimal outcomes for our patients. 6. Engagement on the strategy is being carried out by all CCGs in South East London and as part of this work an early version of the draft case for change was tested with members of the South East London CCG stakeholder reference group; the CCG s engagement and patient experience groups; and Healthwatch organisations. Their comments have helped to inform the current version of the draft case for change.

2 7. The full draft case for change, the summary versions and supporting documents are available from the CCG's website for local people and other stakeholders to comment. 8. Copies have been sent to all the partners in the south east London five year commissioning strategy programme - including all NHS organisations providing services in Greenwich and Greenwich Council - for review and comment and further engagement. Summary of Impact Assessment and Risk Management Issues (x) (please provide detail in the body of the report) Impact on Risk Assurance Framework (x) Yes No N/A Impact on Environment (x) Yes No x N/A Legal Implications (x) Yes No x N/A Resource implications (x) Yes x No N/A Equality impact assessment (x) Yes x No N/A NHS Operating Framework areas of Quality, Reform and finance Yes x No N/A (x) Patient and Public Involvement (x) Yes x No N/A Communications and Engagement (x) Yes x No N/A Impact on CCG Constitution (x) Yes No x N/A Brief Summary of Recommendations Review and comment on the draft case for change and the emerging strategic opportunities for South East London that will underpin South East London s 5 year strategic plan. Note the technical summary. Page 2 of 2

3 South East London Commissioning Strategy Programme Office South East London Commissioning Strategy Programme Case for Change (DRAFT) 28 February 2014

4 CONTENTS 1 Introduction The health of south east London s population has improved significantly but there is more to do The national and London context is changing the way that health and integrated care services are planned and delivered Significant developments and opportunities within south east London help us to make a strong and innovative response to the national and London context Our health services have many strengths but quality is variable and we have tolerated unacceptable and unwarranted variation in quality for too long Patient satisfaction is low compared to national benchmarks and there are common themes regarding how patients would like to see services improved The financial position for commissioners is challenging Our partners face a similar and interrelated set of challenges Significant progress has been made to date The South East London Commissioning Strategy will set out how we work with partners over the next five years to build on existing progress to address these challenges and deliver best possible outcomes and services within our resources Annex A Joint Strategic Needs Assessments (JSNAs) for south east London boroughs

5 1 Introduction 1.1 A vision for healthcare in south east London Our health outcomes in south east London are not as good as they should be: Too many people live with preventable ill health or die too early The outcomes from care in our health services vary significantly and high quality care is not available all the time We don t treat people early enough to have the best results People s experience of care is very variable and can be much better Patients tell us that their care is not joined up between different services The money to pay for the NHS is limited and need is continually increasing It is taxpayers money and we have a responsibility to spend it well The longer we leave these problems, the worse they will get; we all need to change what we do and how we do it In south east London we spend 2.3billion in the NHS. Over the next five years we aim to achieve much better outcomes than we do now by: Supporting people to be more in control of their health and have a greater say in their own care Helping people to live independently and know what to do when things go wrong Making sure primary care services are consistently excellent and with an increased focus on prevention Reducing variation in healthcare outcomes by raising the standards in our health services to match the best Developing joined up care so that people receive the support they need when they need it Delivering services that meet the same high quality standards whenever and wherever care is provided Spending our money wisely, to deliver better outcomes and avoid waste 1.2 NHS Services in south east London The South East London Strategic Planning Group (SPG) covers the six boroughs of Lambeth, Southwark, Lewisham, Bexley, Bromley and Greenwich. The combined population is circa 1.67m and is expected to grow to circa 1.87m by NHS services for the population of south east London are commissioned by Lambeth, Southwark, Lewisham, Greenwich, Bexley and Bromley Clinical Commissioning Groups (CCGs) and by NHS England. Each CCG is coterminous with its local borough. Spend on NHS services in south east London is circa 3bn, approximately half of which is focused on acute hospital-based services. 1 GLA 2012 Round Demographic Projections,

6 These commissioners plan and purchase NHS services from a number of healthcare organisations. NHS services are provided by: Primary care Community services Mental Health services Acute services Ambulance Services 261 general practices, employing over 1,100 General practitioners and 650 practice nurses 242 dental practices 360 community pharmacies Out-of-hours care provided by the GP co-operatives Grabadoc Healthcare Society, South East London doctors Co-operative (SELDOC) and EMDOC Bromley doctors On Call. Four community service providers across the six boroughs: o For Southwark and Lambeth: Guy s and St Thomas NHS Foundation Trust o For Greenwich and Bexley: Oxleas NHS Foundation Trust o For Lewisham: Lewisham and Greenwich NHS Trust o For Bromley: predominantly by Bromley Healthcare, a Community Interest Company. Two mental health NHS Foundation Trusts across the six boroughs: o For Lambeth, Southwark and Lewisham: predominantly South London and Maudsley NHS Foundation Trust o For Bexley, Bromley and Greenwich: predominantly Oxleas NHS Foundation Trust. Dartford and Gravesham NHS Trust, operating from Darent Valley Hospital and Queen Mary s Hospital Sidcup Lewisham and Greenwich NHS Trust, an integrated healthcare trust operating from University Hospitals Lewisham and Queen Elizabeth Hospital Greenwich; with some services also provided at Queen Mary s Hospital Sidcup Guy s and St Thomas NHS Foundation Trust, operating from two main sites at St Thomas Hospital (including the Evelina Children s Hospital) and Guy s Hospital; with some services also provided at Queen Mary s Hospital Sidcup King s College Hospital NHS Foundation Trust, operating from Denmark Hill and from Princess Royal University Hospital in Bromley; with some services also provided at Queen Mary s Hospital Sidcup. London Ambulance Service NHS Trust responds to emergency calls and provides non-emergency patient transport services across all six boroughs. The outline of acute service providers above reflects the organisational transactions that took place as part of the Trust Special Administrator (TSA) programme. The TSA programme was in place for South London Healthcare NHS Trust from August This programme ceased when the Trust was dissolved on 30 September 2013 and its services were transferred to other local NHS providers. The TSA had also made recommendations in relation to some service changes. All work on these recommendations ceased when they were successfully challenged through Judicial Review. The NHS in south east London helps to fund four hospices and a number of other local charitable and voluntary sector organisations via commissioned services. The four hospice organisations are Greenwich and Bexley Community Hospice, Harris Hospice Care, St Christopher s Hospice and Trinity Hospice. The providers of NHS services work in partnership with the voluntary sector and social services, which are provided for their residents by local authorities, to ensure that the needs of patients and service users are met in an integrated fashion. 4

7 South east London has one of the country s six Academic Health Science Centres (AHSCs), King s Health partners. The AHSC is a strategic partnership that brings together King s College London with three NHS Foundation Trusts Guy s and St Thomas, King s College Hospital and South London and Maudsley to improve the health of the patients and population of south east London. South London also has one of only thirteen Academic Health Science Networks, the South London Health Innovation Network (HIN), a membership organisation focused on driving lasting improvements in health and wellbeing across south London by sharing innovations across the health system and capitalising on teaching and research strengths. 1.3 The purpose of this document The purpose of this document is to outline an overarching Case for Change for the south east London Commissioning Strategy. In doing so: it will support further engagement with the stakeholders of the programme it will enable south east London commissioners and their partners to set the priorities and associated level of ambition that will drive the five year commissioning strategy the priority objectives identified will form the basis for design and development work through the programme s Clinical Leadership Groups. The Case for Change provides a south east London level synthesis of the issues and challenges facing our boroughs. It is therefore not intended to be a substitute for borough level Joint Strategic Needs Assessments (JSNAs), local commissioning plans, and Health and Wellbeing Strategies which will focus on borough-specific issues and challenges and will identify these is much greater detail. The document follows and expands on the structure of the Case for Change narrative that has been developed with programme partners and stakeholders. In doing so it covers the following sections and themes: The health of south east London s population has improved significantly but there is more to do: summarises population demographics and health needs The national and London context is changing the way that health and integrated care services are planned and delivered: sets out the strategic context for the Case for Change and Commissioning Strategy Significant developments and opportunities within south east London help us to make a strong and innovative response to the national and London context: sets out the local strategic context for the Case for Change and Commissioning Strategy and seeks to emphasise the opportunities to compliment information in the other sections on the challenges Our health services have many strengths but quality is variable and we have tolerated unacceptable and unwarranted variation in quality for too long: describes the key issues in relation to quality, safety and performance, recognising that variation exists within and between organisations 5

8 Patient satisfaction is low compared to national benchmarks and there are common themes regarding how patients would like to see services improved: sets out what patients and public in south east London have told us The financial position for commissioners is challenging: sets out the high level scale of the financial challenge across CCG commissioned services, primary care Our partners face a similar and interrelated set of challenges: summarises the key issues and drivers affecting our provider partners Significant progress has been made to date: describes the significant work to date on strategies and change programmes transforming the local health system The South East London Commissioning Strategy will set out how we work with partners over the next five years to build on existing progress and address these challenges: describes the approach to the Strategy and next steps. The Case for Change is intended to bring together issues and challenges for the existing health and social care system in south east London and identify with supporting evidence where there are opportunities to improve. In developing this draft we have worked closely with our partners and key stakeholders and to date the work has been enhanced through input from a number of groups including: Public health colleagues NHS provider organisation colleagues Local authority colleagues Senior clinicians from commissioners and NHS provider organisations Patients and local people from the CCGs' representative groups and Lay Members of CCGs. The Case for Change will continue to be developed in response to comments received from engagement activities in March 2014 and throughout the development of the strategy through to submission of the Final Strategy to be submitted in June

9 2 The health of south east London s population has improved significantly but there is more to do Chapter summary and key messages South east London has extremes of deprivation and wealth. A high proportion of the 1.67m population live in areas that are amongst the most deprived fifth (quintile) in England, while a smaller proportion live in the most affluent fifth (quintile) in England. The population of south east London is highly mobile. In Southwark and Lambeth, the equivalent of roughly half the current population has moved in and out over a five year period. Even in Bexley, the borough which has the most settled population, the equivalent of roughly a quarter of the current population has moved in and out over a five year period. Premature mortality and differences in life expectancy are both significant issues. There is a difference in life expectancy between the most and least deprived wards of 8.7 years for women and 9.3 years for men. About 11,000 people died prematurely across south east London over the period 2009 to 2011, with four boroughs being classified in the worst category for premature mortality outcomes in England. There are large and growing numbers of children living in south east London. Child poverty and obesity are significant challenges. South east London population aged zero to fourteen is set to increase from 310,000 in 2011; to 356,000 in This is an increase of 1.39% per annum compared with 1.21% across London and 1.27% across England Four out of six boroughs are bottom quartile for percentage of children in poverty, with an area average of 27.8% versus national median of 17.1%. The average for CCGs in the top quartile is 10.5% Childhood obesity levels in south east London (for year 6 10/11 year old pupils) are consistently higher than the London average and significantly above the England average, with levels ranging from 17.3% to 26%. Five out of six boroughs are in the bottom quartile Nationally 1 in 10 children and young people aged 5-16 suffer from a diagnosable mental health disorder - that is around three children in every class. Helping our children to get the best start in life (through early access to maternity services, high quality parental support, early help, ante and post natal support) is critical to our children thriving in childhood and into adult life, especially those from disadvantaged backgrounds. There are higher proportions of older people living in outer boroughs of south east London. Inner south east London has also experienced an increase in conditions associated with older people through increased life expectancy. Bexley (with 6.6% of males and 9.3% of females aged over 75) and Bromley (6.9% of males and 9.7% of females aged over 75) have relatively high proportions of older people compared with other boroughs Inner south east London boroughs have also experienced an increase in burden of conditions associated with older people, as a result of increased life expectancy (for example in Lambeth, men now live 5 years longer than in 1995 and women 2.7 years). 7

10 The biggest causes of premature mortality are cardiovascular diseases, cancers and respiratory diseases. Mortality rates for these diseases have decreased significantly over recent years, but rates continue to be considerably above London average Cardiovascular disease: Under 75 deaths from CVD in south east London have declined steeply and are now in line with the London average though still slightly above the national average. This masks significant variation between the boroughs, with Greenwich having the highest directly standardised rate at 70 per 100,000 in 2012 compared to Bromley with the lowest at 43 Cancer: Whilst there have been some improvements across the six boroughs prevalence is still above London average. If the number of premature mortalities for Cancer in Southwark, Lambeth and Greenwich is reduced to the south east London average this would lead to a reduction of 64 mortalities per year by 2019 Respiratory diseases: Deaths from chronic obstructive pulmonary disorder across south east London are significantly higher than the national average, driven by high instances in the inner London boroughs, Reducing to the national average level would result in reduction of deaths attributable to chronic obstructive pulmonary disorder across south east London by 88 per year. Mental health continues to place the highest burden of morbidity in this part of London. A 2011 study identified that in south east London all mental health disorders were associated with substantially lower life expectancy compared to National statistics for general population: between 8.0 and 14.6 years lost for men and between 9.8 to 17.5 years lost for women, depending on the specific disorder. Nationally: Three in four people with common mental health problems receive no treatment, and even for psychotic disorders this figure is nearly 1 in 3 People with severe mental illness are in some cases 3 or 4 times more likely to die prematurely from the big killer diseases, when compared to the population as a whole. Improving mental health also makes obvious economic sense The costs to the NHS of co-morbid mental health problems run into billions. A number of other health issues have been identified as a high burden of ill health across south east London where the trend or outlook is worsening. Alcohol-related diseases: there are above average admission rates for alcohol attributable diseases, and an increase in mortality rates. Reducing to the national average in those boroughs that exceed the national average for alcohol specific mortality would lead to a reduction of 17 deaths a year Sexual health: there are the highest levels of HIV and STIs in the country in inner south east London, with a concentration amongst gay men and black African populations for HIV Older People: there is a continuing rise in the numbers of people with dementia in south east London, and only about half of the predicted number of current patients are diagnosed and included on GP dementia registers. Older people tend to have multi-morbidities. National estimates are that 12% of people over 65 will have three or more long term conditions, 34% two or more and 67% one long term condition; 2% of patients with chronic disease account for 30% of unplanned hospital admissions, 80% of GP consultations and 70-80% spend is on people with long term conditions Diabetes: there in an increasing burden of ill health from diabetes, with rates increasing in parallel with the increase in London and England as a whole. It is estimated that about one in four people with diabetes are undiagnosed. 8

11 The outlook is improving across south East London for a number of other health issues identified as high burden of ill health, but these remain significant challenges. Smoking: nearly one in five adults in south east London still smokes. Smoking still remains the biggest current direct cause of preventable mortality and morbidity. If the three boroughs above the south east London average were to reach the average levels this would further reduce smoking prevalence by a total of 9,500 Teenage conceptions: rates are still significantly above national and London averages in inner south east London. The borough with the highest rate was Southwark with 42.7 per 1000 conceptions to under 18 year old young women. This section is intended to provide a high level synthesis of, and therefore not to be a substitute for, the detailed Joint Strategic Needs Assessments (JSNAs) available for each borough. These will provide further detail of specific issues and challenges affecting the populations of individual boroughs (see Annex A for full details). South east London comprises six local authority boroughs. It is a highly varied sub-region of London, and includes four boroughs with inner London characteristics (Lambeth, Southwark, Lewisham and Greenwich), and two with outer London characteristics (Bexley and Bromley). For many health outcomes, there is a clear divide between the inner boroughs (Lambeth, Southwark, Lewisham and Greenwich) and the outer boroughs (Bexley and Bromley), with the inner boroughs experiencing significantly poorer outcomes across a range of mental and physical health outcomes linked to their higher levels of deprivation and greater ethnic diversity. All boroughs experience health inequalities within their boundaries, including Bexley and Bromley which, despite being generally less deprived than the other south east London boroughs, still have pockets of deprivation whose populations experience significantly poorer health. Over the last decade, the population has increased significantly, due to a combination of increasing life expectancy and new housing developments, which has been especially marked along the stretch of south east London adjoining the Thames. 2.1 South east London has a diverse and mobile population with extremes of deprivation and wealth A high proportion of the 1.67m population live in areas that are amongst the most deprived fifth (quintile) in England, while a smaller proportion live in the most affluent fifth (quintile) in England. Four of the six boroughs (Lambeth, Southwark, Lewisham and Greenwich) rank amongst the 15% most deprived local authority areas in the country 2. The other two boroughs (Bexley and Bromley) are significantly less deprived but have pockets of deprivation in particular geographical areas. The population is very ethnically mixed; ranging from 15.7% of the population of Bromley being from black and minority ethic groups to 46.5% in Lewisham 3. Figure 1 shows the estimated numbers of people from different ethnic backgrounds living in South East London in 2014, and the estimated numbers that will be resident in This 2 IMD 2010, 3 Census 2011, Black and Minority Ethnic (BME) Population, 9

12 shows an increase in numbers predicted across all ethnic groups, but with a higher proportional increase amongst Black, Asian and Minority Ethnic (BAME) groups. The graphs show the proportions of the population from different ethnic groups in 2014 and This shows a similar picture with the proportion from white backgrounds predicted to fall by 5% and the proportions from BAME groups increasing. Figure 1 - Ethnic population 2014 & 2024 (numbers and percentages) 4 The age profile of the population includes a relatively high proportion of younger people, especially 0-9 years, and a slowly increasing older population, with more females than males living into older age. Figure 2 below shows the current (2014) age profile for South East London and the predicted change to this profile in 10 years time (2024). This shows a predicted relative decrease in the proportion of the population in the young (<30) age range, and an increase in the proportion of the population in the older (55+) age range. This increasing number of older people, including those surviving into very old age, will continue to require an increase in services to meet their health and social care needs. Figure 2 - Age structure in South East London, 2014 and Source: GLA ethnic group projections 2012 round, SHLAA-based, November

13 The local population is highly mobile. In Southwark and Lambeth, the equivalent of roughly 9% and 10% respectively of the current population moved in and out over a 12 month period mid 2011 to mid Even in Bexley, the borough which has the most settled population, the equivalent figure was around 5%, compared with approximately 3% in London as a whole 5. Looking only at migration into the area, there is a stark difference between boroughs. Figure 3 shows, for example, that 12.5% of the population of Lambeth in 2011 had moved into the borough within the previous 12 months. In Bexley, only 4.5% of the population had moved into the borough during the previous year. Figure 3 -: Population mobility based on Census Meeting Equalities Act (2010) Requirements The six CCGs in south east London each undertake an annual assessment of how effectively the services they commission engage with and meet the needs of 9 protected groups outlined in the Equality Act The protected groups are: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex (gender) and sexual orientation. Each CCG uses the framework of the NHS Equality Delivery System to identify a rolling programme of equality objectives, which set out the improvement priorities for the CCG for the year ahead. The following are some examples of improvement priorities that have been worked on recently in south east London to address equalities issues: Improve access to primary care for older people and people with long term conditions (Lewisham CCG) Improve the physical health of people known to have mental health problems especially people with severe mental illness (SMI) (Lambeth CCG) Integrating equality and human rights into commissioned contracts; ensuring contracts have equality and human rights specifications and demonstrable compliance outcomes for Southwark people (Southwark CCG) Devise a social media strategy to promote healthcare for younger people via media such as Facebook and Twitter (Greenwich CCG) Develop a comprehensive improvement plan based on the Learning Disability Health Self Assessment Framework (Bexley CCG) 5 ONS Migration Indicators Tool, Mid 2012 data, 6 Source: Census

14 Improving the health and well being of older people, particularly those with Dementia (Bromley CCG). 2.2 Premature mortality and differences in life expectancy are both issues There is a difference in life expectancy between the most and least deprived wards of 8.7 years for women and 9.3 years for men. In Woolwich Riverside men live to 74.7 years on average and women to 79.9; whilst in Petts Wood and Knoll men live to 83.4 years on average and women to 89.2 years. South east London population aged zero to fourteen is set to increase from 310,000 in 2011; to 356,000 in This is an increase of 1.39% per annum compared with 1.21% across London and 1.27% across England. Four out of six boroughs are bottom quartile for percentage of children in poverty, with an area average of 27.8% versus national median of 17.1%. The average for CCGs in the top quartile is 10.5%. Bexley (with 6.6% of males and 9.3% of females aged over 75) and Bromley (6.9% of males and 9.7% of females aged over 75) have relatively high proportions of older people compared with other boroughs and with south east London as a whole (4.1% of males and 5.8% of females respectively). Inner south east London boroughs have also experienced an increase in burden of conditions associated with older people, as a result of increased life expectancy (for example in Lambeth, men now live 5 years longer than in 1995 and women 2.7 years). About 11,000 people died prematurely across south east London over the period 2009 to 2011, with four out of six boroughs being classified in the worst category for premature mortality outcomes in England. 2.3 The biggest causes of premature mortality continue to be cardiovascular diseases, cancers and respiratory diseases The biggest causes of premature mortality in south east London continue to be cardiovascular diseases, cancers and respiratory diseases. Whilst mortality is generally declining from these diseases there is still considerable headroom for further improvements. Mental health continues to place the highest burden on morbidity in this part of London. The following have been identified as important issues for south east London: 2.4 A number of health issues have been identified as a high burden of ill health across south east London where the trend or outlook is worsening Obesity: there are very high levels of childhood obesity. Figure 4 below shows that childhood obesity levels in south east London (for year 6 10/11 year old pupils) are consistently higher than the London average and significantly above the England average. The borough level data show a wide variation between CCGs, with Southwark having the highest levels at 26% versus Bromley with the lowest at 17.3% The overall childhood obesity levels are more than 5% higher than national average at year 6.The number of obese 10/11 year olds are predicted to rise to 4170 by 2018/19. Just reducing to the national average level would lead to 780 less obese children in south east London by

15 Figure 4 Childhood Obesity Rates 2012/13 7 Mental ill health: there is a high burden of common and serious mental illness especially in inner south east London; and associated with this the link to lower life expectancy of those with serious mental illness. People with severe mental illness (SMI) die prematurely from the same causes of death that affect the general population, e.g. heart disease, diabetes, cancer, stroke, and pulmonary disease, but at a more frequent rate. Specifically, adults with psychotic disorders die, on average, 11 years earlier than adults with no mental disorder, most often from these comorbid conditions. The modifiable risk factors that contribute to early mortality - smoking, obesity, hypertension, metabolic disorder, substance misuse, low physical activity, poor fitness and diet - are also more common in people with SMI, and their onset is often earlier. Two-thirds or more of adults with SMI smoke; over 40% are obese (60% for women); and metabolic syndrome is highly prevalent, especially in women. Iatrogenic effects of psychiatric medications, which may include weight gain and metabolic disorder, further adversely affect the health of people with SMI, often with rapid onset. A 2011 study 8 identified that in south east London all mental health disorders were associated with substantially lower life expectancy compared to National statistics for general population: 8.0 to 14.6 life years lost for men and 9.8 to 17.5 life years lost for women. The highest reductions were found for men with schizophrenia (14.6 years lost) and women with schizoaffective disorders (17.5 years lost). In June 2013 the Minister for Care Services, Norman Lamb MP, articulated his concern regarding the way in which people with mental health problems receive inadequate care for their mental and physical health needs, resulting in poorer physical health than the general population and premature mortality 9, including: Three in four people with common mental health problems receive no treatment, and even for psychotic disorders this figure is nearly 1 in 3 7 Source: HSCIC, National Child Measurement Programme 8 Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London, Chang et al, 2011, 9 Achieving Parity of Esteem between Mental and Physical Health Norman Lamb MP, Care Services Minister, June 19th

16 People with severe mental illness are in some cases 3 or 4 times more likely to die prematurely from the big killer diseases, when compared to the population as a whole. Improving mental health also makes obvious economic sense The costs to the NHS of co-morbid mental health problems run into billions. The costs of mental illness to the economy and society are higher still. And yet there are effective treatments out there, like IAPT (Improving Access to Psychological Therapies), like RAID (Rapid Access Interface and Discharge), which save money as well as improving lives. Given the high levels of mental health needs especially amongst specific groups within south east London (including some black and minority ethnic groups, some groups of young people, such as those looked after in local authority care, prisoners, those experiencing domestic violence etc), it is critical that the mental and physical health of people with mental illnesses are addressed fully. Alcohol related diseases: there are above average admission rates for alcohol attributable diseases, and an increase in mortality rates. Figures 2 and 3 below show that alcohol specific mortality is lower in south east London than in London and England for males and lower than in England but higher than London for females. Figure 5 Alcohol Mortality (Males ) 10 Average alcohol specific mortality for men in south east London is already lower than the England average, but this is largely driven by comparatively low rates in the outer London boroughs (Bexley and Bromley).The four inner London Boroughs (Lewisham, Greenwich, Lambeth and Southwark) all remain above the national average. Just reducing to the national average in these four boroughs would lead to a reduction of 10 mortalities a year (3, 3, 2 and 2 respectively) due to male alcohol specific mortality in south east London. 10 Source: PHE, Local Alcohol Profiles for England 14

17 Figure 6 Alcohol Mortality (Females ) 11 Average alcohol specific mortality for women in south east London is already significantly lower than the England average, with only Lambeth in excess. This is good news, but we can still improve. If female alcohol specific mortality in Lambeth and Southwark is brought down to the average for south east London, this would lead to a reduction of 7 mortalities per year by 2019 (5 and 2 respectively). Sexual health: there are the highest levels of HIV and STIs in the country in inner south east London, with a concentration amongst gay men and black African populations for HIV. Figure 4 below shows continuing high levels of in STIs in SE London, with an increasing rate for Chlamydia and gonorrhoea. Figure 7 STI Diagnoses in SE London Figure 5 shows that HIV prevalence in south east London continues to be high, and is continuing to increase marginally over time. The rate varies significantly between boroughs with Lambeth and Southwark having very high rates, far in excess of the London average. Bexley and Bromley have relatively low rates; Greenwich is in line with the London average with Lewisham rates slightly higher. 11 Source: PHE, Local Alcohol Profiles for England 12 Source: HPA 15

18 Figure 8 HIV Prevalence across South East London Conditions related to older people: three is an increasing burden of conditions related to the ageing population; especially high numbers of older people in outer south east London; and significant increases in line with improved life expectancy in parts of inner south east London. Figure 6 shows the predicted ongoing rise in the numbers of people with dementia in south east London, and that only about half of the predicted number of current patients with dementia are diagnosed and included on GP Quality Outcomes Framework (QOF) dementia registers. Figure 9 Dementia Projections ( ) and QOF Registration Data 13 Older people tend to have multi-morbidities. 12% of people over 65 will have three or more long term conditions, 34% two or more and 67% one long term condition 14. A Department of Health consultation on the Information Revolution showed that the 2% of patients with chronic disease account for 30% of unplanned hospital admissions, 80% of GP consultations and 70-80% spend is on people with long term conditions. Diabetes: diagnoses of diabetes are trending upwards across south east London. Figure 7 shows a high and increasing burden of ill health in south east London from diabetes, with rates increasing in parallel with the increase in London and England as a whole. These figures represent an underestimate of the true numbers of people with diabetes as it is estimated that about one in four people with diabetes are undiagnosed. 13 Source: POPPI 2014 / Dementia Prevalence Calculator 14 (HSE 1997) 16

19 Figure 10 Diabetes Prevalence in SE London (QOF data ) At the same time the outlook is improving across south East London for a number of other health issues identified as high burden of ill health Cancer: Whilst there have been some improvements across the six boroughs prevalence is still above London average. Figure 8 shows a steady decline in cancer mortality in south east London as well as London and England as a whole. There is considerable variation between the boroughs with the directly standardised rate (DSR) per 100,000 in Southwark being the highest at 114 in 2012, compared to 90 in Bromley. Figure 11 Cancer Mortality ( ) 16 Premature mortality from cancer in south east London is already lower than the England average, but there is significant variation between the boroughs with Southwark, Lambeth and Greenwich all over the national average. If the number of premature mortalities for Cancer in Southwark, Lambeth and Greenwich is reduced to the south east London average this would lead to a reduction of 64 mortalities per year by 2019 (31, 23 and 10 respectively). Smoking: smoking prevalence is now below national average, but nearly one in five adults still smoke. Figure 9 below shows that smoking rates in south east London are declining quickly, faster than the London and national averages. Nevertheless, smoking still remains the biggest current direct cause of preventable mortality and morbidity and as such continues to be a major priority for improving health and addressing health inequalities. Smoking rates are far higher amongst lower socio-economic groups, amongst men, and 15 Source: HSCIC / Diabetes Prevalence Model, APHO 16 Source: HSCIC Indicator Portal 17

20 certain ethnic groups (such as white, Irish, eastern European), and are a major contributory factor to health inequalities. Figure 12 Smoking Prevalence Average smoking prevalence in south east London is already lower than the England average, but if the three boroughs above the south east London average were to reach the average levels this would further reduce smoking prevalence by a total of 9, Cardiovascular disease: premature deaths from CVD continue to decline, though stroke and heart failure are above London average. Figure 10 below shows that under 75 deaths from CVD in south east London have declined steeply and are now in line with the London average though still slightly above the national average. This masks significant variation between the boroughs, with Greenwich having the highest DSR at 70 per 100,000 in 2012 compared to Bromley with the lowest at 43. Figure 13 Premature deaths from cardiovascular diseases Respiratory disease: despite some improvements, rates are still above London average. Figure 11 below shows that deaths from COPD have been falling steadily over the last two decades, but remain well above the London and national averages. There are some signs that the gap is closing. There is considerable variation between the boroughs, with respiratory deaths in Greenwich being the highest in 2012 with a directly standardised 17 Source: Public Health England 18 Reductions by borough: Lewisham: 4,350, Lambeth: 4,650 and Southwark: Source: HSCIC Indicator Portal 18

21 mortality rate (DSR) of 40.4 compared to Bromley having the lowest rate with a DSR of Figure 14 Deaths from Chronic Obstructive Pulmonary Disorder (COPD) Deaths from chronic obstructive pulmonary disorder across south east London are significantly higher than the national average, driven by high instances in the inner London boroughs, Just reducing to the national average level would result in reduction of deaths attributable to chronic obstructive pulmonary disorder across south east London by 88 per year 21. Teenage conceptions: significant decline in recent years, but rates still significantly above national and London averages in inner south east London. The estimated number of conceptions to women aged under 18 in England and Wales in 2011 was the lowest since records began in This was also reflected locally in south east London. Table 1 below shows, in 2011, Bromley was the only borough with an under 18-conception rate lower than the London average at 26.3 per 1000 (compared to the London average of 28.7). The borough with the highest rate was Southwark with 42.7 per 1000 conceptions to under 18 year old young women. Table 1 Under 18 conception rates per 1000 (2011) 22 Area Conception rate (per 1000) Bromley 26.3 Bexley 28.4 Lambeth 34.8 Greenwich 38.1 Lewisham 39.9 Southwark 42.7 SE London average Source: HSCIC Indicator Portal 21 Reduction from deaths per 100,000 population to deaths per 100,000 population 22 Source: ONS 19

22 Area Conception rate (per 1000) London average 28.7 England average The health and well-being of children and young people In addition to the issues outlined above of importance to the younger population, such as obesity, teenage conceptions and sexual health, there are a number of other health concerns of importance to children and young people Mental health and well-being 23 The mental health and well-being of children and young people is critically important to enabling them to have happy, productive and successful childhoods. Good mental health enables children to thrive socially, to do well at school and to develop the resilience and coping skills needed to navigate adolescence and move successfully into adult life. Poor mental health can impair this success. In the UK: 1 in 10 children and young people aged 5-16 suffer from a diagnosable mental health disorder - that is around three children in every class. Between 1 in every 12 and 1 in 15 children and young people deliberately self-harm There has been a big increase in the number of young people being admitted to hospital because of self harm. Over the last ten years this figure has increased by 68% More than half of all adults with mental health problems were diagnosed in childhood. Less than half were treated appropriately at the time Nearly 80,000 children and young people suffer from severe depression Over 8,000 children aged under 10 years old suffer from severe depression 72% of children in care have behavioural or emotional problems - these are some of the most vulnerable people in our society 95% of imprisoned young offenders have a mental health disorder. Many of them are struggling with more than one disorder The number of young people aged with depression nearly doubled between the 1980s and the 2000s The proportion of young people aged with a conduct disorder more than doubled between 1974 and 1999 There is a higher prevalence of mental health problems amongst young people living in more deprived communities, so these kinds of poor mental health behaviours and outcomes are likely to be higher amongst children and young people in inner SE London Best start in life Supporting children to have the best start in life, especially during the first 1000 days of life, is critical to long health outcomes and to social and educational success in childhood and adult life. Factors supporting the best start in life which continue to be important for our populations include: High quality ante-natal care, including early booking for pregnant women, good access to ante-natal and newborn screening programmes, and support to reduce domestic violence, smoking, drug and alcohol abuse during pregnancy Access to high quality parenting advice and support, especially for the most vulnerable children and families, for example through the effective deployment of the Family Nurse 23 Source: 20

23 Partnership approach complementing universal health visiting provision; and support to prevent and tackle post-natal depression High quality advice and support to promote breastfeeding, promote good child and maternal nutrition and ensure high uptake of childhood immunisations Early help for struggling families, to improve outcomes and reduce the need for social care interventions such as care proceedings Smoking Whilst rates of smoking amongst young people are showing some signs of decline, there is a growing concern about the uptake amongst young people of fashion -related tobacco and nicotine related products. There is evidence of young people from all social backgrounds experimenting with smoking using Shisha pipes, through social events such as parties, and of there being a low recognition of the high tobacco content inhaled through the use of Shisha. E-cigarettes are growing in popularity at great pace, and there is significant concern that they will prove a gateway product for young people into smoking real cigarettes. They are promoted as a less dangerous route to managing nicotine cravings for people trying to quit smoking, but are marketed aggressively as fashion items and there is evidence that a significant proportion of people who use them were not previous cigarette smokers; hence the development of a new addition to nicotine. It will be important for our public health, children s services and enforcement colleagues to be vigilant and to work together through effective information sharing and joint action to reduce the risks posed by these newer entrants to the smoking and tobacco world to our young people s health in SE London. 2.7 Some conditions disproportionately affect particular groups Due to the nature of the population in south east London, there are a number of additional health conditions and outcomes that affect smaller numbers of groups within the population disproportionately. These challenges are described in more detail in individual borough JSNAs however some of the key themes are summarised below. These include for example tuberculosis (TB), which is especially prevalent amongst areas with higher numbers of people from the Indian sub-continent (including India, Pakistan and Nepal) and particular African countries such as Somalia and Nigeria. Homeless people also experience proportionately higher levels of TB disease; there are higher numbers of homeless people in inner SEL boroughs than outer. Relatively high numbers of people also experience Malaria in south east London, especially those returning to the UK from visits to a country of origin with a high prevalence of malaria (especially West African and Asian countries) having not taken precautions to protect themselves against infection during their visit. Female genital mutilation (FGM) is a serious health-related practice that affects women from minority groups in SE London. In the UK, FGM tends to be practised in areas of the country with higher concentrations of people from countries where this cultural ritual practice is common, such as sub-saharan and North African countries and to a lesser extent Asia and the Middle East. Often, first-generation immigrants, refugees and asylum seekers from these communities will continue to practice FGM in the UK despite the fact that it is illegal in this country. Given the profile of the population in SE London, this practice continues be an issue for us. 21

24 There are pockets of Gypsy and Traveller communities across SE London, for example in Sidcup in Bexley, Orpington in Bromley and Abbey Wood in Greenwich. Despite a lack of robust national data on the health status of Gypsies and Travellers, studies have revealed their health outcomes to be much poorer than the general population and also poorer than others in socially deprived areas. Gypsies and Travellers have the lowest life expectancy of any group in the UK and experience an infant mortality rate that is three times higher than the national average. Access to routine health services, including primary care, is often lower amongst this group within the population. This can lead, for example, to low levels of childhood immunisation and adult screening uptake, and delays in the diagnosing of health conditions such as diabetes, cardio-vascular and respiratory diseases and cancers. Outbreaks of diseases such as measles are more common amongst these groups than the general population. 22

25 3 The national and London context is changing the way that health and integrated care services are planned and delivered Chapter summary and key messages The way in which health and integrated care services are planned and delivered is changing. NHS England London has told us that: London has growing and ageing population and a rise in long-term conditions (both single and multiple conditions) will require better primary care and more integrated care People in control of their own health and patients in control of their own care is essential The way hospitals are organised is unsustainable and does not support the provision of high quality care Research, education, new technologies and a better understanding of diseases will help us transform the health service. As part of a Call to Action, NHS England has identified six transformational service models that will define the characteristics of the NHS in five years: A completely new approach to ensuring that citizens are fully included in all aspects of service design and change and that patients are fully empowered in their own care Wider primary care, provided at scale A modern model of integrated care Access to the highest quality urgent and emergency care A step-change in the productivity of elective care Specialised services concentrated in centres of excellence. There needs to be wider primary care, provided at scale. Population growth and patients health complexity is placing unprecedented demand and pressure on GPs. Primary care services are struggling to respond Despite some practices achieving excellent clinical outcomes and patient satisfaction, there is significant variation in performance and London practices lag behind the rest of the country in measures of quality and patient satisfaction London needs a primary care service that has the capacity and capability to provide the best care possible, in a modern environment that enables multidisciplinary working and training Plans to change hospital services usually depend on boosting capacity in primary care. If we do not improve access to primary care London s hospitals will be increasingly unsustainable It is predicted there will be a 4 billion funding gap in London by 2020 and financial pressures are forcing some GP practices to close. If we do not address this in a planned way we will see a steady erosion of the quality of care and patients will suffer. A modern model of integrated care is required. Integrated care services must ensure tailored care for vulnerable and older people Services must be integrated around the patient Plans must take account of the 3.8 billion Better Care Fund that comes into operation in 2015/16 and is aimed at supporting the integration of health and social care. 23

26 Our workforce needs to enable modern models of primary and integrated care Patients should be able to easily access and navigate high quality urgent and emergency care. Many people are struggling to navigate and access urgent care services provided outside of hospital. A high rate of 999 calls is being experienced for both emergency and urgent care needs; and patients are defaulting to A&E. At the same time there are significant differences in the types and levels of service provided in A&E departments The report on the first phase Urgent and Emergency Care review suggests that the quality of urgent and emergency care would be enhanced if patients were treated as close to home as possible and if networks were established, with major specialised services offered in between 40 and 70 major emergency centres, supported by other emergency centres and urgent care facilities. Patients should be able to access high quality specialised services concentrated in centres of excellence. Specialised services for less common disorders need to be concentrated in centres of excellence where the highest quality can be delivered. This enables the best possible quality of services to be delivered at volume and in a sustainable way, whilst connecting actively to research and teaching. Quality and safety must be at the heart of commissioning and delivery of local services Ensuring high quality care requires providers, commissioners and individual professionals to work together and consider the different facets of quality to enable the system to: Systematically drive continuous improvements linked to the overarching outcomes or domains set out in the NHS Outcomes Framework Ensure essential standards of quality and safety are maintained (including the London Clinical Standards). 3.1 The way in which health and integrated care services are planned and delivered is changing Everyone Counts: Planning for Patients 2014/ /19 24 sets out the outcomes and ambitions that will deliver the vision of high quality care for all, now and for future generations ; as well as the approach to strategy and planning for health and integrated care services over the next five years Vision, outcomes and ambition High quality care for all, now and for future generations is underpinned by the following elements: The NHS Outcomes Framework and its five domains 24 Everyone Counts: Planning for Patients 2014/ /19, NHS England, 24

27 1. We want to prevent people from dying prematurely, with an increase in life expectancy for all sections of society 2. We want to make sure that those people with long-term conditions, including those with mental illnesses, get the best possible quality of life 3. We want to ensure patients are able to recover quickly and successfully from episodes of ill-health or following an injury 4. We want to ensure patients have a great experience of all their care 5. We want to ensure that patients in our care are kept safe and protected from all avoidable harm. Seven measurable ambitions that will be used as indicators of success 1. Securing additional years of life for the people of England with treatable mental and physical health conditions 2. Improving the health related quality of life of the 15 million+ people with one or more long-term condition, including mental health conditions 3. Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital 4. Increasing the proportion of older people living independently at home following discharge from hospital 5. Increasing the number of people with mental and physical health conditions having a positive experience of hospital care 6. Increasing the number of people with mental and physical health condition having a positive experience of care outside hospital, in general practice and in the community 7. Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care. The further measures on which rapid focus and significant improvement is needed: improving health, which must have as much focus as treating illness in improving health, there must be particular emphasis on reducing inequalities commitment to moving towards parity of esteem between physical and mental health. In July 2013, NHS England along with national partners launched A Call to Action, setting out the challenges and opportunities faced by the health and care systems across the country over the next five to ten years. The review set out the need to find ways to raise the quality of care for all in our communities to the best international standards while closing a potential funding gap of around 30 billion by 2020/21. In the London-wide consultation on A Call to Action the following factors were being considered in the development of a sustainable health service for the capital: A growing and ageing population and a rise in long-term conditions (both single and multiple conditions) will require better primary care and more integrated care People in control of their own health and patients in control of their own care is essential The way hospitals are organised is unsustainable and does not support the provision of high quality care Research, education, new technologies and a better understanding of diseases will help us transform the health service. Based on the responses to A Call to Action NHS England has identified six transformational service models that will define the characteristics of the NHS in five years: 1. A completely new approach to ensuring that citizens are fully included in all aspects of service design and change and that patients are fully empowered in their own care 25

28 2. Wider primary care, provided at scale 3. A modern model of integrated care 4. Access to the highest quality urgent and emergency care 5. A step-change in the productivity of elective care 6. Specialised services concentrated in centres of excellence. Underpinning each of these models are the four essential elements of quality, access, innovation and value for money Purpose of this strategic context section The remainder of this section steps selectively through some of the key strategic considerations raised for the development the five year South East London Commissioning Strategy, by the planning guidance and by other key strategies and programmes. The intention is not to exhaustively cover all elements included in the planning guidance, which can be viewed in full here 25, but to surface the points most pertinent to the strategy. 3.2 Public and patients must be fully included in all aspects of service design and change and patients fully empowered in their own care This means ensuring that that public, patient and carer voices are at the centre of healthcare services from planning to delivery; and empowering patients through digital technology and through transparency and sharing of data. NHS commissioners have a duty to support better patient and public participation, through ensuring: Individual Participation: patients and carers are able to participate in planning, managing and making decisions about their own care and treatment Public participation: effective participation of the public in the commissioning process itself, so that services reflect the needs of local people. The duties of CCGs as commissioners are set out in Transforming Participation in Health and Care 26. The importance of strong user voice in services will be further strengthened by the rollout of Personal Health Budgets during 2014 and related approaches to personalisation of care. 3.3 There needs to be wider primary care, provided at scale NHS England is responsible for commissioning primary care through local area teams. CCGs share a joint responsibility with NHS England for transforming and driving up quality in primary care, and CCGs themselves play a key role in the clinical leadership of primary care to deliver high quality services. 90% of patient contact with the NHS takes place in general practice, amounting to more than 300 million consultations every year. GPs play a key role not only in providing services themselves, but also helping their patients to navigate the system and access the care they need in other settings. 25 Everyone Counts: Planning for Patients 2014/ /19, NHS England, 26 Transforming Participation In Health And Care, NHS England September 2013, 26

29 One of NHS England s key aims as commissioner of primary care is that general practice, community pharmacy and other primary care services should be enabled to play a key role at the heart of integrated community services. This includes a strengthened role in integrated care for vulnerable and older people as agreed in the new GMS contract (outlined further in Section 3.4). There is currently an unprecedented strain on general practice services in London. The pressures include: Population growth and patients health complexity is placing unprecedented demand and pressure on GPs. Primary care services are struggling to respond Despite some practices achieving excellent clinical outcomes and patient satisfaction, there is significant variation in performance and London practices lag behind the rest of the country in measures of quality and patient satisfaction London needs a primary care service that has the capacity and capability to provide the best care possible, in a modern environment that enables multidisciplinary working and training Plans to change hospital services usually depend on boosting capacity in primary care. If we do not improve access to primary care London s hospitals will be increasingly unsustainable It is predicted there will be a 4 billion funding gap in London by 2020 and financial pressures are forcing some GP practices to close. If we do not address this in a planned way we will see a steady erosion of the quality of care and patients will suffer. NHS England has published a Case for Change about London s primary care 27. This sets out the challenges facing general practice today and the priorities that doctors and patients believe are important to address. A consultation is taking place on the Case for Change during the first quarter of The emerging Commissioning Strategy for south east London will need to reflect the resulting outcomes and transformational approaches developed from the consultation; as well as the parallel consultation on the role of community pharmacy. 3.4 A modern model of integrated care is required Everyone Counts sets out a vision for integrated care with a senior clinician taking responsibility (through a personal relationship) for active coordination of the full range of support from lifestyle help to acute care. Some of the key aspects are as follows: Ensuring tailored care for vulnerable and older people. This includes: the current governmental focus on patients aged over 75 and those with complex needs arrangements in the new GP contract for patients aged over 75 to have an accountable GP and for those who need it to have a comprehensive and co-ordinated package of care the transfer of 5 per head from CCGs to fund practice plans to transform care for the over 75s and reduce avoidable admissions. Care integrated around the patient. Integrated care around the patient can encompass a range of different service models, but each is likely to include the following features: senior clinicians (within a team) taking full responsibility for people with multiple longterm conditions 27 Transforming Primary Care in London: General Practice A Call to Action, NHS England November 2013, 27

30 full responsibility lasting from presentation to episodic care, including personalised care planning for those who would benefit co-ordination of care including lifestyle support and advice, social care, general practice care and hospital episode co-management. The Better Care Fund. The 3.8 billion Better Care Fund that comes into operation in 2015/16 is aimed at supporting the integration of health and social care. Commissioners must include in their plans their vision for how health and social care services work together to provide better support at home and earlier treatment in the community to prevent people needing emergency care in hospital or care homes. All CCGs are setting our plans for how they will take in 2014/15 to create the funding required to make the Better Care Fund affordable when it is introduced in 2015/16 in order to fulfil their duty to commission sustainable services for patients. 3.5 Our workforce needs to enable modern models of primary and integrated care To deliver high quality care, we need staff in the right numbers, with the right skills, values and behaviours. Over and above this, the following need to be in place to enable population based healthcare: Every healthcare worker has the knowledge, skills and ability to carry out their role for which they are valued; every patient and carer feels able to play a full part in determining the care they need and to obtain it in a timely way Every member of the workforce thinks proactively about how they can support their patient to improve or maintain their own health and wellbeing, prevent illness, and move towards recovery, and identify how and when they need to access health and social care services Staff need to be trained to help communities mobilise and work together to improve their health Staff will support patients to feel in control of their own health and wellbeing Staff are equipped with excellent skills in communication, team working, and the ability to navigate professional and organisational boundaries to get the best for their patients Structures, systems and processes are important elements of working in a preventative, community-focused approach but the key contribution is the response of each individual staff member. Having been trained largely in addressing illness, staff will need to shift their way of thinking to wellness. In addition to the expectation of curing illness, staff will need to adjust to empowering patients, families and communities to maintain their own wellbeing, by prioritising interventions such as, for example, rehabilitation. This will require not only new skills and ways of working but the evolution of new roles and career pathways. We need to ensure that the training and education of our workforce, whether initial undergraduate training or via CPPD, reflects the way healthcare delivery is moving and contributes to the requirements of the Education Outcomes Framework13. As with simulation-based learning, the closer education and training is to real life working experiences the better prepared the individual. Therefore, we need to increase opportunities for multidisciplinary and inter-professional learning and train students, trainees and staff in settings most similar to where they work (or, for students, will work). This will enhance the learning experience of different workforce groups by more accurately reflecting the environments they work within. 28

31 3.6 Patients should be able to easily access and navigate high quality urgent and emergency care Many people are struggling to navigate and access urgent care services provided outside of hospital. A high rate of 999 calls is being experienced for both emergency and urgent care needs; and patients are defaulting to A&E. At the same time there are significant differences in the types and levels of service provided in A&E departments. Three major elements set the context for the strategic development of urgent and emergency care services. The Urgent and Emergency Care Review 28. The report on the first phase Urgent and Emergency Care review suggests that the quality of urgent and emergency care would be enhanced if patients were treated as close to home as possible and if networks were established, with major specialised services offered in between 40 and 70 major emergency centres, supported by other emergency centres and urgent care facilities. NHS 111. NHS 111 services will be a key component of the urgent care service. NHS 111 services will be rolled out to cover the whole of England. In addition, NHS England and CCGs will produce a new service specification for 111 to support the future commissioning of a comprehensive and high quality service. Urgent Care Working Groups. Urgent Care Working Groups (UCWGs) will lead local resilience planning, including acting as the vehicle for reaching agreement on the investment plans to be funded by the retained 70 per cent from the application of the marginal rate rule. 3.7 Patients should be able to access high quality specialised services concentrated in centres of excellence Specialised services for less common disorders need to be concentrated in centres of excellence where the highest quality can be delivered. This enables not only the best possible quality of services to be delivered at volume and in a sustainable way, whilst connecting actively to research and teaching. In some cases specialised services are currently being delivered out of too many sites, with too much variety in quality and at too high a cost in some places 29. Since April 2013, prescribed specialised services have been a core responsibility of NHS England. The Specialised Commissioning Team (SCT) for the London Region of NHS England incorporates both the area and regional structure in one team and is supporting NHS England s A Call to Action. A national five year strategy for Specialised Commissioning will be published in April 2014 will address the service specific objectives for the next 5 years, overarching strategic objectives for the provision of a system of specialised healthcare as a whole and the impact of co-dependency between service areas. The strategic commissioning approach has the following 6 strands: 28 Phase 1 Report of the National review of Urgent and Emergency Care, NHS England November 2013, 29 Everyone Counts: Planning for Patients 2014/ /19, NHS England, 29

32 Figure 15 Strategic commissioning approach for specialised services 3.8 Quality and safety must be at the heart of commissioning and delivery of local services The quality of patient care and patient safety should come before all other considerations in local NHS services. Ensuring high quality care requires providers, commissioners and individual professionals to work together and consider the different facets of quality to enable the system to: Systematically drive continuous improvements linked to the overarching outcomes or domains set out in the NHS Outcomes Framework Ensure essential standards of quality and safety are maintained (including the London Clinical Standards). Figure 16 The quality curve showing the different facets of quality Adapted from: Quality in the new health system-maintaining and improving quality, National Quality Board January

33 To effectively improve and sustain high quality care and patient safety there is a need to ensure: An open and honest culture exists across the system Continual learning and improvement Patients are proactively engaged, empowered and involved That robust, relevant and timely information available at every level of the system There are agreed quality and patient safety metrics (qualitative and quantitative) that are routinely and effectively measured Effective use of comparative quality indicators Development and implementation of innovative approaches to delivering healthcare. There are a number of high profile reports that demonstrate the need to prioritise and monitor quality and safety across the system: The Francis Report into the systemic failings at the Mid Staffordshire NHS Foundation Trust 31 sets out a series of recommendations to ensure best possible care for patients in the NHS. Responses to the Francis Report by the Government 32 and the National Quality Board 33 will drive approaches to improving nursing, midwifery and care staffing to ensure best possible care for patients in the NHS. Transforming Care: A national response to Winterbourne View Hospital 34 sets out the basis on which CCGs, Local Authorities and specialised commissioners should work together to implement the core specification, the document setting out the principles that must be present in all education, health and social care services for children, young people, adults and older people with learning disabilities and/or autism who either display, or are at risk of displaying, behaviour that challenges The Berwick review into patient safety 35 has significant implications for how CCGs take an active part in their local patient safety improvement collaborative and support local improvement setting out a number of recommendations. The key messages were a promise to learn and a commitment to act Also key to the quality agenda are the findings of the NHS Services, Seven Days a Week Forum 36. The Forum has reported to NHS England on how NHS services can be improved to provide a more responsive and patient centred service across the seven day week, with an initial focus on urgent and emergency care. The review found significant variation in outcomes for patients admitted to hospital at the weekend, seen in mortality rates, patient experience, length of stay and re-admission rates Hard Truths, Department of Health January 2014, 33 How to ensure the right people, with the right skills, are in the right place at the right time, National Quality Board November 2013, 34 Department of Health December 2012, 35 A promise to learn a commitment to act: Improving the Safety of Patients in England, National Advisory Group on the Safety of Patients in England, August NHS England December 2013, 31

34 4 Significant developments and opportunities within south east London help us to make a strong and innovative response to the national and London context Chapter summary and key messages Our CCGs are playing a key role in providing clinical leadership for their local health systems. In practice this includes: Maintaining a constant clinical focus on improving quality and health outcomes and reducing health inequalities Engaging and providing leadership to their member practices in the improvement of local services Ensuring that public and patient voice is at the heart of commissioning decisions Working with local Health and Wellbeing Boards and local partnership arrangements to deliver local Health and Wellbeing Strategies; and now to develop and deliver plans in relation to the Better Care Fund. We have a longstanding history of joint working across the six boroughs, including: Integrated governance, joint working arrangements for working across the six boroughs A history of working across the six boroughs on strategic and transformational work including A Picture of Health for South East London, and more recently the TSA Implementation Programme at South London Healthcare Trust. The South East London Community Based Care (CBC) Strategy is starting to transform community based care through three delivery programmes: Primary and Community Care: Providing easy access to high quality, responsive primary and community care as the first point of call for people in order to provide a universal service for the whole population and to proactively support people in staying healthy Integrated Care: Ensuring there is high quality integrated care for high-risk groups (such as those with long term conditions, the frail elderly and people with long term mental health problems) and that providers (health and social care) are working together, with the patient at the centre. This will enable people to remain active, well and supported in their own homes wherever possible Planned Care: For episodes where people require it, they should receive simple, timely, convenient and effective planned care with seamless transitions across primary and secondary care, supported by a set of consistent protocols and guidelines for referrals and the use of diagnostics. Delivering the organisational changes associated with the dissolution of South London Healthcare Trust has created a pattern of NHS organisations which provides a good foundation for the future. South east London has one of the country s six Academic Health Science Centres (AHSCs), King s Health Partners. The work of the AHSC includes: Working through Clinical Academic Groups which bring together subject matter experts into operational units focused on ensuring that learnings from research are used quickly, consistently and systematically to improve clinical services Four key delivery programmes, which include locally: o Southwark and Lambeth Integrated Care a programme which aims to organise 32

35 o local systems of health and social care more effectively and to provide care in a more integrated way so that patients in south east London get the best service possible Integrated Cancer Centre - a major collaboration across our Trusts and university to combine ground breaking cancer research with first-class clinical care for cancer patients. South London Health Innovation Network is responsible for sharing innovations across the health system, capitalising on teaching and research strengths to drive lasting improvements in health and wellbeing across South London. Programmes being taken forward locally include diabetes, alcohol, musculoskeletal, dementia and cancer. 4.1 Our CCGs are playing a key role in providing clinical leadership on behalf of their members and local populations South East London s CCGs are the autonomous statutory decision making bodies responsible alongside NHS England Direct Commissioning, for the commissioning of NHS services across the local health system. Our CCGs have a key role in providing clinical leadership within their boroughs. In practice this includes: Understanding the health needs and priorities of their local population to ensure the right services are commissioned and delivered Ensuring that patient and public voice is at the heart of commissioning Ensuring patients are proactively engaged in treatment decisions Maintaining a continual clinical focus on improving quality, safety, patient experience and health outcomes as well as reducing health inequalities Engaging and providing leadership to their member practices in the improvement of local services Working with local Health and Wellbeing Boards and local partnership arrangements to deliver local Health and Wellbeing Strategies; and now to develop and deliver plans in relation to the Better Care Fund. Working with all partner organisations including research and health sciences to develop and implement innovative approaches to commissioning and delivering healthcare. We have a longstanding history of joint working across the six boroughs, including: integrated governance and joint working arrangements for working across the six boroughs well established collaborative and lead commissioning relationships with local providers a history of working across the six boroughs on strategic and transformational work including A Picture of Health for South East London, and more recently the TSA Implementation Programme at South London Healthcare Trust. 4.2 The Better Care Fund is an opportunity to integrate and transform services The Better Care Fund, which comes into effect from 2014/15, is a 3.8bn fund which is being created as 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. 37 It 37 Local Government Association and NHS England 2013, 33

36 offers a substantial opportunity both to address the immediate pressures on local services and to transform and provide the basis for a more integrated health and care system 38. CCGs in south east London are working with their Local Authorities and other partners to develop local visions and plans for use of the fund. These are being agreed with local Health and Wellbeing Boards in early The plans will be a key part of two year operating plans and five year strategies. Plans must include detail of how the following will be provided: Protection for social care services Seven-day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends Better data sharing between health and social care, based on the NHS number A joint approach to assessments and care planning and, where funding is used for integrated packages of care, an accountable professional Agreement on the consequential impact of changes in the acute sector, with an analysis, provider-by-provider, of what the impact will be in their local area alongside public and patient and service user engagement in this planning, and plans for political buy-in. 4.3 The South East London Community Based Care (CBC) Strategy is starting to transform community based care through three delivery programmes The South East London Community Based Care (CBC) Strategy was approved in 2012 by the six CCGs in south east London. The strategy sets out aspirations for community based care which all south east London CCGs have committed to deliver. Each CCG started from a different point and through their operating plans set out plans for year one delivery. These were then embedded into contracts with providers or developed into specific work programmes such as service redesign and other change programmes to be implemented throughout the year. There are three delivery programmes: Primary and Community Care: Providing easy access to high quality, responsive primary and community care as the first point of call for people in order to provide a universal service for the whole population and to proactively support people in staying healthy. Integrated Care: Ensuring there is high quality integrated care for high risk groups (such as those with long term conditions, the frail elderly and people with long term mental health problems) and that providers (health and social care) are working together, with the patient at the centre. This will enable people to remain active, well and supported in their own homes wherever possible. Planned Care: For episodes where people require it, they should receive simple, timely, convenient and effective planned care with seamless transitions across primary and secondary care, supported by a set of consistent protocols and guidelines for referrals and the use of diagnostics. These delivery work programmes are supported by five enabling programmes: Communications, Self-management, IM&T, Workforce and Contract Levers. 38 Making best use of the Better Care Fund, Kings Fund 2014, 34

37 All boroughs are taking forward innovative integrated care programmes in support of the CBC Strategy. Progress on these schemes is described further in Section 9. Some examples include: Greenwich CCG and its partners have been awarded national pioneer status for a programme that will build upon the existing integrated care system for older people and people with physical disabilities, enabling health and social care partners to base integrated services within clusters of GP practices to further improve care for patients and contribute to delivering community based care across south east London Southwark and Lambeth CCGs are taking an integrated approach across the two boroughs on the development of an Academic Integrated Care Organisation (AICO) including a home (virtual) ward and enhanced rapid response to manage service users in their own homes; and integrated care for service users with long term conditions and the frail elderly. 4.4 South east London has one of the country s six Academic Health Science Centres, King s Health Partners King s Health Partners 39 is one of six Academic Health Science Centres (AHSCs) in England. It is a partnership that brings together King s College London with three NHS Foundation Trusts Guy s and St Thomas, King s College Hospital and South London and Maudsley to improve the health of the patients and population of south east London. This powerful collaboration combines research, clinical care, education and training to ensure the broadest possible provision of services, including acute and mental healthcare, as well as enabling a closer dialogue between the academic and the clinician, speeding up the time it takes for discoveries in the laboratory to be translated into trials and, ultimately, treatments. The work of King s Health Partners is focused through Clinical Academic Groups which bring together subject matter experts into operational units focused on ensuring that learning from research is used quickly, consistently and systematically to improve a wide range of clinical services, for example cancer care, dementia and diabetes, and a number of programmes that use the combined expertise of their staff to tackle challenging healthcare issues across London. Current programmes are: Southwark and Lambeth Integrated Care a programme which aims to organise local systems of health and social care more effectively and to provide care in a more integrated way so that patients in south east London get the best service possible Integrated Cancer Centre a major collaboration across member Trusts and university to combine ground breaking cancer research with first-class clinical care for cancer patients King's Centre for Global Health a programme to co-ordinate all Global Health activities across all schools within King's College London and the NHS organisations across Kings Health Partners. Work involves establishing close partnerships with countries to offer a range of support to their health institutions and improve standards of care King's Improvement Science an initiative that aims to improve people's health by improving health services

38 4.5 South London s Health Innovation Network is driving lasting improvements in health and wellbeing across south London The South London Health Innovation Network (HIN) 40 is one of thirteen Academic Health Science Networks (AHSNs) across the country. It is a membership organisation that includes Local Authorities, Acute, Mental Health and other Trusts, Commissioners, Primary Care Providers, Higher Education Institutions, Third Sector, Patient and Charity Organisations, Industry and Commercial Partners. The HIN is driving lasting improvements in health and wellbeing across south London by sharing innovations across the health system and capitalising on teaching and research strengths. It is focussed on health priorities for local communities across a number of clinical areas and cross-cutting innovation themes, to deliver service improvement and sustainable change. Work of the HIN is focused on a combination of: Clinical areas, consisting of: diabetes, alcohol, musculoskeletal, dementia and cancer. For example the Diabetes Clinical Programme is working in partnership with local stakeholders to develop and implement innovative ways of improving health outcomes for people with diabetes, working to share best practice across the network. Innovation themes, consisting of: patient experience, information, wealth creation, education and training, and research. For example in relation to Patient Experience, South London HIN is working to accelerate feedback service improvement cycles, focusing on diabetes and dementia pathways. A major project is underway, working with dementia patients and carers as well as the people who provide health services, to co-create experience metrics for dementia patients and carers. This work will shape the way care is delivered in the future

39 5 Our health services have many strengths but quality is variable and we have tolerated unacceptable and unwarranted variation in quality for too long Chapter summary and key messages No Trust in south east London fully meets the London standards for safety and quality in emergency care and maternity services. Compliance with London Adult Emergency Standards varies. There were five standards across medicine and surgery which all hospitals across south east London failed to meet Across south east London there was broad variation amongst hospitals with no individual hospital either meeting or not meeting all of the key national standards for Critical Care, Emergency Department, Fractured Neck of Femur, Maternity and Paediatrics standards. There were two standards which all hospitals in south east London failed to meet. There is significant variation in the performance of acute Trusts, both within and between organisations. Based on analysis prior to the dissolution of South London Healthcare Trust: All Trusts in south east London were in the fourth (bottom) quartile for median time in Accident and Emergency from arrival to treatment Patients reported bottom quartile experience of care in three of four Trusts South London Healthcare, Kings College Hospital and Lewisham Healthcare Trust Patients diagnosed with cancer were experiencing higher than average over 31 day waits for their first treatment in the majority of trusts with Guys and St Thomas being in the fourth (bottom) quartile Only Kings College Hospital was above average for number of two week referral to first outpatient appointment for breast symptoms with Guys and St Thomas and University Hospital Lewisham in the fourth (bottom) quartile All Trusts showed better than average performance in terms of emergency readmissions within 28 days of discharge Three out of four Trusts were in the first (top) quartile for the summary indicator on low hospital mortality, although South London Healthcare Trust was in the third quartile for this measure. In primary care, many patients find it hard to get an appointment with their GP. The services available are inconsistent and quality and outcomes variable, with lower patient satisfaction scores compared to other parts of England. Patients report 4th (bottom) quartile experience of care in four of the six CCGs in south east London with the remaining two CCGs, Lambeth and Lewisham, in the 3rd quartile All south east London CCGs have lower than average GP access, with Bexley, Lewisham and Southwark in the fourth quartile nationally; and remaining CCGs in the third quartile There is significant variation in achievement of GP outcomes, both within and between boroughs. Best performance against GP outcomes across south east London was Bromley where 54% of practices are achieving or higher achieving practices; the worst performance was in Lambeth where this figure is only 12%. The equivalent England average is 62% All south east London CCGs have lower than average (1st quartile) primary care spend 37

40 compared to the rest of England. Within south east London there are specific challenges to ensure that maternity services provision meets the highest standards of care and quality and health outcomes. Failure to meet a number of national standards and key performance indicators for example, screening and first antenatal appointment Employment and retention of the highly skilled workforce required to deliver a service across all health settings, linking to performance against the London Quality Standards set out elsewhere Current capacity issues, which results in maternity services being suspended at hospitals, and women being diverted away from their hospital of choice. Between April 2011 and November 2012, providers of maternity services across SEL suspended services on 37 occasions The recent CQC Patients Survey highlighted areas for improvement in each of the SEL maternity service providers including staff attitude in postnatal wards, pain relief and breastfeeding information and advice. As a system we have need to improve quality and to drive consistency and productivity in community and mental health services. For Mental Health services: Services deliver top quartile performance on only one out of eleven observed outcomes, namely CPA review in the past 12 months Three out of six CCGs had high (bottom quartile) incidents of serious harm in MH care (Lambeth, Lewisham, and Southwark) whilst the remanding 3 are in the 3rd quartile Three of six CCGs have low employment for adults with MH conditions (Bexley, Bromley, Greenwich). For Community services: Immunisation of children is bottom quartile for Greenwich, Lambeth, Lewisham, Southwark and 3rd quartile for the rest All CCGs struggle with patient safety in the community with 5 of 6 CCGs in the bottom quartile for pressure ulcer prevention (all boroughs except Lambeth), and 3 in bottom quartile for falls in the community (Lambeth, Southwark and Lewisham) All of the SEL CCGs are in 3rd quartile on delayed transfer of care. Note further detail on quality and performance for specialised services to be incorporated once information available. 5.1 There is significant variation in the performance of acute Trusts, both within and between organisations Acute Trusts in south east London are currently balancing increased volumes and complexity of care, more stringent quality standards and a challenging financial environment, as summarised in Section 7 below. Figure 15 below provides a summary of regional analysis compiled for the 2014/15 planning process on key effectiveness measures in acute care. Please note this is based on analysis prior to the dissolution of South London Healthcare Trust in September The analysis indicates the following themes: 38

41 All four Trusts in south east London are in the fourth (bottom) quartile for median time in Accident and Emergency from arrival to treatment, with South London Healthcare Trust also in the fourth (bottom) quartile for Accident and Emergency waits over four hours. Patients report fourth (bottom) quartile experience of care in three of four Trusts in south east London, with only Guys and St Thomas in the first (top) quartile The majority of Trusts in south east London are below average for Cancelled operations not rebooked within 28 days, with South London Healthcare Trust in the fourth (bottom) quartile Patients diagnosed with cancer are experiencing higher than average incidents over 31 day waits for their first treatment in the majority of trusts with Guys and St Thomas being in the fourth (bottom) quartile Only Kings College Hospital is above average for number two week referral to first outpatient appointment for breast symptoms with Guys and St Thomas and University Hospital Lewisham in the fourth (bottom) quartile All Trusts perform show better than average performance in terms of emergency readmissions within 28 days of discharge Three out of four Trusts are in the first (top) quartile for the summary hospital mortality indicator, although South London Healthcare Trust was in the third quartile for this measure. Figure 17 Summary of acute care effectiveness in south east London South east London Strategic Planning Group Data Pack NHS England November

42 5.2 No Trust in south east London fully meets the London standards for safety and quality in emergency care and maternity services Please note this section will be updated with results of the 2012/13 self-assessment exercise once these are available, expected early March Improving the quality and safety of acute emergency (adult and paediatric) and maternity services was identified as one of the NHS in London s key priorities in 2012/13. The Quality and Safety Programme was established in 2012 with this purpose, and resulted in a set of quality standards to be met within London s acute emergency and maternity services across all seven days of the week 42. These were signed off by the Clinical Senate and published in February All CCGs in south east London are committed to commissioning services to these standards and have provided formal agreement through their governing bodies. The following analysis summarises the position of south east London hospitals against clinical standards based on audits and self-assessments conducted during July to September Hospitals were examined against the London adult emergency standards, plus national standards for critical care, emergency departments, fractured neck of femur, maternity and paediatrics. It should be noted that in most cases the London standards subsequently developed are more stringent than the associated national standards. The audit findings represent a point in time view, and do not reflect any actions taken by providers since September Providers in south east London have performed a new self-assessment against the London clinical standards during 2013, the results of which are awaited at the time of writing. This section of the Case for Change will be updated to reflect the findings of the 2013 assessment once these are available. The headline findings of the 2012 audit and self-assessment for south east London acute providers are set out in and below Compliance with London Adult Emergency Standards varies There were five standards across medicine and surgery which all hospitals across south east London failed to meet: Standard 2: A clear multi-disciplinary assessment to be undertaken within 12 hours and a treatment or management plan to be in place within 24 hours Standard 3b: Consultant involvement is required for patients who reach trigger criteria. Consultant involvement for patients considered high risk to be within one hour Standard 6: All patients on acute medical and surgical units to be seen and reviewed by a consultant during twice daily ward rounds, including all acutely ill patients directly transferred, or others who deteriorate Standard 20: Consultant-led communication and information to be provided to patients Standard 23: Prompt screening of all complex needs inpatients to take place by a multiprofessional team which has access to pharmacy and therapy services, including physiotherapy and occupational therapy, seven days a week with an overnight rota for respiratory physiotherapy. Kings College Hospital and University Hospital Lewisham had robust plans in place to achieve compliance with standard 20 in surgery during 2012/ For further detail please see: 40

43 Figure 18 Level of compliance with London adult emergency standards across south east London acute providers, July to September Compliance with National Standards for Critical Care, Emergency Department, Fractured Neck of Femur, Maternity and Paediatrics standards is better but with room for improvement Across south east London there was broad variation amongst hospitals with no individual hospital either meeting or not meeting all of the key national standards considered. King s College Hospital, St Thomas and University Hospital Lewisham were notable for achieving compliance with the majority of the standards considered. There were two standards which all hospitals in south east London failed to meet, these were: Paediatrics standard 2(a): All emergency admissions to be seen and assessed by the responsible consultant within 12 hours of admission or within 14 hours of time of arrival at the hospital Paediatrics standard 2(b): Where children with surgical problems are admitted to a nonspecialist surgical unit, they should be jointly managed and reviewed by both surgical and paediatric senior teams within 12 hours of admission. 5.3 In primary care, many patients find it hard to get an appointment with their GP and the services available are inconsistent, with lower patient satisfaction scores compared to other parts of England. There is currently an unprecedented strain on general practice services in London, as summarised in Section 3.3 above. Figure 17 provides a summary of regional analysis compiled for the 2014/15 planning process on key spend and effectiveness measures in primary care. 43 South east London Strategic Planning Group Data Pack NHS England November

44 Figure 19 Summary of primary care spend and effectiveness in south east London 44 The analysis and other key sources of data on quality and performance in local primary care indicate the following themes: Patients report 4th (bottom) quartile experience of care in four of the six CCGs in south east London with the remaining two CCGs, Lambeth and Lewisham, in the 3 rd quartile All south east London CCGs have lower than average GP access, with Bexley, Lewisham and Southwark in the fourth quartile nationally; and remaining CCGs in the third quartile The percentage of GPs with a review planned due to breaches of GP Outcome Standards is variable, as further indicated in Figure 18 below. Best performance across south east London was Bromley where 54% of practices are achieving or higher achieving practices; the worst performance was in Lambeth where this figure is only 12%. The equivalent England average is 62% There is also significant variation in achievement of GP outcomes within individual boroughs, comparing performance of practices against each outcome indicator. There are notable successes for example in the last quarter all GP practices across south East London were within 1 standard deviation of the mean for achievement of outcomes for end of life and early detection of cancer. However there were high levels of variation across all boroughs in relation to achievement of outcomes for serious mental illness, smoking cessation advice, and identification of asthma All south east London CCGs have lower than average (1st quartile) primary care spend compared to the rest of England. The condition of local premises and infrastructure also impact on how effectively local GP services can respond to pressures through achievement of scale and better integration: Work on the London-wide Case for Change for Primary Care indicates that across the capital only a small percentage of practices are utilising their current digital capacity to access records (circa 3% of practices); cancel or book appointments on line (circa 40% of practices); or order repeat prescriptions on lines (again circa 40% of practices) A thorough diagnostic of one London region found 30% of practices to be operating from substandard premises the proportion elsewhere is likely to be similar. 44 South east London Strategic Planning Group Data Pack NHS England November

45 Figure 20 Proportion of practices in each London CCG by GP outcome achievement As a system we need to respond to the need to improve quality and to drive consistency and productivity in community and mental health services. Mental health and learning disabilities services Performance on Mental Health (MH) and Learning Disabilities (LD) services is variable across south east London. Figure 19 sets out regional analysis compiled for the 2014/15 planning process, which indicates that: Services deliver top quartile performance on one out of eleven observed outcomes, namely CPA review in the past 12 months Three out of six CCGs had high (bottom quartile) incidents of serious harm in MH care (Lambeth, Lewisham, and Southwark) whilst the remanding 3 are in the 3rd quartile Three of six CCGs have low employment for adults with MH conditions (Bexley, Bromley, Greenwich) MH spend is in the highest quartile for 4 CCGs (Greenwich, Lambeth, Lewisham, Southwark) and lowest quartile for Bexley and Bromley LD spend is in the 3rd quartile for Greenwich and Lambeth and lowest spend quartile for the rest A number of CCGs have noted a poor (but improving) interface between primary care and mental health services, resulting in slow response times, lack of clarity on link staff, and variation in GPs knowledge about mental health and primary care access to specialist interventions and expertise. 45 South east London Strategic Planning Group Data Pack NHS England November

46 A number of CCGs also have priorities in relation to improving IAPT services and improving CAMHS services to focus on prevention and early help. Figure 21 Enhancing quality of life for people with mental illness and learning disabilities 46 Community Services Performance on Community Services is also variable. Figure 20 below sets out regional analysis compiled for the 2014/15 planning process, which indicates that: Performance of ambulatory care sensitive (ACS) admissions from selected community sources varies from top quartile (Lambeth, Southwark) to bottom quartile (Bromley), with remaining CCGs in the 3rd quartile Immunisation of children is bottom quartile for Greenwich, Lambeth, Lewisham, Southwark and 3rd quartile for the rest All CCGs struggle with patient safety in the community with 5 of 6 CCGs in the bottom quartile for pressure ulcer prevention (all boroughs except Lambeth), and 3 in bottom quartile for falls in the community (Lambeth, Southwark and Lewisham) All of the SEL CCGs are in 3rd quartile on delayed transfer of care Spend is variable across the CCGs with Southwark in the lowest (1st) quartile on community spend and Bexley, Lambeth and Lewisham in the 3rd quartile. Workforce recruitment and retention of district nurses and health visitors in inner city London is a challenge affecting a number of CCGs. 46 South east London Strategic Planning Group Data Pack NHS England November

47 Figure 22 Enhancing quality of life in the Community Within south east London there are specific challenges to ensure that maternity services provision meets the highest standards of care and quality and health outcomes As well as an increasing population and consequent demand for maternity services, south east London contains an increasing number of women with more complicated health and social care needs who require more support. Locally the acute provider landscape has been through considerable change in the last year. Whilst not immediately impacting on the current provision of maternity services it has not resolved either the financial issues or the existing capacity (both physical and workforce) issues in local maternity services. Some of the particular challenges facing maternity services in south east London include: Failure to meet a number of national standards and key performance indicators for example, screening and first antenatal appointment. Performance against assorted national measures for maternity services is set out in the figure below for each south east London borough Employment and retention of the highly skilled workforce required to deliver a service across all health settings. All SEL Trusts are signed up to achieving the London Health Programme Standards in relation to midwifery and obstetrician staffing, however a recent audit across all Trusts in London showed very few maternity services currently achieving these Current capacity issues, which results in maternity services being suspended at hospitals, and women being diverted away from their hospital of choice. Between April 2011 and November 2012, providers of maternity services across SEL suspended services on 37 occasions. On 26 of those occasions suspension was necessary because of lack of beds. The other reasons were shortage of medical or midwifery staff Although service users are broadly satisfied with their care in SEL, the recent CQC Patients Survey highlighted areas for improvement in each of the SEL maternity service 47 South east London Strategic Planning Group Data Pack NHS England November

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