Clinical Strategy December 2017

Transcription

1 Executive Summary Clinical Strategy December 2017 London North West University Healthcare NHS Trust has evolved over a 25 year period by the successive mergers of four separate and distinct acute hospitals and three borough based community healthcare providers. It employs nearly 9,000 clinical and non-clinical staff, including over 1,000 undergraduate and post graduate medical trainees, and trainee nurses and other clinical professionals across its three hospital sites and 11 community properties, other shared facilities and mobile services, within the London Boroughs of Ealing, Harrow and Brent. The Trust offers a diverse range of secondary and tertiary acute and community services commissioned by clinical commissioning groups (67.5% of operating income) and NHS England (14.1%). 1 It services a local population of approximately 1 million patients as well as those drawn to its tertiary services from the region, England and even internationally. Since the most recent merger in 2014 the Trust remains financially and operationally challenged, with an underlying recurrent deficit of around 68 million. This is a significant improvement from just under 100m at the time of the merger, but reflects ongoing poor financial margins and substantial operational challenges meeting some key national performance targets for emergency, cancer and elective treatment pathways; against the background of an aging population. The Trust s estate is not fully fit for purpose due to historic under-investment and age. Facilities are also sub-optimally utilised, with excessive operational pressures on the Northwick Park and St Mark s Hospital site and under-use of operational capacity at Ealing Hospital and Central Middlesex Hospital. Notwithstanding these challenges, the Trust s national mortality rating is in the top quartile reflecting fundamentally strong clinical capability and performance. The Trust provides one of the busiest and safest emergency pathways in the country. 2 Each day dealing safely with some 1,000 patients who attend emergency and urgent care services and doing so 365 days a year. The A&E department at Northwick Park Hospital is often one of the busiest in London and the large flow of local patients coming to the Trust also includes amongst the highest numbers of cancer presentations to any NHS hospital in London. The Trust provides some outstanding tertiary level services, including the internationally recognised specialty bowel and lower gastro-intestinal medicine and surgery performed in St Mark s. Together with national centres of excellence for hyper-acute stroke care and hyperacute rehabilitation, and specialist hubs for head and neck surgery, vascular and interventional radiology m in fiscal year 2016/17 2 The relative risk of in-hospital mortality for 41,710 non-elective admissions via A&E in 2016/17 was 80.6, equivalent to 430 avoided deaths (source: Dr Foster)

2 Page2 These specialist acute services are complemented by a wide range of adult and children s services delivered in the community, which continue to play a central role in moving care closer to home. The Trust as a large scale integrated care organisation is also in a strong position to respond to commissioners ambitions: to reduce variation, and deliver more consistent quality standards and a better patient experience; to create new streamlined models of care; and to work collectively on closing gaps between service providers in primary care, social care, care homes and voluntary sector. In developing the clinical strategy we have drawn extensively on the views and experiences of our clinical staff, built up first-hand from providing care day-in and day-out over many years. We have considered the wider context in which we find ourselves, including: national and local policies, funding constraints, changes in technology, local demographic and public health factors as well as our own strengths and weaknesses. The result is a clinical strategy designed to meet all the local, regional and national needs by framing its forward priorities and decision-making around three key pillars that are essential to the future success of the organisation: Emergency and ambulatory care End to end Integrated care, and Specialist services. Leveraging the Trust s considerable strengths to deliver even higher quality clinical care in acute and community settings, whilst also ensuring that it develops and grows by exploiting the manifest opportunities available to it. Alongside the three pillars, the clinical strategy sets out ambitions to improve outcomes and experiences for frail older people, to integrate cancer care and to play a greater role in North West London s goals around prevention and wellbeing. Some opportunities, such as decanting activity from Northwick Park Hospital to decrease pressure on the capacity available on that site whilst increasing activity at both Ealing Hospital and Central Middlesex Hospital are critical building blocks that need urgent implementation. Other opportunities, such as the estates improvements required by Shaping a Healthier Future, including increases in critical care and pharmacy capacity, and enhancements to the Ealing Hospital site, are also vital but await the necessary capital funding to progress. Development of a centre of excellence for cancer diagnosis and specialised cancer treatment at Northwick Park / St Mark s; and centres of excellence for respiratory care at Central Middlesex Hospital and for care of the frail and elderly at Ealing Hospital; are natural opportunities waiting to be developed and arise in response to local patient needs and the Trust s existing strengths and capabilities. Others, such as the West London Vascular and Interventional Radiology Centre are based on the Trust s first-mover and innovative approach to clinical advances that have yet to be adopted widely by the NHS. The evolution of accountable care systems and emergence of lead-providers for integrated services are further opportunities for the Trust to shape new pathways that genuinely

3 Page3 empower people to be in control of their healthcare outcomes. Linked to this is an emphasis on being a partner of choice for clinical commissioners and local authorities; and an ability to work effectively with other primary, mental health and acute care providers; and the voluntary sector. This document provides an overview of the clinical strategy for the next stage in this organisation s evolution and positions the Trust to continue supporting the vision of Shaping a Healthier Future and the North West London Sustainability and Transformation Plan. It coincides with the adoption of new HEART values and the recognition of our role in education and research by our recent membership of the Association of UK University Hospitals, which we celebrated by changing our name to become the London North West University Healthcare NHS Trust in November The rest of this document has four parts: Part one sets the context national, regional, local and historical for our future strategy Part two describes the vision underpinning our clinical strategy and summarises the overarching themes and clinical priorities that have been developed with our clinical divisions and leaders Part three describes the enablers of the clinical strategy and priorities within the supporting strategies of the corporate functions; and Part four provides a roadmap of how the strategy will be implemented, and where more detailed work will need to take place; with an accompanying appendix detailing high-impact priorities already identified by the divisions. Key determinants of success in implementing this clinical strategy will include the Trust s capacity to execute our ambitions at scale and speed; our HEART values; and an emerging culture of self-belief and earned autonomy. We recognise the importance of corporate enablers to assist our clinical strategy: developing our estates and digital environment; our workforce plans; growth in clinical education and training, innovation and research activities; and enhancing clinical and wider collaboration with third parties. These will also address or mitigate the risks apparent from the Trust s identified weakness and threats. The Trust acknowledges the need to pursue implementation of the clinical strategy with a sense of can do urgency and belief in our ability to take more control of this organisation s destiny. The clinical strategy necessarily describes the future in broad brush-strokes, with an emphasis on priorities for the next five years. Implementation plans for the clinical strategy will look for opportunities that can be delivered over the next 1-2 years. As well as paving the way for more radical transformation beyond five years that depend on major estate, digital and workforce changes. Clinical and corporate services have been tasked with taking the priorities set out here and developing the detail to bring the strategy to life. It is this detail that will underpin the practical tasks of planning and carrying out the changes to deliver our ambitions.

4 Page4 1 Context This section covers: Services provided by London North West University Healthcare NHS Trust External national and local factors that influence the Trust, including the Five Year Forward View, North West London Sustainability and Transformation Plan and Shaping a Healthier Future programme The challenges which the Trust has faced since it came into being in 2014 and the progress we have made in addressing them, and A summary of our strengths, weaknesses, opportunities and threats. 1.1 About London North West University Healthcare London North West University Healthcare NHS Trust (LNWUHT) came into being on 1st October 2014 through the merger of North West London Hospitals NHS Trust and Ealing Hospital NHS Trust. Creating a large integrated care provider, with services spanning home and community based services, traditional acute services and Tertiary specialist centres, some of which have national and international significance. Figure 1 shows the location of hospitals, community healthcare hubs and associated units operated by the Trust across the outer North West London (NWL) boroughs of Brent, Ealing and Harrow. The three main acute sites are Central Middlesex Hospital (CMH), Ealing Hospital (EH) and Northwick Park Hospital (NPH) inclusive of St Mark s Hospital. Health services are commissioned mainly by Brent, Ealing and Harrow clinical commissioning groups (CCGs). In addition, NHS England (NHSE) commissions national and specialist services. Summary activity data for hospital-based services are set out in Table 1. A further 600,000 contacts with local residents take place each year in community settings. Figure 1 Location of the Trust's main sites in NWL (hospitals marked in red)

5 Page5 Table 1 Summary of activity 2016/17 fiscal year (source: Qlikview) Activity Type CMH EH NPH Total Non-Elective (Maternity & Other) ,506 17,619 Emergency 1,002 19,628 47,181 67,811 Average Length of Stay (ALOS, days) Elective 1, ,843 9,337 ALOS (days) Daycase Elective 18,592 12,553 41,120 72,265 Outpatients 122, , , ,706 of which New (or First) Attendances 39,666 59, , ,997 A&E (Type 1) Attendances 40, , ,353 Performance against 4 hour Standard 81.2% 63.2% 68.3% Births 5,133 5,133 of which home births LNWUHT employs some 8,900 people, including over 1,300 doctors and 4,400 nurses, as well as therapists, scientists, other health professionals, and administrative and support staff; making it one of the largest local employers. Postgraduate medical students from the London and the South East region make up the largest proportion of nearly 1,000 clinical trainees in the organisation at any given time, contributing substantially to the clinical working environment. During 2016/17, in addition to 515 postgraduate medical trainees, we provided clinical placements for 218 undergraduates from Imperial College London (ICL) School of Medicine, 179 pre-registration adult & paediatric nursing students, 25 midwifery students and 39 allied health professional (AHP) students (from the physiotherapy, occupational therapy, audiology, radiography, dietetics and podiatry specialties). Pre-registration training for nursing and AHPs is carried out in conjunction with Bucks New University and the University of Hertfordshire. Academic-clinical links with ICL are deep and long-standing and will continue to be built upon. In addition to being a major site for medical training, 14 of our staff currently hold joint academic appointments and plans are being considered to establish an examination centre. Education and research allied to the provision of high-quality healthcare are at the core of our vision for the Trust and are central to our clinical strategy. This was recognised by the Trust s membership of the Association of UK University Hospitals (AUKUH) in 2017, which acknowledges the important role that LNWUHT plays in training clinicians of the future and bringing the benefits of healthcare innovations to the public. The Trust is a hub for clinical research in outer NWL and is a large recruiter to clinical trials, which form the mainstay of research activity. In addition, nursing teams are active in translational research aimed at reducing risk and improving patient outcomes. Other areas of activity include our participation in the national 100,000 genomes programme and, more recently, the development of innovative devices and digital medical applications. A proposed joint venture (JV) to rebuild the existing clinical trials facility with a commercial partner will substantially boost our capacity to host research. An update of the academic strategy covering clinical education and research is underway. Education priorities for the future will include widening access to training, expanding support for the creation of new roles and an increased effort to meet internal demand for skills. Ambitions for the Trust s research activities include raising our profile as a centre of

6 Page6 excellence for research, ensuring research benefits as many of our patients and local residents as possible and increasing grant income The clinical divisions Services are provided through five clinical divisions, each led by a triumvirate comprising a clinical director, head of nursing and divisional general manager. One of the major benefits of the 2014 merger was the ability to integrate previously separate borough community services into a streamlined divisional structure (see Table 2). This allowed the creation of service lines extending end to end from out of hospital settings, through to general and where necessary specialist services delivered at the Trust s three acute sites. Table 2 Service lines & significant sub-specialties within the five clinical divisions Emergency & Ambulatory Care Integrated medicine Surgery & St Mark s Integrated clinical services Women & Children Accident & Emergency (A&E) Ambulatory Care District nursing Cardiology Care of the Elderly Dermatology Diabetes and Endocrinology Genitourinary Medicine (GUM) including HIV & Sexual Health Haematology Infectious Diseases Anaesthetics Breast Surgery Community Dental Services Critical Care (Intensive Care & High Dependency Units, ITU/HDU) Ear, Nose & Throat Services (ENT) Head & Neck Surgery Oral and Maxillofacial Surgery (OMFS) Ophthalmology Orthodontics Trauma & Orthopaedics Urology Cancer General Pathology Pharmacy Radiology Specialist Palliative Care Specialist Pathology (including Regional Cytology, Point of Care Testing [POCT], Mortuary, Bowel Cancer Screening, Laboratory & Clinical Genetics and the Within gynaecology: General Gynaecology Emergency Gynaecology / Early Pregnancy Unit Community Gynaecology Gynaecological Cancer Colposcopy / Hysteroscopy Fertility Services Emergency Medicine (admissions and the acute medical assessment units) Short Term Assessment, Rehabilitation and Reablement Service (STARRS) Urgent Care Centres (UCC) Nephrology Neurology Orthotics Pulmonary Rehabilitation Regional Hyper-acute Rehabilitation Unit (RHRU) Respiratory Medicine Rheumatology Hyper-Acute Stroke Unit (HASU) Vascular Surgery And within St Mark s: Gastroenterology Endoscopy (including Polyposis, Biofeedback, Irritable Bowel Disease [IBD] and the Psychological Medicine Unit) Intestinal Failure (IF) Service General Surgery Colorectal Surgery Bowel Screening Regional Genetics Service) Community services: Acute and Community Therapies Adult Learning Disabilities Community Hospitals (including Neuroand General Rehabilitation) Community Specialist Palliative Care Perinatal Mental Health Children s acute services: CAMHS Paediatric HDU / Critical Care (Level 3) Paediatric Inpatients (Jack's Place), outpatients, Paediatric A&E & Paediatric Assessment Unit and day care

7 Page7 Women & Children cont. Within maternity: High Risk Obstetrics Low Risk Midwifery Neonatal Services Foetal and Maternity Medicine Children s community services: Universal Healthy Child Community Paediatric Therapies Community Children s Nursing & Medical Teams Community services Now integrated within the clinical divisions, the Trust s community services began as independent borough-based provider organisations in Brent, Ealing and Harrow. Despite the award of community services to competitors, notably to Central London Community Healthcare NHS Trust by Harrow CCG, out of hospital services continue to account for over 60m income from a broad range of local and specialist services comprising: district nursing, and musculoskeletal, podiatry, rehabilitation and palliative care services for adults; and speech and language therapy (SLT), physiotherapy (PT) and occupational therapy (OT) for children (Figure 2). Figure 2 Breakdown of out of hospital activity Community service activity supports a significant cohort of nurses and, in particular, therapists, with specialist skills and expertise that bring substantial benefits to our ability to effectively rehabilitate and re-able patients; and play a critical role in maintaining patient flow through our acute beds. The service includes community beds in Brent (Willesden Hospital, 60 beds), Harrow (Denham Unit, 30 beds) and Ealing (Clayponds) that provide vital step-up and step-down capacity across NWL. 1.2 National priorities Many external priorities play a role in shaping organisational priorities. The following sections concentrate on those of greatest relevance to the clinical strategy Five Year Forward View and new models of care New care models are an important feature of the 2014 NHS Five Year Forward View (FYFV), which set out the national ambitions to close gaps in health and social care, increase the focus on prevention and improve joined-up working across health and social

8 Page8 care. Increasingly, NHS organisations can expect to join one of the vanguard types launched in 2015, be they: 3 Integrated primary and acute care systems (PACS) that join up GP, hospital, community and mental health services Multispecialty community providers (MCP) that move specialist care out of hospitals into the community Enhanced health in care homes that offers older people better, joined up health, care and rehabilitation services Urgent and emergency care (UEC) vanguards offering new approaches to coordinate services and reduce pressure on A&E departments, or Acute care collaborations that link local hospitals together. In the mid-term Next Steps review of the FYFV published in March 2017, NHS England encouraged the introduction of single budgets across accountable care partnerships (ACP) spanning NHS, local authorities and other partners as a means of supporting integration. Simultaneously, NHSE confirmed its commitment to invest in new models, based on emerging evidence of the tangible impacts achieved by vanguards on reducing rates of emergency admissions growth. 4 The Next Steps review also announced additional investments in earlier diagnosis of cancer, mental health services and the expansions in training places. Currently, the accountable care agenda is being pursued at an individual CCG-level in NWL. Each taking a different approach to the services, populations and conditions included in the ACP and the nature of the partnership. These models are expected to converge over time as they mature North West London Sustainability and Transformation Plan and Shaping a Healthier Future NWL has the same underlying challenges that are faced across the NHS as it approaches its 70th anniversary: an ageing population, rising public and political expectations, medical cost inflation and increasing pressure on staff. To which are added the as yet unknown impact of Brexit on public finances, the availability of overseas staff and other factors such as regulatory changes and currency depreciation. Health and social care partners across the eight boroughs of NWL jointly created a sustainability and transformation plan (STP) to achieve the ambitions of the FYFV, with a vision that everyone living, working and visiting NWL should have the opportunity to be well and live well. Publication of the NWL STP in November 2016 marked the launch of an extensive programme to address the number of people living in unhealthy situations and making unhealthy choices, the poor quality and inefficiency of some of NWLs services, and the fact that health and social care costs are outstripping the available budget Rates of year on year growth in per capita emergency admissions were 1.9% and 1.1% for MCPs and PACS, respectively, significantly lower than the 3.3% across the rest of the NHS in England and Wales,

9 Page9 A combination of cross-sector and borough-based initiatives in the following themes form the basis of the NWL STP: improving your health and wellbeing better care for people with long-term conditions better care for older people improving mental health services, and safe, high quality and sustainable services Shaping a Healthier Future Shaping a Healthier Future (SaHF), the public consultation exercise carried out across NWL, in 2012 that resulted in a recommendation for reconfiguring hospital services (Figure 3). This sought to enable more sustainable staffing and improved seven day service delivery, with better clinical outcomes as a result. Hand-in-hand with the proposed changes to hospitals is an expansion of out of hospital care, allowing significant proportions of activity to move to more appropriate settings and nearer to peoples homes. Figure 3 Hospital configuration in NWL recommended by SaHF Implementation of SaHF began in 2012 and major changes to the Trust are currently expected to complete construction between 2023 and 2025, 5 providing progress is maintained through the NHS and Treasury approval processes required to secure capital funding for NWL that includes an investment of 270m into the Trust s hospital sites. Under SaHF the CMH site becomes a local hospital and elective centre. EH undergoes major redevelopment to a local hospital model, involving shifts of emergency, inpatient paediatric and maternity activity to NPH and other NWL hospitals. The vision for Ealing site includes a centre dedicated to older people s care and a local A&E 6 that is integrated with 5 Under SaHF, CMH s A&E closed in September 2014, followed by the closure of the maternity unit at EH in July 2015 and paediatric inpatient unit at EH in the summer of The local A&E will offer a safe emergency service for all attendances, but not take emergency admissions, and be linked to the main NPH A&E in terms of technology, governance and staffing

10 Page10 emergency services including the major acute A&E at NPH, but is not expected to include emergency admissions. NPH remains the Trust s major hospital site, with investments into additional critical care capacity, clinical support infrastructure and other site improvements to accommodate increased activity. The Trust is committed to maintaining the current A&E service at EH until the transition to the new local hospital model is agreed and measures are in place to accommodate patient flows safely, in particular for the local residents that represent the main users of the site. Implementation of SaHF forms part of the safe, high quality and sustainable services theme of the NWL STP Productivity improvement Although the NHS delivers outstanding services there is still scope for greater efficiency. Lord Carter s 2016 report on operational efficiency in acute hospitals valued this opportunity at 9% of total acute hospital spend and identified a wide range of opportunities to reduce variation. Participation in NHS Improvement s programme to act on the Carter recommendations will drive change across clinical and non-clinical activities, and includes the extension of the clinically-led Getting it Right First Time (GIRFT) programme to all clinical services. Greater standardisation, adoption of best practice and consolidation to improve scale and sustainability are prominent features of the Carter programme Quality improvement The clinical strategy will continue to be shaped by quality priorities in national guidance and recommendations arising from investigations and enquiries such as the Keogh reviews of mortality and urgent and emergency care, Francis Report on Mid Staffordshire, Bubb report on Winterborne View, Berwick review of patient safety etc. The quality agenda will also evolve to reflect local learning emerging from the rigorous analysis of patient feedback, clinical incidents and other valuable sources of quality improvement knowledge. The clinical strategy also needs to align with external strategies in key areas like cancer care and specialist surgery that aim to improve access, experience and outcomes for patients. Where appropriate this will create opportunities for the Trust to be a hub for NWL or beyond, though in some cases alignment may involve services moving to other centres. A separate quality strategy and plan will address the Trust s ambition to meet and where possible exceed standards, such as those governing access, and the goal of achieving the highest ratings in independent measures of service quality by the Care Quality Commission (CQC) and service users. 1.3 North West London Each year, the eight CCGs and eight local authorities that make up NWL invest 4bn in health and social care for their two million residents. The NHS organisations we collaborate with, and on occasion compete against, to provide health services to the sector include: Four mental health and community service-providers West London Mental Health NHS Trust (WLMH), Central and North West London NHS Foundation Trust (including medical trainees and junior doctors). As well as being integrated with the on-site UCC and local primary and community care services.

11 Page11 (CNWL), Central London Community Healthcare NHS Trust (CLCH) and Hounslow and Richmond Community Healthcare NHS Trust (HRCH) Three hospital Trusts Chelsea and Westminster Hospital NHS Foundation Trust (C&W), Imperial College Healthcare NHS Trust (ICH) and The Hillingdon Hospitals NHS Foundation Trust (THH), all of which operate from multiple sites Two specialist hospitals The Royal Marsden NHS Foundation Trust (RM) and Royal Brompton and Harefield NHS Foundation Trust (RBH), and The London Ambulance Service NHS Trust (LAS). 1.4 Needs of our local population Without action, population growth and greater longevity will increase existing gaps in health and wellbeing and the associated funding challenge significantly. Projections for the next decade are summarised in Table 3 for the outer NWL boroughs, over which period the population of over 65s is predicted to increase by a quarter. Table 3 Ten-year demographic trends (GLA model) Brent Ealing Harrow 3 Boroughs Total population , , , ,520 Male / Female life expectancy at birth 79.8 / / / / 85.3 Births 5,285 5,428 3,641 14,354 Over 65 36, % Over 75 16, % 41, % 18, % 38, % 17, % 115, % 53, % Deaths 1,666 1,832 1,421 4,920 Total population , , ,724 1,034,690 Male / Female life expectancy at birth 82.6 / / / / 87.9 Births 5,289 5,382 3,596 14,267 Over 65 45, % Over 75 20, % 51, % 23, % 47, % 23, % 144, % 67, % Deaths 1,668 1,875 1,446 4,989 Population growth 8.4% 8.3% 11.1% 9.1% Growth in over 65s 24.8% 26.0% 23.9% 24.9% Growth in over 75s 22.0% 28.6% 29.1% 26.7% Implications of demographic change on demand for health and social care are analysed extensively in the NWL STP from which Figure 4 is taken and have influenced the design of the STP implementation programme.

12 Page12 Figure 4 NWL STP challenge 1.5 Strengths, weaknesses, opportunities and threats facing the organisation From the outset, the Trust was created out of a commitment to provide the best healthcare possible to the people of Brent, Ealing and Harrow; and a belief that the two legacy Trusts would be stronger and more effective working together as a single integrated organisation. Many improvements have been made since the merger and we are justifiably proud of our achievements, including recently: Increasing intensive care unit capacity at NPH Launching the West London Vascular and Interventional Centre (WLVIC) Being again named as the best stroke service in the country by the Royal College of Physicians, and Receiving best practice awards and citations for our sepsis and heart failure bundles and multidisciplinary specialist foot care team; to name but a few. These examples have taken place in parallel with the delivery of a large transformation programme that has, over the past two years, enabled us to achieve cost improvements exceeding 4% of operating expenditure year on year. Teams are larger and the expertise and scope available in house have become far greater as a result, making us much more resilient and flexible as an organisation. But our journey is far from over. Goals we set ourselves as part of the merger are still to be achieved and have become more difficult as demand has risen and the operational and financial environment for the NHS generally has become more constrained. Key challenges remain in maintaining seven day services across our three hospital sites and stabilising the emergency pathway. We are not consistently meeting the national access standards for four hour waits in A&E, 18 week referral-to-treatment times in all elective specialties and 62 day waiting times for all cancer types. We need to achieve a better overall CQC rating than the requires improvement assessment made at our most recent inspection in June Our efficiency and finances also need to improve significantly if we are to reach an operating surplus, from a current deficit of c 68m. Table 4 summarises the Trust s strengths, weaknesses, opportunities and threats (SWOT) analysis that complete the context within which our clinical strategy was developed.

13 Page13 Table 4 SWOT analysis key internal factors (strengths and weaknesses) and external factors (opportunities and threats) influencing clinical strategy priorities STRENGTHS (+) WEAKNESSES (-) Growth, scale and diversity of the catchment population that sustains a comprehensive service portfolio and sub-specialisation; is important to other Tertiary providers / clinical networks reliant on onward referrals from LNWUHT; and attractive for clinical trials recruitment Multi-site estate of acute & community hospitals, and other facilities across outer NWL, providing flexibility to optimise the configuration of services, e.g. consolidation of elective surgery at CMH Excellence in education & training University hospital status and link to ICL, established offerings including specialist surgical training, education hubs and multidisciplinary training Specialist and tertiary hubs and the associated strong brands, established networks, R&D and education, including StM, head & neck, WLVIC, RHRU, tuberculosis (TB), HASU, GUM/HIV, sickle cell & thalassemia unit, level 3 haemato-oncology unit etc. Large and loyal workforce with clinical skills spanning tertiary, acute and out of hospital services; including large number of multi-disciplinary allied health professionals, and new/extended roles Large scale integrated care organisation with exemplar integrated services and models of care that have fostered collaboration and new ways of working, e.g. STARRS, community nursing, sexual health, ambulatory care pathways, enhanced recovery, rapid-access / one-stop / nurse-led clinics etc. Persistent operational and financial under-performance due to a combination of factors including structural issues at CMH (PFI and under-use), EH (uncertainty and under-use due to SaHF changes) and NPH (over-occupancy driven by emergency pathway) Inadequate access to long-term capital to address insufficient capacity in pharmacy, ICU/HDU (on all sites), theatres, imaging etc.; aging physical and digital infrastructure that is under-maintained and/or no longer fit-for-purpose Inconsistent and inefficient commissioning across CCGs (particularly Brent, Ealing and Harrow), but also within clinical networks (e.g. cancer) Operational weaknesses arising from failure to integrate historic mergers of acute and community services or progress unification of systems, processes, governance, management and local culture Historic inability to punch our weight with external stakeholders or in external programmes like SaHF or STP on account of distracting effect of transactions and post-merger integration; and related lack of recognition of our role, particularly in cancer care Inadequate long-term workforce planning to address persistent workforce issues Lack of belief in the Trust s own capacity and capability to transform and respond with urgency and tolerance of under-performing teams, poor collaboration and weak leadership Negative perception of Trust leading to poor relationships with some key GP-decision-makers and a lack of interest in / confidence in the Trust s services Lack of accurate real-time business information to inform decision-making OPPORTUNITIES (+) THREATS (-) Identify and exploit the growth potential of the catchment population and prospects for General Threats expansion beyond the M25, e.g. to establish centres for cancer diagnosis and specialist Inability to achieve required operational and financial performance targets, resulting in special treatment, elective orthopaedics / day surgery; and to repatriate activity from other providers measures and the loss of autonomy On the basis of demand, develop new tertiary and specialist services, building on brands Inability to effectively execute the opportunities identified in the clinical strategy at scale or at the and clinical networks created by existing centres of excellence and specialist services necessary speed Create additional operational capacity by relocating activities between NWP, EH and CMH; Inability to capitalise on the opportunities created by system-wide changes, in particular consolidating back office functions and optimising the use of all acute and community sites commissioner plans for ACPs and lead provider arrangements, or other opportunities associated with the Enter long-term ventures to secure investment and create revenue streams and avoid the FYFV, STP, SaHF and vanguard programme that are intended to support system sustainability need for land sales and loss of capital to revenue, including JVs with commercial partners to Specific Threats access non-nhs funds to develop academic and research facilities, e.g. with the Northwick Park Institute for Medical Research (NPIMR), education facilities (with ICL), private patient capacity etc. Expand education and training provision, with ICL and other regional and international universities and institutions, to secure revenue streams and support goal of training our own, growing demand for new roles and for wider access to training, e.g. care workers, apprentices Expand research & development activity in line with the Trust s strengths and partnerships, and to drive the adoption of new technologies such as robotics, telehealth, imaging and wearables Increase participation in external stakeholder and programme activities such as the STP, to support standardisation of care models; prevention and admission avoidance; proactive care for intensive users / long term conditions (LTCs) etc. Increase impact of charitable activities, including fund-raising potential and volunteering Focus on income-generation including relaunch of private patient service; other commercial ventures, e.g. aseptic manufacturing Use the organisational development programme and HEART values to drive quality improvement and the transformation of services Unintended consequences of service reconfiguration, in particular linked to the transition of EH to a local hospital model under SaHF and difficulties that ongoing uncertainty creates in maintaining the site s continued role delivering the emergency pathway; insufficient sector bed capacity to ensure flow / discharge inpatient, community and nursing / care homes; and pathway bottlenecks outside the trust s control, e.g. assessment, care homes; but also including the impact of ACPs Further reductions in capital and revenue, including additional reductions in key non-nhs public sector expenditure in particular associated with for social care Increasingly intense competition from other providers, e.g. ICH, Royal Free, CLCH, for specialist staff, patients, research funds, trainees and high margin services Deterioration in relationships with key partners in education (ICL, Health Education North West London [HENWL]), research (ICHP), specialist services (Great Ormond Street Hospital [GOSH], genetic medicine), clinical networks (Royal Marsden Partners [RMP], cancer vanguard), locally commissioned services (Greenbrooke, UCCs), GPs / CCGs etc. Services ceasing to be viable through decommissioning, tertiary service consolidation, tightening of accreditation requirements, clinical network decisions or unfavourable movements of tariffs Unexpected and unfunded demand growth that cannot be met by efficiency improvements, for example due to innovations such as improved screening etc. Impact of Brexit on supply chains and restrictions on overseas staff & trainees

14 Page14 Enabling objectives Patient-facing objectives 2 Clinical strategy 2.1 Alignment of the clinical strategy to the Trust s vision and objectives During the preparation of the clinical strategy we also worked with staff to update our organisational vision and values. The five values emerging from this work: Honesty, Equality, Accountability, Respect and Teamwork are combined into a new vision of putting patients at the HEART of everything we do that is the purpose of this strategy. The clinical strategy has also been aligned to the six Trust objectives adopted in July This allows the Board to monitor the progress we make in delivering the clinical strategy through its assurance of the Trust objectives, as well as providing a mechanism to regularly test that the clinical strategy continues to be relevant. Table 5 Corporate objectives for (Trust Board July 2017) Objective 1: Improve our focus on safety and quality We will ensure the safety and wellbeing of all patients in our care We will work with our patients to continuously improve patient safety and deliver high quality care We will be a leading University hospital and centre of excellence for clinical education, training and research Corresponding Strategic Risk on the Board Assurance Framework (BAF): Failure to improve quality and safety [SR1] Objective 2: Improve patient experience, satisfaction and engagement We will work with all our partners to develop a culture of openness, caring and compassion We will actively involve patients and carers in all aspects of care and service delivery and act on their feedback We will continue to improve our hospital and community estate Corresponding Strategic Risk on the BAF: Failure to improve patient experience, satisfaction and engagement [SR2] Objective 3: Continue the journey to becoming an excellent integrated care organisation We will strive to transform services to achieve closer integration with our partners in acute and community settings, mental health, social care and the voluntary sector We will provide care that wraps around patients, eliminating unnecessary variation across acute and community settings We will use our strengths as an organisation with a wide range of acute, community and specialist services to develop innovative services for patients Corresponding Strategic Risk on the BAF: Failure to integrate successfully Objective 4: Create a sustainable workforce that is engaged in developing and improving services We will aim to become the employer of choice for healthcare staff We will ensure our values are understood and embedded Corresponding Strategic Risk on the BAF: Failure to maintain an effective workforce Objective 5: Ensure financial sustainability We will deliver a financial strategy that supports our vision and HEART values We will use our resources efficiently and in ways that do not undermine our focus on patient safety We will put the Trust on a sustainable financial footing to secure our services for the needs of current and future generations Corresponding Strategic Risk on the BAF: Failure to attain financial stability

15 Page15 Objective 6: Plan for our future We will support implementation of the North West London Sustainability and Transformation and Shaping a Healthier Future Programme to enable better standards of care for our patients We will be a Trusted partner for other organisations and a provider of choice for patients We will be an outward-looking organisation, open to learning from others Corresponding Strategic Risk on the BAF: Failure to secure the long-term future of the organisation 2.2 How the clinical strategy is structured The image we have chosen to illustrate the clinical strategy is that of a building (Figure 5). In which the clinical strategy forms the walls that support the roof formed by our vision and values. It rests on strong foundations made up of key priorities and corporate strategies that enable us to deliver the clinical strategy and achieve our vision. Figure 5 Structure of our clinical strategy Over the course of developing this clinical strategy we identified three pillars, each representing a distinct area of activity that will feature prominently in the future shape of our organisation. These are: Emergency and ambulatory care End-to-end integrated care, and Specialist services. We also recognised three overarching priorities around frailty, cancer care, and prevention that cut across the pillars and in whose delivery all divisions will play a role. The next level of detail of the changes and ambitions that link to the pillars and overarching priorities is emerging and initial headlines collated from the operational divisions are set out in Appendix 1. These are yet to be fully developed, but will when complete consist of strategic priorities linked to strengths, weaknesses, opportunities and threats within divisions and their service lines and subspecialties.

16 Page16 The focus of the remainder of this section is on the six overarching themes linked to the three pillars and three overarching priorities that define the clinical strategy of the Trust: Responding to growing emergency demand Achieving better outcomes and experiences for frail older people Providing excellence in delivering integrated cancer care Maintaining and growing our role tertiary and specialist services Playing a stronger role in prevention and wellbeing, and Integrating our services into the wider health and social care systems. Each is described in more detail in the following sections. 2.3 Responding to growing emergency demand Double-digit growth in blue light attendances has been the norm for some years (Table 6). Although the overall volume of emergency pathway attendances has decreased slightly, the marked rise in blue light transfers highlights a trend of increasing patient-acuity that continues to drive up hospital admissions (from 57,409 in 2015/16 to 59,321 in 2016/17; equivalent to 3.3% growth). Table 6 Year on year changes in A&E and UCC attendances (source: Qikview & NHS England) Blue Light Ambulance Everything Else Total Type 1 Urgent Care Centre Total 2015/16 8,266 48,063 79, , , , /17 9,237 49,081 83, , , ,947 Growth 11.7% 2.1% 4.7% 4.2% -5.5% -1.7% New ambulatory care pathways, length of stay reductions made possible by streamlining patient flow within the Trust and improved collaboration with partners in areas such as discharge to assess have partially mitigated this growth. As seen in the reduction of UCC attendances. The continuing rise of type 1 A&E attendances (i.e. other than UCC) and growing emergency admissions, coupled with inadequate reimbursement of associated costs and insufficient acute and critical care bed capacity for peak periods of demand, has created unsustainable pressure on our staff and resources. As well as having a reputational cost, it also lies at the heart of the Trust s inability to reliably achieve the four hour national access standard for A&E. A particularly serious impact of growing emergency demand is the reduced ability to cope with spikes in demand, whether these are unexpected or linked to the seasonal peak around winter. Pressure to make urgent admissions leads to cancellations and delays of planned procedures or diagnostics and a more general reduction in operational efficiency. This particularly affects surgical patients on the NPH site and the smooth operation of tertiary services that depend on the ability to accept referrals from spoke sites. The dominance of unplanned care across the Trust can be seen clearly from occupancy data (Figure 6). Fully 81% of bed capacity in 2016/17 was used by patients admitted on emergency pathways. Planned elective admissions play a slightly greater role at NPH, which reflects the concentration of specialist services on that site.

17 Page17 Figure 6 Bed occupancy by emergency admissions in 2016/17 (source Qlikview, c.1,100 beds in total) Effectively managing the emergency pathway is a challenge facing the whole organisation, not just the emergency department or the emergency and ambulatory care division. The emergency pathway to a large extent determines quality, safety, operational and financial performance throughout the Trust. Arguably, the large volume of activity associated with unplanned care has driven and continues to drive the development of most of our clinical capabilities and services. Our two A&E departments are also some of the most publically-visible aspects of LNWUHT and an important front door into the organisation for a significant proportion of the local population. Population-aging is believed to represent the most significant of multiple factors driving emergency demand. Today, nearly one in three A&E attendees is over 65 and one in five is over 75, with numbers in these cohorts set to continue increasing (Table 3). This demographic effect is compounded by increases in acuity and co-morbidities with age, both of which link to longer admissions being needed until patients are fit to discharge and greater difficulties returning people to the community. An associated priority is to redesign both the care for frail elderly patients and the approach to this care, with the aim of dramatically reducing the risk of unplanned deterioration in health. This is dealt with in the subsequent section. Emergency care is a pillar of the Trust and the future evolution, performance and reputation hinges on this area. We need to set our sights at achieving pre-eminence amongst London providers for the quality and effectiveness of our emergency and ambulatory care pathways.

18 Page18 This is an overarching priority for all our services and is inextricably linked to the need to ensure that facilities on the NWP are allowed to concentrate on patient pathways where needs are most complex. 2.4 Achieving better outcomes and experiences for frail older people The previous section highlighted impacts of the growing population of frail older people with multiple long-term conditions and complex health and social care. In terms of admissions of over-65s, emergency medical treatment accounts for 80% of non-elective bed days. In planned care it is surgery that plays a greater role for over-65s, who account for 70% of elective bed days; particularly in the colorectal and orthopaedic surgical specialties. Year-on-year admissions growth of 3.6% for year olds, 6.3% for year olds and 10.2% for over 85s provides a measure of how future demand for inpatient beds will evolve. One need only consider the correlation of age with non-elective length of stay (LOS), which increases five-fold from <2 days at age 25-35, to 10 days by age 85 (Figure 7). The consequences of this can be seen by comparing over-65s, who account for 34% of admissions and 61% of hospital bed days, with over-85s, who account for only 7% of admissions but 21% of bed days. Part of the correlation between LOS and age arises from increased acuity and comorbidities, but there is also a component driven by non-clinical factors. In particular, delays arise in assessing the ongoing care and support needs of frail older patients and agreeing and securing the necessary care packages or residential requirements; irrespective of the individual being medically optimised and fit for discharge. Around 800 bed days are lost to delayed transfers each month, which consistently exceeds targets agreed with commissioners and local authorities and is in turn linked to acute shortages in residential capacity and underfunding of community health and social care. Figure 7 Average LOS by age group The sustainability of the care home sector in particular has been strongly affected by reductions in social care funding. Strategic priorities in relation to frail older people include: Effectively managing the emergency medical and elective surgical pathways for this cohort and strengthening associated clinical leadership Working with partners to shape an effective frailty strategy for NWL and collaborating in implementing this

19 Page19 Improving skills within our own workforce and those of our partners, with particular emphasis on the ability to identify needs of frail older people sooner so that these can be better-managed and in other key areas such as last phase of life, dementia and nutrition Integrating care to allow resources to be deployed in a more co-ordinated manner across the system, providing an effective patient-centred alternative to hospital admissions Developing new roles and teams able to work across health, housing and social care delivering new models of care, and Ensuring there is effective intermediate care that links acute and community settings, with step-up and step-down capacity. New models, in particular, those associated with ACPs are expected to play an important role in allowing these priorities to be achieved. From the Trust s perspective, two key enablers for this are in the areas of finance and partnerships. Firstly, funding mechanisms are expected to change to more outcomes-based specifications and pooled-budgets. Secondly, services will increasingly be commissioned jointly by health and social care budget-holders and delivered through collaborative provider arrangements. The Trust s ability to work effectively in partnerships will be vital, as is the need for it to project a strong voice in shaping this agenda. Providing excellent care to frail older people is vital and reflects the demographic reality of our catchment population. A co-ordinated and effective response to frailty is essential to allow the Trust to take control of the emergency pathway, which is a prerequisite to our ambitions around tertiary and specialist services and to putting the Trust on a sound operational and financial footing. 2.5 Excellence in integrated cancer care Cancer is fundamental to the Trust s work on its hospital sites and within the community services. We receive 19,000 urgent cancer referrals from GPs each year, to which are added primary and secondary cancer diagnoses arising elsewhere, in particular following an A&E attendance. Figure 8 Patients with cancer as a primary diagnosis Specialists within the Trust see one tenth of London s cancer referrals, making the Trust the fourth largest centre after the Royal Free, Barts Health and Barking Havering and Redbridge Trusts. 7 One in nine of all admissions, some 1,500 patients a month, have a primary cancer diagnosis and one fifth of all planned admissions are for cancer-related care (Figure 8). But 7 By cancer patients seen (Source: NHS England Cancer Waiting Times Statistics Q4 2016/17)

20 Page20 we remain relatively unrecognised for our cancer care, internally or externally. Despite high admissions-levels and the significant role the Trust plays in the prevention, diagnosis, treatment and ongoing support of cancer patients across NWL. The range of specialist services we offer, such as bowel screening, complex cancer surgery, specialist palliative care and genomic medicine, also differentiates us from a typical district general hospital (DGH). LNWUHT is also an important spoke and major source of tertiary referrals into the cancer hubs at ICL and the Mount Vernon Cancer Centre. All five divisions within LNWUHT are involved in cancer care, with cancer patients accounting for a significant proportion of activity and ward stays across a wide range of medical and surgical specialities. Historically, the distributed nature of cancer care has to an extent masked its importance to the organisation. Addressing this is an imperative for the clinical strategy. Not least because strong growth in demand for cancer care is expected due to demographics (Figure 4), better screening and improved survivorship. As for the emergency pathway, a co-ordinated approach to cancer care will mitigate potential impacts on operational efficiency due to rising demand. Equally importantly, cancer care has synergies that support our ambitions to expand specialist services, strengthen clinical research and extend the Trust s reach into the community. The strategic priorities for cancer care include: Raising our profile in cancer care, by building on the brands of our established centres of excellence and leading specialist services as these strengthen further Creating a new vision and strategy for cancer care, supported by an operating model that co-ordinates the way our services work together to deliver high quality cancer care, excellent clinical outcomes and a superior patient experience Establishing a Cancer Treatment Centre that brings together the main cancerrelated facilities and services into a dedicated patient-centred state-of-the-art facility that provides a hub for hospital and out of hospital based cancer care in outer NWL Partnerships, and how we work with other organisations and the public, will be a critical enabler of our cancer care ambitions. As a member of Royal Marsden Partners, our cancer strategy needs to align with the priorities of this vanguard. Effective relationships will also play an important role in securing tenders (for example our participation in the GOSH-led response to NHS England s reconfiguration of genetic laboratory services), the future success of our specialist hubs, our ability to influence the development of new care pathways, and our role in other collaborative ventures aimed at transforming cancer care. 2.6 Maintaining and growing tertiary and specialist services The amount of complex specialist and tertiary work carried out by the Trust is one of its key strengths, differentiates us from other providers and places us in the top league of institutions in a number of specialties. A number of benefits result from hosting such services: Tertiary services act as hubs for clinical networks, providing access to a wider catchment population and extending the reach and influence of our organisation They support academic activities including clinical education and R&D and create strong professional networks and loyalties, particularly amongst trainees

21 Page21 The diverse and complex case mix associated with specialist services is professionally attractive, creating a pull for clinical recruitment and retention Eligibility for specialist tariffs offers an income premium that supports additional investment in people and facilities, and Potential to attract R&D grants and investment and private patient activity. Tertiary and specialist services are recognised as a pillar of the clinical strategy, because they make the whole portfolio of services more resilient as well as providing innovative, leading edge care in their own right. Ranging from St Mark s, which is an internationally recognised long-established centre with strong academic and research credentials, to other centres of excellence, such as the regional hyper-acute rehabilitation unit, and in infectious diseases and palliative care. New opportunities continue to emerge, for example in personalised medicine following on from the participation of our genetic medicine service in The 100,000 Genomes Project. Our portfolio extends into integrated and community-based services where, for example, we have built up specialist children s therapies in Ealing and a best-in class rehabilitation and reablement model in our STARRs service. The disproportionate impact of acute specialist services can be seen by considering NHS England commissioned activity. Although accounting for only 4% of admitted patients, one in nine elective inpatients is on a specialist pathway and the associated income plays a significant role in the integrated medicine and surgery divisions; accounting for 28% of income in the case of St Mark s specialties (Figure 9). Figure 9 Analysis of divisional income from specialist commissioning Tertiary services are very dependent on external factors and the intention to make changes to their provision and commissioning were signalled in the FYFV. Alongside the launch of the vanguard programmes aimed at piloting different service models, introducing new treatments and testing alternative partnership models. NHS England will also continue to revise national standards and service specifications, with a particular focus reducing unwarranted variation. There is growth potential from demographics, as well as from innovation and the emergence of new fields such as personalised medicine. However, this is countered by an NHS-wide imperative to contain specialist service expenditure as a proportion of total NHS spending. These factors create a push to reduce fragmentation and encourage greater collaboration. Further re-configuration and consolidation is expected, not least because data from previous changes in vascular surgery, stroke and major trauma show this can improve outcomes.

22 Page22 Details of the priorities for the Trust s individual specialist services will emerge from the next phase of work to complete the relevant service line strategies. Until this work is done, the priorities for tertiary and specialist services need to address dependencies and enabling issues: The overarching priority is to maintain and where possible grow existing specialist services, with the proviso that a viable business case can be made and a positive financial contribution and adequate return on capital investment demonstrated Divisional and service line clinical strategies must take account of the needs of Tertiary acute services, which often rely on a complex delivery infrastructure, extensive requirements for clinical input from other specialties and can have significant implications for specific clinical support services Ensuring capacity and demand match along patient pathways means providing adequate ward, theatre, recovery, critical care, imaging, diagnostic and pharmacy capacity, and therapy input; to allow the timely admissions required to comply with service specifications and to enable the Trust to pursue opportunities for growth Complex surgical tertiary services are likely to need to stay at NPH to maintain adjacencies to critical care, complex diagnostics etc.; other acute services will therefore need to move to CMH and EH, or out of hospital, to optimise patient flow and free up space at NPH, and Existing networks that are central to specialist services will be strengthened and expanded and new ones created where needed, to provide a smooth link between spokes and the Trust s centres of excellence; relationships will be more actively managed and appropriate digital infrastructure put in place to support communication and information exchange. We will return to the future needs of tertiary and specialist services in subsequent sections outlining the enabling academic, digital, estates and finance strategies. Growing specialist centres of excellence is critical to our academic ambitions as a University hospital, as well as building our reputation through the brands associated with these centres. There is no doubt that these services will be vital to our ability to attract investment and revenue into the organisation from outside the NHS. 2.7 A stronger role in prevention and wellbeing Radically upgrading prevention and wellbeing is a priority across NWL and one of the main themes of the STP. The Trust is well placed to play a much greater role in helping local people, in particular children and young people and those with LTCs, to be healthy and live well. Having the largest concentration of clinical expertise, knowledge and experience in outer NWL means we have much to offer. Including prevention and wellbeing as a clinical priority has direct benefits for the Trust. Mitigating demand growth, particularly on the emergency pathway, to allow resources within our hospitals to focus on providing healthcare where needs are urgent, complex and best met in an acute setting. Improving the health and wellbeing of our own workforce is also important. This strategic theme builds on our reach into communities across NWL. Several hundred thousand local residents attend A&E and outpatient services or are admitted to our hospital or community wards each year (Table 1). In addition, the diverse adult and children s services we provide in Brent, Harrow and Ealing put community teams in direct contact with local people in their homes and other community settings (Figure 10); with a further 45,000

23 Page23 contacts with adult clients and 11,000 with children taking place each month. Added to these numbers are the associated interactions we have with relatives, carers, professionals and workers in other organisations. Many of whom are also local residents. Figure 10 Breakdown of community service activity Details of specific prevention and wellbeing ambitions will form part of the service line strategies to follow, in particular those of the clinical specialities dealing with LTCs and from our community services. Alignment with NWL ambitions will be a prerequisite to securing support and funding from commissioners for the Trust to play a greater role in prevention and wellbeing. For these reasons, enabling issues once again feature strongly in the strategic priorities for this theme: Take active measures to promote prevention and wellbeing as part of our existing services and through our contacts with patients, staff and the wider public Improve LTC management, with a focus on increasing access to support out of hospital and promoting self-care Develop tools to provide easy access to appropriate information, signposting and advice, to increasing self-care and support the sector commitment to making every contact count Apply our clinical expertise and knowledge of the local population to lead the design of whole system pathways to include effective self-care and prevention measures Identify services to act as pathfinders for the Trust to develop new offerings aimed at prevention and wellbeing, for example children s community services are well-placed given the recognised long-term health and social benefits of providing children with the best start in life, and Build the capability to carry out health surveillance linked to preventative measures and targeted, earlier interventions as part of future population health based models of care. The prevention and wellbeing agenda represents a substantial opportunity to expand the educational activities of the Trust, for example to provide members of public and professionals from other services with skills to support self-management of LTCs. 2.8 Integrating our services into the wider health and social care systems The goal of integration has evolved since the Trust formed. Our initial ambition was to combine hospital-based services to obtain benefits of scale, and vertically integrate our

24 Page24 acute and community services to support a shift of care out of hospital and the accompanying reconfiguration of acute care across NWL. Ambitions for integration have increased dramatically since the FYFV, with STPs setting out roadmaps to deliver population health and care under wholly different operational and financial arrangements that link physical and mental health services, with social care. Whilst the realities of accountable care are yet to emerge at scale in NWL, excellence in delivering end-to-end integrated care is a pillar of the clinical strategy. Integration, in its broadest sense, therefore has to be at the heart of the future models of care that our services provide. Community services have historically played a significant role in the Trust s view of itself as an integrated care organisation. Recent commissioning decisions have significantly reduced this role, in particular the loss of adult community services in Harrow. The current portfolio remains strong in both general and specialist offerings, but the outcome of Ealing borough s tendering of out of hospital services has the potential to substantially reduce the Trust s community service footprint. Irrespective of the possible future outcome for our community services, the integration of our clinical services into the wider health and social care systems remains a strategic priority. There will be an increasing expectation and pressure to embrace multi-agency working at an organisational level and multi-disciplinary working at a team level. End-to-end pathways imply that whatever elements of care are provided by the Trust, there will be a requirement for services to allow seamless transfers between organisations, locations and professionals. Designing such pathways will require a whole-system approach, working with partners representing other providers, commissioners and service users to a far greater extent than is currently the case. It is expected that the accompanying operating models will involve multiple partners collaborating in the delivery of services. At this point the strategic ambition of the Trust is to maintain its strong presence across the entirety of end-to-end pathways, and to include providing healthcare in both acute and out of hospital settings. The priorities for this theme reflect this and focus on important enablers: Maintain LNWUHT as one the leading providers of community services in outer NWL and work closely with commissioning partners and local GP s to identify and address the factors that have contributed to decommissioning decisions in recent years Continue improving the design and delivery of out of hospital services to achieve significant improvements in health outcomes and reductions in lifetime costs, and promote the benefits of these models to commissioners and GPs Active engagement of the executive and clinical leadership within the STP, borough Health and Wellbeing Boards etc. to ensure the Trust influences local and NWL priorities, wherever possible securing leadership of programmes to shape the integration agenda Provide the digital infrastructure to support mobile-working, collaboration and information-sharing along end-to-end pathways and across organisational boundaries and offer the accompanying business intelligence capability to analyse population data, stratify risk, target early interventions and effectively co-ordinate care and support for individuals Equip the workforce with skills to operate effectively in an integrated care environment, including the provision of new roles and skills to improve effective multiagency and multi-disciplinary working, and

25 Page25 Support the development of future funding models to ensure that allow the Trust s services to be financially sustainable and that provide a share of benefits arising from long-term reductions in hospital admissions and improvements in population health outcomes. Details of integration priorities will be contained in the individual clinical service line strategies that will be published separately. In the case of predominantly hospital-based services, this will include the developments needed to optimise links with out of hospital services, opportunities to work with community services, streamlining hand-overs and measures to reduce variation. 2.9 Divisional priorities linked to the overarching clinical priorities Appendix 1 summarises the high-impact changes that each of the five clinical divisions has identified as must-do s to support the implementation of the six clinical strategy priorities discussed in the sections above. These priorities will be expanded on as the implementation plan for the clinical strategy is prepared, but a summary of the most significant changes we expect to take place in the short term (Phase 1 of clinical strategy over the next 2 years, outlined in Part 4.1) is provided in Table 7 below. Setting out what, at the time of writing, we anticipate to be the key early projects needed to drive the clinical strategy at speed. Table 7 Short term early projects Emergency Frailty Cancer Expansion of critical care Implementation of NWL Expansion of bed base (to frailty model across all support reduction in NPH sites occupancy) Creation of respiratory failure unit Decanting of clinical and corporate services off NPH site (including consolidation of elective surgery at CMH) Expansion and standardisation of ambulatory care pathways Expansion of STARRS Business cases for critical care, theatre, recovery and pharmacy expansion and refurbishment as part of SaHF Developments linked to and included within outer NWL ACP s or within lead provider arrangements Development of future local hospital model for Ealing Review of use of elderly beds on acute sites and links to frailty models of service Stabilisation of performance across RMP vanguard Gain sector support for cancer strategy and preferred option for Cancer Diagnostics and Treatment Service (as a precursor to the cancer centre ambition) Agree managed services contract for of expansion diagnostic capacity Open new clinical trials facility Expansion of endoscopy capacity & JAG accreditation at EH Business Case for Haemato-oncology bed replacement as part of SaHF

26 Page26 Prevention Specialty Integration Use STP workstreams as a platform to establish Consolidate WLVIC and head and neck hubs preventative services StM Institute fundraising Develop population-based service models for LTC Relocate RHRU to support expansion of capacity Education and training Secure partners to expand care models offering for self-care and non-health professionals TrustPlus and parenteral feed and specialist drug Greater access and use of manufacturing ventures digital technology for our staff and patients to manage conditions and Expand referrals into specialist services from outside current catchment recognise trigger points for further healthcare support Actively influence Trust future role in NHSE specialist commissioning changes for intestinal failure and genomics Use Ealing out of hospital service tender and emerging outer NWL ACPs to accelerate the development of integrated Expand Trust role in out of hospital network of care, focusing on STP priorities such as end of life, diabetes and giving children the best start in life and diabetes New community based and cross-pathway roles, with focus on nursing and therapy staff Produce estates master plan and business cases for estate projects: SaHF (site investments and Ealing local hospital), one public estate (NPH), STP (CMH hub) Support provision of primary care and other community based services on Trust sites i.e. CMH Care Village

27 Page27 3 Enablers of the clinical strategy As highlighted in section 2.2, the clinical strategy rests on a foundation of enabling priorities that teams from the corporate functions will play a vital role in bringing about to support the ambitions of the divisions. This part of the document outlines important issues for each corporate strategy, with an emphasis on the following over-riding themes identified by clinicians: Making the best use of the Trust s estate and providing greater clarity on the future roles of CMH and EH which is discussed in the context of the estates strategy Achieving financial sustainability which is discussed in the context of the financial strategy Developing organisational capacity, capabilities and leadership, and investing in education and training to grow our own and equip staff for new roles and ways of working which is discussed in the context of the workforce and academic strategies Deploying technology to integrate and share clinical information which is discussed in the context of the digital strategy Providing data analytics to enhance decision-making which is discussed in the context of the business intelligence strategy Building partnerships and relationships with other organisations, including other providers and GPs, and improving marketing and communications which is discussed in the context of the partnership strategy; and Equipping the organisation to thrive and achieve transformational change at scale which is addressed in the context of the academic strategy. 3.1 Estates strategy: Making the best use of the Trust s estate The Trust s physical footprint in NWL is one of its strengths (Figure 1) and the clinical strategy presents an opportunity to optimise the estate s use. Though buildings should not drive the clinical strategy, the three hospital sites to an extent represent fixed points in the medium term. Figure 11 Distribution of activity by site (01/04/ /12/2016) As illustrated in Figure 11, NPH provides two-thirds of the Trust s admitted patient activity and, following changes under SaHF in Ealing, its centre for maternity admissions. NPH s role will remain as the focus for emergency and Tertiary service admissions and for accommodating patients with the most complex dependencies on other services such as critical care and advanced diagnostics.