Commissioning Strategic Plan 2010/ /15

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1 Commissioning Strategic Plan 2010/ /15 1

2 Contents 1 Foreword Vision...5 Our Vision for Tower Hamlets...5 Transforming our Health Economy The Case for Change...9 Health Needs Assessment...9 Performance...20 Market Management...22 Finance...25 Conclusion Our Strategic Outcomes...40 Our Strategic Outcomes 2010/ Rationale for Strategic Outcomes Healthcare for Tower Hamlets: Putting HfL into practice...45 Introduction...45 Maternity...45 Children and Young People...46 Staying Healthy...48 Planned Care...53 Long Term Conditions...54 Unscheduled Care...56 Mental Health...58 End of Life Care Moving Care Closer to Home...61 Introduction...61 Care Closer to Home the Goal...62 Implementing our Polysystems...64 South East Locality: an example Our Strategic Initiatives Key Enablers to deliver change...70 Clinical Commissioning and Leadership...70 Strategic Clinical Leadership Group (SCLG)...71 Practice Based Commissioning...71 Capital Development, Estates and Facilities...72 IT...73 Organisational Development...74 Communication and Patient Engagement...74 A relentless focus on delivery Initiatives and trajectories...76 Staying Healthy...76 Acute Contracting...77 Care Closer to Home...78 Primary Care Investment Programme

3 Improving CHS Productivity...82 Unscheduled Care...83 Mental Health...85 Affordability...87 Risk and Mitigation Board Declaration

4 1 Foreword Tower Hamlets is a unique and exciting area. It is densely populated and highly diverse, with some of the country s poorest communities living alongside the financial powerhouses of Canary Wharf and the City. The borough has stark health inequalities with death rates from major causes higher than the national average including for cardiovascular disease, cancer, diabetes, smoking and obesity. The difference in life expectancy at birth is 8 years for men and 4 years for women between the most deprived ward (East India and Lansbury) and least deprived ward (Millwall). We have a track record of success in tackling those health outcomes: stopping people smoking (fifth best in the country), increasing breast cancer screening by 10% and improving access to GPs (the greatest improvement in the country for the last two years). This is based on intense working with our partners within the borough and across north east London. We are proud of our track record but we know we need to do more. We need to do more to continue improving health outcomes but we also need to do more because of the financial situation facing the NHS and our public sector partners. Over the next five years, it is likely that there will not be any new investment, despite rising health needs and demands. Our projections show that if we do nothing, we will have a 50m deficit by 2015/16. To continue to improve services and health outcomes in this situation will be very challenging but we can achieve this by increasing the pace of change. Our Strategy is based on implementing fully Healthcare for London in Tower Hamlets. Part of this is about driving up productivity across the whole health system by better managing care for people with Long Term Conditions like diabetes, so that fewer people end up in hospital. But it s also about moving care closer to home. That s why we in recent years, we have targeted investment over 12m - to increase the capacity and capability of primary and community care and taken vigorous action to address poor performance. This will make sure our polysystems are effective, integrated across different providers including the Council and delivering the best possible care close to home. We will also continue many of our programmes that are improving health outcomes around tobacco use, reducing obesity and improving maternity services. Patient and public engagement is critical to delivering success making sure that the services we commission not only take account of local people's views but engage and involve people in their care as well. This will be fundamental to deliver the scale of change needed and all our proposals will be based on detailed consultation and engagement. Over the last year, the East London and the City Alliance has been set up. We know that there are significant opportunities by working across the sector - to improve services and value for money. We have developed our CSP in close collaboration with the sector and they form a coherent and robust approach. Section 2 sets our Vision for healthcare in Tower Hamlets (as part of inner north east London) Section 3 sets out our Case for Change examining the detailed health needs of the borough, the views of stakeholders, our past performance, provider landscape and perhaps most importantly, the potential future financial viability of the local health economy. This highlights explicitly the key challenges that we must face over the next five years. Section 4 draws on the Case for Change and in particular the needs analysis to set out the ten WCC outcomes that the PCT will use to measure its impact on health improvement. Section 5 considers in detail how we can use the Healthcare for London framework to drive those improvements. It considers each of the Darzi pathways looking at good practice, our existing initiatives and the progress we have made and the key gaps we need to tackle so that we close performance and quality gaps. 4

5 Section 6 sets out the detailed work we have undertaken with extensive clinical leadership and involvement to shift care closer to home by developing our polysystems. Section 7 sets out our programme of strategic initiatives to deliver the transformation of health in Tower Hamlets drawing on the analysis set out in Section 2, 3 and 5. Section 8 considers the key enablers such as clinical leadership - that will be critical to ensure the effective implementation of our CSP. Section 9 provides a detailed delivery programme for each of the initiatives Section 10 provides the Board declaration Stephen O Brien Chair NHS Tower Hamlets Alwen Williams Chief Executive NHS Tower Hamlets 2 Vision Our Vision for Tower Hamlets Our Vision for the borough is to improve the quality of life for everyone who lives and works in Tower Hamlets, under the banner of One Tower Hamlets'. One Tower Hamlets' is about reducing poverty and inequality, bringing local communities closer together, public sector organisations showing strong local leadership and residents taking personal responsibility to improve their own lives. This is set out in the Tower Hamlets 2020 Community Plan that was developed after widespread community consultation and its priorities are based on what matters most too local people: A Great Place to Live including the provision of decent and affordable housing A Prosperous Community learning, helping local people to get work and businesses to thrive A Safe and Supportive Community preventing and reducing crime and supporting vulnerable residents A Healthy Community making it easier for everyone to get the support and treatment they need and to live more healthily. We believe strongly that we can only achieve this Vision through exceptional partnership working across the borough and the emerging East London and City Alliance. That s why we were one of the founder members of the Tower Hamlets Partnership (THP) and place considerable priority on making ELCA successful. Our joint Improving Health and Well Being Strategy (IHWB) sets out how the PCT and other members of the THP will deliver on the Community Plan commitments for a Healthy Community. The IHWB outlines our Vision and commitment to improving health and well being and strengthening delivery of services closer to home. Our joint IHWB was developed with extensive involvement and 5

6 consultation with local people, community organisations, service users and staff. We first agreed an IHWB strategy in 2005/06 but have just updated this following the refresh of the Community Plan to make sure it is still relevant and pertinent to meet the health challenges of the next decade. Again we undertook considerable consultation and engagement with stakeholders in developing the update. Our Vision for health in Tower Hamlets is that by 2015: Our services will be the best in the country, and will be recognised by the people of Tower Hamlets as being so High quality services will be provided to a dramatically regenerated borough, with a population half as big again as it is now. They will offer equal access and choice to every single person in the borough, reflecting the diversity of the population, and will be overwhelmingly staffed by local people whose profile reflects the community served Nobody will ever have the experience of being asked for the same information twice by different health and social care professionals; information will be controlled by the service user, not the professionals, and subject to that control will be instantly available to everybody who needs to see it, wherever and whenever the need arises. Care will be experienced as if it were provided by one organisation in a completely co-ordinated and seamless way, irrespective of the actual organisational arrangements in place. The great majority of care and support will be provided in the communities in which people live, not in hospital and not in institutional settings. It will however be supported by the highest quality secondary care services, with maximum ease of access. It will be largely delivered in or close to people s homes, using modern technology to reduce travelling and to ensure prompt response. Health, social care, voluntary sector and service user groups will work alongside each other in high quality primary and community care facilities, offering one point of localised access to the full range of services. The care and treatment of the individual will be controlled by that individual, supported by the best professional staff. Services will be embedded in their local communities, drawing on all the resources of those communities, and with a clear accountability to those communities. Individuals will feel informed and enabled to take decisions on their care, whether that be care by themselves or others. Individuals will feel that they really have a choice. Appropriate care and support will enable more children to reach their potential, supporting schools in increasing achievement to ensure our young people attain the skills needed to access employment To achieve this our IHWB has five strategic aims: Reducing inequalities in health Improving the experience of those who use services Developing excellent integrated and more localised services Promoting independence, choice and control by service users Investing resources effectively Our IHWB set out our first stage plans for developing polysystems within Tower Hamlets and integrating health and social care services to not only improve services but improve the health of local people. This established our service framework that we use in developing all services. We have implemented successfully the IHWB including one of London s first polyclinics the Barkantine that is still seen as a leader in its field. We believe that our Vision is aligned fully with the aims and ambitions set out in HfL to transform London s health 6 Our Service Framework Specialist London-wide. Acute Sector Xx, 000 pop. Borough 1 x 280,000 pop. Locality / Polysystem 4 x 70,000 pop. Primary Care Networks 8 x 10-20,000 pop.

7 services in London. These are: Services focused on individual needs and choices: Provision should, wherever possible, be tailored to the particular needs of each individual. Patients should feel in control of their care and be able to make informed choices. Localise where possible, centralise where necessary: Routine healthcare should take place as close to home as possible. More complex care should be centralised to ensure it is carried out by the most skilled professionals with the most cutting-edge equipment. Truly integrated care and partnership working, maximising the contribution of the entire workforce: Better communication and co-operation is needed between the community and the hospital, between urgent and planned care, between health and social care to stop people from falling through the gaps. Care should be multidisciplinary, bringing together the valuable contributions of practitioners from different disciplines. The NHS should be committed to working in partnership with other organisations, including local government and the voluntary and private sectors. Prevention is better than cure: Health improvement, including proactive care for people with longterm conditions, should be embedded in everything the NHS does. Close working with local authority partners is needed to help people stay mentally and physically healthy. A focus on health inequalities and diversity: The most deprived areas of London, such as East London, need better access to high quality healthcare. Preventative and outreach work should focus on the most deprived populations and new facilities should be located in the areas of greatest need. Improvements need to take account of London s rich ethnic and cultural diversity and patients should have more information to make choices about their care. This Vision is still very relevant and our Commissioning Strategic Plan (CSP) is based on implementing the Vision of HfL within Tower Hamlets. We have used the HfL pathways and care settings as the framework for developing our CSP to assess and agree the key changes that we need to make to meet the health needs and demands of Tower Hamlets within an affordable future. Our Vision and CSP is also aligned with the East London and City Alliance. The Alliance is one of the six new sectors for London to strengthen commissioning, particularly for the acute sector. The Alliance has four aims: Implement Healthcare for London Ensure that acute hospitals deliver high quality, timely services Improve mental health services Ensure the effective development of community health services Its initial priorities are focused on: performance improvement - including reducing waiting times in A&E to less than four hours and under 18 weeks for hospital appointments and in areas such as improving breast screening and immunising children. It will also ensure that Barts and the London NHS Trust improve and sustain its performance on access target and deliver the Commissioning for Quality and Innovation (CQUIN) improvements in all acute contracts strategic transformation - Reviewing health services across north east London (working with PCTs in outer north east London) particularly Health4NEL that is proposing a significant changes in hospitals to improve quality, performance and affordability and reduce health inequalities. The Case for Change was published in February 2009 with detailed public and partner consultation running from November 2009 to February The Alliance is also developing integrated commissioning for acute commissioning, mental health, health intelligence and procurement so we improve services across inner north east London. The Alliance has set out more detail on its aims and priorities in Working Together. 7

8 The Alliance is also producing a single Commissioning Strategic Plan that will use the HfL framework to integrate the sector and borough Commissioning Strategic Plans. We have developed our Commissioning Strategic Plan alongside that of the Sector so that they form an integrated and holistic plan for Tower Hamlets as part of inner north east London. Integrated Alliance and Borough Strategies HfL and Health4NEL Specialist A c u t e Major Ac ute Local Hospital Elective E n d f L if e Alliance Integrated Strategic Plan C & Y P Polysystem Home M a t e r n it y Tower Hamlets Commissioning Strategic Plan P l a n n e d C a r e M e S t a y i n g H lt h y L T C n t al H lt h HfL Care Pathway Improving Health and Wellbeing Strategy Transforming our Health Economy We have made significant progress in transforming many areas of the health economy in Tower Hamlets in line with both HfL and our Improving Health and Wellbeing strategy. Key successes include: Health inequalities and variation in clinical outcomes Improved patient satisfaction with GP access from 69% to 82% Increased number of appointments by 25% at no extra cost (with an implicit decrease in unit cost of 5 per patient) Performance management of GP practices to reduce variations Developed and now piloting IT tools to support 5 core functions of integrated care, including 1) disease registry, 2) multi-disciplinary team, 3) call/recall, 4) performance tracking, 5) patient care planning Increase satisfaction with Maternity services Met our smoking quitters targets for the last five years Increased breast screening by nearly 10% in 2008/09 High cost hospital care Only Integrated Care pilot in London Focusing on tighter integration across primary care/acute for long term conditions and closer integration of community health services and social services Productivity 8

9 Defined 12 main care packages using polyclinic economic model, created strategy to increase primary care capacity to deliver best practice care, raising our spend on primary care from 9% to 13% (just above national average) Clinical Assessment Service with reduced out patient referrals and improved carpal tunnel management; claims management Initiated tariff based costing and performance management system for CHS to provide activity transparency and realise productivity gains of 17%. There is an implicit unit cost reduction of 15% Improved primary care Developed detailed investment plan to roll out best practice care packages across primary care over next 5 years Worked in depth with clinicians to agree risk stratification and key interventions for diabetes care package Established eight primary care networks through a rigorous developmental and bidding process with a structured organisational development programme for all networks Opening of Barkantine centre as a first wave polyclinic and best in class Primary care sites have been substantially renovated Reduced the number of GP practices from 43 to 34 in five years Our track record on delivering improvements is also recognised by local people. More than 1,100 local people were interviewed as part of the annual residents survey in February This survey is conducted by interview and reflects the make up of the borough in terms of gender, age, housing tenure and ethnicity. Concern about health services has been reducing over the past ten years. In 1999, 35% of local people said they had concerns about the health service but this is now down to 15%. In contrast 65% say health services are good to excellent, up from 59% in 2007/08. This is substantiated further in the NHS-London s recent survey (Nov 2009) about public perception of the NHS. For Tower Hamlets this showed that local people felt that the local NHS was improving services significantly above the London average (Tower Hamlets 65%, London average 58%). Given the health and affordability challenges that the borough faces however, we know that we need to accelerate the pace of change. The next section outlines the case for change drawing on our JSNA including insights from clinicians and local people, current performance against national and local targets, our provider landscape and the future financial scenario. 3 The Case for Change This section sets out the context for our CSP. It starts with our JSNA / HNA that assesses the health needs of the borough and community insights, considers our current performance against both national and local targets, our provider landscape and the financial position and scenarios facing the PCT. Health Needs Assessment We have a well-established JSNA with Tower Hamlets Council that takes a high level view of health and wellbeing needs and assesses the extent to which our strategies are meeting need. Each year we also produce a Health Needs Analysis to inform our strategic planning. This draws from the same core data set but focuses specifically on the analysis required to underpin our Commissioning Strategic Plan. We have refreshed the data and undertaken more in depth analyses in some areas. The overriding conclusion however, is that our main health improvement priorities remain unchanged. Population Our population is estimated to be 235,000 (although we have a GP registered population of 242,000) and is characterised by diversity, mobility, high growth and a significantly higher proportion of young people than elsewhere. 9

10 We have developed a bespoke population model (PPCG) with Tower Hamlets Council that is based on the most recent housing development data and the current and anticipated impact of the recession. This predicts that the population will increase from 234,973 in 2009 to 261,875 by 2015 with the fastest growth rate between 2013 and The sharp rise is based on an assumption of resumption of housing development as the economic climate improves. The overall growth rate is not significantly different to the GLA population model, although this does suggest the highest growth rates between 2010 to Projected population growth comparing PPCG and GLA estimates % population growth 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% PPCG GLA Annual Population Growth Rates 0.0% Year The important demographic characteristics of our population include the following: Average birth rates for London (although historically higher) A high proportion of the population aged 25 to 39 compared to London High ethnicity (50% of the population are non white and 34% Bangladeshi) 57% of under 19s are Bangladeshi 36% of the population Muslim and 38% Christian 92% of the population heterosexual and 8% gay, lesbian, bisexual or transgender 19% of the population move in or out of the borough per year 7% of the population move within the borough per year Around 3% of the GP registered population per year are new immigrants Rapid population growth (by 9% between 2009 and 2014) Deprivation Tower Hamlets is one of the most deprived areas in the country with 78.5% of residents living in the 20% most deprived areas in England compared to around 26% for London. In 2004, Tower Hamlets had an average score of 45.8 (higher means more deprived) and was ranked the fourth most deprived local authority area in the country. This picture did not change substantially in 2007 when the average scores was 44.6 and Tower Hamlets was ranked third most deprived (second most deprived in London next to Hackney). In 2007, 16 out of 17 wards were ranked in the 20% most deprived in the country and 12 were in the lowest 5%. Between 2004 and 2007 there were no substantial changes in deprivation scores by ward except for Millwall where the inward migration of more affluent people into Canary Wharf and its surroundings has probably reduced its deprivation score. 10

11 Wider Determinants of Health Income, employment, education and housing are associated closely with health and wellbeing and Tower Hamlets has significant challenges here. 66.7% of under 16s live in low income households - by far the highest level of child poverty in London (and the highest in England). 11.1% of the 16+ population were unemployed in compared to a London average of 6.8% (the highest unemployment rate in London). Benefits takeup is high with 18.1% of the working age population (27,569) claiming key out of work benefits at Feb 2009 compared to 13.3% in London. 19% of those claiming Job Seekers Allowance (2,005) had been claiming for over a year compared to 10% of those claiming in London. 23.4% of the working age population in 2008 had no qualifications compared to 12% in London. Health related benefits amount to 40% of all benefits and this has increased in the last 12 months. There are significant levels of non-decent housing: in 2008, 59% of council housing, 15% housing association and 33% of private rented dwelling were non-decent. The Impact of the Recession Tower Hamlets Council has modelled the impact of the recession in Tower Hamlets and this predicts a fall of 7.6% in GDP in 2009 compared to economic growth of 2.5% in Full recovery is not predicted until The fall in workplace employment is predicted to be higher than resident employment as the financial services sector has been hardest hit and a lower proportion of residents work in this sector. The number of residents in employment is predicted to fall by 5,500 over the period from 2007 to The recession will increase the need for: Psychological therapies Targeted mental health promotion activities Integration of employment and mental health services Identification of hazardous drinking Life Expectancy and Mortality High level life expectancy and mortality indicators indicate year on year improvements but with limited evidence of a reduction in the gap. Male life expectancy is 75.3 compared to 77.7 nationally (2005-7). Tower Hamlets has the twentieth lowest life expectancy of the Spearhead group and the relative gap with national life expectancy is 3.1%. Female life expectancy is 80.4 compared to 81.8 nationally (2005-7). Tower Hamlets has the 40 th lowest life expectancy of the Spearhead group and the relative gap with national life expectancy is 1.7% Compared to other Spearheads, the gap in life expectancy has a significantly higher contribution from deaths due to circulatory disease and cancer. The story around mortality trends is familiar. Life expectancy, all age all cause mortality and mortality from the three main causes of death (cardiovascular disease, cancer and respiratory disease) continue to improve but generally at the same rate as the country as a whole and with limited evidence of a reduction in the gap. Trends suggest that we are close to our targets on all age all cause mortality and cardiovascular disease but not significantly below them. To reduce the gap, cardiovascular disease is the area we are likely to have the biggest impact in the shorter term through continuing our efforts to systematically improve identification of those at risk and effectively manage those with existing disease. A further significant contributor to all age all cause mortality is chronic obstructive pulmonary disease (COPD) where our rates are around twice those of England and London. Cancer is a major concern as we continue to be significantly off target and have the highest mortality rates in London. The higher mortality is not explained simply by higher incidence as there is also evidence of poorer survival. This is a trend that it is harder to shift in the shorter term as the scope for prevention is more limited. While improving screening uptake may have a small impact on mortality, we 11

12 need to undertake further work to understand poorer survival coupled with intensifying our efforts to improve early detection. Prevalence We have developed a predictive model for common disease prevalence in Tower Hamlets that adjusts for Bangladeshi ethnicity and deprivation. Comparison of the expected numbers with primary care data (08/09) shows significant underdiagnosis (either high number or high proportion) for: Hypertension Chronic obstructive pulmonary disease Chronic kidney disease Coronary heart disease Heart failure Mental health disorders Dementia Expected vs Observed Prevalence of common long term conditions 08/09 On register (08/09) Expected Estimated undiagnosed % undiagnosed CHD Hypertension Diabetes CKD Heart Failure COPD 2873 Being verified Dementia CHD = Coronary Heart Disease; CKD = Chronic Kidney Disease; COPD = Chronic Obstructive Pulmonary Disease Healthy Lifestyles This is covered in greater depth in the Staying Healthy section (which covers both healthy lifestyles and health protection). The important characteristics of the Tower Hamlets population are: High smoking prevalence (particularly Bangladeshi men) Lower consumption of five fruit or vegetables a day compared to national rates Lower physical activity compared to London and England High childhood obesity compared to London and England Low alcohol consumption for the population as a whole (reflecting the large Muslim population in the borough) but evidence of high levels of harmful drinking in the white population Analysis of the initial findings of our Health and Lifestyle Survey highlights the importance of population segmentation in supporting lifestyle change as different segments have significantly different prevalence (particularly smoking and alcohol). For this reason, the locality based community development approach currently being developed through healthy lifestyle programme managers, health trainers and tobacco leads needs to continue to be embedded alongside borough-wide lifestyle initiatives. Health Inequalities within the Borough The previous section highlighted inequalities between Tower Hamlets and elsewhere in terms of risk factors for health, disease prevalence and life expectancy/mortality rates. We recognise however that there are significant inequalities within Tower Hamlets by geography, socioeconomic status and ethnicity. Geographical inequalities Life expectancy is highest in Millwall ward in both males and females (80.2 and 84.6 respectively) and lowest for both in St Dunstan s and Stepney Green (71.9 and 78.2). It is 8.3 years shorter for men and 6.4 for females. Comparison with the previous year s analysis indicates that the gap between the wards 12

13 with the highest and lowest life expectancies has remained the same for males (8.3 in compared to 8.5 in ) but increased in females (6.4 compared to 4.6). For males there is a clear polarity in life expectancy between the two most affluent wards (Millwall and St Katherine s/wapping) where it exceeds 80 and the remaining 15 wards where it varies from 71.9 to In females, the link with ward deprivation is less clear cut. Cardiovascular disease mortality has particularly high inequalities across the Borough. Four wards (Mile End East, Whitechapel, Bethnal Green North and Shadwell) have mortality rates that are close to twice the national average. This contrasts again with Millwall and St Katherine s where mortality is below national average. There is a fairly strong correlation between ward deprivation and mortality Although there are also sharp inequalities in Cancer across the Borough, the pattern is different to cardiovascular disease. Bow East and West have by far the highest mortality (around 50% higher than national averages) with the remaining wards tending to be fairly similar except for Millwall and St Katherine s which have mortality rates 30% below the national average. Ethnicity We have analysed mortality in Tower Hamlets by ethnicity and it was expected that age adjusted mortality rates would be higher in Bangladeshi groups due to higher prevalence of risk factors such as smoking in males and the higher prevalence of coronary heart disease. The results consistently indicated however, significantly higher mortality rates in the white population for all age all cause mortality, cardiovascular disease (under 75) and cancer (under 75). All Age All Cause Mortality by Ethnicity (pooled age standardised data ELCIS) Directly Age Standardised Death Rate White Bangla Other Mortality by Ethnicity (cancer, cardiovascular disease and all age all cause mortality) - pooled mortality data Cancer CVD AACM Male AACM Female AACM Persons White Bangladeshi Other AACM = All Age All Cause Mortality 13

14 This relationship is consistent for cancer and cardiovascular disease and across gender. Analysis of vascular control by ethnicity is also consistent with poorer outcomes in the White population. The findings might be considered to be surprising particularly in the context of higher prevalence of cardiovascular disease in South Asians. Possible explanations might be lower alcohol consumption in Bangladeshis and lower prevalence of smoking in Bangladeshi females. In addition, it could reflect highly deprived white communities in the borough. We are analysing the data in detail and will use this to inform future commissioning. Local Area Partnership Areas Comparative Analysis We have eight Local Area Partnerships in Tower Hamlets Tower Hamlets Local Area Partnerships / Networks that all partners use for integrated service planning, Local Area Partnership / partnership working and Network 1 community development. The PCT s eight primary care networks are aligned with the Local Area LAPs. There is some variation partnerhsip / Network 2 between LAPs (and also within some LAPs) that is related to differences in deprivation, Local Area ethnicity, disease prevalence Partnership / and mortality. Network 3 Local Area partnership / Network 5 Local Area Partnership / Network 6 Local Area partnership / Network 7 Local Area partnership / Network 4 Local Area Partnership / Network 8 Population and LAPs The joint bespoke population model shows that the substantial growth in population will be spread unevenly across the Borough. 48% is expected to be in LAPs 7 and 8, 27% in LAPs 5 and 6, 21% in LAPs 1 and 2 and only 3% in LAPs 3 and 4. Growth rates for paired LAPs (our polysystems). Growth rate 9.0% 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 1.0% 2.0% LAPs 1&2 Annual Population Growth Rates LAPs 3&4 LAPs 5&6 LAPs 7& Year 14

15 Disease Prevalence and LAPs There is considerable variation in observed prevalence of long term conditions by LAP. This could be partly explained by true differences in prevalence in the population (eg due to age, ethnicity and deprivation) and partly by diagnosis differences in primary care. Some generalisations can be made from the data: LAP 1 has a prevalence of long term conditions broadly similar to the Borough LAP 2 appears to have a consistently lower observed prevalence of long term conditions. It is not self evident why this is the case based on population characteristics. LAP 3, like LAP 2, generally has lower observed prevalence the Borough average. LAP 4 has a generally higher prevalence of long term conditions than the Borough. Conditions that particularly stand out are asthma, COPD and all vascular conditions (hypertension, diabetes, ischaemic heart disease, chronic kidney disease and stroke) LAP 5 is in general similar to the Borough (and LAP 1) with slightly higher prevalence of asthma, hypertension and depression. LAP 6 has a similar pattern as LAP 4 with higher prevalence of most conditions and particularly asthma, depression and the vascular conditions. LAP 7 has a similar pattern to LAPs 4 and 6 although prevalence of diabetes and hypertension are not as high LAP 8 consistently has lower prevalence of long term conditions compared to the Borough average and this is consistent with its relative affluence and lower Prevalence of common chronic conditions by LAP (CEQ SQUID 07/08) LAP 1 LAP 2 LAP 3 LAP 4 LAP 5 LAP 6 LAP 7 LAP 8 TH Asthma 9.3% 5.2% 4.6% 12.3% 9.6% 11.4% 12.4% 6.4% 8.4% Hypertension 7.5% 4.6% 6.1% 13.6% 9.5% 13.2% 10.2% 4.7% 7.9% Depression 8.0% 5.0% 3.0% 12.0% 9.1% 9.2% 9.9% 5.3% 7.2% Diabetes 3.9% 3.4% 4.5% 7.1% 4.2% 7.6% 5.3% 2.1% 4.4% IHD 1.9% 1.2% 1.6% 3.3% 2.1% 3.1% 2.6% 1.2% 1.9% CKD 1.1% 0.2% 0.8% 1.9% 1.8% 2.6% 1.9% 0.6% 1.2% COPD 1.4% 0.5% 0.6% 2.2% 1.5% 1.7% 1.9% 0.7% 1.2% Stroke 0.9% 0.4% 0.5% 1.4% 0.9% 1.5% 1.2% 0.4% 0.8% MI 0.7% 0.5% 0.6% 1.1% 0.8% 1.3% 1.0% 0.4% 0.7% Epilepsy 0.4% 0.2% 0.2% 0.5% 0.5% 0.4% 0.6% 0.3% 0.4% Dementia 0.1% 0.1% 0.1% 0.3% 0.2% 0.4% 0.3% 0.1% 0.2% As a very rough generalisation, in terms of disease patterns, LAPs could be clustered in terms of: LAPs 1 and 5 similar to Borough averages LAPs 2 and 3 lower prevalence than Borough averages LAPs 4, 5 and 7 generally significantly higher prevalence LAP 8 lower prevalence consistent with affluence and ethnic composition These groupings make intuitive sense geographically as the LAPs within the clusters are adjacent. 15

16 Disease prevalence within ethnicity groups by LAP (CEG Squid 07/08) Diabetes Hypertension COPD Bangl adesh Bangl adesh White is Black White is Black White Bangl adesh is LAP 1 4% 10% 6% 13% 11% 13% 3% 1% 0% LAP 2 2% 6% 3% 5% 6% 6% 1% 0% 0% LAP 3 7% 6% 7% 11% 7% 10% 1% 1% 1% LAP 4 6% 16% 12% 15% 16% 30% 3% 1% 2% LAP 5 5% 5% 6% 13% 6% 13% 3% 1% 1% LAP 6 12% 7% 10% 29% 8% 21% 5% 1% 1% LAP 7 6% 9% 6% 16% 8% 14% 4% 1% 1% LAP 8 3% 4% 6% 8% 4% 11% 1% 1% 1% TH 5% 7% 6% 13% 8% 13% 3% 1% 1% Black The table above focuses on the observed prevalence of selected conditions within ethnic groups by LAP. This highlights that: Within ethnic groups, there is variation in observed prevalence by LAP. This is interesting because it emphasises that ethnicity is only one factor in disease prevalence. For example, prevalence of diabetes and hypertension is lower in Bangladeshis in the least deprived LAP (LAP 8) The LAP 6 white population stands out strongly in the above analysis. This population represents around 28% of the LAP 6 population. Observed disease prevalence within this group is remarkably high. 12.3% are known to have diabetes compared to a Borough average of 5%. 28.5% are diagnosed with hypertension compared to 12.6%. Data not presented here indicate that 7.1% have ischaemic heart disease compared to 3.3%. 4.1% have had a stroke compared to 1.5%. We are exploring this further to consider the implications for our commissioned services. Observed prevalence of diabetes in Bangladeshis is higher than other groups as would be expected from the evidence base. However, prevalence within this group varies considerably across the Borough. Based on the data, 16% of the LAP 4, 10% of the LAP 1 and 9% of the LAP 7 Bangladeshi populations are diagnosed with diabetes. However, for LAPs 2, 3 and 5 the prevalence in the population is 5% to 6%. The reasons for this difference are not self evident and further analysis is needed to understand whether the lower prevalence in these areas could be due to underdiagnosis. COPD is one condition in which there is significantly higher prevalence in the white population. This is not unexpected as it tends to be a condition of older age and three quarters of the over 65 population are white. Observed prevalence within the white population varies with highest prevalence in LAPs 6 and 7 and slightly lower prevalence in LAPs 1, 4 and 5. LAPS 2 and 3 have considerably lower prevalence and again the reasons for this are not self evident. The health inequalities within the borough described above are one of the key drivers in developing our primary care networks. Each network will develop local analysis with staying healthy embedded fully so that we can ensure our locality commissioning through the polysystem will tackle more effectively these local inequalities and ensure services are tailored to meet the needs of local communities. This is set out in more detail in section 6. Community Insights Effective commissioning requires an understanding of how local people feel that their needs are being prioritised and addressed and we use a range of community intelligence to achieve this with the main insights summarised below. 16

17 Improving Health and Wellbeing Strategy Refresh consultation The consultation on the refresh of the Improving Health and Wellbeing Strategy was a significant exercise conducted over April to May 2009 to engage with local people to explore their views on service changes over the past three years and their priorities for the future. This found that perceptions on how services have changed over the past three years: Easier to see local GP although perception that less time for consultation Extended role of other primary care practitioners (eg pharmacists) welcomed Barkantine seen as a positive example of centre with broader range local services Cultural sensitivity of services remains a potential barrier to service access and use Some gaps in services were identified including lack of therapy support for those with mental health problems, support for carers and a day centre support for those with disabilities The consultation highlighted weight, exercise, alcohol, drugs and tobacco as the highest areas of concern with more information and support needed, particularly to families at home, in community centres and schools and greater use of planning to promote healthy lifestyles by encouraging walking and cycling and controlling fast food. This also highlighted support for integrated health centres (polysystem) with good local access such as clinics in community settings and the importance of training of local people in health and well being skills and expanding the role of the voluntary sector both in promoting healthy lifestyles and providing care Tower Hamlets Involvement Network (THINk) In Tower Hamlets, the local involvement network is called the Tower Hamlets Involvement Network and was established formally in September Since then, it has gathered valuable insights from the community on local health and social care need and perceptions of services using questionnaires, interviews, surveys, outreach programmes and attendance at health and social care events. To identify priority issues for their work, THINk consulted with their members using the 2008/09 JSNA as a starting point. The current priorities of THINk member are scrutiny of GP surgeries, hospital services, mental health, disability services and care in the community. THINk also produces a quarterly feedback bulletin and this is circulated to commissioners. GP Patient Survey The results of the GP survey 2009 indicate satisfaction with services that is close to the London average. In 2007/8, only 74% of participants reported being able to see a doctor within 48 hours in Tower Hamlets practices. This was the lowest in the country and a focussed campaign to improve access and satisfaction with access was implemented locally. Tower Hamlets is the most improved PCT on this indicator nationally and is now close to the London average. GP Survey 2009 results from selected questions (CQC website) Tower London Bangladeshi Hamlets Able to see doctor within 48 hours 80% 80% 73% Overall satisfaction with care 86% 87% 83% Giving enough time 82% 86% 76% Asking about symptoms 82% 84% 79% Listening 83% 85% 78% Explaining tests and treatments 75% 75% 71% Involvement in decisions 69% 70% 64% Care and consideration 77% 80% 69% Taking problem seriously 76% 78% 67% Confidence and trust 90% 92% 87% 17

18 We also analysed the data by ethnicity and this demonstrates lower satisfaction in the Bangladeshi population. This could be influenced by the younger age profile of the Bangladeshi community and we are exploring this further. Social Marketing Since 2007, we have commissioned a number of social marketing projects on a range of health issues including cancer screening, childhood obesity, smoking, immunisation, sexual health, GP access, diabetes education, mental health stigma and physical activity. This provides further evidence of the issues highlighted above including: The struggle of parents in Tower Hamlets to help their children lead healthier lives due lack of available places to play safely, the proliferation of fast food outlets, low incomes, peer pressure (and gang pressure) and social norms. Strong cultural differences between different ethnic groups in relation to knowledge, attitudes and beliefs about services leading to differences in how services are used eg screening, immunisation and smoking cessation. Fear as a key factor influencing behaviour whether this relates to fear of finding out what is wrong (eg screening), fear of healthcare environments (eg dental services), fear of taking on people with mental illness (eg tackling stigma associate with mental illness) or fear of breaking from activities that provide social benefits (eg smoking, paan chewing) Generally good knowledge about what constitutes a healthy lifestyle but some misconceptions eg relating to what is healthy These insights are being used to inform service reconfiguration and health promotion campaigns at both a borough and network level. Needs by Darzi Pathway As part of our drive to use the Healthcare for London framework to structure our CSP, we have also undertaken a needs analysis by Darzi pathway. For each pathway it sets out the key needs within the borough and shows how we are already working to meet those needs. We have set this out in Section 6. Allocative Efficiency Allocative efficiency looks at the extent to which the PCT is allocating resources between different areas to maximise impact on health outcomes, quality of care and reduction of health inequalities. We are part of the London Programme Budgeting Group and are developing further our approach. At present, the main source is the Department of Health Programme Budgeting data that analyses spend by PCT on 23 programme budgeting categories. Analysis is useful in raising questions around relative spend across programmes triangulated against other data such as outcomes and activity. The diagram below shows our expenditure by each programme area in comparison to other PCTs. 18

19 We have prioritised our analysis on those areas where we are an outlier (national and/or cluster); there are clearly poorer outcomes for the category and/or the category has a high level of resource allocation. We are continuing to analyse this information to inform our commissioning and are focusing on the following areas: Cancer - Tower Hamlets has amongst the highest incidence of cancer in London, the highest mortality rates in the country with five year survival poor but our spending is relatively low (141st in the country). Cardiovascular disease - We have among the highest rates of circulatory disease mortality in the country and second highest in London. Primary care outcomes (eg cholesterol and blood pressure outcomes) are relatively good, although outcomes in secondary care are hard to assess and benchmark as are outcomes of cardiac and stroke rehabilitation. We are using CQUIN as a driver to get better data. Programme budgeting data suggest that the ratio of secondary care to primary care data expenditure is high and our spend is relatively low (142nd in the country). Mental Health - Tower Hamlets is estimated to have amongst the highest prevalence of mental health problems in London (7th highest). It is not easy to assess the outcomes of mental health services although a data set is currently being developed as part of the CQUIN process. 19

20 Expenditure is relatively high nationally although low compared to cluster. However, breakdown of expenditure indicates a significantly lower spend on psychotic disorders and child and adolescent mental health disorders. These differences may be explained by the lower prevalence of psychotic disorder and mental health problems in Asian populations. We are conducting a more detailed assessment on ethnicity and mental health in children and adolescents as part of our JSNA. Trauma - Tower Hamlets has the third highest rate of people killed or seriously injured on the roads in London after Westminster and City of London. In 2007, 151 people were killed or seriously injured in Tower Hamlets. Furthermore, it has the highest increase in children killed or seriously injured in road traffic accidents over the past decade as well as the highest rate of intentional and deliberate injuries in children and young people. It is therefore perhaps unsurprising that we have the second highest expenditure per 100,000 on trauma and injuries in the country. Learning disabilities - Tower Hamlets has amongst the highest percentage of people on the learning disability register in London. However, it is almost bottom in the whole country on expenditure. It is unclear why it is such an extreme outlier in this category in the context of a high prevalence. An in depth needs assessment is currently being conducted as part of the JSNA process between the LA and PCT. Performance Over the past year NHS Tower Hamlets has made considerable progress against the targets we have direct control over, particularly those that improve health and well-being. We exceeded our ambitious target for Chlamydia screening and also achieved substantial improvements in the numbers of smoking quitters. We made further progress in implementing the supporting strategies of oral health, pharmacy, mental health, long-term conditions and sexual health. There was particular emphasis last year on developing the care pathways for diabetes and stroke. We have improved significantly access to GPs by ensuring an additional 200,000 appointments each year, largely through better performance management. All but one of our practices are now open for extended hours and, following patient feedback, reception services have been improved with bespoke customer care training following national procurement of an innovative provider. In 2008 and 2009 Tower Hamlets was the most improved area in the national MORI survey that assesses patient satisfaction with GP Access. The Care Quality Commission published their assessment of our performance against financial and service targets and the Commission s core standards. This supported our full compliance with the Commission s core standards for 2008/09 and excellent financial performance in 2008/09 that was reflected in our score of 3 (out of 4) under the new Use of Resources assessment. We were compliant fully on all 44 core standards set by the Commission including improving the healthy of the public, whether we have a patient focus, responsive health care, good amenities, on safety, clinical and cost effectiveness and good management. Our maximum points for safety and cleanliness and dignity and respect - given that these are key public concerns nationally - were particularly important. On the Care Quality Commission s existing targets and national targets, our performance is more mixed. While we improved our performance on the national targets, our performance rating for existing targets fell for 2008/09 to weak. This was very disappointing and principally the result of Barts and the London s failure to meet the national targets for waiting for treatment and A&E, despite significant investment and support from the PCT. The primary reasons for failure started with BLT adopting and implementing the CRS system in April This exposed significant weaknesses in the Trust s operational systems and processes and the inadequacy of their predeployment programme that led to significant data reporting and quality issues. During this time, NHS Tower Hamlets, NHS-London and the Department of Health performance managed BLT to achieve recovery including full use of the performance levers in the acute contract, a 20

21 national intensive support team, weekly Chief Executive and Director meetings and close monitoring of action plans. Although this has taken time, it has been effective and BLT performance in 2009/10 is much stronger: On inpatients waiting longer than 26 weeks, breaches have reduced substantially from 2008/09 On outpatients waiting longer than 13 weeks, there were no breaches in June, July and September, although there were 2 in August (this remains a green overall). The 4 hour waiting time target in A&E is now achieved consistently BLT has committed to recovering fully the 18 Week standard by December This is now managed through the ELCA Sector Acute Commissioning Unit. There are other areas of performance such as breast and cervical cancer screening that continue to challenge us and we are redoubling our efforts to improve across the full range of targets. As part of this we have strengthened our performance management framework with additional scrutiny and challenge through a Performance Review Group and established a Delivery Improvement Unit that focuses exclusively on our WCC strategic outcomes. Delivering our Community Plan and Local Area Agreement We have robust performance management of the Community Plan and LAA targets through the Tower Hamlets Partnership Healthy Community Delivery Group (co-chaired by the PCT). Performance against all targets is monitored quarterly with progress and issues also reported to the Partnership Executive. Each LAA target has a Partnership delivery plan with progress monitored every six months with peer challenge and review around targets at risk. Our latest monitoring shows good progress against our LAA targets, although there are challenges around the child obesity target. Indicator Description Base 08/09 Actual 08/09 Outturn July 09 Target July 09 Actual 09/10 Target DoT Priority Outcome: Reduce differences in people s health and promote healthy lifestyles Obesity among primary LAA NI56 school age children in 23.0% 24.49% Red N/R N/R 23.6% N/R year six LAA NI120 All-age all-cause mortality LAA NI120a Male Green N/R N/R 804 N/R LAA NI120b Female Green N/R N/R 555 N/R LAA NI123 Stopped smoking Green (Q1) CP Local Adult participation in sport Green N/A (interim NI008 and active recreation ) 18.7 Priority Outcome: Focusing on Early Intervention Carers receiving needs LAA NI135 assessment or review and a specific carer s service % Green % 21

22 CAA report The Audit Commission has just published the first area assessment for Tower Hamlets as part of the Comprehensive Area Assessment (CAA) and this recognised the depth of health needs and inequalities in the borough and the significant action that is being taken by NHS Tower Hamlets and its partners to address those needs. In particular the Area Assessment noted the: very good understanding of local people s needs the effective engagement and communication with local people (a green flag) track record of improving the quality of life for local people in a challenging context For health specifically, it noted that inequality is reducing, although there is still some way to go the significant work to tackle and reduce obesity, particularly among children including the Healthy Towns Initiative the success of initiatives to tackle smoking and tobacco use, particularly among the Bangladeshi community the priority given to improving mental health, particularly among children access to health services and particularly GPs has improved dramatically, as well as satisfaction with maternity services We were pleased with this first assessment as it recognises the effectiveness of our partnership working that is essential to deliver the improvements in health and health services that we want. Market Management The PCT is developing the provider landscape through a number of strategic commissioning frameworks to address weaknesses in current provision. We have developed a Commercial Strategy and a database tool for market analysis and segmentation as well as several other key workstreams. The PCT (as part of ELCA) has established market analysis of the existing providers for community service provision. This information provides the basis of market mapping to inform commissioning strategies and is focussed on the Healthcare for London pathways as well as sector priorities. We use segmentation to understand and focus commissioning of service, for example our minor ailments scheme targets children and families to reduce GP and urgent care use and our long term conditions strategy identified vulnerable people who have a long term condition as a group with specific needs. We are using market testing across the PCT and have competitively procured a new staff development programme for leadership. This year we established a Competition Choice and Contestability Committee to: Develop a healthcare procurement framework Implement a decision making process for market testing services Establish a local competition dispute process Develop our market stimulation strategy Arbitrate on potential conflicts of interest We have also formed a Primary Care Procurement Committee to standardise the approach to procurement of independent contracts and development of a set of standard contract documents (including performance, tariff and KPIs) for general practice and other primary care procurements. Through this group we will steer innovative service design and procurement of pharmaceutical services using local contracts to provide medicines support to polysystems. We reviewed previous procurements and contract management activity and incorporated lessons learned into the procurement activities for new contracts and commissioned services. This includes areas such as performance management requirements of new and existing contract. We have developed a weighted approach to penalties against contract variables in our GP Lead Health Centre procurement for example. We use detailed service specifications with all providers. The largest of the contracts acute, mental health, community and GPs - have detailed balanced scorecards or dashboards that are RAG rated and monitored formally. We have a well established quality monitoring for acute and community services that 22

23 supports performance management and intense clinical quality support for independent contractors. The use of patient/user feedback forms an intrinsic part of our overall performance assessment with, for example, GP contracts including patient survey results as part of the RAG rating. We continue to address poor performance through performance management, new commissions, targeted commissions, decommissions and remodelling the specifications. The areas of highest impact for Tower Hamlets are set out below. Acute Healthcare The development of a Strategic Acute Commissioning Unit for inner north east London is a key acute market management lever for NHS Tower Hamlets. The unit is hosted by the PCT which is also London s lead commissioner for Barts and the London NHS Trust. We spend 88% of our 197m acute budget with BLT. Acute services have been segmented by specialty, taking into account any required dependencies for co-location. The SACU leads on these aspects of market management and procurement Health4NEL sets out the proposed role of providers within a major service reconfiguration and the Royal London Hospital will be designated as a major acute hospital (subject to consultation). This will concentrate complex surgery on children under 2 and urgent surgery and complex surgery on children between 2 and 15 at the Royal London. The Homerton and NUHT will remain as local hospitals with BLT continuing as a specialist resource for London. A large number of acute productivity initiatives come directly from development of the strategy and these are being picked up by the SACU. Choice in elective care is reinforced through: a contract with an independent sector provider, Inhealth, for a range of diagnostic services; progressive implementation of direct booking through Choose & Book; ensuring that the Trusts develop high quality directories of services and providing information to patients and the public about their rights to choose. The SACU has identified specific VfM areas to review in 2010/11, taking into account potential gain, deliverability and where there is scope to secure better VfM through market testing and use of alternative providers. This will include: Decommissioning low/no value clinical procedures Reducing the ratio of first to follow-up outpatient procedures Demand management schemes to reduce GP elective referrals Targeting sub-specialty level excess bed day numbers and reducing lengths of stay Retendering direct access diagnostics and reviewing clinical practice for diagnostic referrals Retendering patient transport services (unbundled from tariff from April 2009). Community Healthcare Services We have recently completed a market analysis of the current state of the external market for Out of Hospital services in inner north east London and beyond. We now have a database and market segmentation tool that commissioners are using for market testing. It includes NHS organisations, practice based providers, third sector organisations, and the independent sector. We have also mapped the current providers of inner north east London community services for the following programme areas: Children and Young People Public Health Rehabilitation and Intermediate Care End of Life Care Integrated Programmes for Long Term Conditions Acute Services in the Community Ambulatory Services Discreet Specialist Services (for example: MSK /Physiotherapy, Wheelchair services, Neurorehabilitation and Phlebotomy) Sexual Health Mental Health 23

24 Dental Prison Health Primary Care. We took account of the priority areas suggested by HfL and the key local areas of need across ELCA. Each of the programme areas above was disaggregated to service lines to allow a detailed focus in commissioning. Long Term Conditions, for example, is an identified priority across ELCA within Community Services. It is recognised that people with Long Term Conditions are often admitted to hospital when they could manage their illness more effectively closer to or at home. The market analysis tool segments different approaches to providing the care and the suppliers that can provide them. From 1st April 2009, we have externalised our provider services (Community Health Services CHS) as a Direct Provider Organisation. A separate financial ledger was set up and internal financial and cashflow mechanisms put into place. The finance team was disaggregated into Provider, Commissioning and Corporate functions and an 11 strong team finance team was created headed by an Associate Director of Finance. A clear and costed SLA was agreed on which both the Commissioner and the CHS Provider operate. As at the end of November 2009, CHS is financially stable and self-sufficient financially. We have reviewed the commissioning approach for all services outside hospital and agreed performance and quality standards for CHS. We apply similar performance and quality standards to the Third Sector organisations to ensure consistency for patients and support choice. Key developments introduced in 2009 are: Shadow clinical currencies and financial tariffs for a large part of THCHS service line activity. The remaining tariff roll-out will occur in Introduction of Activity Based Costing (ABC) software and model to support Provider tariff costing and service line reporting. The productivity of District Nursing services in-year has returned an impressive 10% increase net of tariff deflation since December 2008 measured in tariff currency units, as a result of applying ABC techniques and tariff. There has been no corresponding activity generated increase to the SLA value. Further impressive productivity improvements in excess of 10% after net tariff uplift are planned over the next 3 years. We continue to use market analysis and testing for smaller but important services. For example, we plan to market test Diabetes Education, Pulmonary Rehabilitation, Interpreting and Advocacy and Dentistry in 2010 using the market analysis tool referred to above. We already know from market mapping that these services could be provided by the third and / or independent sectors. Primary Care Our Primary Care Investment Programme (PCIP) established in 2008/09 is a significant investment in primary care using a polysystem model that will improve health outcomes by the delivery of care packages from networks of local providers. The first phase is on target and by April 2010 every GP practice will be offering care packages for diabetes and child immunisations. We have constructed the care packages around projected demand (using prevalence and clinical evidence) and will measure their success by tangible health outcomes. We are commissioning these care packages through assessment, capacity and capability building of the networks including supporting the less able providers. The shift of activity from acute to primary and community care is underway within our Care Closer to Home strategy. The priority areas are identified and delivery modelled within our polysystems using population forecasts, disease prevalence and activity requirements. We are assessing provider capacity and expect to have a mix of independent contractors, community providers and some secondary care outreach. By December 2009 we will have a comprehensive delivery plan. 24

25 Third Sector We have just launched a joint Third Sector strategy with Tower Hamlets Council that aims to enable the Third Sector in Tower Hamlets to fulfil its potential to improve the quality of life of everyone living or working in the borough and to contribute to the Tower Hamlets Community Plan to The Strategy highlights four areas for action: Infrastructure - The National Survey of Third Sector Organisations indicated that Tower Hamlets Third Sector feels comparatively unsupported and Tower Hamlets is currently the only borough in London without a Council for Voluntary Service (CVS). There is strong support for establishing a CVS from the Third Sector and the strategy proposes that one is established. Voice and Representation - The Third Sector has a key role in improving service delivery and representing local communities. Third Sector representation on key decision making forums could be much stronger and the strategy proposes to address this. Commissioning and Funding - The strategy commits the Council to review the mainstream grants process to make it more accessible and that an equalities impact assessment is undertaken. The strategy also commits the Council and PCT to review procurement and commissioning practice - using the market segmentation tool - to identify service lines where the Third Sector could contribute. This will include capacity building within the Third Sector. Finance Financial position Current Year The PCT set a surplus budget of 10.2 million for the current year and expects to meet its control total set by NHS London as at month 9 provided that there is no significant escalation in the run-rate for acute sector over-performance. For month 9 the PCT s outturn shows a surplus of 7.6 million with a forecast year end surplus of million. This is in line with the control total reported to NHS London in the 2009/10 Operating Plan. There are significant financial risks around acute sector over-performance and the impact of HRG4 at the time of writing. A deterioration in the current year financial position would of course impact in and reduce the headroom resources which the PCT has available for investment. At the time of writing the PCT is confident that it will meet its control total surplus. Financial Planning Assumptions for 2009/10 to 2014/15 The financial planning assumptions used by the PCT are consistent with the NHS key assumptions at both the base, upside and downside levels issued by the DH see below. 11/12-13/14 14/15-16/ / /11 Inflation Normal inflation 2.5% 2.5% 2.5% 2.5% NHS inflation 2.2% 1.0% 1.0% 1.0% Total inflation 4.7% 3.5% 3.5% 3.5% PCT Allocation PCT uplift (nominal) PCT real growth (nominal growth less normal inflation) Base case 2.50% 2.50% Upside Allocation growth 3.25% 3.25% Downside published as part 0.00% 3.00% Base case of Operating 0.00% 0.00% Upside Framework 0.75% 0.75% Downside -2.50% 0.50% Tariff Assumptions Gross Tariff uplift 4.7% 3.5% 3.5% 3.5% less efficiency -3.0% -3.5% -4.0% -4.0% Net tariff uplift 1.7% 0% -0.5% -0.5% 25

26 Contracting Assumptions Proportion of total contract value that should be paid on delivery of agreed CQUINs 0.5% 1.5% 1.5% 1.5% To inform the case for change the PCT has modelled three financial scenarios using the funding assumptions outlined above. The opening scenarios outline the projected deficits facing the PCT should it do nothing and simply apply the rising trajectory of population and non-population driven costs against available funding. The next section on assumptions goes into further detail on this. Assumptions 1. The latest detailed planning guidance issued by NHS London in January 2010 version 6 applies. This is consistent with the table above. 2. All NHS Providers except GMS/PMS/APMS and GDS receive the same net inflation uplift as is applied to acute tariff activity costs. Cost efficiencies are therefore assumed at the same rate as the acute sector 3.5% next year and thereafter. 3. The inflation uplift for Primary Care providers is assumed at a flat 1.5% net although this would need to be tested against central contract uplifts. This is purely net inflation uplift. Primary care costs in general are uplifted by demographic growth factors also see point 5 below. 4. Productivity savings which are significantly in excess of price deflation will need to be found from all functional spend areas to bridge the affordability gap. 5. Compound annual growth rates CAGR are applied to current year baselines using local analysis and reconciled back to GLA low and HfL assumptions. These have both demographic and non-demographic components. There is a separate outline of population growth issues for Tower Hamlets at the end of this finance section. 6. The demographic growth element in the CAGR rates is derived from testing the GLA revised low population growth scenario for Tower Hamlets against the localised planning model developed in partnership with the Borough of Tower Hamlets. It has been applied to all contracts with the exception of acute mental health and PCT Provider services which are treated as block contracts in line with historic treatments. Productivity assumptions in excess of the inflation deflator take account of population growth in both areas. The PCT will be commissioning CHS from April 1 st 2010 with a tariff mechanism. As well as absorbing population growth, CHS is required to deliver additional CIP s of 2% above the 3.5% CIP for tariff deflator. For Mental Health services, there has been substantial investment in the past 5 years with the creation of new community based services which have absorbed new demand and population growth. Patients care has been transferred from existing community mental health teams to, for example, early intervention or assertive outreach services. It is assumed that the impact of population growth on mental health services will be resourced by productivity improvements in these new service areas. 7. Non-demographic growth assumptions are applied to current year baselines using local analysis and reconciled back to HfL assumptions. 8. Prescribing costs include demographic and non-demographic factors as well as inflation and are assumed to increase between 7% and 8% per annum based on historic trends. It may be that these assumptions will be lowered pending the agreement of a strategic pharma management plan to support the CSP submission. 9. A contingency equivalent to 0.5% of total resources is built into each year of the scenario planning. 10. A surplus assumption of 2 million has been assumed in the outlook for 2010/11. Base Case Scenario After Application of Affordability Levers The base case is for 2.5% nominal allocations growth across the period to 2013/14 excepting next year which is in line with the third year of the current CSR at 5.14%. The assumption equates to 0% real growth across the planning period. This scenario produces a surplus in each financial year and the tables below show how this builds up. 26

27 Cumulative PCT Surplus/Deficit Non Year Rec 000s Rec 000s Total 000s 2009/ / / / / The financial plans and projections take account of investment and expenditure required to fund the new commissioning models including Polysystems. More detail on commissioning models and Polysystems is included below but the base model above shows, in brief, that NHS Tower Hamlets is able to fund the operation and transition costs of Polysystems. The financial plan will need to be achieving savings from shifting care settings next year. The surpluses in each year under base-case should therefore be regarded as additional risk-based contingency to support unplanned transition and double running costs under new commissioning models. The graph below plots the development of the PCT financial position over the time series THPCT - Base Case cumulative financial Position Cumulative Surplus/Deficit Rec 000's Non Rec 000's Total 000's / / / / /14 Financial year Downside Scenario After Application of Affordability Levers The downside is for 0% nominal allocations growth in the next CSR period rising to 3% thereafter. The assumption is for -2.5% real growth in the first CSR and 0.5% thereafter. This scenario shows a small surplus in each year of the CSP and the table below show how this builds up in each year after 2010/11. Cumulative PCT Surplus/Deficit Non Year Rec 000s Rec 000s 27 Total 000s 2009/ / / / / The downside scenario is very challenging. The PCT is only able to show financial balance across the CSP timeframe by deferring or cancelling a significant total for Polysystem commissioning initiatives spread across the 3-years of the CSP - 7 million next year, rising to 10 million in the last year of the

28 CSP. These initiatives are part of the PCT s work on valuing the historic shortfall of GMS/PMS funding against what would be required for expected prevalence in key long-term conditions. There removal would be considered as high risk. The graph below plots the development of the PCT financial position over the time series THPCT - Downside Case cumulative financial Position Cumulative Surplus/Deficit Rec 000's Non Rec 000's Total 000's / / / / /14 Financial year Upside After Application of Affordability Levers The upside case is for 3.25% nominal allocations growth across the period excepting next year which is in line with the third year of the current CSR at 5.14%. The assumption is for 0.75% real growth across the planning period. This scenario produces a cumulative surplus of just over 34 million by 2013/14, and the table below show how this builds up with a surplus shown in each year. NHS Tower Hamlets is assuming that this relatively generous planning scenario is unrealistic however it is presented here for completeness. Cumulative PCT Surplus/Deficit Year Rec 000s Non Rec 000s Total 000s 2009/ / / / / THPCT - Upside Case cumulative financial Position Cumulative Surplus/Deficit / / / / /14 Financial year 28 Rec 000's Non Rec 000's Total 000's

29 2010/2011 Sources and Applications of Funding The PCT will receive million growth funding on its revenue resource baseline next year. This equates to 5.14% on the opening 2010/11 baseline of million. In addition to exposition book growth the PCT has the following additional new sources of income next year; Sources of New Funds 2010/11 The summary analysis of the PCT s total funding sources is outlined in the table below. This shows all of the new recurrent and non-recurrent funds which the PCT can expect to receive next year. It assumes that the PCT meets its control total requirement of 10.2 million surplus and that the NHS growth assumption within the last year of the current CSR is not amended downward. There is a risk that this will happen dependent on the strength of the UK economy and the PSBR. Summary analysis of the PCT s total funding sources Source of Funds Recurrent Non Total Recurrent '000 '000 '000 Comment 1. Growth allocation 10/11 23, , % on initial resource baseline. 2. Headroom from previous year investment programme 5, ,905 Recurrent elements of prior year nonrecurrent investment programme 3. Impact of surplus/deficit 2,791 7,409 10,200 PCT Revenue Surplus/(Deficit) position 4. MFF Gain 1, ,800 Assumed 2% cap annually Sub total 33,510 7,409 40,919 Real increase in resources - mix of growth and technical adjustments Recurrent Assumptions Please refer to the numbered items on the table above million growth funding equivalent to 5.1% on baseline million recurrent headroom from the prior year non-recurrent investment programme million gain under the agreed transition for the recalibration of MFF. Non-Recurrent Assumptions 3. Non-recurrent funds of 10.2 million current year surplus to control total. Total sources of new funds available for investment for 2010/11 are therefore million. Applications of New Funds 2010/11 The table below summarises the applications of funds. 29

30 Applications of Funds Recurrent Non Total Recurrent Comment '000 '000 ' Commitment on FYE of prior year investments 0 0 The 'full-year' effect of new investments 0 made in the previous year. 2. Committed New IHWB schemes Newby Place ,073 Polysystem development costs Harford Street Polysystem development costs Dunbridge Street Polysystem development costs St Andrews ,614 Polysystem development costs 3. Additional costs of LIFT schemes re IFRS PCT balance sheet restated for IFRS 4. Additional costs of London Stroke and Trauma services As per London Business Case 5. 10/11 High cost drugs and devices ex from PBR 1, ,000 Based on 3-year moving average 6. 10/11 Population Growth Pressure on acute activity 2,434 0 Assumes GLA model growth ,434 moderated to local population planning tool 6. 10/11 Population Growth Pressure on Primary Care list Size As above 6. 10/11 Non-Population Growth Pressure on acute activity 1, ,685 As above 7. 10/11 Specialist Commissioning Growth 1, ,500 Based on LSCG OP 8. 10/11 Complex Care/Continuing Care Growth 1,000 Based on 0910 projection of overperformance. 1, Movement to full tariff for EOLC Inpatient and community services at St 690 Josephs based on agreed business case. 10. Inflation/Generic cost pressures - Acute SLA's 1, % for PbR & non-pbr (includes) 3.5% efficiency) and assumes 1.5% CQUIN on 1,872 baseline SLA values 10. Inflation/Generic cost pressures - Mental health SLA's As above 10. Inflation/Generic cost pressures - Specialist Commissionin As above 10. Inflation/Generic cost pressures - Primary Care % for Primary Care 10. Inflation/Generic cost pressures - Prescribing. 2, % uplift - prudent assumption based on 2,449 historic outturns 10. Inflation/Generic cost pressures - Community (610) 0 1% for PbR & non-pbr (includes) 3.5% efficiency) and assumes 1.5% CQUIN on (610) baseline SLA values 10. Inflation/Generic cost pressures - PCT non-provider 2, ,136 As per NHS gross inflation 10. Inflation/Generic cost pressures - Other OOH 1, ,109 5% uplift - prudent assumption 11. Uncommitted contingency 3,000 3, % of resource limit 12. Contribution to London Levy % 3,477 3,477 Planning assumption subject to variation 13. PCT planned surplus 2,000 2,000 Residue of lodged funds Sub total 23,368 7,150 30,518 Balance available for investment 10, ,401 To meet all cost pressures, capacity needs & investments, unless further resources can be released by demand management or other dis-investment. There is a significant list of commitments on the total sources of funding. These are listed below in the applications table and consist of: 1. Commitments on prior year investment are assumed to be nil and all full year effects are assumed to have taken place in the current year. 2. The costs in-year of developing the Polysystem hub and spoke model will be 1634k recurrently and 1673k non-recurrently. These costs are for the infrastructure costs of new developments and reflect planned net service costs. 3. The full year effect of bringing such schemes onto the PCT balance sheet will be 800k k cost pressure on stroke and trauma services. This figure is based on the NHSL plan for rolling out the new tariffs million cost pressure on high cost acute drugs excluded from tariff. 6. The impact of 2009/10 population growth on the costs of acute services and primary care is assumed to 2.4 million and 701k respectively based on locally validated population growth assumptions reconciled back to the revised GLA low model. Additionally non-population derived growth of million has been applied to the acute baseline cost. Population growth has not been applied to CHS services as these are subject to a new tariff mechanism and will have a further productivity target of 2% CIP in addition to net tariff uplift of zero. Acute Mental Health services are also assumed not to have population and non-population growth effects in as a direct result of the large investments into community based and non-acute mental health services in and

31 The effect of these will be to shift a significant caseload from acute to other settings of care. The creation of new services has absorbed new demand and population growth, as patients care has been transferred from existing community mental health teams to, for example, early intervention, assertive outreach services and IAPT services. 7. Growth on the cost of services within Specialist Commissioning is assumed to be in the order of 1.5 million on the basis of a LSCG draft Operating Plan submitted to London Commissioners. 8. Continuing Care packages are assumed to be subject to a 1million cost pressure based on overperformance for the last two years and the evidence of a rising cost trend. 9. A further cost pressure of 690k has been inserted here in relation to the additional costs of moving to a full tariff basis for End of Life Care EOLC third sector providers as outlined in the EOLC CCI and the relevant business case. 10. Around 8.4 million net will be required for inflation net tariff uplift being set at zero which is also the likely marker for non-tariff activity. An assumption of 1.5% for CQUIN on all NHS acute and community baseline contracts is included under the general inflation figure. GMS/PMS inflation is assumed at 1.5% but is dependent on the ongoing negotiations between the DH and the GMS/PMS representative groups. It may well be in excess of this figure and the PCT s investment plan will need to take account of this risk. For Primary Care Prescribing inflation has been set at 8% based on historical outturn over the past five years less the price reductions for Category M generic drug costs. This also includes an assumption for the cost impact of new NICE drugs in 2009/10 prescribed in Primary Care which explains why no non-demographic cost pressures have been applied to Primary Care drugs. Further work is on-going to finalise the detailed prescribing budgets. Inflation for Community services is as per tariff with an additional 2% CIP based on adoption of new tariffs for Community Services. Inflation for non-nhs agreements are prudently assumed at 5%. Efficiencies of 3.5% are assumed for all Commissioned activity excluding non-nhs contracts. 11. The PCT has allocated uncommitted contingencies in the 2010/11 Operating Plan of 3 million or 0.6% of its planned resource limit. 12. The PCT has assumed that it will be required to fund the second year of the levy for London risk pool funding at a rate of 0.79% of resources. This is non-recurrent and is 3.48million. 13. Planned surplus in 2010/11is 2 million which is essentially the residual element of the PCT s 21.6 million return of lodged funds. In summary, the PCT has net 10.4 million to invest in new services and so on in 2010/11. This equates to around 2% of resources and will be used to transition the PCT to a new Polysystem-based commissioning model using the affordability levers developed in the INEL planning model. The next stage of the financial section will therefore go on to describe in more detail the affordability lever assumptions Financial Summary The activity and financial planning model developed for the CSP shows that financial viability is achieved across the upside, downside and core revenue funding assumptions and across the whole of the CSP planning timeframe see table below. However, the contribution of the affordability levers and initiatives is very significant and there is a large amount of risk within the CSP therefore especially in the downside scenario. Financial Year 10/11 11/12 12/13 13/14 000s 000s 000s 000s Downside Core Upside The next section will look at the affordability levers in turn and what the respective contribution is to the PCT position. 31

32 Affordability Levers NHS Tower Hamlets has an integrated set of affordability levers to narrow the projected gap between resources and expenditure in the cycle to 2013/14 as well as to release further resource headroom in 2010/11 for investment into polysystems. This approach has been developed across the whole of the ELCA or INEL sector through the sector Health Intelligence Unit HIU. A sophisticated activity and planning tool has been developed by the HIU and all three INEL PCTs are following a similar approach. The downside funding assumption has been used to populate the model so that a worst-case set of planning assumptions is produced. The following table summarises the costs, savings and the transition for each commissioning lever and the net overall impact of all levers in each financial year. The savings are taken up to 2013/14 and shown in the year they fall. The position shown in the table below is the net savings position, not including any transition and double-running costs to the new Commissioning models, although they do include the costs of running services outside hospital. So for example, the 10 million of funding available in 10/11 will be used to fund the transition costs of the Polysystems and act as a risk reserve. The affordability lever summary shows that a net saving of 4.7 million is planned across all affordability levers for 2010/11. However, the risks around this assumption are deemed to be very high and therefore the retention of the 10 million outlined in sources and application above is considered to be sensible. The Polysystem lever shows the recurrent cost of setting up the Polysystems in each year of the CSP and it is shown as a cost to distinguish it from the savings which accrue functionally through the LTC, prevention, new/fu and GP referral saving levers. The first year of the long-term conditions lever is a net cost as savings are not assumed to accrue immediately and will take time to develop. Initiative 10/11 11/12 12/13 13/14 Care closer to Home - Polysystem Saving Primary Care Investment Programme - LTC Saving Prevention Saving Decommissioned Saving New/FU Saving Day Case Saving GP Referral Saving Excess BD Saving Tariff Efficiency Saving Management Cost Saving Other Saving Total The levers are described in more detail below: 1. Polysystems As outlined above the Polysystem lever is a net cost lever. It reflects the costs of putting into place the new services that will deliver Care Closer to Home - the main polyclinic programme. The following table shows the percentage of baseline activity moved to a Polysystem for each category by PoD. Note that in 32

33 some cases the percentages may be less than expected, i.e. the input value. This is due to activity already being removed through other initiatives (particularly reduction in OP follow ups and reduction in non-gp referrals). % Specialty Shift A&E 40.00% OP 14.82% Non-Elective Medicine Complex 10.00% Elective Medicine Complex 20.00% Non-Elective Medicine Non- Complex 10.00% Elective Medicine Non-Complex 20.00% Non-Elective Medicine LTC 10.00% Elective Medicine LTC 20.00% Non-Elective Medicine Under 17s 10.00% Elective Medicine Under 17s 20.00% The planning assumption is that the Polysystem initiative will determine the Activity shifts are phased linearly over 5 years. 2. LTC and Case Management LTCs are shown as a net cost in the planning model in 2010/11 because it is considered unrealistic that savings will follow immediately. A time-lag is therefore built into the LTC delivery assumption and full ramp-up of savings is not assumed until 2012/13 with some savings coming through in 2011/12. The planning model assumes aggressive HfL shift percentages but assumes a proportion cost of 75% - i.e. that the substitution effect of treating LTCs in polysystems effectively saves 25% of the relevant acute tariff cost. The specific shifts of activity are detailed below; 20% of elective LTC 10% of non-elective complex medicine 30% of non-elective non-complex medicine 40% of non-elective LTC All of the above are phased linearly over the first 5 years 3. Prevention The planning model uses the HfL shift percentages, and assumes a substitution saving of 25% of the relevant acute cost - equivalent to a proportion cost of 75%. The core assumption here is that the PCT will shift 10% of non-elective medicine, phased linearly over the first 5 years. 4. Decommissioning The PCT assumption is less aggressive than the HfL model as outlined below; 3% of all elective procedures 20% of outpatients 0% of A&E Again, this is phased linearly over 5 years and this is a SACU lever initiative. 5. Reduction in OP Follow Up Appointments The PCT planning assumption is to move to a first OP to follow up ratio (FU to FA) of 3:1. The assumption is that this will be phased equally over two years. This is a SACU lever initiative. 6. Reduction in Non-GP Referrals The planning assumption is that 75% of all referrals will be by GP for both polysystem and acute activity. The phasing of this lever is 40% next year and movement to 100% in 2011/12. 33

34 7. Reduction in Excess Bed Day Cost The planning assumption is that we will save 15% of the XBD cost. Based on the input specialties where XBD costs are incurred (as determined from SUS 08/09 data), the planning model has identified specialties where XBD savings can be made and which will be targeted by the SACU from April The phasing of this is linearly over two years. 8. Tariff Efficiency The planning model has only applied this productivity/tariff decrease to Community Care which is currently provided by the PCT. For Community Care the following productivity assumptions have been assumed over the CSP planning period. These are in addition to efficiency/productivity savings which result from the application of the tariff deflation and net uplift assumptions for acute Provider being applied to Community Providers as well. 11/12-2%, 12/13-4%, 13/14-4%. Position after Application of Affordability Levers The table below shows the impact year on year of the affordability levers being applied to the do nothing downside scenario. The revenue funding assumptions show the revenue resource limit allocation plus additional funds received on the allocation working paper such as Dental funding and the central bundle. As can be seen, the do nothing cost scenario leads to a 24 million cumulative deficit by 2013/14. This is mitigated by the application of the affordability levers which yield 29.2 million of savings by the end of the period. The impacts of the savings realised through lever application on the deficits within year are also shown. Across the period and broadly, financial balance is achieved across the CSP period although the levels of projected surplus are not huge. This is further justification for holding the 10m balance of sources and applications as a risk contingency in Description 09/10 000's 10/11 000's 11/12 000's 12/13 000's 13/14 000's Revenue Funding Assumptions Do Nothing Cost Surplus/-deficit Cost with affordability levers applied Value of affordability levers Surplus/-deficit The table below outlines the relative impacts of each of the affordability levers showing savings from the various acute initiative and decommissioning levers as being the largest followed by Out of Hospital tariff efficiency/productivity. 34

35 TH Downside Polysystem Saving LTC Saving Prevention Saving Decommissioned Saving New/FU Saving Day Case Saving GP Referral Saving Excess BD Saving Tariff Efficiency Saving Management Cost Saving Other Saving /10 10/11 11/12 12/13 13/14 14/15 15/16 16/17 17/18 18/19 19/20 The waterfall diagram below shows this is a slightly different format the red area above the line on the far left hand side shows the specific Polysystem initiative as a net cost rather than a savings initiative. Polysystem savings are released in the LTC and acute productivity levers. The latter being the saving from shifting care outside hospital TH Downside 2013/14 m Revenue Do Nothing Cost Polysystem Saving LTC Saving Prevention Saving Decommissioned Saving Acute Productivity Saving Tariff Efficiency Saving Management Cost Savings Other Savings Surplus/Deficit On the left hand axis is shown both the projected do nothing cost and the financial allocation under the downside scenario. The allocation is ca 513 million whilst the do nothing costs are just over 536 million. This shows a projected shortfall of 23 million before the application of the commissioning initiatives and levers. Reading from left to right shows the relative contributions of all levers and the forecast position at the end of the CSP period with those applied a 5 million surplus. 35

36 Reconciliation of CSP Assumptions on Shift of Care NHS Tower Hamlets has done a great deal of work to model the shifts of activity into settings of care in its Care Closer to Home programme. The table below shows the aggregated Care Closer to Home assumptions (also aligned with the latest shift assumptions in our detailed HIU activity and financial planning model): assumptions compared to HfL and, importantly, the Health4NEL assumptions as per the Clinical Working Groups in the PCBC. Shift of Care Comparison Specialty % Shift TH Health4NEL HfL Details of CC2H assumptions A&E 39.0% 40.0% 50.0% Acute OP 37.0% 42.0% 40.0% Based on Health4NEL specialty assumptions (4 clinical trios) Assumes we shift 60% of all A and E minors (clinical trio) Total IP EL 6.3% n/a 20.0% Weighted average using assumptions outlined below ELIP 4.4% 4.7% n/a Based on Health4NEL HRG shift assumptions ELDC 9.2% 12.0% n/a Based on Health4NEL HRG shift assumptions RA 1.3% 0.9% n/a Based on Health4NEL HRG shift assumptions Total IP NEL 1.7% 0.8% 10.0% Based on Health4NEL HRG shift assumptions Local assumptions for Care Closer to Home in Tower Hamlets are based on the shifts proposed in Health4NEL as defined through the detailed work of the Clinical Working Groups. The shift assumptions have been applied to Tower Hamlets local data at OP specialty and IP HRG level. Clinical trios were formed in Tower Hamlets for A and E, diabetes, anticoagulation, paediatrics and maternity; trios have ratified all proposed shifts making slight changes to diabetes activity and increasing the anticoagulation shift that they feel can be achieved in Tower Hamlets. It is also worth noting that some activity has already been removed locally through other initiatives (particularly reduction in OP follow ups and reduction in non-gp referrals). The downside especially is very challenging and the PCT believes that it faces inequities in its funding that many other PCTs do not. Population growth will play a large part in how NHS Tower Hamlets plans for financial viability and the section below provides a bit more detail. Population Growth North-East London has one of the largest projected increases of population in the country over the next ten to fifteen years with Newham and Tower Hamlets PCTs seeing the highest growth. There are two main models available to assess population projections ONS and GLA. ONS relies on births, deaths inward & outward migration plus trend over last five years. It does not take housing development into account and is widely accepted to underestimate the population and so is not widely used among local authorities in London and therefore is discounted here. GLA (revised low) projects future population using trend natural growth and migration and then distributing this between boroughs in proportion to predicted numbers of dwellings. GLA takes housing development into account but ONS does not. The table below compares ONS to GLA. It is important to understand that ONS population projections are the basis of the NHS allocations formula. The analysis shows that there is substantial variation between ONS and GLA populations which give rise to theoretical funding shortfalls. The table shows that for England and London the variation between ONS and GLA populations is nil or negligible. However for North-East London in general and Tower Hamlets in particular the variation is very significant. As at 2011 there is a net GLA population which is 18,000 headcount higher than the ONS population on which the PCT financial allocation is based. This is a 7.9% variation which in resource terms would mean that, crudely, actual resources were 7.9% less than required worth approximately 39 million gross. Actually, a non-recurrent allocation was allocated to those PCTs with high population growth from 2005/06 up to 2007/08 but this ceased in 2008/9. This was a marginal rate per head of around 1000 plus MFF. Even at that level, NHS Tower Hamlets is short by around 20 million on its resource allocations. 36

37 Table : GLA and ONS Population estimates and projections for NE London PCTs at Jan 10 Type England London North East London Tower Hamlets base_ye ar Dat a ON GLA as % of S ONS % % % % GL GLA less A ONS ths ON GLA as % of S ONS 99.2% 99.8% % 99.8% GL GLA less A ONS ths ON GLA as % of S ONS % % % % GL GLA less A ONS ths ON GLA as % of S ONS % % % % GL GLA less A ONS ths Planning for Population Change & Growth - PPCG NHS Tower Hamlets has developed a bespoke planning tool based on the GLA planning model in partnership with the London Borough of Tower Hamlets. This is called the PPCG model. Both the GLA and PPCG do take housing development into account. They mainly differ in that GLA looks at housing growth at a strategic plan level whilst the planning for population change and growth (PPCG) model has made an assessment of all potential development sites in the borough of Tower Hamlets so the PPCG model considers population at a much finer level and so is the preferred option for PCT planning. The population projections for GLA and PPCG are broadly similar although the phasing is slightly different as PPCG has taken account of the impact of the recession on new house build starts whilst GLA has not The PPPCG model gives the following projection of population growth to 2014 note this has been run since the start of the recession which is why it shows a slow down a period of little growth and then picks up again. Population growth up to 2014/15 will be just over 20,000. A comparison between GLA 2008 low and PPCG is shown in the graphs below - GLA starts higher then reduces over the CSP period. However GLA (low) has not been re-run post recession to take account of the decline in planning applications and building developments. PPCG is a live model so has been updated post current recession shows a decline a period of stagnation followed by a return to growth. Start End Persons % Headcount % % % % % 8913 Total

38 By 2014/15 the population of the borough can be assumed to have increased by just over twenty thousand people. The current mechanism for calculating PCT resource allocations does not include funding for such population growth. The hypothetical capitation growth funding element for the NHS is around 1,000 per head which means that the PCT faces a shortfall of 20 million to fund healthcare services for its new population by 2014/15. The problem is exacerbated by the recalculation of the allocations formula last year. This significantly adjusted the differential weightings used in the formula with the result that there was a significant notional resource shift away from PCTs with a relatively young population to those with a more elderly one. The relative weighting of the health inequalities parts of the formula was proportionately downgraded also. In principle poor inner city PCTs saw a shift of notional resource to typically rural based PCTs with more elderly populations but arguably less health inequality. This moved NHS Tower Hamlets from being significantly under capitation target resources to being significantly over target. The very small amount of additional funding we used to get from movement toward target funding has therefore now become a small funding cut to compensate those PCTs now newly under-target. Not only does the PCT not receive any funding for significant population growth but is has also moved over its capitation based target resources and is being managed back down toward that. Evaluation of the NHS Tower Hamlet s CSP will need to take account of the unfunded population growth pressures it is facing, pressures that many other PCTs are not facing. The INEL sector has two PCTs Tower Hamlets and Newham with some of the largest population growth projections in England. The table below outlines what the impact of the expected population growth is on the THPCT's demand and activity projections assuming two different population growth figures the first one average national population growth and the second one the real figure being used by NHS Tower Hamlets in its planning assumptions. It compares the cost of the Tower Hamlets current year population plus average national growth with local PCT growth pulled through the detailed activity and planning model, using our PPCG model. 2009/10 000s 2010/11 000s 2011/12 000s 2012/13 000s 2013/14 000s 2014/15 000s Local Growth National Growth Difference (local - National)

39 The table above shows that irrespective of the argument around the hypothecated level of NHS resources which ought to be identified at a capitation level, the incoming population can clearly be seen to have a marginal impact on the overall coast of healthcare in the Borough for which NHS Tower Hamlets is not funded. The cumulative value of this by 2014/15 is just over 21 million which is very close to the GLA/ONS variation. PPCG and GLA assumptions are very similar apart from the phasing differences generated by the recession. The conclusion from this section is that NHS Tower Hamlet is carrying million of costs which are entirely driven by population growth and that most other England or London PCTs do not have this level of unfunded cost pressure. This will impact significantly on the ability of NHS Tower Hamlets to achieve financial balance over the term of the CSP and beyond that. Conclusion The preceding sections on health needs, community intelligence, performance and finance highlight a compelling case for change in Tower Hamlets. We have deep-seated health needs and inequalities that although we can see improvements, they are not reducing fast enough. There is undue variation in clinical outcomes and performance between different practices that are improving significantly but we must push that improvement deeper and sustain it. We know that there is too much care taking place in high cost hospital settings and we want to drive greater care closer to peoples homes. Perhaps most significantly of all, we know that there is a sea change in the financial resources available to the PCT and for the public sector more broadly going from a period of significant investment ( 100m over the last five years) to one where we will have to deliver savings through productivity, decommissioning and shifting care to lower cost settings to create the resources to invest in services. We believe that if we are to continue delivering health improvements with less resource then we need quicken the pace of change that we have already started. This means that we will take a transformative approach to our CSP with priority given to securing an affordable health economy over the next five years. The next section draws on the analysis here and sets out our strategic outcomes for the next five years. 39

40 4 Our Strategic Outcomes During 2009/10 we made significant progress against some of the most significant health needs within our community: % Patient Satisfaction with GP Access 2006/ / /2009 NHS Tower Hamlets NHS London GP Access We are the most improved PCT nationally for a second year running. We have improved greatly from being the worst ranked PCT in the country in 2006/2007; in 2009/10 residents of our borough experienced the same ease of access as the rest of London. This improvement has been made due to the development of our robust visual management tools and Access LES. Source: National GP Patient Survey Rate per 100,000 NHS Stop Smoking Services Quitters 2006/ / /2009 NHS Tower Hamlets NHS London Stop Smoking Services We are the 5 th best performing PCT with regard to smoking quitters nationally. We significantly exceeded our 2008/2009 target of smoking quitters (1361 quitters per 100,000 vs target.) This 13% over performance is attributed to programmes such as the Bangladeshi Stop Tobacco Project in the community and the hard work of local GP s and pharmacists in encouraging referrals. Source: NHS Information Centre Breast Cancer Screening We improved our performance by 10% in 2008/2009 thanks to our focussed efforts in increasing uptake through effective social marketing. 65% of eligible women have now received breast cancer screening within the last 3 years, and our improvements leave us well placed to meet the national standard of 75%. Progress on other Strategic Outcomes We have implemented key initiatives which have helped us make positive progress in achieving our remaining strategic outcomes: Diabetes and Immunisations care packages Development of Primary Care networks Collaborative work with Tower Hamlets Partnership to reduce the year-on-year rise in childhood obesity Development of primary/secondary care Mental Health interface Roll out of NHS Health checks Our Strategic Outcomes 2010/2011 As part of our 2010/11 CSP we have chosen ten strategic outcomes to support our strategic priorities. Our Joint Strategic Needs Assessment has been the cornerstone to identifying these goals and we remain committed to the outcomes which have the greatest impact on local people. 40

41 The table below is a summary of our planned year-on-year trajectory for achieving each of our 5 Year Strategic Outcomes: Change Outcome Goal (measurement) Mandatory Mandatory Mandatory Mandatory Health inequalities (male) Health inequalities (female) Life expectancy (male) Life expectancy (female) Slope index of inequality for life expectancy at birth at LSOA Slope index of inequality for life expectancy at birth at LSOA Improvement aspiration (5 years) Rationale for aspiration Y3 Y4 Y5 Y6 Y New indicator; additional modelling being carried out after consultation with partner PCTs/LHO New indicator; additional modelling being carried out after consultation with partner PCTs/LHO Life expectancy (DSR) Trajectory is based on ambitious National Spearhead indicator targets Life expectancy (DSR) Trajectory is based on ambitious National Spearhead indicator targets X Diabetes % diabetic patients with blood pressure of 145/85 or less X Child imms % children receiving MMR (I+II) by 5th birthday 85.12% 86.09% 87.06% 88.03% 89.00% The trajectory has been set as the average rate of increase from the last 2 years to continue to % 90.5% 91.0% 91.5% 92.0% Aspiration to become best in England X Breast screening % breast screening coverage age % 70.0% 72.0% 74.0% 75.0% Aspiration to meet the national standard of 75% Child obesity % obese children in Y6 (VSB09) 25.5% 25.9% 26.2% 26.4% 26.5% Continued strive to achieve ambitious targets of reducing upward rise in childhood obesity given particularly high levels of year 6 obese children in borough X Smoking cessation Rate of smoking quitters per 100,000 aged 16 or over CVD mortality CVD mortality DASR per 100, (07 09 result) Target trajectory increased to achieve Top 5 level performance in England We have set ambitious targets to reduce gap between ourselves and other London PCTs X GP access % satisfaction with 48 hour access 85% 86% 87% 88% 89% PCT to match current best in London performance X Mental health % patients with severe mental illness with a review of their physical health recorded in the preceding 15 months 93.0% 93.5% 94% 94.5% 95.0% PCT to achieve current best in London performance Our approach to Refreshing Strategic Outcomes Strategic outcome teams and NHS Tower Hamlets Delivery Improvement Unit (DIU) have applied a framework to identify priorities which has been tested as part of local CSP goal delivery routines. We have applied a challenge process that requires delivery teams to think through sub-metrics, rationale, relative benchmarking (e.g. best in England, best in London), available levers for change, and how our goals help us address the affordability agenda and moving care closer to home. All strategic outcomes are either listed in DH guidance on WCC or nationally benchmarkable for the previous 12 months. We have elected to change some of our trajectories due to our excellent performance in meeting our outcomes in 2008/2009: Our continued excellent progress in encouraging smokers to quit has led to an increase in the ambition of out smoking cessation goal assuring we continue to achieve top 5 performance nationally. We have increased the ambition of our breast cancer screening goal in order we meet the national standard of 75%. We have revised our GP Access goal trajectory in line with changes in national patient survey methodology. 41

42 Rationale for Strategic Outcomes We have detailed below our rationale for choosing our ten strategic outcomes and the associated improvement trajectories: Slope Index of Deprivation High priority due to 8 year gap in male life expectancy in different wards Department of Health Strategic Outcome for all PCTs Our delivery plan will be targeted at the least well off within our community We have modelled our trajectory based on our life expectancy goal, guidance from the London Public Health observatory and partner PCTs Life Expectancy Department of Health Strategic Outcome for all PCTs We have modelled our trajectory based on our Vital Sign All Age All Cause Mortality targets Based on local application of PSA target of reducing gap in life expectancy between national average and spearhead PCTs Diabetes This outcome has been selected as a high priority given its high prevalence within our community. We have shifted from a controlled Hba1c outcome to blood pressure due to clinical guidance that it offers the most high impact and cost effective intervention for our population Our trajectory has been selected based on past historical performance Childhood Immunisations We will strive to continue delivering our ambitious improvement trajectory which recognises the clinical importance of immunisations on child health WHO research suggests immunisations are one of the single most effective health interventions per LYG We are aiming to increase performance above the current best in England England average 08/09 81%, London average 69% 42

43 Breast Cancer Screening Breast screening remains a priority in our 2010/11 refresh due to our historically low uptake levels We aim to increase early detection of breast cancer through a highly successful screening programme Our aim is to achieve national standard performance of 75% which we believe is achievable given our 10% rise to 65% in 2008/2009. England average 08/09 78%, London average 64% Childhood Obesity Childhood Obesity remains a strategic outcome due to its growing significant as a health challenge within our community Levels of obesity are above London and National average We have developed a delivery plan using national and international best practice to reduce the year-onyear increase in rates Although our trajectory is extremely ambitious and developed prior to having historical data, we remain committed to addressing the challenge Stop Smoking Services We remain committed to increasing the number of smoking quitters through NHS services Evidence suggests for every 80 needed to treat, one premature death is avoided Smoking cessation services are some of the most cost effective health interventions available (West 2006) We have increased the ambition of our trajectory in order that we remain a top 5 performing PCT England average 08/09 813, London average 761 CVD Mortality CVD Mortality remains a challenging yet crucial outcome as we have some of the highest rates in the country We are developing an integrated vascular strategy which is making a positive impact on achieving our outcome The rationale behind our trajectory is to reduce the absolute gap between NHS Tower Hamlets and England mortality rates England average , London 89 GP Access Satisfaction with 48 hour access remains one of the most important aspects of healthcare delivery We have made significant progress in recent years and are striving to be the best in London during the next 5 years Maintaining good levels of access in primary care is crucial for delivering the Care Closer to Home and Primary Care Networks agenda. England average 08/09 85, London average 81 43

44 Mental Health We want to ensure patients with serious mental illnesses undergo a physical health check every 15 months with their GP This goal has been chosen because patients with serious mental illnesses are at considerably greater risk of physical ill-health than the general population. We aim through this strategic outcome to achieve best in class performance for London Our Process for Engaging the Right Stakeholders at the Right Time 44

45 5. Healthcare for Tower Hamlets: Putting HfL into practice Introduction HfL uses eight broad patient pathways that set out the changes necessary to deliver first class health and health services for London. These pathways were developed through clinical working groups and refined further by more detailed clinical and community engagement. They are: Maternity Children and young people Staying healthy Planned care Long term conditions Unplanned care (emergencies) Mental health End of Life Health for North East London (Health4NEL) Programme was launched formally in March 2009 with Making Healthcare for London happen in North East London. This case for change was framed within HfL and presents a compelling argument that acute reconfiguration is required across north east London to meet increasing health demands and improve health outcomes and services. There is more information set out in the Integrated Sector Commissioning Plan and Health4NEL. The initial proposals for reconfiguration are out for formal consultation at present (November 2009 to March 2010). It is recognised however, particularly given the financial challenges ahead, that we will need to keep the future acute configuration under review across NEL to make sure it delivers the improvements needed. This will have ongoing implications for the application of Healthcare for London including polysystems - across north east London. To ensure our CSP is framed around HfL and took account of Health4NEL, we conducted a detailed analysis against each of the Darzi pathways. We did this in five stages. 1. We developed an outline of the Darzi pathways with detailed supporting metrics, information and benchmarks so we started with a model of good practice. 2. We reframed our Health Needs Assessment drawn from our JSNA across the pathways 3. We assessed our current progress against each of the pathways 4. This was then used to develop a vision against each pathway of what we wanted to achieve over the lifetime of our CSP 5. Drawing on the good practice information and data, our assessment of progress and vision, we then agreed the key gaps and challenges that faced us in delivering the pathway. 6. Finally we set out the key initiatives that we needed to pursue to realise our vision. This process was aligned across ELCA through a series of workshops where we developed the methodology and then considered our initiatives collectively so that our initiatives were aligned across the sector. The outcome for each pathway is set out below. The ELCA initiatives to support pathway implementation are set out in the ISP. Maternity The Maternity pathway is based on four stages - pre-pregnancy care, antenatal care, care during labour and delivery and postnatal care. 45

46 Needs There were 4,255 births to women resident in Tower Hamlets in 2008/9. This equates to a birth rate of 68 per 1000 which is close to the London average and higher than England. 45% of births are to Bangladeshi mothers, 14% to White mothers and 7% to Black African mothers. Risk factors for poor outcomes in pregnancy specific to Tower Hamlets are high social deprivation, high smoking rates in the white population (overall rates are low due to low smoking in the Bangladeshi women), teenage pregnancy (rates are lower than London but have recently started rising), late booking (although this has improved markedly over the past few years) and rising rates of gestational diabetes. A higher proportion of newborn babies have low birth weight (<2500g) compared to London and the highest are to Bangladeshi mothers. Despite this, infant and perinatal rates are not significantly different to London or England. Our Vision for Maternity To deliver early assessment of pregnancy by a midwife to ensure care is right for them and high quality information to inform choices about where to have their baby and pain relief; care before and after birth is provided at local one-stop centres; services that meet womens' choice of where they give birth e.g. at home, in a midwifery unit, or in an obstetric (doctor-led unit); one-to-one midwifery care during labour; Strong links with GP networks, Children centres and extended schools Our progress to date Our Improving Maternity programme involves significant engagement through our Maternity Services Liaison Committee that has increased satisfaction. We have: Increased antenatal appointments in community settings with emphasis on health promotion, prevention and early identification Introduced postnatal clinics in children centres and community settings Opened the successful Barkantine birth centre and increased capacity in community midwifery To meet the challenges over next five years, we will: Continue to implement our Improving Maternity Programme including Maternity Services Liaison Committee and Maternity Strategic board Implement direct access to midwifery services including central booking in 2010/ 11 Increase antenatal and postnatal care in community by establishing post natal clinics in 2010 /11 Developing and implementing low risk pathway maternity to ensure care is delivered in community settings Develop multi disciplinary pathways that work across care settings and boundaries Define further standards for practitioners and services and support through workforce development training and education Extend further our links to the sector maternity networks GP networks, children s trust partnership children centres and extended schools Children and Young People The children s pathway is focussed around prevention, identification, assessment and early intervention (primary care), as well as urgent care and planned care. Needs There are an estimated 56,400 under 19s in Tower Hamlets (24% of the population similar to London). 60% of under 20s are Bangladeshi compared to 25% over 20s. 46

47 Three indicators of good nutrition in under fives are breast feeding rates, oral health and childhood obesity at reception year. The most recent reliable data (2007/8) indicates that breast feeding initiation rates are higher than London although there are significantly problems obtaining reliable data on breast feeding at 6-8 weeks. Availability of timely, accurate data is limited by problems with the child record system. Tooth decay rates in five year olds have historically been higher than London but there is recent evidence that the gap is closing. Tower Hamlets aged 4-5 had the fourth highest prevalence of obesity in London. The commonest long term conditions in children and young people is asthma (4,460 cases in under 19s in 2008/9) followed by epilepsy (125 cases) and diabetes (74 cases). In 2008, there were 3053 children on the borough s disability register and 545 with learning disabilities. The number of children on the Child Protection Register increased from 77 in 2004/05 (15.9 per 10,000) to 267 in 2008/09 (38.9 per 10,000) with the greatest increase in Bangladeshi children. The percentage of deregistration (an indicator of effective child protection work) was lower in 2008/9 (2-3%) compared to England (4%). Trends in rates of Looked After Children have been opposite to those for children with protection plan and fell between 2004/5 and 2007/8 (possibly reflecting improvements in prevention). Vision Our vision for children s health services is that children and their families can access high quality, personalised care and support when they need it and as close to home as possible. The whole system will work together effectively and will represent a good return on investment, both in terms of value for money and value to the public. Vision for Children s Services We have made very good progress with implementing the healthy child programme including: Prevention: Initiatives in smoking, obesity, breast feeding support, immunisations and vaccinations commissioned and in place Community Initiatives to expand the hours of the community children s service commissioned with a planned start of April 2010 Health care is commissioned from the local authority and being delivered in children centres Family Nurse Partnership programme an intensive home visiting programme for at risk parents has commissioned jointly with Tower Hamlets Council and is being piloted But we know that there is more to do including: Reviewing whole system effectiveness and value for money 47

48 Reviewing the effectiveness of local prevention interventions such as obesity, smoking prevention and family nurse partnership Integrating further across primary and secondary care and Council services to deliver the pathway for children including community nursing teams working reduce the admission of children to hospital and increase early discharge Improving the coordination of services between hospital and home and school for some children with disabilities Developing the pathway so that children with palliative care needs have access to end of life care at home. To meet these challenges, we will: Move care closer to home by providing more planned care locally and investing in community children s nursing team to provide care for children who are ill have long term conditions or complex health needs. The service will commence in April 2010 Commission a 24/7 children s urgent care facility as part of the wider urgent care initiative which will open in 2011 Increase the proportion of children s health care in non acute settings by commissioning community based children outpatient clinics for non acute medical conditions. The clinics will begin in September 2010 with a planned shift of 50% of new referrals in paediatric medical outpatient care Create more appropriate access points for children s unplanned care in urgent care spokes located within our polysystems from Commission an outreach service for children with palliative care needs in 2010/11 Create multi disciplinary teams that work across care settings and boundaries to ensure that services are centred and delivered around the child. Staying Healthy The Staying Healthy pathway covers four areas; the determinants of health such as poor housing; healthy lifestyles; protection and the early detection of disease and prevention in health services. Wider Determinants Lifestyle Changes Protection Early Diagnosis and Disease management Tower Hamlets Partnership Community Plan / LAA Core Strategy and planning Education Planning Regeneration Tobacco Alliance smoking quitters Diet & exercise children, adults and Healthy Borough Alcohol and Drugs Mental health promotion Health trainers Child Immunisation Sexual health HIV, teenage pregnancy, Chlamydia, STIs TB Adult Vacs including flu Pollution Cancer screening Care packages, e.g. diabetes and cardiovascular disease Networks and links with better management of LTC This section particularly concentrates on lifestyle, health protection, cancer (other specific long term conditions are in the long term conditions section) and healthy employment. For lifestyles the approach is similar in each area: stopping people starting unhealthy behaviour (with a focus on young people), helping people stop unhealthy behaviour (such as smoking) and creating a 48

49 supportive environment that helps promote healthy lifestyles such as cycling lanes, improving access to green spaces and increasing the availability of healthy food. For health protection the priorities are to prevent transmission (either through behavioural change or immunisation), identifying and treating infected people early, preventing onward transmission and improving outcomes and reducing complications for those affected. This pathway also recognises the link between employee wellbeing and productivity. NHS employees are on average absent through sickness for 10.7 days a year compared to 6.4 days in the private sector. There is evidence that as staff health and wellbeing improve so do indicators such as patient satisfaction. Needs Evidence indicates that people adopting four healthy behaviours (not smoking, physical activity, moderate alcohol intake and five a day) potentially have a life expectancy 14 years longer than people who adopt none of these. Based on findings from our own TH local healthy lifestyle survey, one in four of adults in the Tower Hamlets population adopt none of these. Tower Hamlets has the highest death rate attributable to smoking in London. 1 in 5 children under 15 have tried a cigarette and 4 out 10 retailers are selling cigarettes to under 18s. 27% of adults smoke compared to 21% nationally with particularly high smoking prevalence in Bangladeshis males. Low smoking prevalence in pregnancy masks particularly high rates in the white population. Tower Hamlets children have the fifth highest obesity prevalence in London at reception year and the second highest at year 6. Lower proportions participate in physical activity and eat five a day. The picture in adults is similar with 9 out of 10 eating less than five a day compared to 7 out of 10 nationally. A lower proportion participates in sport/active recreation (18% compared to 21% nationally) and participation rates are particularly low in Bangladeshi females. 3 in 10 of Tower Hamlets children have ever had an alcoholic drink compared to 7 in 10 nationally (reflecting the large Muslim population in the borough). Similarly, 1 in 2 of adults say they have not had any alcoholic drinks in the past year. In the White population, 4 in 10 are classified as harmful drinkers compared to 2 in 10 nationally. Despite low prevalence of alcohol use, alcohol related admission rates are higher than London averages. The incidence of sexually transmitted disease has plateaued over the past few years following the sharp rise at the start of the decade. Teenage pregnancy rates are lower than London averages but have stopped falling in the past few years. Prevalence rates of both HIV are the third highest in North East London and significantly above London averages. 7 out of 10 cases due to sex between men and 2 out 10 to sex between men and women. 20% were diagnosed late compared to 30% across the NEL sector. Prevalence rates for tuberculosis have been rising slowly over the past few years and is significantly above London levels. The proportion of patients with TB that have a recorded offer of HIV testing, recorded risk assessment for illicit drug use and completion of treatment within one year are slightly lower than NEL averages. Although childhood immunisation uptake is higher than London, MMR uptake at 24 months and 5 years remains well below herd immunity. Seasonal flu uptake is adequate in over 65s (75%) but low in under 65s with long term conditions (54%). The overall mortality from cancer is high, the largest contributor being lung cancer. However we have relatively poor survival rates, particularly at one year which suggests late presentation and diagnosis. Breast cancer in particular has relatively poor survival rates and we have a low uptake of screening. 49

50 Our Vision and progress Our vision is to make Tower Hamlets a place where it is easy to be healthy, where people have sufficient information and incentives to adopt healthy choices and there is the social and physical environment to support healthy lifestyles. Our progress includes: A comprehensive Tower Hamlets Partnership Tobacco Control Strategy: Stopping people starting (enforcement under 18 sales, work in schools), helping people stop (commissioning range of cessation services) and smoke free Tower Hamlets (maximising impact of smoking ban). This has been supported by significant investment in tobacco control and has been very successful, as measured by smoking quitters (5 th highest rate in England). The Tower Hamlets Partnership Healthy Weight, Healthy Lives strategy: We have invested significantly in addressing obesity over the last 2 years. We were awarded Healthy Borough status by the DH this year, 1 of only 9 areas nationally, on the strength of our joint strategy and its implementation. As emphasised by the Foresight report obesity is a complex problem and includes environmental issues such as making healthier food more easily available and increasing walking and cycling routes, initiatives to encourage healthy eating and physical activity in children and young people and implementing childhood and adult obesity care pathways including weight management services. We are refreshing our joint alcohol strategy and have invested in brief interventions in primary care, diversion at accident and emergency, commissioned social marketing looking at drinking amongst young and older people, re-commissioned and increased capacity at our community alcohol services, taken action to address alcohol availability and the broader promotion of healthy drinking. Supporting work in all this three lifestyle interventions are other initiatives, such as our health trainers programme; the provision of advice on health, based within local community groups and our public healthy lifestyle programme managers who are working closely with primary care networks to integrate health promotion. For health protection our vision is to minimise the incidence of infectious diseases, reduce their spread. Our progress includes: By improving the data available, social marketing campaigns and focusing on poorly performing practices, we have improved immunisation rates over the last two years and are among the better performers in London. Our uptake of seasonal flu vaccine amongst older people remains consistently over 80% and our performance in tackling swine flu has been described as one of the best in London by the HPA. Our performance against the London TB quality criteria remains good consistently and although there is a high incidence of TB, our strong service includes an outreach team for vulnerable and disadvantaged people such as homeless people. We have a high incidence of HIV / AIDS and a relatively high late diagnosis rate. Through a combination of increased availability, publicity and working with communities we have increased the uptake of HIV tests and are reducing the proportion diagnosed late; by 10% over the last year. Work on sexual health is clearly linked with initiatives to reduce teenage pregnancy rates which remain relatively high, although we have achieved a more significant reduction in rates than most of the rest of London. We have performed consistently well in achieving the screening target for Chlamydia. On cancer our vision is to significantly reduce the incidence of cancer through prevention and enable members of the public and clinicians to identify rapidly and refer to effective services and provide continuing support including high quality palliative care. Our progress includes: 50

51 Implementing the relevant prevention initiatives described above. In addition other cancer specific prevention such as cartoons conveying messages on risk and symptom awareness, addressing potential literacy issues; a health literacy programme within ESOL classes etc A 10% improvement in breast screening coverage, as a result of comprehensive programme of initiatives, including locally based facilitators supporting groups of general practices to implement best practice, community outreach including working with community organisations and housing associations to encourage participation, iplato text messaging, improvements to the flexibility and accessibility of the breast screening service, targeting women who haven t attended etc. Significant programme of work to improve screening services and uptake for cervical and bowel cancer. Finally for promoting the NHS as a healthy employer, our aim is to protect, promote, maintain and improve the physical and mental wellbeing of NHS staff, and through them, service users, partner agencies and the wider community. Our initiatives include: Adopting a Health and Wellbeing at Work Policy, strategy and action plan in 2009 and joint Healthy Workplace Manager and joint active travel promotion officer with Tower Hamlets Council. Working with the Centre for Workplace Health and East London Business Alliance to provide support and resources for at least 35 businesses and organisations in Tower Hamlets to become accredited Healthy Workplaces by Working with BLT to become a Health Promoting Hospital Our Mental Health Model Employer project to improve the mental health of staff including training and guidance for managers in mental health issues and access for individual employees to mental health support services Achieving accreditation in the Healthier Food Mark Scheme Our key challenges Despite our achievements, we face a number of challenges in implementing further the Staying Healthy pathway. These include: Healthy Lifestyles: In each of the main areas there remain significant challenges: Although we have had considerable success in supporting people to quit our local data tells us that there are over 50,000 smokers locally. We need to maintain our initiatives across all areas of tobacco control, but review the effectiveness of our existing interventions and focus on harder to reach communities and the most effective interventions. Achieving change on levels of obesity is clearly a long term challenge and whilst rates have decreased in 4-5 year olds they remain high and have been increasing in year olds. We will need to ensure we are focusing sufficiently on younger children with health visitors and children services, strengthen the engagement of partners into our school based health promotion work and improve engagement of partners and evaluate and redesign our child weight management services. Our work on alcohol is at a relatively early stage and the challenge will be to successfully implement our existing initiatives, ensure that population changes and the ongoing process of acculturisation does not increase hazardous and harmful drinking and work more closely with Tower Hamlets Council and local business on the cost and availability of alcohol for example. There is much to be gained by better integrating this work more closely with mainstream services and ensuring screening and brief interventions are a routine part of service provision. We have commissioned a significant program of social marketing initiatives and there is a great deal to be gained by better co-ordination. 51

52 Health Protection: Whilst we have performed relatively well on immunisation, there remains a significant challenge to achieve herd immunity, which is our aspiration. For some hospitalised patients with TB who are medically fit for discharge, but are without accommodation and those requiring supported housing to ensure adherence to TB therapy there is a need to find ways of supporting that. Our uptake of seasonal flu vaccine among younger at risk groups is relatively low and we want this to reach the levels achieved for older people. We want to reduce the incidence of HIV/AIDS and increase cases found at an early stage. We will need to ensure that our good performance on Chlamydia screening includes reaching those at higher risk with a higher proportion of positive tests. Recent data on teenage pregnancy are very encouraging and suggest that our rate is falling further still, but achieving a 55% reduction from remains a challenge. Cancer: Screening uptake remains below the national standards for all cancer screening. Relatively poor 1-year survival implies late detection of cancers, suggesting that patients often identify symptoms late or they are not picked up in primary care To maintain and improve waiting times for assessment and treatment Services for patients with lymphoedema, psychological support and follow up for those who have had cancer needs strengthening. Healthy Employees: Improving our management of sickness absence including better sickness reporting, promoting healthy lifestyles further by signing up to Cycle to Work, improving the availability of healthier food choices and making sure that occupational health at BLT is engaged fully in healthy workplace initiatives. Considering how we can give healthy opportunities to all staff including those working away from main sites or on shift and night staff. Extending Health and Wellbeing policy across all employers including Tower Hamlets Council and making it easier for staff to make changes in their working practices to contribute to sustainable development, financial savings and improved health. To meet the challenges we will: Healthy Lifestyles: Continue to deliver our programmes on tobacco control, healthy weight, healthy lives and safer drinking, e.g. delivering at least 200 more quitters in 2010, making a total of 2100 focusing on areas of greatest need, 370 children, 250 adults attending weight management programme and 550 referred for exercise on referral in For alcohol we aim to get increased coverage for the locally enhanced service to all practices and increased from 30-50% of new patients being offered an audit C alcohol screen to 70% in 2010/11. Integrate health promotion in all primary care networks to systematically deliver screening and brief interventions to promote healthy lifestyles. Health Protection: Improve further our programmes for immunisation and vaccination including the delivery of a care package through primary care networks and improve uptake of seasonal flu vaccination amongst the younger at risk groups: to establish the immunisation care package in all networks, achieve our CSP and vital signs in 2010 for childhood immunisations, 80% uptake of seasonal flu vaccine amongst older people and 60% amongst younger at risk groups. Continued implementation of our sexual health strategy including providing young people friendly contraception services and effective delivery of SRE in schools and non-school settings, target 52

53 interventions around HIV: for example we will screen 35% of young people aged 15-24years for Chlamydia. Cancer: Work with ELCSACU to improve services at BLT and contribute to sector wide initiatives to improve screening uptake, including social marketing. Strengthen the engagement of primary care in the increasing the uptake of all 3 cancer screening programmes alongside wider outreach initiatives. Put in place a programme of work to improve local awareness of cancer symptoms and the speed of referral and diagnosis; this will include a validated survey of population knowledge, a retrospective audit of 40 GP records and developing, implementing an education package for GPs and other frontline staff, the audit will be complete by March 2010 and 16 locality based sessions are planned from March-December 2010 to train clinicians in early detection and timely referral. ELCSACU will drive the improvement of cancer waiting times through its performance framework with Bart s and the London NHS Trust, supported by the NEL Cancer Network Improve the psychological support for people with cancer by training healthcare professionals in counselling Improve services for the survivors of cancer by commissioning a survivorship service to identify people in need of help and signpost them to the relevant service. This service will also provide cancer education and training to Tower Hamlets community staff and in-reach into tertiary settings to promote uptake of services and link with the patient support centre. Timescale service to start in full April 2010 Continue developing & embedding a lymphoedema care pathway and configure the lymphoedema service to see patients with cancer related lymphoedema. Timescale ongoing Healthy Employer: Review our strategy and action plan to take account of the recommendations of the NHS Health and Wellbeing Review (November 2009) and NICE guidance on Increasing Physical Activity in the Workplace and Improving Mental Health in the Workplace: the related actions have timebound metrics e.g sign up for Mindful Employer status (July 2009) provide access to training and guidance in managing staff with mental health issues, including Mind s in-house training programme (starting 2010), commission, promote and evaluate an early intervention service for staff with musculoskeletal problems (starting Jan 2010). Embedding measures to promote healthy employees in our specifications with all providers and including these within our performance management and monitoring regimes from Planned Care Needs Based on NHS Comparators data 08/09, Tower Hamlets has amongst the lowest standardised outpatient first attendance rates in London. Whilst average outpatient to follow up is similar to London (2.3 compared to 2.2), the percentage of outpatients discharged at first appointment is the lower in London and the percentage of outpatients who did not attend is the second highest. Standardised elective admission rates are the lowest in London. Elective inpatient rates and day case rates are correspondingly low (day case rates are the lowest in London). Mean length of stay is the fourth highest in London (07/08 data). Data from the 08/09 GP survey indicates performance on access close to London averages. The percentage reporting that they are able to get an appointment within 48 hours (79.6%) is similar to the London average but this reflects the fastest improvement in London compared to 07/08. Satisfaction with telephone access, ability to book an appointment in advance and opening hours is higher although ability to get an appointment with a specific GP is lower. Satisfaction with the experience of consultation is 53

54 consistently close to but just below the London average. Findings from the Annual Residents Survey 2008/9 indicated that 65% of local residents rate their health services as good or excellent. This is similar to London averages but represents a 6% increase from the previous year. Our Vision We want to create improved access to services in community settings and create new ways of working with clinicians using care networks. We also want to separate the provision of elective and non-elective care to improve efficiency and quality and delivery in inpatient care. Our aspiration is to identify the configuration and enablers required to deliver care closer to home within expected funding over the next 10 years. This will include: Access to surgery, diagnostic and specialist opinion including minor procedures, routine diagnostics (x-ray, u/s, phlebotomy) and greater access to specialist opinion New ways of working through integrated clinical networks that streamline the flow of patients across integrated care pathways, target expertise where it will have most impact with specialists supporting multidisciplinary team reviews, providing advice and seeing the most complex patients and regular review of performance against true quality outcomes Separating elective and non-elective patient flows to maximise quality and productivity. Our Care Closer to Home programme is focused on shifting planned care from acute settings to the polysystem and this is described in more detail in section 6. Long Term Conditions The long term conditions pathway covers prevention and early diagnosis, integrated primary and community care, ambulatory specialist input, inpatient and acute care and end of life care. Needs Tower Hamlets has the second highest age adjusted mortality rate in London from deaths amenable to healthcare. Most of these are due to cardiovascular disease, cancer and chronic respiratory disease. For these conditions, Tower Hamlets has either the highest (cancer, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD)) or the second highest (all circulatory diseases, stroke) mortality rates in London. Around 9000 people aged 40 to 74 are estimated to have a 20% risk of a cardiovascular disease event in the next ten years. National prevalence models do not work well with our local outlier population (high ethnicity, young population) and we have therefore had to develop our own local bespoke model. This suggest underdiagnosis across all long term conditions but particularly hypertension, CHD, chronic kidney disease (CKD) and COPD. Outcomes in primary care are generally well above national averages for secondary prevention of vascular disease through management of blood pressure and cholesterol control in CHD, diabetes, stroke (the exception is blood pressure control in stroke patient which is 140 th in the country). On all indicators there are wide variations between practices which are not necessarily linked with differences in practice population. Secondary care standardised admission rates for CHD, stroke, heart failure, coronary heart disease and COPD are the highest in London. Vision Our vision for LTCs is to reduce the variation in delivery and quality of care delivered across the borough, and to reduce the gap between observed and expected prevalence for the key long term conditions. Our aim is to commission a model of integrated care across health and social care, with clear outcomes, providing effective best value care. 54

55 We are aiming to commission services that are accessible, of high quality, equitable, integrated and that offer choice, maximise self-management and quality of life through providing holistic care. Our progress We have made significant progress in commissioning effective interventions and models of care to meet the requirements of NICE guidance and the National Service Framework for Long Term Conditions. The JSNA and Public Health data has influenced the location and delivery of specific services. Our Primary Care Investment Programme (PCIP) aims to standardise patient care across the borough. It is part of our joint Tower Hamlets Integrated Care Agenda with Tower Hamlets Council. It focuses on: 1. Developing well-defined care packages for priority conditions based on high clinical quality standards and set out the care patients can expect. 2. Investing in eight primary care Networks of providers. The networks are sharing resources to work together to deliver high quality specialist services, for example for those with long term conditions like diabetes. This investment is improving management, administrative and clinical leadership and making it easier for providers to work together to deliver consistently high quality care. Three networks began delivering the first care packages in September 2009 and these will be rolled out across all networks and further care packages developed including for CVD and COPD. To improve further we need to: Develop our Networks further, as they are a relatively recent change in the provider landscape and an innovative and new way of working Review whole system effectiveness and value for money so that our LTC services match current and future need, are of high quality, improve productivity and value for money. Improve prevention and early diagnosis including evaluating the effectiveness of prevention activities, understanding better the variation in prevalence rates given differences in demography within the borough and having clearer referral thresholds for diagnosis or specialist advice Integrating primary and community care with proactive regular planned review commissioned for all LTCs, clear points of access to all commissioned services for patients / families / carers, Clinical pathways linked using shared records and joint care plans and ensure the skill mix and competencies of the workforce Review ambulatory specialist input to ensure specialist teams commissioned from community health services are providing co-ordinated, cost-effective and coherent care and working effectively to reduce unnecessary A&E admissions and improve discharges. To meet these challenges, we will: Stratify our population to identify at risk groups for each care package (Diabetes complete, Respiratory disease 2010, 2011 for CHD) and target behaviour interventions Continue to implement our programme of care packages and extend it cover more LTCs (Respiratory disease 2010, 2011 for CHD) and determine where low activity but high cost care could be provided in innovative ways Establish clear outcome measures across the pathway by agreeing dashboards for each care package and performance manage commissioned services against these outcomes including benchmarking, provider dashboards and using Map of Medicine. Ensure that all people with LTC have a personalised integrated care plan focused on their goals, available through a shared IT system. This will include structured education programmes and buddy support / peer education following diagnosis Integrate specialist and generalist teams including health and social care teams to review virtually complex patients Monitor average length of stay and occupied bed days in inpatient settings from 2010/11 55

56 Unscheduled Care Unplanned care is when local people need help, care and advice urgently without an appointment. It ranges from serious conditions to relatively minor illness but it is required 24 hours a day. Needs Tower Hamlets had the second highest standardised emergency admission rates in London in 2008/9 (95.8 per 1000 compare to 78.0 per 1000). Non elective admission rates do not differ significantly from the London average but, where admitted, their length of stay is greater than anywhere else in London. Analysis of A&E attendances in 2006 showed that the highest levels of usage and repeat were seen in 0-4 years olds and years olds of which a high proportion were for mild ailments. The most common causes of admission are circulatory disease, respiratory conditions and accidents. In 2006/7, admission rates were the highest in London for stroke, second highest for fracture neck of femur, third highest for assault and seventh highest for accidents (5 th highest for accidental falls). In 2007/8, admission rates for long term conditions were the third highest in London (693.6 per 1000). Contributing to demand for emergency care, Tower Hamlets had the third highest rate of people killed or seriously injured on the road in 2007 (151 equating to a rate of 7 per 10,000) and had the highest rate of children and young people admitted for unintentional or deliberate injuries (133.8 per 10,000). Our Vision In line with HfL, we will reconfigure services for unscheduled care to include: emergency response - one sector based trauma centre at the Royal London Hospital Emergency Department (24/7). urgent response - one borough based primary care led Urgent Care Centre (24/7) which will be integrated with the emergency department at the Royal London Hospital. rapid/moderate response - community based clinics, GP practices and other community based services that will be delivered through 3 networks across the borough (8am-8pm, 7 days). One network will also deliver additional capabilities for paediatric cases presenting with minor illnesses and injuries. These services will be underpinned by a 24/7 single telephone access number (STAN). The Urgent Care Centre (UCC) at the Royal London Hospital (RLH) will accept all ambulatory and non trauma patients brought by LAS. Care will be provided by primary care clinicians supported by multi disciplinary teams within the UCC and at our polyclinics. In turn the Emergency Department (ED) will only accept patients referred from the UCC, blue light ambulance and Helicopter Emergency Medical Service. In line with NHS London guidance, the Clinical Decision Unit and Medical Assessment Unit will be replaced by a single Acute Assessment Unit (AAU) that GPs can refer patients to for specialist opinion, investigations and diagnosis. The primary aim of the AAU is to diagnose to admit, rather than admit to diagnose. ED clinicians will use the AAU to thoroughly assess patients and reduce the number of hospital admissions through the Emergency Department. The UCC will be part of a wider integrated system of urgent care provision that is delivered through our polysystems. Designated GP practices within 3 networks will provide access to unscheduled primary care services, seven days a week 8am-8pm. These services will be underpinned by an integrated health and social care system to meet the non-urgent care needs of local people. The proposed changes will improve quality by ensuring that: service users presenting with unscheduled urgent care needs receive timely, high quality care by an appropriate health care professional 56

57 appropriate clinical data is shared across primary and secondary care to optimise longer term care service users are integrated back into primary care there is a more focused use of acute clinicians expertise development of new clinical pathways will help prevent zero length of stay admissions. There will be a one point of telephone access to non emergency unscheduled care services provided through a single telephone access number (STAN) that will operate 24/7. This service will supply a triage system to navigate the patient to the most appropriate clinical service and co-ordinate calls for the UCC, GP OOH, urgent and out of hours dentistry and community based services such as district nursing teams and the find a doctor/dentist service. Vision for Urgent Care Framework Referrals by healthcare professionals Acute Assessment Unit Emergency Department (majors & resus) 999 (helicopter, ambulance) Integrated Primary Care network 3 Networks to deliver7 day a week 8-8 walk in GP services for registered and unregistered patients. As part of a polysystems approach. One of 3 networks to include paediatric service. Dentistry, pharmacy and other community services will also be provided in line with needs analysis. LAS Mile End Hospital Urgent Care Centre Streaming Barkantine St Andrews STAN - Will provide clinical telephone advice, information on how to register with GPs/dentists, ability to book appointments with the UCC or primary care networks, arrange home visits where deemed clinically appropriate, facilitate access to urgent dental care. Self care Urgent Care Centre Hub for unscheduled care 24hrs a day, seven days a week. All ambulatory patients (both adults and children) will access the centre by walking in, ambulance conveyance (not blue light response), or obtaining an appointment via STAN. Provides urgent care for minor injuries, illnesses and minor surgery through multidisciplinary team (primary care led) including GPs, Emergency Care Practitioners, Emergency Nurse Practitioners and Navigators. It will replace the current streaming team, minors, OOHs and WIC. Our progress so far Since January 2009 we have commissioned a streaming service at the front end of A&E with GPs and non clinical Navigators. All ambulatory, adult patients who arrive at A&E between 10am-10pm are streamed. 50% of patients streamed are directed back to their GP, to the Whitechapel Walk in Centre (WWIC), a pharmacy or other community health service. They also recommend self care. This represents 14% of total A&E attendances. The remaining cohort of patients is directed into the A&E Department. We anticipate releasing 300k for 2008/09 through the reconciliation process. During we will implement an enhanced service that models the future UCC with improved access to unscheduled primary care. The interim UCC will facilitate testing of an agreed model. This is so that when we open the new UCC in December 2011 (in line with Barts & the London s opening of the Emergency Department in its new build), the model will be tried and tested, providing the most appropriate care by the right clinicians. 57

58 What we need to do to meet gaps / challenges over next five years Based on the outline business case for the new UCC we are looking to de-commission the following services and re-commission them to offer a single point of access: A&E minors GP Out of Hours services Whitechapel Walk in Centre Canary Wharf Walk in Centre the weekend Barkantine service Minor Injuries Unit based at St Bartholomew s Hospital, Smithfield the Clinical Decision Unit (CDU) and Medical Assessment Unit (MAU), at the Royal London Hospital, Whitechapel A Primary Care led, Integrated Urgent Care Centre and Emergency Department, staffed by a multidisciplinary team of clinicians will provide: GP OOHs face to face appointments Whitechapel Walk in Centre Minor injuries unit at Barts ED Minors (adults and paediatrics) The current activity from the Canary Wharf WiC and Barkantine weekend service will be reprovided through our networked model of primary care (polysystems). These services are undergoing a phased procurement which is linked to our Improving Health & Wellbeing Strategy. The commissioning of a Single Telephone Access Number (STAN) requires scoping, production of a business case to support the proposed model and implementation. Mental Health The mental health pathway includes prevention (public health), identification, assessment and early intervention (primary care), specialist assessment, intervention and living well (secondary and social care). It covers the full range of mental health problems from depression and anxiety to schizophrenia, bipolar disorder and dementia for all adults. Needs Prevalence of mental health disorders in Tower Hamlets children is estimated to be similar to national averages (just under 1 in 10). Data from Children and Adolescent Mental Health Services (CAMHS) suggests a lower proportion of Bangladeshi children than would be expected from the proportion in the under 19 population. Suicides are a high level indicator of mental health and we have the fourth highest rate in London. Based on estimates from the National Psychiatric Morbidity Survey, there would be expected to be around 31,000 adults in Tower Hamlets with any neurotic disorder (a rate of 198 per 100,000 the ninth highest in London) of which around 7,000 would benefit from psychological therapies at any point in time. Schizophrenia prevalence is just under three times the national average reflecting higher risk factors such as homelessness and substance misuse. Overall prevalence of dementia is lower than London due to the younger population. However, 7% of the over 65s are estimated to suffer from dementia and there is evidence of significant underreporting or under diagnosis in primary care. Vision Our vision for 2010/11 is to ensure that the mental health pathway works well for all local people, from prevention to in-patient care to rehabilitation so that they can access high quality, personalised care and support in the right place at the right time. 58

59 Our progress in implementing the pathway We have made significant progress in implementing the pathway particularly on implementing the National Service Framework for Mental Health. It includes: Prevention: Mental health promotion strategy in place including action on tackling stigma and inequalities and promoting initiatives in BME communities Primary care: Improving Access to Psychological Therapies services commissioned and in place Community specialist intervention: The full range of NSF functional teams are commissioned and in place including Home Treatment, Assertive Outreach and Early Intervention Teams. Specialist teams beyond the NSF have also been commissioned including the Personality Disorder Service Inpatient care: A brand new unit providing modern facilities for all in-patient assessment for adults of working age was opened at the Tower Hamlets Centre for Mental Health in 2007 Accommodation and rehabilitation: Rehabilitation and Resettlement Teams have been commissioned to support the recovery and accommodation of people with severe and enduring mental health needs. Despite our considerable achievements, there remains a challenging national and local agenda for the full implementation of the pathway. In particular, current national, Healthcare for London and local priorities along the pathway include: Supporting the mental health and well-being of the whole community, through prevention and early identification, assessment and intervention Providing care closer to home, with a focus on ensuring that accommodation is provided that is appropriate to need Improving services for people with dementia and their carers, particularly through memory services and in general hospital care The physical health of people with mental health problems in primary and secondary care, and the mental health of people with physically unexplained symptoms in general hospital care Personalised services for people with severe and enduring mental health problems Quality of services, in particular in-patient care Whole system effectiveness and value for money, including roll out of the mental health currency. What are the challenges we face? Current specific gaps in the mental health pathway include: Whole system effectiveness and value for money - a deeper understanding of how mental health services match current and future need, are of good quality, and represent value for money Prevention and public health We need to improve the evidence base for the effectiveness of local mental health interventions for health prevention, older people and people with dementia. Identification, assessment and intervention in primary care - the extent to which primary and secondary care currently work together effectively to improve the physical health of people with severe and enduring mental health problems. Community specialist assessment, intervention and living well assessing how effective community mental health, assertive outreach and home treatment teams and Third Sector services work together effectively to prevent the admission of people of working age to hospital and promote early discharge The extent to which people with dementia in general hospital care have appropriately tailored mental health assessment and intervention in order to promote better patient experience and promote earlier and more effective discharge and whether memory services are compliant with national standards In-patient assessment and intervention tackle over occupancy and poor patient experience on acute ELFT adult wards and the under-occupancy of older people in Mental Health in-patient units Accommodation, rehabilitation and living well reduce the year on year growth in users living in out of borough residential care homes and tackle problems in moving service users out of inborough supported accommodation and into general needs housing. 59

60 What will we do to meet these challenges? To meet these challenges, we will: Commission whole system review of mental health services across ELCA with a focus on spend, productivity, and the effectiveness of whole system working, for completion by end September Implement fully the Tower Hamlets Mental Health Promotion Strategy and develop specific public health interventions aimed at people with dementia and their carers Deliver DoH (2009b) Living Well with Dementia by developing an integrated health and social care pathway for older people with mental health problems, with a focus on people with dementia and their carers by end March Commission a Mental Health Care of Older People Liaison Team at the Royal London Hospital that focuses on improving patient experience and shortening length of stay for people with dementia. Team to be established by July Develop an accommodation pathway for working age people with a mental health problem to ensure they have access to high quality local accommodation that meets their needs and delivers a 50% reduction in people in residential care over the next five years Improve the physical health of people with a mental health problem in primary care by ensuring all service users have an annual physical health review, and incentivise primary care to reduce the numbers of people with a mental health problem who smoke Use CQUIN and other contractual levers to improve ELFT s quality of in-patient care End of Life Care End of life care covers the care of adults with progressive, incurable disease, provided in all settings in the last year(s) of life and includes care to patients, carers and family including bereavement care. Needs Around 1200 Tower Hamlets residents will die per year based on current mortality rates. Based on modelling data it is estimated that around 900 people per year will need some form of palliative care but level of care will vary considerably. The main cases of death are circulatory disease (31%), cancer (31%) and respiratory disease (12%). Most people, when asked, state that they would like to die at home if possible (Delivering Choice Programme, 2008). Tower Hamlets has a higher hospital death rate compared to the national average (64% compared to 57%) and a lower home death rates (16% compared to 19%). The percentage of hospital deaths has been falling (from 71% in 2005), the percentage of death in hospices has risen (from 9% to 13% between 2005 and 2007) and the percentage of deaths at home has remained static. Our progress so far Our Delivering Choice programme is reviewing systematically end of life care across sectors. We have: Appointed a Head of Commissioning for End of Life Care to coordinate EOLC commissioning, liaise with Tower Hamlets Council, manage the Delivering Choice Programme work and developed service specifications for generic and specialist End of life care services (NEL). Appointment of LCP facilitators for acute and community setting Promoting GSF through LES including a LES for care homes Commissioned a range of services from the voluntary sector including Age concern Lay network to support vulnerable patients and St Josephs Hospice development of non cancer services Improved information through a directory of end of life care services Training across providers including Initiating Difficult discussions training, basic palliative care age concern and Carer centre and LCP training. 60

61 Our Vision for the future We want to achieve a coordinated approach to end of life care that fosters good communication between services, easy access and quick response for patients and carers and quality in care from all services. The gaps and challenges we face Our main areas of concern and challenge are that we need to reduce the high levels of hospital deaths and increase the number of home deaths compared to national and inner north east London. This includes: Reduce the variation in among primary care using end of life care tools and approaches to caring for patients. We need to get greater consistency of services using the same pathways, metrics and information Improve Integration with social care workforce development and training. Increase use of LCP across hospital and community settings including funding for LCP facilitators Develop a detailed EOLC pathway that all providers implement What we will do to meet gaps / challenges over next five years We will: Write and EOLC strategy for Tower Hamlets (aim to complete by March 2010 and then implement over next 5 years) Continue to implement our Marie Curie Delivering Choice Programme including (ongoing work with pilots for 2-3 years) development of a palliative care centre to coordinate care, develop services and manage staff and gather data and information regarding service needs and use. Development of EOLC posts to support care homes Wok with acute sector and social care to develop service links Improve hospital care and discharge process Develop an EoL care package (define package in 2010 and implement in 2011, evaluate in 2012, review and implement changes 2013) Support the Collaborative commissioning initiatives across INEL (plan runs until 2012) Develop monitoring methods for palliative and end of life care providers and collate data centrally (initial wok by Dec 2010 then ongoing) 6 Moving Care Closer to Home Introduction Alongside the Darzi pathways, HfL also argued that to implement its proposals effectively, London needed to change dramatically its configuration of where services are delivered from. If care is to be moved outside of hospitals, then new care settings needed to be developed to provide that care much closer to people s homes. The action has to be focused on providing primary care that can take the transfer of care from hospitals this involves establishing elective centres, polyclinics and a range of GP and other primary care services from GPs to dentists, pharmacies and health and social care integration with local councils. The integration is essential to provide a joined up system that deals effectively with patients no matter where they are seen. Transferring care from expensive acute settings, much closer to people s homes will also provide much lower cost care that not only provides value for money but the most effective use of scarce resources. We have been implementing this since our joint IHWB strategy in 2006 and have made significant progress. We have also used the experience of opening one of London s first polyclinics - the Barkantine - in December 2007 to inform our plans. This highlights the importance of strong clinical and managerial leadership with dedicated project management wide engagement with all stakeholders and particularly neighbouring general practices and key partners 61

62 detailed health needs assessment and service line activity and financial modelling to inform capacity, workforce and space setting high design standards for the patient environment. a clear governance structure and attention to enablers such as diagnostics, IT, patient and public engagement. clear quality and performance measures including extensive patient feedback to review progress once opened We have applied these lessons to our plans to our Care Closer to Home programme that will develop our polysystems, as well as more generally. As part of producing our CSP this year, we have undertaken detailed planning and modelling to develop a Care Closer to Home (CC2H) strategy and the next section sets out the main elements. Care Closer to Home the Goal Our aspiration is to identify the configuration and enablers needed to deliver care closer to home within expected funding over the next 10 years. CC2H will provide improvements in patient experience, patient access, quality and cost efficiencies. We have developed our CC2H programme by: 1. developing an activity and capacity model to support our understanding not only the volume of activity to shift, but the implications that this will have on our workforce and on our polysystems. The model covered all activities and projects and looked at the skill mix. settings and cost required to deliver the care shifts. This included looking at the current activity and budget, likely growth, the impact of our Primary Care Investment Programme and services that required decommissioning. This was used to project the staffing mix, estate and space requirements and cost needed by engaging clinicians from primary and acute sectors through clinical trios to validate the shift to community settings. They considered not only the potential volume of shift but also the key requirements and potential barriers to the shift including clinical space and staff and skill mixes. Our trios discussed in detail 5 selected specialities: A&E, Diabetes, Paediatric Surgery, Anti- Coagulation and Maternity. 3. developed detailed locality health needs assessment to ensure services are co-located based on need. 4. holding a borough-wide conference with over 200 representatives from acute and all Networks to outline our future vision for care closer to home in Tower Hamlets. This discussed the proposed shift of activity and the configuration of our polysystems. This was a resounding success with overwhelming support for the Vision. Our Care Closer to Home model demonstrates that we can shift 125,000 activities from the acute settings to primary care over the next 10 years. This includes 84,000 outpatient, 2,000 inpatient elective, 1,000 inpatient non-elective and 38,000 A&E activities. This is broken down by speciality as the table below shows. 62

63 Activity to be delivered in the community in 2019 Specialty Activity to be delivered in the community in 2019* Current service provision in the community A & E Trauma & Orthopaedics MSK CAS Dermatology 8117 Dermatology CAS Gynaecology 8055 Menorrhagia Clinic GUM 6737 ENT 5833 Gastroenterology 4803 Gastroenterology CAS Haematology 4789 Anti-Coagulation LES Ophthalmology 4531 Urology 4189 Urology CAS Thoracic Medicine 4103 Obstetrics 3392 General Medicine 3021 General Surgery 2687 Diabetes 1275 Dental Medicine 559 Paediatric Surgery 407 Paediatric Medicine 130 Geriatric Medicine 24 Persistent Pain n/a Persistent Pain CAS *The activity to be delivered in the community is based on a baseline of activity from 2007/08. We are already providing a number of services in community settings and we will extend or re-provide these services so that they can take on increasing levels of activity. This includes: Musculoskeletal CAS This provides assessment and treatment for patients who would previously have been referred to secondary care orthopaedic and rheumatology - both of which had long waiting times. The service is provided mainly by Extended Scope Practitioner (ESP), physiotherapists, occupational therapists and also by GPs with a Specialist Interest (GPwSI) in Rheumatology and Orthopaedics. Dermatology CAS This started in May 2007 and uses mainly clinical nurse specialist staff and some GPwSIs to triage and treat adult patients with minor skin conditions and provides specialist support to nursing teams working with children. A target of 40% of GP referrals to be managed within this service has been set. An enhanced wound care service has also been commissioned to divert activity away from plastics outpatients and the walk in centre. Persistent Pain CAS - This was established in 2007/8 as a multi-disciplinary team bringing together a consultant specialising in Pain Management, plus specialist physiotherapists, occupational therapists, psychologists and support workers (Health and advice link workers). 63

64 Implementing our Polysystems We are developing four polysystems that each cover approximately 60-75,000 local people. Our polysystems will consist of paired primary care networks with a hub. Each polysystem will consist of a hub and spoke model with a hub at the heart and other GP surgeries, Children s centres and pharmacies forming the spokes. We are undertaking the detailed planning to implement our polysystems in close collaboration with clinicians and PBC Locality commissioning groups. NW Current Pop 73,000 Predicted ,000 NE Current Pop 54,000 Predicted ,000 Mile End St. Andrews Polysystems Mile End NW Registered Population 2010/ /15 63,372 67,748 Operational Timeline 2012 St Andrews NE 47,826 54,843 March 2011 Royal London The Barkantine SE 63,096 76,190 Open since Dec 2007 Whitechapel SW 52,247 53, SW Current Pop 53,000 Predicted ,000 The Barkantine SE Current Pop 66,000 Predicted ,000 The building blocks of our polysystem Poly. setting Mile End Offering Step-down beds Post acute stroke, palliative care, mental health Staffing Nurses, AHPs Some consultant-led services Diagnostics Xray, ECG, point of care, ultrasound, other simple tests Estates 6 wards, 100 beds, at Mile End, Hub At least 12x7 opening hours Full range of services Consultants GPs Nurse practitioners Nurses AHPs HCAs Case managers X-ray, ECG, point of care, ultrasound, other simple tests Ophthalmology, audiology testing; electro physiology ~2000 sq m Consulting rooms Home base for field staff Team room Group therapy rooms Spoke ngms plus extended hours Core primary care services GPs Nurses HCAs ECG, possibly ultrasound Rapid access to blood tests Rapid access referral to hub/hospital ~200 sq m Consulting rooms Team room Home/community Community care Elderly care Postnatal care District nurses Health visitors None Access to consulting rooms/team room 64

65 We are modelling the core activities to be delivered in each care setting for the following key areas Long term conditions Diagnostics Outpatients Urgent care Mental Health Integrated Health and Social Care Teams To implement successfully our CC2H programme will require action across a number of key areas and these are highlighted below. 1. Clinical Engagement Sustaining clinical engagement will be critical to our success and we are engaging activity with all clinical leads and our PBC Executive. Our clinical trios will continue to work on the care shifts within pathways and link this work to our PBC Executive. We are ensuring that their knowledge and experience in delivering patient care is integral to how our polysystems develop. We also have four PBC locality groups so that the development of the polysystems are clinically led. In the longer term, we will devolve further commissioning to the 4 PBC locality groups. 2. Workforce Capacity We are developing a training and development programme which will skill our workforce to deliver more care in the community. We are reviewing opportunities for staff substitution and are working with current providers to bring staff from secondary care settings into community based settings. This is based on our successful Open Doors initiative. 3. Organisational Development The development of Networks is fundamental to delivering care closer to home including our proposed care packages. We are establishing new contractual and governance arrangements to allow Networks (rather than practices) to employ staff and deliver key services across the polysystem. 4. Diagnostics The hubs will be the main centres for a full range of diagnostic equipment with some low level diagnostics in selected GP practices. We will provide x-ray at our Mile End, St Andrews and Whitechapel hubs. We are assessing in detail the future locations for low level diagnostics linked to our activity shifts and will discuss these with Networks. 5. Patient Engagement Public and patient engagement is critical to the successful delivery of care closer to home. This is particularly important as it will change radically the way that local people access health services. We have considerable experience and success in undertaking this based on our first GP Led Health Centre, the development of the Barkantine and the refresh of our Improving Health and Wellbeing strategy. We will build on this work to engage with local people about our overall polysystem plans as part of the Health4NEL consultation in January and February 2010 and as we move into detailed implementation in each locality will agree consultation and engagement plans with each Network as we implement the polysystem in their area. 6. IT We are determining the IT requirements to deliver services across our polysystems. We are reviewing the existing IT capabilities and gaps to deliver an integrated IT system across organisations and different providers. Key areas to be supported include instant access to patient information for all services, access to new and archived diagnostics, choose and book services, access to clinical protocols, audit 65

66 research and patient journey tracking and management information and webcams for remote consultations with consultants. Our Care Closer to Home programme will deliver efficient and effective polysystems covering the whole borough An outline of the plans for the South East Locality is provided below to demonstrate the depth of information and plans that we have. South East Locality: an example Needs LAP 7: Limehouse, East India and Lansbury Demographics Population: 36,619 Expected growth: 32% between 2008 and 2020 a bigger % change than the borough as a whole. Ethnic Breakdown: 44% White, 32% Bangladeshi, 11% Black Age Breakdown: A younger population than Tower Hamlets (24% <16 years old) Life Expectancy: Male 73.5, Female 78.7 (both lower than the borough) Health Headlines Very high prevalence of long term conditions with highest mortality rates for CVD and COPD. The mortality rate is the highest in the borough. Prevalence of asthma is also high within the LAP. Generally better than average uptake of childhood immunisations. Higher than average under-18 conception rates. LAP 8: Millwall, Blackwall and Cubitt Town Demographics Population: 29,485 Expected growth: 50% between 2008 and 2020 a much bigger % change than the borough as a whole Ethnic Breakdown: 56% White, 17% Bangladeshi, 9% Other Asian Age Breakdown: Larger population of working age than Tower Hamlets (79% years old) Life Expectancy: Male 77.8, Female 82.9 (both higher than the borough) Health Headlines Lower prevalence of long term conditions compared to the borough average and this is consistent with its relative affluence. Cancer is the biggest killer, followed by CVD. Despite overall affluence, some neighbourhoods are as deprived as other parts of the borough Lower than average uptake of childhood immunisations. This locality has the largest predicted population growth most of which is in the North of the Isle of Dogs in Network 8 close to Canary Wharf. Our CC2H modelling has shown that by 2019 activity will rise to 518,000 (from 281,000). This includes an acute shift of 38,000 appointments. Of the total 179,000 will be in hubs with 339,000 in spokes. This increase will require more staff with a new skill mix. Our work shows that by 2019 total clinical staff will rise to 179 (from 79 today). This includes an acute shift of 24 staff. Of the 179 clinical staff, 79 will be in the hub with 100 in spokes. This includes 7 consultants, 63 GPs, 30 advanced practitioners, 70 nurses and 10 other staff. 66

67 The map shows the future potential configuration of the SE polysystem. The hub is the Barkantine (33 on the map) but because of limited transport links from Poplar to the Isle of Dogs and a number of large and busy roads forming barriers, we are proposing a super spoke at Newby Place (a on the map) that will provide a wide range of primary and community services with some outpatient activity, an urgent care spoke site and possibly sexual health services. a a Newby Place The SE Locality PBC Group are reviewing the detailed health need and activity modelling to inform the proposed future configuration of additional acute shift and community health services across the spoke sites. Some sites are already significant in terms of their capacity and ability to deliver a wide range of services such as the Island Health (35), Docklands Medical Practice (34) and Chrisp Street (38). Clinicians will review configuration proposals to refine the future affordable options. Network 8 are forming the Healthy Island Partnership and propose a federated approach to the delivery of services across the Isle of Dogs with services available across the 3 main practices rather than a concentration at the existing hub in Barkantine. A number of possible proposed new spoke developments are also under consideration to expand primary care provision and community health service provision. Polysystems across Inner North East London ELCA recognises that there is a need for all three PCTs to develop a sector polysystem strategy so that there is equitable access and no unintended variation in services or outcomes. To ensure this, ELCA has agreed that a Strategic Outline Case is developed to drive the delivery of a network of polysystems across inner NE London. Led by an Executive Director, the ELCA Polysystem Strategy Group will review all PCT polysystem plans for consistency and deliverability. It will also share and apply the lessons learnt from first polyclinics such as the Barkantine. Working through ELCA we will agree: A clear rationale for all polyclinic locations The services that will be provided in each hub and spoke how service delivery will change and the impact on patients and providers the economic viability of polysystems and the financial impact across the whole health economy; how providers, communities and local interest groups can inform polysystem development in their area how we best share resources such as service specifications and workforce training. 7 Our Strategic Initiatives The preceding section developed an analysis by both pathway and care setting and highlighted the key areas that we need to address to ensure we implement HfL effectively and meet the health and service needs within Tower Hamlets. To develop the initiatives to deliver this, we undertook a robust development and prioritisation process that is integrated fully with the development of ELCA s Integrated Commissioning Strategic Plan. We did this in three stages: 67

68 Stage 1 was to undertake an analysis of the Darzi Pathways that looked at good practice across the pathway and assess that against the PCT s existing and planned activity. This highlighted both gaps and strengths (as section 6 makes clear). Stage 2 took the long list of potential initiatives and assessed their potential against three criteria. These were: Health impact on patient outcomes including clinical benefits and improving patient experience Affordability - an assessment of the timing and investment (if any) needed to deliver the improvements against the savings generated Must-dos activity that is required to meet national or London targets. This includes ensuring acute access targets, improving cancer screening and implementing the national priority around dementia.. We gave particular emphasis to affordability particularly in 2010/11 - given the financial scenario facing both the NHS and public sector more broadly (as this will affect partner s ability to work alongside the PCT). We also required evidence and robust data so that each initiative was credible. Initiatives that could not provide robust evidence were excluded. We agreed this process with our Commissioning Executive Committee and we included wider clinical engagement as we moved through the process. This included for example consulting with our Strategic Clinical Reference Group with two members on our Steering Group, as well as the PBCE Chair the Tower Hamlets Local Involvement Network Council and discussion with our Health Scrutiny Panel. Each initiative has also had wider clinical and stakeholder input, as these were drawn primarily from the continued implementation of our IHWB developed with considerable stakeholder, clinical and public involvement, as well as the clinical engagement developed through ELCA. This process refined our long list from 71 initiatives to 8 strategic programmes. For Stage 3, we applied a further robustness test to each of the strategic programmes and mapped them against three financial scenarios. The robustness test was based on a detailed financial analysis of investment and savings profiles through to 2016/17 and an assessment of deliverability that considered whether there was an agreed plan, resources available, management capacity and stakeholder engagement to implement the initiative effectively. This assessment involved fully the relevant lead clinical representatives, as well as being considered by our Commissioning Executive Committee. Our eight strategic initiatives will deliver both health improvements and affordability. They are: Staying Healthy by focusing on the key health challenges facing Tower Hamlets on obesity, tobacco use, screening, and immunisation. This will be delivered systematically through our primary care networks and strengthening further our commissioning through the Tower Hamlets Partnership and Local Area Partnerships. Acute Contracting by focusing on reducing activity of low clinical value, claims management and validation. Acute contracts will be changed to reflect the phased shift of care into polysystem supported by better information and systems to GPs and PBCE to reinforce the shifts of care by reducing referrals Care Closer to Home - by continuing and quickening our polysystem development so that we reduce services in acute and shift them into our polysystem, Unscheduled Care improve access to urgent care while reducing A&E attendances through the polysystem by commissioning an urgent care centre and sustaining and extending access to primary care Primary Care Investment Programme to better manage long term conditions with improved self care and reduced hospital admissions - through implementing a number of care packages including diabetes, COPD and staying healthy. 68

69 Improving CHS productivity by introducing a full tariff across CHS to raise productivity and transparency, as well as market testing three CHS services Mental Health by enhancing further our mental health services with a focus on working collaboratively across ELCA and with the ELFT and looking to improve further the efficiency and effectiveness of services Affordability a number of initiatives that will deliver early savings to the PCT to allow investment in longer term improvements including 30% reduction in management costs. They will use six levers to deliver affordability: shifting settings of care moving services out of acute hospitals and reproviding them in our polysystem demand management and decommissioning stopping activity that is of low clinical value and better managing referrals LTC management so that more peoples conditions are controlled avoiding clinical (and particularly acute) intervention Health prevention targeted programmes that focus on the major killers and avoidable health conditions such as immunisation, tobacco use and obesity primary care productivity driving up activity with less than proportionate funding growth by improving estates, IT, performance management) CHS productivity through tariff and a greater transparency on costs and the integration of CHS services within the polysystems. Each programme will use the relevant levers to deliver affordable health improvements over the next five years. For example Staying Healthy will provide long term demand management (and avoidance), while the Primary Care Investment Programme will deliver around care shifts, demand management as GPs and PBCE exert greater control over referrals to acute settings for example by increasing use of our Clinical Advisory Service (CAS) and the closer integration of health prevention through primary care. Initiative projects mapped across Darzi pathways Initiatives by care pathway Maternity & newborns Outpatient shift of care Develop maternity strategy / increase prod. Ensure Maternity Matters in recurrent funding/ incl in 2010/11 Children Paediatric shift of care Access & urgent care Imms & Vaccs Paediatric medicine Acute care Planned care Decommissioning A&E streaming Access & urgent care Decommissioning Demand management Minor surgery Anti-coag Trauma & orthopaedics Active contract management Diabetic & paediatric shift of care CHS tariff Market test CHS services Active contract management Procurement/ market management Procurement / market mgmt GUM Referral management LTCs CVD care package Respiratory care package Diabetes care package Medicines mgmt care package Healthy Lifestyles care package Adult flu vaccination End of Life Further implementation of 2009/10 CCI Mental Health Dementia liaisons to reduce LOS MH Staying Healthy Develop alternatives to residential care Mental Health baseline review Creation of sector MH commissioning unit Staying Healthy Childhood Immunisation Adult flu vaccination Healthy Living care package MH Staying Healthy Others Review exp on continuing care Review legal spend CHS productivity Review take-up of best-value contracts Review discretionary spend Review full 09/10 baseline 30% reduction in Mgt Costs Some initiatives will cover a number of pathways 69 = Sector

70 Within each initiative, we will implement a number of projects and as the diagram above shows, these cover all the Darzi pathways. We are confident that these eight strategic initiatives will deliver the step change in the Tower Hamlets health economy to improve health and wellbeing within an affordable future. 8 Key Enablers to deliver change To deliver our Vision, outcomes and goals and ensure we implement successfully our programmes, there are a number of crosscutting enablers that we must deliver on and these are described below. Clinical Commissioning and Leadership We believe that it is essential that our clinical leadership is of the highest order. We have reviewed our clinical leadership and are now implementing a series of measures that will make sure we have the clinical leadership and engagement that will be essential to deliver our demanding CSP (see diagram below). We have restructured our commissioning governance structure to combine Non Executive Director (NED) scrutiny with clinical oversight through our new Commissioning Executive Committee. Together this group will jointly challenge and support NHS Tower Hamlet s approach to strategic commissioning, prioritisation and service development, combining oversight of the trust s investments and disinvestment decisions and performance against targets and/or delivery of outcomes. It will hold those bodies NHS Tower Hamlets Board ELCA / JCPCT / SCG SCLG CEC Inc. NEDs (strategic & ID priorities) ELCA CPG PBC NHSTH Advisors / Commissioning Groups LITS Map of Medicine Commissioning groups 70 Professional Leadership Medical Director / Quality Lead H4NEL Maternity and newborn Children services Scheduled care Unscheduled care HfL / Darzi Pathways Groups Maternity & newborn Children services Staying healthy Mental health Unscheduled care Planned care Long term conditions End of life care Stroke and major trauma Cancer Cardiovascular

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