Help us build a new NHS in south west London
Foreword by local GP leaders This paper sets out a number of challenges faced by the NHS in south west London. We have been talking to local people about these challenges and how we might tackle them for the last three years and we want to work with you to build an NHS that is truly fit for the 21st century. We want patients to have the same high quality care wherever they access services and we want to create safe and sustainable services that meet the needs of a population that is changing. We aim to meet the challenges and aspirations set out in the NHS Five-Year Forward View, published in October 2014, which sets a new direction for the NHS and is summarised in section 2 of this paper. The six south west London NHS clinical commissioning groups (CCGs) Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth and the health commissioners from NHS England (London) are working together with hospitals, mental health, primary and community care services, local councils, local people and patients on a five-year plan to improve health and services for everyone. The partnership between the CCGs and NHS England is called Collaborative Commissioning and in June 2014, we published an outline strategy for south west London. We are now discussing the best way to implement this strategy and what it means in practice for each of our health services. This includes talking to our local NHS trusts, local councils and neighbouring commissioners like Surrey Downs CCG who commission services in one of our trusts, as well as to local people.we are seeking to address a number of challenges, many of them common across the NHS and some specific to south west London. We know things need to change. We expect to deliver more care in community settings and less care in hospitals and we will have a bigger focus on making service joined up, helping people to stay well and making sure that all patients get the standards of care they have the right to expect. Dr Tony Brzezicki Dr Andrew Murray Dr Brendan Hudson Croydon CCG Merton CCG Sutton CCG Dr Nicola Jones Wandwsworth CCG Dr Graham Lewis Richmond CCG Dr Naz Jivani Kingston CCG Why things need to change P4 About this issues paper The national context P16 What changes are being put forward? P19 What happens next and how can you get involved? P36 This paper is published for discussion by the whole of the NHS in south west London. It has the support of local commissioners, the trusts providing hospital, community and mental health services and NHS England. It is not part of a formal consultation process it is published to set out the challenges facing the local NHS and our initial response to them, for further discussion with local people. We have published our plan for local health services and we are discussing the next steps with local hospitals, mental health trusts, community services, GPs and other health professionals, local councils and local people. This paper is published to summarise our current thinking and test it with the people of south west London. Should our discussions about the best way to make changes lead to proposals emerging for major service change at any of our local hospitals, we would of course carry out a formal public consultation on the options available. We are not at the stage yet of knowing whether this will be needed, but we would welcome your views and questions on this. 2 3
1Why things need to change There are five broad reasons why the local NHS needs to change the way it works. Quality of care. All patients should get the best possible care, but the quality and safety of all our health services varies enormously and depends on where and when you are treated. For example, senior doctors are not always available round the clock for patients admitted to hospital in an emergency. This can cost lives. And people can t always get help when they need to, for example from their GP or another health professional. Changes in what patients need. The needs of our population have changed, so we need to deliver health services differently. For example, people live longer and many more people are living with long term conditions such as diabetes,, heart disease or dementia. This means we need more care outside hospital and more support to help people stay well. Financial and workforce challenges. We do not have the money or staff to go on as we are. The cost of delivering health services is rising much faster than inflation and without changes, the local NHS will not be able to afford what it is delivering today in five years. There is also a national shortage of qualified staff such as GPs, midwives and specialist children s doctors. The need for joined up services. Patients need services that work together and across professional boundaries. This does not happen effectively enough now and means their care can be fragmented. We can provide better care with the same budget. While the financial and staffing challenges are huge and urgent, there is compelling evidence that if we spend our money differently, we can get services that are both better and more affordable. Quality of care All patients should get the best possible care but the quality and safety of our health services varies enormously depending on where and when they are treated People tell us that the way we provide services in the community needs to change and that they have difficulty in getting a GP appointment. Community-based services are under-resourced and often struggle to meet demand, meaning that the outcomes for patients are inconsistent and that not all services meet the standards of care we would expect. None of our hospitals meet all of the quality standards for London for having senior doctors to be present in emergency departments 16 hours a day, in maternity units 24 hours a day and in children s services 14 hours a day. There is clear evidence that having senior doctors (consultants) on these hospital wards leads to better outcomes and that services decline in safety when there is no consultant present. But people taken ill at weekends or in the evenings are less likely to see a senior doctor in hospital. Evidence suggests that in an emergency, patients who do not see a senior doctor are less likely to survive. It is important to remember that there is a shortage of senior doctors in some clinical disciplines, and that no hospital anywhere in London is currently meeting all of the London Quality Standards but each standard is met in at least one hospital. All 32 London CCGs and all London hospitals have signed up to and are working towards the standards and south west London hospitals have improved against them in recent years. 4 5
But until we meet the standards everywhere, our services will not be as safe as they could be and more patients will die or suffer life-changing illness than needs to be the case. It is also important that services based in the community, such as GP surgeries, physiotherapy, podiatry, occupational therapy and pharmacies, meet the best available quality standards, but these services also vary enormously in quality. In mental health, too often we do not provide the support people need at an early enough stage. This means that service users can become more seriously unwell and need to be admitted to a mental health hospital, when earlier support could have prevented this. In cancer services, we also need to diagnose and treat people much earlier in order to give them the best chance of survival. We also need to improve the way we look after people who are nearing the end of their lives. Nationally 16 million people attend A&E every year, but four in ten of these need no treatment or could have been managed by their GP. In 2012-13, 5.2 million people were admitted to hospital in an emergency: 1.2 million (23%) of these people could have been treated elsewhwere, more conveniently to them and at lower cost to the NHS. This means that our hospitals are busier than they need to be. The result is that patients who really need hospital care sometimes in an emergency - can face needless delays in their treatment even though our hospitals have historically met the Government s waiting time standard for A&E. It also means that planned operations are too often cancelled, causing upset and disruption for patients. 2015 5.2 million were admitted to hospital in an emergency 1.2 million of these admissions were avoidable. Finally, we need to do much more to help people to look after themselves and stay well. We need to work with people and support them to live healthier lives and to support people sooner so problems don t become more serious. This includes helping people with long term conditions and their carers to self-manage their conditions and to be able to get help when and where they need it. It also means NHS staff in different services - and colleagues in social care services run by local councils - working much more closely together, with patients rather than services at the centre of all we do. 6 7
Changes in what patients need The needs of our patients have changed, so we need to deliver health services differently The NHS is treating more people than ever before and advances in medicine mean that the treatments available are much better than they were in the early days of the NHS. There are some great success stories and we want all our patients to have access to the best care available. But local doctors, nurses, therapists, midwives and other clinicians know that an NHS system built for the 1950s and 60s is often not giving their patients the care they need in the 21st century. Advances in medicine and changes to the way people live and work mean people live much longer than they used to do though often they are living with ongoing physical or mental health problems. One in three people is living with one or more long term illness, including conditions such as heart disease, dementia, diabetes and asthma. This means that the demands on our health services are greater than ever and that the way in which we deliver services needs to change. We need to make sure that people can get the highest standard of care whenever they need it, when they need it. More and better, joined up services need to be provided outside hospitals in GP surgeries, community services and, where appropriate, in people s homes. We need to support people sooner, to prevent them becoming physically or mentally ill enough to need specialist hospital care. For example, services such as diabetes care, physiotherapy or counselling, do not need to be provided in a hospital. And older people are often better treated at home or in their local health centre than in hospital, as it is closer to home, minimises the risk of infection and avoids the stress of going into hospital unnecessarily. We need to get much better at working with people to help them live healthier lives and avoid becoming ill. Prevention of illness will be a much stronger focus in our future health services. For people with long term illnesses, we need to work with them and their carers to monitor and manage their condition, with the support of doctors, nurses and therapists based in their community. The different parts of the NHS need to work much more effectively together and to work with local councils and, where appropriate, the voluntary sector, in supporting people to kep well, prevent needless hospital admissions and support those coming out of hospital in a joined up way. Better healthcare in the community would make us less reliant on hospitals, which would be better able to help people who need specialist care. Our hospitals should be specialist centres of excellence, geared up to treat people who really need them, while our GP practices and other communitybased services need to provide more services in the community, closer to where people live and working together with the social care services provided by local councils. Doctors and nurses have recognised this for some time and the NHS has been trying for many years to shift more services into the community. In south west London, the last few years has seen a major expansion of community-based services and we very much need this to continue. All six of our boroughs have plans in place to provide more services outside hospital or are already doing so. This could mean big changes in the way NHS staff work in future, with more staff working in the community. Because of the way NHS works at the moment, we have a situation where A&Es can become overcrowded, people struggle to see a GP out of hours and patients end up having several appointments where they feel they are sharing the same information with different people, over and over again. The NHS has served us well for many years and it can continue to do so, but we need to improve the way in which services are delivered if we are to get the best care and outcomes for patients. 8 9
Financial and workforce challenges We do not have the money or staff to go on as we are NHS spending has not been cut. It has risen slightly above the inflation rate every year since 2010. But the costs of providing care are rising much more quickly than that, due to innovative but costly new technologies and rapidly increasing demand from a rising and ageing population. This means that there is an emerging financial gap. Our analysis* from 2014 showed that if we did nothing differently, the CCGs in south west London, who hold the budget for local health services, would have significantly less than current services are expected to cost by 2018/19. Within five years, we would not be able to pay for the services we currently provide. This situation has not improved; we know that with increased demand and similar levels of funding, we cannot go on as we are. In addition to this gap in the budget for local services, our four local hospital trusts (Croydon, Epsom and St Helier, Kingston and St George s) have identified millions of pounds worth of savings they need to make to balance their books. Three of the four trusts are expecting to be in financial deficit this year. Mental health services have also identified significant financial challenges and the social care budgets for our local authorities have been significantly cut making it more important than ever that the NHS works closely with these services. The current government has pledged to provide an additional 8 billion a year for the NHS by 2020, as part of its support for the NHS Five-Year Forward View. We do not yet know how this money will be divided among commissioners. If it were to be divided on the basis of population numbers in each areas, it would alleviate less than a third of the overall shortfall. While this would be helpful, it would not completely close the financial gap and indeed the NHS Five-Year Forward View is clear that the extra money requested will only address the challenges if the NHS changes the way in which it delivers services. Community-based services are often safer and more convenient for patients. Most NHS care takes place outside hospital, especially in GP surgeries, but most of the money is currently spent in hospitals. We can t improve community-based services without investment and this means we either need more money from the taxpayer or we need to move money from one budget to another within south west London. We only have one pot of money and we know that there is not going to be enough to bridge the gap, so we have to reallocate some of the funds we have to give patients more of what they need. This is why the NHS has for several years been trying to focus more care in the community, making hospitals specialist centres of excellence which are there when people need them. In addition to the financial challenge, there is a workforce challenge. There is a national shortage of key specialist staff and nurses, so getting the right staff in our services is a major challenge. For example, there are not enough staff available fot all of our hospitals to meet the minimum quality standards for London is emergency, maternity or children s services. There is a national shortage of GPs and we need primary care staff such as nurses, pharmacists and GPs to work differently and together to support patients. We need more district nurses to provide better community-based care and more midwives to support women through pregnancy. For patients, it may mean you see a wider range of clinicians than you do now. The NHS needs to make better use of the expertise of pharmacists and nurses reducing the pressure on GPs and other hospitals. New roles are also emerging, including Care Navigators to manage a patient s care and support them to get the care they need from the system. *SWLCC Strategy, published in June 2014 and available at 10 11
The need for joined up services Patients need integrated services that work together and across boundaries and this does not happen effectively enough now. We can provide better care with the same budget The NHS and social care professionals talk a lot about joined up services. In simple terms, what we are saying is that the many services people use do not work well enough together. They are not always based around the needs of the people who use them and patients often complain that they have to keep providing the same information to different people, or that they are passed from pillar to post without the different services seeming to talk to each other. This has to improve. We need all of the services that people in south west London use GP services, hospitals, mental health, community services and the social care provided by local councils, as well as voluntary sector services, to work much more closely together. We know that this is ambitious and that we need to break down professional boundaries and develop new ways of working together. But if we are to improve care for the people of south west London, we know that an integrated approach to delivering services is absolutely crucial. This is why integrated care and joined up services are central to what we are trying to do. While the financial and workforce challenges are very real and need to be urgently addressed, there is compelling evidence that we can get improved services that are also more affordable for the NHS, if we spend our money differently. Changes to stroke, major trauma and heart attack services in London - with acute care of these conditions concentrated in specialist centres while local hospitals provide care during rehabilitation have transformed outcomes in London in these clinical areas, from among the worst in the country to the best. More people survive strokes, major trauma injuries and heart attacks in London than ever before. These changes have transformed clinical care and outcomes for the better. They also cost the NHS less money than the previous arrangements. We know that by spending our money differently and planning service changes carefully with local people, we can replicate this success across our local NHS. See page 19 for a summary of why the NHS in south west London needs to change. 12 13
Why the NHS in south west London needs to change All patients should get the best possible care but the quality and safety of our health services varies enormously depending on where and when people are treated. Patients tell us that the way we provide services in the community needs to change and that they have difficulty in getting a GP appointment. None of our hospitals meet all of the minimum safety standards for having senior doctors on emergency, maternity and children s wards. We often fail to provide mental health support for at an early enough stage, leading to service users becoming more seriously unwell. The needs of our patients have changed so we need to deliver health services differently. We have an ageing population and many more people living with long term conditions. More and better services need to be provided outside hospitals in GP surgeries, community services and, where appropriate, at home. People need to be supported to live healthier lives and to avoid becoming ill. Better healthcare in the community would make us less reliant on hospitals, which would be better able to help people who need specialist care. All health services and social care services need to work more closely together. We do not have the money or staff to go on as we are. While NHS spending has not been cut, the costs of providing care are rising every year due to rapidly increasing demand from a rising and ageing population. If we do nothing, then by 2018/19 we will not have the money to pay for the services we currently provide. In addition, the local hospitals have identified millions of pounds worth of savings they need to make and mental health services have also identified financial challenges. There is a national shortage of key specialist staff and nurses, so getting the right workforce is a major challenge. For example, there are not enough staff available for all of our hospitals to meet the minimum quality standards required in emergency, maternity and children s services. And we need to transform our workforce so that more care can be delivered outside hospital in the community. 14 15
2 The national context: how the NHS is responding to the challenges it faces The NHS Five Year Forward View was published in October 2014. It sets out a vision for the future of the NHS. It has been developed by the bodies that deliver and oversee health and care services nationally, including NHS England, Public Health England, Monitor, Health Education England, the Care Quality Commission and the NHS Trust Development Authority. Patient groups, clinicians and independent experts have also provided their advice to create a collective view of how the health service needs to change over the next five years if it is to close the widening gaps in the health of the population, quality of care and the funding of services. The Five Year Forward View starts the move towards a different NHS, recognising the challenges and outlining potential solutions to the big questions facing health and care services in England. You can read the report online at www.england.nhs. uk/ourwork/futurenhs/5yfv-exec-sum Some of the key points are: The NHS has dramatically improved over the past fifteen years. Cancer and cardiac outcomes are better; waits are shorter; patient satisfaction much higher. But quality of care can be variable, preventable illness is widespread, and health inequalities are deeprooted. Our patients needs are changing, new treatment options are emerging, and we face particular challenges in areas such as mental health, cancer and support for frail older patients. There is now quite broad agreement on how we can improve things. The Forward View sets out a clear direction for the NHS showing why change is needed and what it will look like. Some of what is needed can be brought about by the NHS itself. Other actions require new partnerships with local communities, local council and employers. Some critical decisions will need explicit support from the next government. The future health of millions of children, the NHS and the economic prosperity of the country all depend on a radical upgrade in prevention and public health. The NHS will back hard-hitting national action on obesity, smoking, alcohol and other major health risks. We will help develop and support new workplace incentives to promote employee health and cut sickness-related unemployment. And we will advocate for stronger public health-related powers for local councils and elected mayors. When people need health services, patients will get far greater control of their own care including the option of shared budgets combining health and social care. The 1.4 million full time unpaid carers in England will get new support, and the NHS will become a better partner with voluntary organisations and local communities. The NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between NHS and local council services The future will see far more care delivered locally but with some services in specialist centres, organised to support people with multiple health conditions, not just single diseases. England is too diverse for a one size fits all care model to apply everywhere. But nor is the answer simply to let a thousand flowers bloom. Different local health communities will instead be supported by the NHS national leadership to choose from among a small number of radical new care delivery options, and then given the resources and support to implement them where that makes sense. One new option will permit groups of GPs to combine with nurses, other community health services, hospital specialists and perhaps mental health and social care to create joined up care outside hospital. A further new option will be combining general practice and hospital services. Across the NHS, urgent and emergency care services will be redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services. Smaller hospitals will have new options to help them remain viable, including forming partnerships with other hospitals and partnering with specialist hospitals to provide more local services. Midwives will have new options to take charge of the maternity services they offer. The NHS will provide more support for frail older people living in care homes. 16 17
The foundation of NHS care will remain primary care. Given the pressures they are under, we need a new deal for GPs. Over the next five years the NHS will invest more in primary care, while stabilising core funding for general practice nationally over the next two years. GP-led CCGs will have the option of more control over the wider NHS budget, enabling a shift in investment from acute hospital care to primary and community services. The number of GPs in training needs to be increased as fast as possible, with new options to make sure we retain GPs. Our vision for the future is in line with the key points set out in the Five Year Forward View and we will work with NHS England and the national leadership of the NHS as our plans develop. However, we are not currently at the stage where we plan to adopt any of the suggested new models above. They are ideas for new ways of working which will inform our thinking, but we need to work with others locally our GPs, hospitals, local councils, Healthwatch, local charities and local people as we think about what would work in south west London. 3 The London Health Commission In December 2013, the Mayor of London launched What changes an independent London Health Commission to look at how healthcare could be improved for Londoners. A report, Better Health for London, was published in October 2014. The report made a series of recommendations, including measures to are being put tackle childhood obesity, get people living healthier lives, better support for people with mental illness, improving GP access and more support in the community for people with long term conditions. All of the recommendations and aspirations in the forward in south London Health Commission report are in line with those set out in our strategy and in the NHS Five Year Forward View Our six CCGs, in common with the 32 CCGs across London, working with NHS west London? England, have developed local plans to support the recommendations of the London Health Commission. Our clinical commissioning groups (CCGs), led by forward some possible solutions. This work was local GPs, have identified eight broad clinical areas informed by the feedback from extensive public where we have challenges that we need to address. engagement over the last three years, which was These are: further tested with local people in May 2014. 18 Transforming primary care Developing better out of hospital care Improving outcomes in urgent and emergency care Improving outcomes in children s services Improving outcomes in maternity and new born care Improving outcomes in planned care (care that is arranged in advance) Improving outcomes in mental health services Improving outcomes in cancer services Groups made up of doctors, nurses, midwives, therapists, pharmacists and managers from the local NHS, representatives of local councils, patients and members of the public, have been set up to discuss the challenges in these eight clinical areas and put The initial thinking from these groups has been discussed by the six CCGs and NHS England. In an outline strategy published in June 2014, we set out a plan for the local NHS, detailing the standards of care we expect for people in south west London. Since the strategy was published, we have started to take forward some of the work that could be progressed immediately, such as improving services based in the community. We are also discussing with local hospitals, mental health trusts and community services the best way to achieve the parts of the strategy that they will deliver and what role each of them could play. Should these discussions lead to proposals for major changes to local services, we would carry out a public consultation on the options available before making any of these changes. 19
Help us improve your local NHS Transforming primary care The case for change: Patients tell us that they find it difficult to get a GP appointment, especially out of surgery hours There is a huge variation in the services provided by different GP surgeries and they do not work with each other or always work as well as they could with the wider health and social care system Demand for primary care is increasing rapidly; nationwide, GPs have 330 million consultations a year and this has risen substantially (by about 10%) over recent years Primary care is not well enough resourced: the NHS spends a large proportion of its funding on hospital care and not enough on primary care It has become difficult to recruit GPs because it is not always seen by new doctors as an attractive career choice, particularly given the workload Some buildings where primary care is delivered, such as GP surgeries, are not fit for delivering modern healthcare services We do not always make the best use of other primary care professionals, such as pharmacists we do not do enough to help people live healthier lives, prevent them becoming ill and help people with long term conditions and their carers to manage their illness on a day to day basis with support from the NHS when they need it. Some of the ideas we are thinking about to transform primary care Local practice networks that take a collective responsibility for the health of their population GPs, primary care teams, community services, social care, mental health and specialist services to work jointly, to provide coordinated care for patients with long term conditions or complex needs A review of primary care premises/estates, to ensure that primary care is delivered in appropriate settings and is located alongside other services where appropriate Increase the use of technology to create more capacity and support the preferences of patients who do not need face-to-face care (e.g. Skype, email appointments/queries) GPs and their practices being key to delivering care in their communities, taking a more proactive approach to wellbeing, public health and self-management. New roles, such as care navigators to help support patients on a day to day basis, making sure they get the care they need, to be created. We could also make more of existing NHS staff, such as enhancing the role played by pharmacists and nurses in delivering care. Patients also often dial 999 when they need primary care: the London Ambulance Service is working closely with CCGs and provider trusts to make care more joined up. Primary care is the day-to-day healthcare, typically provided by clinicians who act as the first point of contact patients have with the system. It includes services provided by GPs, practice nurses, pharmacists and others Your views What is working well in GP or other primary care services that we can build on? What do we need to improve? What is your view on the ideas set out above? What would make them work or stop them from working? 20 21
Out of hospital care Out of hospital services are obviously those that are delivered outside hospital. This includes services delivered by community health providers such as district and community nurses, physiotherapists, occupational therapists, podiatrists, speech and language therapists and nutritionists. It also includes services delivered in community settings by clinicians who are usually based in hospital, and the social care services that are provided by local councils rather than the NHS. The case for change: Patients tell us that services in the community are not joined up enough. Services do not always talk to each other so people end up having to provide the same information several times and some feel they are passed from pillar to post by different community-based services. Services are not always in place in the community to support patients leaving hospital, meaning that many patients end up staying in hospital longer than they want or need to. There is a huge challenge in social care as local councils have had their budgets cut. This means it is more important than ever that the NHS and social care work closely together to ensure people have the support they need. Too many people end up going to hospital when they could be treated in a more convenient and appropriate location in the community, or in their own homes. As a result, too much of the NHS budget is spent in hospitals, meaning there is not enough left for the community-based care people need. Many people live unhealthy lifestyles, increasing the demands on health services. More could be done to support people to live healthier lives The standard of care in services outside hospital varies enormously and we want to make sure that all services meet the best available standards so that there is consistency for patients. The London Ambulance (LAS) is a 24 hour service, but many out of hospital services are not. This has an impact on the LAS ability to take patients to the best placefor their needs if they don t need hospital care. Some of the ideas we are thinking about to improve out of hospital care Transform our workforce so that much more care can be delivered outside hospital. This will mean a big training and development programme and we will need to address gaps in our workforce, such as a shortage of district nurses and midwives. Work together to make every contact with our services count, so patients don t have to keep providing the same information to different professionals. Community, primary care, social care and community-based specialists need to be more joined up. Encourage and promote healthier lifestyles, working with people to prevent them becoming unwell. Harness the energy in our communities, so that people are better able to support one another and that all the resources available to people who are unwell or vulnerable are working together. Better support for people living with long term conditions and their carers, making them better able to manage their condition on a day-to-day basis and to seek help when they need it. This support should be available in the community and at home where appropriate. It should include much better rapid response and urgent care treatment in the community. Support older people, particularly those who are frail or living with a long term illness, to stay well, maintain their independence and to be treated closer to home where possible, avoiding unnecessary hospital admissions Improve hospital discharge planning, postdischarge support and rehabilitation. Provide better support for patients known to be nearing the end of their lives. Your views What is working well in your community services that we can build on? What do we need to improve? What is your view on the ideas set out above? What would make them work or stop them from working? 22 23
Urgent and emergency care Emergency care services are for people who have a condition that is potentially lifethreatening or life-changing. These services are usually provided by hospital emergency departments. Urgent care services are for people who have a problem that needs attention the same day, but is not life-threatening. These services are provided by a number of health professionals, including GPs, nurses and hospital doctors. The case for change: A recent audit showed that none of our four main acute hospitals meet the minimum safety standards for emergency care the London Quality Standards. These include the requirement that a senior doctor should be present in an emergency department seven days a week, for a minimum of 16 hours. We know that having a senior doctor present makes services safer and increases survival rates in an emergency. There are not enough consultants (senior doctors) to provide this level of care in all our hospitals. We know the standards are challenging and that most London hospitals are not able to meet them - but we also know that meeting them would save lives. Patients find services hard to navigate and often end up in A&E because they are unclear where they should go, especially out of hours and at weekends. This leads to some A&Es being overcrowded, increasing the risk and waiting times of those who do need emergency care. Patients are not always seen soon enough by a senior clinician when they go to A&E People who are admitted to hospital sometimes stay there longer than they need to because discharge arrangements are not in place. Your views People are not supported to stay well: too often people end up needing urgent or emergency care for a physical or mental health problem because the NHS or another service did not help them at an earlier stage. Some of the ideas we are thinking about to improve urgent and emergency care Specialist hospital care when needed from senior doctors seven days a week, meeting the London Quality Standards at all acute hospitals Better information for patients about services and how to access them Ensure that hospital and community services adjust their service levels in response to changes in demand from patients A&E departments should follow best practice for handling patients with major illnesses or injuries, including early review by a senior clinician Make sure that hospitals and local authority social services and housing departments are better coordinated, to avoid delayed discharges and reduce length of hospital stay where appropriate. Better, earlier support for people in the community to help them to avoid ending up in hospital. What is working well in urgent and emergency care that we can build on? What do we need to improve? What is your view on the ideas set out above? What would make them work or stop them from working? Would having urgent and emergency care located in the same place, as happens at some hospitals, make navigating the system easier? How can services like the 111 helpline meet your needs? 24 25
The case for change: Children and young people too often end up going to hospital when they could be better looked after in the community None of our hospital children s wards meet the minimum safety standards for children in London the London Quality Standards. These include the requirement that a senior doctor should be present on children s wards seven days a week, for a minimum of 14 hours. There are not enough consultants (senior children s doctors) to provide this level of care in all or hospitals. Children s services across south west London and even within some boroughs do not work closely enough together Childhood obesity is increasing across the UK and in south west London. We need to do more to encourage families and children to live healthier lives and have a healthy diet. Some of the ideas we are thinking about to improve children and young people s services Develop more resilient community services and closer work between the NHS and local authorities to develop integrated services that keep children well, happy and out of hospital unless they need to be there Children and young people should get specialist hospital care when they need it, from senior doctors and specialist nurses, seven days a week, meeting the London Quality Standards at all hospitals that keep children in overnight A south west London-wide review of children s services, to assess the differential health indicators of children across south west London and how well existing services support them, to include an analysis of changes to the population and their impact A new Children s Network was established in December 2014. This network is developing shared clinical guidelines and pathways across south west London Networked services across south west London, bringing together local expertise and service leaders to advise CCGs on priorities and working together to improve children s health services. Children and young people s services Services for children and young people include those provided in hospital and those provided in the community. Children and young people also use the full range of NHS services, as well as those provided specifically for them. Your views What is working well in services for children and young people that we can build on? What do we need to improve? What is your view on the ideas set out above? What would make them work or stop them from working? How can different health professionals help children and their parents? What support do you need from your GP or other community-based professional? What support would you expect from a hospital if your child needed to go there? 26 27
The case for change: None of our hospital obstetric wards meet the minimum safety standards for obstetric wards in London the London Quality Standards. These include the requirement that a senior doctor should be present on obstetric wards seven days a week, 24 hours a day. We believe that meeting these standards would reduce the number of adverse incidents for high risk women, such as still birth or emergency caesarean section. There are not enough obstetricians (senior maternity doctors) to provide this level of care in all our acute labour wards. Women have told us that they would like the option of a home birth or giving birth in a midwife-led unit. There is evidence that for low risk women, midwife-led care results in fewer interventions and better outcomes. These birthing options are not currently as widely available as we would like. The needs of women who have chronic medical conditions are not always assessed early enough in their pregnancy Services before and after childbirth are inconsistent across south west London and women do not always get the support they need. Some of the ideas we are thinking about to improve maternity services 24/7 care In hospital obstetric units, led by senior consultants in line with the London Quality Standards, to improve outcomes in hospital births Easier access to high quality obstetric care for women with complex needs and easier access to midwife-led care for low risk women Increased availability of midwife-led care and home births for those women who want these options. More continuity of midwife-led care. A more holistic approach to caring for both mother and baby, supporting women and their families throughout their pregnancy and after giving birth Better services outside hospital to support antenatal and postnatal care and improve the access, consistency and range of these services. Improve the quality of referrals to maternity services, so that women with chronic medical conditions can be assessed by ten weeks and seen by the appropriate specialist team early in their pregnancy A new Maternity Network, launched in July 2013, is working with women across the six boroughs in south west London to better understand their experience of maternity services. The feedback should be used to drive improvements in maternity care. Maternity Maternity services support women and their families before, during and after childbirth Your views What is working well in maternity services that we can build on? What do we need to improve? What is your view on the ideas set out above? What would make them work or stop them from working? What support would you and your family need before, during and after giving birth from different health professionals, such as your GP, midwife, health visitor or hospital doctor? Where would you ideally want to give birth? 28 29
The case for change: Too many planned procedures are cancelled due to emergencies happening elsewhere in a hospital, leading to upset and inconvenience for patients Specialists do not always carry out procedures often enough to develop their expertise to the very highest level Patients often end up staying in hospital too long before or after a procedure, or providing the same information to several different professionals Some of the ideas we are thinking about to improve planned care Within five years, no planned surgery in south west London should be cancelled due to emergencies elsewhere in a hospital. We should develop centres of excellence in different surgical specialties, based on the Elective Orthopaedic Centre at Epsom Hospital, which is jointly managed by our four local hospital trusts. Urology services could be a potential pilot as there is strong clinical support for change among urologists We should develop a more efficient system, separating planned operations from emergency care we think this would lead to better outcomes, fewer cancellations, and better experience for patients. Your views What is working well in planned care services that we can build on? What do we need to improve? What is your view on the ideas set out above? What would make them work or stop them from working? Would you be prepared to travel further for a procedure, such as an operation, if you knew the outcome was likely to be better and the procedure was unlikely to be cancelled? Planned care Planned care is care that is arranged in advance for example, an operation in hospital 30 31
The case for change: Mental health is equally as important as physical health, but this has not always been reflected in the way services are provided and funded We do not always help people with mental health problems at an early enough stage, meaning that they become more ill and can end up being admitted to hospital, when earlier support may have helped them to get better more quickly Services are not well joined up for people with mental ill health: communication between GPs, social care services, hospitals and mental and community health services is not always as good as it should be Service users should be able to expect much better quality of and access to mental health services in the community, helping people to stay well and out of hospital where possible Service users should have better access to crisis care in an emergency People heading towards a mental health crisis should have access to appropriate and timely support, with an plan in place ahead of any crisis developing Systems should be put in place to measure the quality of life for people with mental health problems, to make sure that the most effective services achieving the best outcomes for people are protected and funded We should increase patient choice and the personalisation of services. Some of the ideas we are thinking about to improve mental health services Services across physical healthcare, social care and the voluntary sector should be more joined up, working together to develop care plans for service users that treat them as a whole person Your views Mental health Mental health services are provided in the community and in specialist hospitals. Many mental health service users also have regular contact with GPs and other health and social care services. What is working well in mental health services that we can build on? What do we need to improve? What is your view on the ideas set out above? What would make them work or stop them from working? How can we make sure that mental and physical health are treated as equally important? 32 33
The case for change: Cancer is one of the major causes of premature death in south west London We do not always detect and treat cancer early enough Cancer patients are often treated in hospital when they could be better cared for in the community Some of the ideas we are thinking about to improve cancer services Greater focus on prevention of disease, early diagnosis and patient experience, with an emphasis on patient choice and care provision in the community during active treatment, recovery, and, where necessary, improved support during the end of life phase. We need to get better at making sure every patient is treated as an individual and offered the full support of the healthcare professionals involved. Your views What is working well in cancer services that we can build on? What do we need to improve? What is your view on the ideas set out above? What would make them work or stop them from working? When we know people are nearing the end of their lives, how can we best support them and their families/carers? Cancer Cancer services are provided across south west London and involve a wide range of health professionals, form hospital doctors to GPs and community nurses 34 35
Get involved You can read our outline five-year strategy at /wp-content/ uploads/2014/06/swl-5-year-strategic-plan.pdf This strategy sets out the direction of travel, but the detail of how we implement it is still being discussed. We have already started work in each borough, improving and increasing the care available in community settings and supporting these services to work more closely together. But we are still considering what our strategy means for each of our local hospitals, for community services and mental health services. Should we come to the conclusion that we need to develop proposals for major service change in any of our local hospital services, we would put these forward for public consultation. Local clinicians and local people have helped us develop our outline plan. We would like this to continue. We will be taking the advice of The Consultation Institute and following NHS best practice guidance to ensure that our public engagement on these issues follows best practice. To respond to any or all of the questions, you can either complete the online feedback form at, contact your local CCG or write to the Programme Team directly. If you or someone you know wants this Issues Paper translated or in another accessible format, please contact us via the details below. Write to us: Collaborative Commissioning, 120 The Broadway, Wimbledon, SW19 1RH. Email us: swlccgcomms@swlondon.nhs.uk Visit our website: Follow us on Twitter: @swlccgs Collaborative Commissioning Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth NHS Clinical Commissioning Groups and NHS England (London) Working together to improve the quality of care in This has been jointly produced by Collaborative Commissioning and the following local trusts: Croydon University Hospitals Trust. Epsom and St Helier University Hospitals Trust, Kingston NHS Foundation Trust, St George s University Hospitals NHS Foundation Trust, & St George s Mental Health Trust, Royal Marsden NHS Foundation Trust, South London and Maudsley NHS Foundation Trust, Hounslow and Richmond Community Healthcare Trust, Your Healthcare, West Middlesex University Hospital NHS Trust, London Ambulance Service. 36