North West London Draft Sustainability and Transformation Plan Review In carrying out our work and preparing our report, we have worked solely on the instructions of the West London Alliance (specifically Brent, Harrow, Hounslow, Kensington & Chelsea and Westminster Councils) and for their purposes. It should not be provided to any third party without our prior written consent. Our report may not have considered issues relevant to any third parties, any use such third parties may choose to make of our report is entirely at their own risk and we shall have no responsibility whatsoever in relation to any such use.
Contents Section Title Page Number Section 1 Introduction 4 Section 2 Health and Social Care Integration in North West London 6 Section 3 Importance of Out of Hospital Care 9 Section 4 Successful Implementation of the STP Locally 13 Page 2
Section 1 Introduction Page 3
Background and context Purpose of this review EY was commissioned by five local authorities within the North West London STP footprint to carry out an independent assessment of the assumptions in the draft Sustainability and Transformation Plan (STP). The aim being to support local government to understand the key areas of delivery risk and the required actions to mitigate these risks. EY used the following method: Consultation & Data Collection Weeks 1-3 Stakeholder meetings Familiarisation with assumptions and model High level Estates analysis Development & Validation Weeks 4-6 Validation of baseline, trajectory and Estates analysis Draft report Deliverable W eek 7 Final report EY REVIEW Sign off Week 8 Sign off final report The STP is the mechanism by which local areas set out a programme of work and projected funding requirements to deliver sustainability and transformation In December 2015, the NHS outlined that every health and care system in England must produce a multi-year Sustainability and Transformation Plan (STP), showing how local services will evolve and become sustainable over the next five years ultimately delivering NHS England s (NHSE) Five Year Forward View vision. In January 2016, 44 STP footprints were announced across the country. The draft NW London STP sets out the change required to meet this challenge across the NW London footprint. The NWL footprint has over two million people across the eight boroughs stretching from the Thames in the south to Watford in the north. There is currently significant pressure on the whole system and both the NHS and local government need to find ways of providing care for an ageing population and managing increasing demand with fewer resources. The health system is clear that it cannot deliver a clinically and financially sustainable system without transforming the way care is delivered, and without reconfiguring acute services. However, local government has faced unprecedented reductions in budget through the last two comprehensive spending reviews, putting particular pressure on social care funding. To deliver change at scale and pace requires the system to work differently to enable delivery and sustain the transformation from a reactive to proactive and preventative system. The STP is a bid for funding to NHSE which is a requirement in every area of the country. Draft STPs were submitted to NHSE in June 2016. The STP is one element of a complex health and social care integration that has been underway since 2011 The Shaping a Healthier Future (SaHF) Programme had a primary focus to reconfigure acute care in NW London and many concerns were raised around the evidence and assumptions behind these reforms. The Independent Healthcare Commission (December 2015), recommended that all SaHF measures were halted until a series of recommendations had been implemented. The draft STP looks to take forward the acute changes in SaHF but recognises Hammersmith & Fulham and Ealing do not support this. The STP states that all STP partners will review the assumptions underpinning the changes to acute services and the focus will be on the delivery of local services before making further changes to acute provision. Page 4
Section 2 Health and Social Care Integration in North West London Page 5
Health and social care transformation in NWL Strategic Plans Capital Bid There are three key elements to health and social care transformation in NWL Strategic Plans Capital Bid SaHF (DMBC) CCG-level OOH strategies Developing Primary Care Delivery of the OOH Estate (e.g. hubs) Urgent Care Centres 1,269m gap in funding across the whole system QIPP Targets NEL admissions Coordinated Care A.Admissions Avoidance (e.g. Rapid Response) B. Diagnostic & Assessment (targeting zero LOS patients) C. Appropriate Discharge (e.g.. Step Down, Rehab, Reablement) Proactive Care D. Whole Systems (e.g. MDT, Care Coordination, Care Plans) ImBC from 2017 onwards DMBC, QIPP, STP DA1 Radically upgrading prevention & wellbeing DA2 Eliminating unwarranted variation and improving LTC management DA3 Achieving better outcomes and experiences for older people DA4 Improving outcomes for children & adults with mental health needs DA5 Ensuring we have safe, high quality sustainable acute services The DMBC for SaHF focused primarily on acute reconfiguration, but in order to deliver the required demand reduction, also included a combined approach to increasing out of hospital (OOH) capacity around the development plans in each of the 8 CCGs, developing primary care, delivering OOH estate plans e.g. hubs, and developing urgent care centres. It was recognised at the ImBC CCG July 2016 workshops that there had been some OOH changes as a result of the SaHF programme but that they were not yet sufficient. QIPP savings are business as usual savings and improvement plans for the NHS. The STP aims to develop the OOH changes in SaHF into a more comprehensive programme, particularly Delivery Area 3 around achieving better outcomes and experiences for older people. It also includes increased mental health provision in the community (Delivery Area 4) and a new programme around prevention and wellbeing more widely (Delivery Area 1). STP The SOCs, which make up the ImBC (see diagram on previous page), are currently in development and are a bid for funding. They are a subset of the STP and a continuation of the development of OOH hubs in the SaHF programme by developing the business case around the capital ask required to realise the full benefits of the SaHF programme. The SOCs articulate the hubs planned for each borough, the capital and revenue requirements, and a value for money assessment. The process of developing the STP has been collaborative and has received positive feedback from stakeholders Generally stakeholders have expressed a positive view about the process and their engagement in developing the draft STP, recognising that the June Submission represented a point in time and that the timelines and requirements set by NHS England across the country have driven the process. All stakeholders are keen to continue and further embed joint working across health and social care in order to deliver the strategic position within the STP. The financial assumptions in the STP have been set out at a programme level to give a view on the level of transformation required to make the Health and Care Economy stable against the three elements in the Five Year Forward View In order to address the Triple Aims in NHS England s Five Year Forward View, which focus on improving people s health and wellbeing, improving the quality of care that people receive, and addressing the financial gap, the STP articulates a clear view on the level of shift of activity out of hospital and into the community to stabilise the acute sector. Within the context of what the STP is required to achieve, the financial targets and investments are set out at a programme level and set the aspirations and potential requirements to close the gap. There is acknowledgement in the STP that social care is hugely important in this shift and therefore the document proposes 110m in transformational funding to stabilise social care. The STP also focuses on getting the model of care right to support this transformation and create a greater focus on prevention and promoting wellness. Page 6
Health and social care transformation in NWL In order to demonstrate transformation to date, notably progress toward the bed reduction requirement and closing the financial gap since the DMBC in 2012, bottom up modelling has been undertaken and is summarised below: Area QIPP Delivery Acute beds Pt 1 DMBC (FY12/13 FY17/18) (SaHF) 2% QIPP average of annual allocation ( 365m net savings) - 555m gross savings FY12/13 to FY17/18 62% from acute. 3 year plan suggests reduction in acute beds of 391. Pt 2 - ImBC Baseline Update (FY12/13 FY15/16) (2 years into DMBC plan) 40m of acute QIPP per annum has been delivered across NWL ( 80m cumulatively) of which c. 30m is transactional and c. 50m transformational. This compares with a plan of c. 118m, representing c.68% delivery. At best the number of beds has remained constant. Pt 3 ImBC Forecast to 2021 (FY15/16 FY20/21) (additional capital investment) linked to SaHF & STP) QIPP opportunities focus on NEL admissions using improved data set / analysis. Headline figures show admissions avoidance of 67k NEL avoidable admissions, Gross savings of 129m over 5 years with 60m investment. Overall reduction in 364 beds across the NWL trusts over 5 years. Some issues raised by key stakeholders regarding assumptions underpinning the SaFH DMBC have been address through the STP and ImBC processes Throughout the evolution of the STP plans, challenges have been raised about the assumptions behind the work. This review has surfaced key stakeholder issues through interviews. Some of the issues raised have been mitigated through the ongoing work (see the table opposite). Due to the scale and complexity of the task, the partnership recognises that further work is required to ensure optimal local delivery. Most of this additional work is about the OOH capacity and capability and therefore the remainder of this review will focus on the activity required to achieve this. Partners across the system recognise that getting the OOH offer right is essential to ensure that the health and wellbeing gap, the care and quality gap, and the finance and efficiency gap mentioned in the NHS 5 Year Forward View are addressed. Issues Dealt with Adequately through Ongoing Work Issue Raised Finding Residual Issues Population Assumptions The Independent Healthcare Commission (Mansfield Review) states that the original SaHF business case underestimated the increasing size of the population in NWL specifically it did not recognise that regeneration schemes planned by local authorities would mean that in some places the population size would grow at a greater rate than broad demographic projections would suggest. GP Capacity GPs are already at capacity and unable to recruit at required levels to be able to increase primary provision and therefore they have less ability to take on capacity from acute. Winter Pressures It is not clear whether the impact of winter pressures has been factored in to the workings around the ability of out of hospital services to pick up the shift from acute. Social Care Precept The STP assumes that all local authorities have opted to implement the social care precept, which allows them to raise additional funding for social care through council tax rises, however not all local authorities are likely to implement this. Public Consultation The STP plans have not been consulted on. The SaHF modelling work used the higher of the ONS and GLA population projections for each area - part of the assurance for GLA figures includes verification with the relevant planning departments. In addition there is consideration of population projections post 2021. The STP submission has considered this to an appropriate level for this stage of planning, including considering the turnover of GPs, GP opening hours and additional out of core GP hours. In addition some thought has been given to mitigating these issues. Business as usual (BAU) activity and finance modelling has been undertaken on an annual basis, which includes seasonality impacts/ changes, therefore the work has included winter pressures. Six of the eight local authorities have introduced the social care precept. The other two local authorities will be required to raise a similar level of funding to meet increasing social care pressures, therefore the assumptions are valid. SaHF went through a public consultation process in 2012 and the STP June submission is a continuation of that work. NHSE guidance on STP submission states that it does not expect local proposals to go through formal local NHS or other organisations board approval and/ or formal public engagement or consultation at this early stage. Although significant regeneration schemes are planned in several areas, these are unlikely to have significant impact on the 5 year projections used for the STP submission. However, the impact of regeneration schemes should continue to be included in the scope of work, not just in terms of the additional increases in population which may ensue, but also the opportunities in terms of estate planning. GP capacity is likely to continue to be an issue that requires ongoing mitigation, therefore the efficacy of the current approaches should be monitored. There is a wider issue around the OOH capacity to pick up the shift from the acute and whether this has been adequately modelled for both health and social care. Further work has been done as part of this review regarding the funding gap for social care (see page 10). It is expected that most footprints will take a version of their STP to their organisation s public board meetings for discussion between late October and the end of this year [2016]. Page 7
Section 3 Importance of Out of Hospital Care Page 8
The importance of out of hospital care All stakeholders recognise the importance of getting the model, approach, and capacity for out of hospital (OOH) care right Stakeholders recognise that developing OOH capacity is crucial to ensure older people receive the right care, at the right time, and in the right place. There are currently an estimated 30% avoidable/ inappropriate admissions across NW London and therefore the OOH model needs to be developed jointly across health and social care to deliver improved patient experience and transformation of services. As there are implications on capacity in all areas of the system, local government are fundamental to the development of the OOH model as they have the ability to influence the local area, ensure local services are available and efficient, and have access to assets that will allow for estate optimisation. The schemes proposed to improve the quality and experience of care are supported by national evidence The interventions chosen in the draft STP for NW London have an international and national evidence base to support them, however, many studies comment that how these are implemented are key to their success, for example getting the governance right and having strong leadership: Admissions Avoidance/ Rapid Response Every extra 1 spent on the POPP services resulted in approximately 1.20 in savings on emergency bed days There was a 47% reduction in overnight hospital stays and use of Accident & Emergency departments reduced by 29% 1 Step Down Intermediate Care & Reablement Effectiveness and cost effectiveness of intermediate care & reablement 2 Care Planning Increase in self-reported wellbeing, including from evaluation of inner NWL integrated care pilot 3 Multi-Disciplinary Teams (MDTs) Increased skill mix (raising the number of different types of staff by one) is associated with a 17% reduction in service costs. 4 STP plans for other footprints reflect the different local landscapes and priorities. However, all are looking to provide a range of OOH services to support a shift of activity out of the acute sector. Many of these services are similar to those that NWL are looking at including risk stratification and case management, step up and down bedded and nonbedded care, as well as an increasing focus on prevention. Locally some good progress has been made on developing OOH services to reduce demand on the acute Hammersmith & Fulham Virtual Ward Model Integrated and co-located health, community and social care teams, connecting GP practices, occupational therapists, intermediate care and community nursing teams. 23% increase in commissioned hours over the last 2.5 years and also an increasing intensity of package size, with 26% having 15 hours or more in March 14, rising to 29% in September 16 Conversely, 44% of customers received 0-7 hours in March 14, dropping to 38% in September 16 However, forecasting a gross overspend of 3.3m on the Home Care Packages in 2016/17 Hounslow Community Recovery Service An integrated health and social care service for adults identified with uniand multi-disciplinary recovery needs, including acquired and long-term neurological conditions. The average change in package size for people referred to and discharged from CRS who also receive homecare (25% of total referrals) has been a reduction by 2.7 hours per week. Estimation of savings on Domiciliary Care is c. 1.5m pa by 2019/20 (caveats apply). 4 out of 5 people were still at home 91 days after discharge via reablement. There is further work required to assess the impact of these interventions on whole system savings e.g. whether there has been a reduction in non-elective admissions or reduction of delays in hospital discharges. Source: Integrated Care Evidence Review, November 2013, Local Government Association 1 p.29; 2 p.52; 3 p.7; 4 p.96 Page 9
The importance of out of hospital care Social Care is a fundamental part of the OOH model but is already experiencing significant pressure There are already demographic and non-demographic pressures on social care services which, if there were no STP (do nothing scenario), would result in pressures of 187m. These are mitigated to some extent by additional funding that Local Authorities will put into the system, for example from the social care precept (where local authorities decide to levy this). However this still results in a funding gap of 118m. In addition, there is a risk around the business as usual pressures in the Medium Term Financial Strategy (MTFS). 000 over 5 years to 2021 Total Baseline budget (assumed balanced budget) - Do Nothing: Demographic pressures 126,250 National Living Wage 34,794 Inflationary pressures on contracts 26,466 187,510 Additional local authority contributions / precept (69,088) 118,422 Business as Usual: Pressure: Public health 12,910 Pressure: MTFS 95,558 Interventions to address pressures (108,486) 0 Integrated admissions avoidance interventions will help address the 30% avoidable admissions. This will put additional pressures on social care, which have not yet been quantified as the care needs of the 30% are not understood. The additional pressures on social care from the DTOCs where the reason for waiting is related to social care have been quantified as totalling 1.5m over 5 years. This is mainly quantified in terms of additional residential and nursing care. In addition there may be the following changes to these types of care: Additional pressures resulting from more people requiring long term care Additional savings from fewer people being admitted to hospital and therefore their independence not deteriorating further A shift from residential/ nursing care to a greater proportion of service users receiving home care An increase in complexity of care to cope with increasing comorbidity and frailty Social Care has a key role to play in providing additional capacity to the system to have a positive impact on experience and demand management and it is therefore imperative that it is properly funded If the STP is delivered, there will be two key pressures on social care: Transformed System: Unmet demand 1,517 Additional pressures 119,939 Unmet demand indicated by delayed transfers of care (DTOC) where the delay is linked to social care assessments services Additional demand shift of avoidable admissions into the community, which has been estimated at 30% of current acute nonelective admissions These services include: Admissions Avoidance e.g. Rapid Response Virtual Ward Case Management Clinical input to Nursing Care Mental Health interventions Intermediate care Assistive technology Acute 30% avoidable admissions DTOC Short Term e.g. Rehab/ Reablement Intermediate care Step Down Virtual Ward/ integrated case management Dementia support Including bedded & non-bedded Longer Term e.g. Home Care Residential Care Nursing Care Assistive technology Page 10
The importance of out of hospital care Adequate funding of social care in a transformed system will also be fundamental in the mitigation of system risks The table below sets out the key issues for local authorities to consider as work on developing OOH care continues and possible steps to mitigate them. Key Risks to Local Authorities Additional social care demand There is a risk to the local authorities and the system as a whole that the additional demand which the transformed model of care creates in the social care system has not been adequately estimated at this stage. The social care needs of the people who make up the 30% of avoidable non-elective admissions are unknown and the extent to which these are new customers to social care has not been modelled. In addition the additional needs of these people i.e. if they require more complex care is not understood. Without an understanding of the likely needs and numbers around this additional demand commissioners are not able to adequately plan for it. Social care market The social care market is currently fragile and it is not known to what extent it is able to take on the additional requirements coming out of STP. The Care Act puts a duty on local authorities to avoid market failure around current needs before "sub acute needs" enter the market. The increased complexity and acuity of needs coming out of hospital sooner requires more capacity in supply but it needs more capability in the workforce too. Funding uncertainty There is currently uncertainty about funding for STP including how the shift in demand from acute to out of hospital will be funded, what the timeline for receiving STP funding will be, how much it will be and how it will be distributed. Operating Model There is a risk that the operating model for out of hospital care has not been clearly articulated at this stage. Each local authority has already several parts of the system in place, some of these differ according to local priorities, however there is a need for an overarching integrated operating model which sets out for all how the vision for OOH care will operate. Integrated Programme There are many moving parts that make up the transformation of out of hospital care, including the STP, the QIPP programme, Local Authority MTFS and others. There is a risk that each of these large and complex programmes are not coordinated and therefore the impact of each is piecemeal, rather than transformative on the whole system. Local Authorities should consider the following Mitigation Steps - Develop a better understanding of current capacity of OOH care both in terms of activity and finance - Within this also develop a better understanding of current levels of complexity which are provided in the various OOH services across the system - Carry out more detailed work around each of the delivery areas to assess the impact on social care these will have, including understanding the impact on activity, finance and complexity of care - Therefore there should be a clear understanding of what commissioners need to commission in the future to support the OOH demand - Develop a better understanding of current market position across all LAs - Assess the impact on the market of future demand (using the output from the work on social care demand above) - Develop a coordinated strategy across all LAs to address market stability/ development, including workforce strategy - Develop further clarity around funding as the programme develops further refine the financial estimates with a view to providing investment up front - Develop contingency plans for where the level of funding received is not as high as anticipated, for example around the capital ask for funding hubs. - Develop an overarching integrated operating model which is linked to the demand forecasts - Develop an integrated programme for OOH care including reviewed governance arrangements - The overarching programme should additionally consider some of the wider opportunities around joint working and wider culture change Estates Plan There is a risk that the overall estates plan and plan for hubs does not adequately take into account local authority needs or opportunities for example the services that are anticipated to be delivered through the hubs only include health services at this stage, and alternatives to actual physical hubs have not been fully considered. There is work underway to bring this together, however non-delivery would represent a risk to the local authorities and the whole system. - Develop an overarching estates plan, which links to the operating model mentioned above and makes best use of current assets Given the OOH model is fundamental to the success of the system as a whole, stakeholders recognise the scale and pace of implementation needs to be accelerated There has been some progress, particularly seen in local models in the patch, however the current out of hospital model is not consistent across NW London and is not yet achieving what is required to deliver the full shift from an acute setting. Further consideration of social care capacity is needed given the market and acuity risks. Page 11
Page 12 Section 4 Successful Implementation of the STP Locally
Successful implementation of the STP locally following the funding allocations To ensure the benefits from the estates work stream are optimised, it is key that a clear OOH operating model for NWL is developed Each CCG and local authority has a separate estates strategy. An overarching estates strategy at the STP level is in its early stages of development with an Estates Group formed as part of the STP governance structures to identify a suitable approach for NW London. Developing a cohesive estates strategy of this size to support the delivery of the STP across multiple stakeholders is a hugely complex task. The initial CCG strategies are a solid foundation to build upon, but this is a long term programme and much work is required to deliver the optimum strategy for all stakeholders. The following is a checklist of good practice for this group to consider: The current portfolio Basic portfolio data required, including number, size, location, and flexibility. Further information required such as qualitative data, valuations (including highest and best use), and running costs. Confirmation of who owns each property in the portfolio. Need an understanding of all stakeholder objectives e.g. GP practices. Need an understanding of any other potential barriers such as title, listing, planning, etc. How to fit for purpose Identify hold / modify / dispose properties in existing portfolio Undertake gap analysis Develop three transformation streams: dispose, modify and new Plan to maximise disposal value vs timing vs risk Site identification and acquisition for new sites Capital plans for new build and modify build Robust business cases required with financial and operational evaluation Identify other funding sources e.g. regeneration, private sector. Understand role of One Public Estate principles Following the allocation of STP funding, to ensure all stakeholders in the system have confidence in the ability to deliver the ambitions in the STP, further work is required as part of the local implementation In order to support the delivery of the commitments in the STP, there needs to be a translation of the current STP and related plans into a deliverable programme of work that will deliver the required OOH capacity. Progress has already been made in this direction by work streams developing the business cases to underpin each of the delivery areas in the STP. However there is also a need to develop an overarching programme plan, which will allow for the management of dependencies across the programme. It is proposed that a programme scoping brief is developed to include: The OOH outline model (principles and key components) Programme scope (including interface with enablers) Delivery approach (including assessment against current work) Key deliverables Delivery plan (Milestones, activities and timelines) Governance (aligned to broader STP governance and accounting for democratic landscape) Risks, issues and dependencies Resourcing options The overarching programme, in addition to the projects supporting each delivery area, should deliver: 1. Further whole system activity, demand & financial modelling 2. A coordinated overarching operating model, linked to the activity & demand model 3. Clarification of priorities and delivery approach 4. An estates & capital plan, linked to the operating model 5. Further financial modelling aligned to a new operating model and resulting capital plan Page 13
EY Assurance Tax Transactions Advisory Ernst & Young LLP 2015 Ernst & Young LLP. Published in the UK. All Rights Reserved. The UK firm Ernst & Young LLP is a limited liability partnership registered in England and Wales with registered number OC300001 and is a member firm of Ernst & Young Global Limited. Ernst & Young LLP, 1 More London Place, London, SE1 2AF. ey.com Disclaimer: In carrying out our work and preparing our report, we have worked solely on the instructions of the West London Alliance (specifically Brent, Harrow, Hounslow, Kensington & Chelsea and Westminster Councils) and for their purposes. It should not be provided to any third party without our prior written consent. Our report may not have considered issues relevant to any third parties, any use such third parties may choose to make of our report is entirely at their own risk and we shall have no responsibility whatsoever in relation to any such use.