Wandsworth Clinical Commissioning Group. Public Sector Equality Duty

Wandsworth Clinical Commissioning Group Public Sector Equality Duty 2017-18 Chan Maher Patient and public Involvement and Equality and Diversity Development Manager 1

Contents Introduction... 4 Public Sector Equality Duty... 4 About Wandsworth Clinical Commissioning Group... 5 South West London Health and Care Partnership... 5 Merton and Wandsworth Local Transformation Board... 6 Commissioning Intentions & System Impact... 7 Health needs in Wandsworth... 8 Equality, Diversity and Inclusion... 10 Governance... 10 Patient and public involvement... 12 CCG patient and public involvement groups... 13 Patient and Public Involvement Reference Group (PPI RG)... 13 Thinking Partners Group (TPG)... 14 CCG Accountability Structures for PPI... 15 Clinical Reference Groups (CRGs)... 16 General Practice patient and public involvement... 16 Productive Patient and Public Involvement... 16 Community and Seldom Heard Group GP Visit Programme... 16 Community Grant Scheme (CGS)... 17 Learning Lunches... 18 CCG newsletter- Healthy Wandsworth... 19 Healthwatch Assembly and Voluntary Sector Forum... 19 Equality Delivery System 2 (EDS2)... 20 EDS2 external grading Workshop... 20 Key Commissioning Achievements... 28 Locality Commissioning... 28 Locality Commissioning Groups... 28 Battersea... 29 Wandle... 30 West Wandsworth... 30 CCG/Wandsworth Council Joint Programmes... 32 Preventing Ill Health... 32 An Overview of Social Prescribing and Self-Management in Wandsworth... 33 The Wandsworth Wellbeing Hub... 33 The Wandsworth Wellbeing Hub Primary Care Pilot... 34 2

Commissioning Programme achievements... 35 Planned Care... 35 Blood Testing... 35 Ear, Nose and Throat... 35 Diabetes... 35 Gynaecology... 36 Mental Health... 36 Older Peoples... 38 Acute Admission Avoidance (AAA) Pathway... 38 Case Study: Older People Multiple Long-term conditions service development... 38 Care homes... 39 Red Bag Hospital Transfer pathway... 40 End of Life Care... 40 ELC Coordination Centre aims... 41 Intermediate Care or Reablement and Rehabilitation... 41 Integrated Urgent Care Service (NHS111/ GP Out of Hours)... 41 Child and Adolescent Mental Health Services (CAMHS)... 42 Multispecialty Community Provider (MCP) a New Model for Care... 43 Looked After Children... 45 Improving Quality... 46 Improving Quality and Safety... 47 Enhanced Quality Monitoring of Smaller Providers... 47 Quality Monitoring of Primary Care... 47 St George s Clinical Quality Review Meeting (CQRMs)... 48 Attendance of Clinical Quality Review Meetings- Associate Commissioner... 48 Improvement and Assessment Framework Clinical Priority Areas... 48 Make a Difference Alert System... 49 Workforce Race Equality Standard... 50 Aims for 2018... 51 3

Introduction Public Sector Equality Duty As a public sector body, Wandsworth CCG has a statutory requirement to meet the legal duties as required within the Equality Act 2010 and Human Rights Act 1998. In addition, the CCG continually focuses on addressing health inequalities associated with socio-economic factors to help us to better understand the views of our patients across the 9 protected characteristics. The Equality Act 2010 requires all public authorities, when carrying out their functions, to have due regard to the need to: Eliminate discrimination, harassment and victimisation and any other conduct that is prohibited by or under the Act. Advance equality of opportunity between people who share a relevant protected characteristic and people who do not share it. Foster good relations between people who share a relevant protected characteristic and those who do not share it. The nine protected characteristics under the Public Sector Equality Duty are: Age Religion or belief Disability Sex Gender reassignment Sexual orientation Pregnancy and maternity Marriage and civil partnership Race Wandsworth and Merton CCGs have agreed a joint set of equality and diversity outcomes for 2018. These will focus on: - Health inequalities: Increase overall access to Wandsworth Improving Access to Psychological Therapies services to 15% of morbid population and 25% of referrals to come from BAME communities - Provider assurance: Ensure all providers provide clear information on how services commissioned have led to better outcomes and access for groups protected by the Equality Act at primary and secondary care - Patient/public engagement: Undertake engagement with young people to raise awareness of mental health support services and remove barriers to accessing them over the next 12 months - Staff engagement/development: Improve staff well-being, engagement and development to ensure workforce is supported and well-represented by implementing Merton and Wandsworth staff survey action plan 4

About Wandsworth Clinical Commissioning Group The London Borough of Wandsworth is one of the largest inner London boroughs with a resident population of 312,000 and a GP registered population of 391,700. Led by our 40 GP practices, Wandsworth Clinical Commissioning Group (CCG) is responsible for designing, commissioning, and monitoring health services within our three localities; West Wandsworth, Wandle, and Battersea. The services we commission include: Rehabilitation care Non-emergency hospital care Urgent and emergency care Mental health and learning disability services Most community health services Enhanced primary care: we have delegated responsibility for commissioning core GP services. Our 40 GP practices in Wandsworth work together with NHS partners pharmacists, dentists, hospitals and mental health providers, Wandsworth Council and local community groups to improve health and wellbeing, reduce health inequalities and make sure everyone has equal access to healthcare services. Wandsworth CCG s work continues to be underpinned by our vision as encapsulated in the phrase better care and a healthier future for Wandsworth and the principles outlined below. We will commission care in a way that is: Patient focused Outcomes driven Principled Collaborative Progressive & Professional South West London Health and Care Partnership Wandsworth CCG s local work supports the objectives set out in South West London s Sustainability and Transformation Plan, also known as the South West London Five Year Plan. The partners within the Partnership are: Our six Clinical Commissioning Groups (CCG) of: Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth Our six Local Authorities: Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth The GP Federations in each of the six boroughs The London Ambulance Service Healthwatch 5

Acute and Community Providers: Central London Community Healthcare, Croydon Health Services NHS Trust, Epsom and St Helier University Hospitals NHS Trust, Hounslow and Richmond Community Healthcare, Kingston Hospital NHS Foundation Trust, Royal Marsden Foundation Trust, St George s NHS Foundation Trust and Your Healthcare Our two Mental Health Providers: South West London and St George s Mental Health NHS Trust, South London and the Maudsley NHS Foundation Trust Merton and Wandsworth Local Transformation Board As part of the South West London Health and Care Partnership, Wandsworth and Merton CCGs have come together to form a Local Delivery Unit headed by a new Managing Director. This will bring new ways of working by sharing expertise and using our resources more effectively. Our agreed joint vision is to enable the people in Merton and Wandsworth to live healthy, independent lives for as long as possible. Our vision is to have health and care services where: we work together to prevent ill health and reduce inequalities health and care are co-ordinated around the needs of the individual the experience of using health and care services is seamless we break down barriers between primary, community, social and mental health services we ensure prompt access to services which mean that people are treated as close to home as possible and that only the people who really need to go into hospital do so care for patients with long-term and complex needs is tailored to the individual so that the care they receive meets their personal needs hospital services are accessible, high quality and joined up with other health and care organisations local people are confident to manage their own health and wellbeing people receive a consistent service and we ensure those with the greatest needs get a service that fully reflects their challenges 6

Commissioning Intentions & System Impact Wandsworth CCG s commissioning intentions for the financial year 2017/2018 demonstrate our response to the strategic vision described in the Five Year Forward View, and our local priorities as set out in the Wandsworth Joint Strategic Needs Assessment and the Wandsworth Health & Wellbeing Strategy. Commissioning Programme Urgent Care Primary Care Planned Care Integrated Care Children Mental Health Delivering a reduction in A&E attendances and emergency admissions Non elective bed days and emergency readmissions Hospital based diagnostics Outpatient first and follow ups Planned bed days (LOS & DTOCs) Ambulance call outs and conveyance Commissioning Cycle Shaping our Commissioning Intentions 7

Health needs in Wandsworth The 2017 joint strategic needs assessment (JSNA) draws together a wide range of data and research to provide a robust understanding of the borough population s overall health and wellbeing. Wandsworth CCG uses these guidelines alongside several others to shape our commissioning intentions. The table below summarises some of the important demographic information about the health of the Wandsworth population, which will prove opportunities and challenges when commissioning activities to reduce health inequalities. Theme Population ethnicity Population Adult health Elderly care Wandsworth Foodbank Sexually transmitted infections Data The population is diverse, with over a quarter of the population having a nationality other than British. Black and minority ethnic (BME) groups make up 29% of the overall population and accounts for more than half the population of Tooting (52.7%). Wandsworth is the largest inner London Borough and has a growing population, currently estimated at 314,544 residents. The population of Wandsworth is much younger than both the London and England average. Nearly half of all people living in Wandsworth are aged between 25-44 years old. 37,000 (15%) adults in Wandsworth are estimated to smoke. It is estimated smoking is responsible for over 500 hospital admissions and 250 deaths in Wandsworth per year. A survey of local people indicates that 44% of adults drink more than the limit of 14 units of alcohol per week In 2015/16, around one in five people starting treatment for drug use were homeless or had housing problems and the proportion who were unemployed (59%) was high compared to the national average (43%). Life expectancy for over 65s in Wandsworth is lower than the London average and the average resident can expect 15 years of deteriorating health in old age. Over a third of people aged over 65 are living alone, which increases the risk of social isolation and many of the unpaid carers in the borough are themselves part of the older population, and particularly vulnerable to ill health. In 2016/17, Wandsworth foodbank provided 4,712 emergency food supplies to people referred in crisis, of which one in three were children. Problems with benefits was the most common reason for crisis referral. In 2015, there were 4,950 new sexually transmitted infection (STI) diagnoses, excluding Chlamydia in under 25-year-olds (2,145 per 100,000). This is significantly higher than the London average (1,606 per 100,000) and the England average (815 per 100,000). 8

Causes of death Hearing impairment Disabilities FGM Child mental health Domestic and sexual violence In 2015, cancer overtook circulatory disease as the leading cause of death in the borough (as elsewhere), accounting for 28% of all deaths, compared to 27% of deaths due to circulatory disease and 14% due to respiratory disease. Around 180 people aged 18-64 are registered deaf or hard of hearing. Those with severe hearing loss who do not use hearing aids have unemployment rates nearly double those who do.57 People with hearing loss are significantly more likely to experience emotional distress and reduced social engagement. An estimated 10% of the Wandsworth population has a disability affecting day to day activities. One in three of Citizens Advice Wandsworth clients are disabled or have a long term condition. Citizens Advice found disability to be the single biggest cause of employment discrimination amongst clients. Each year, 100 out of 2,600 female babies in Wandsworth are estimated to be born to women with FGM, which puts them at higher risk of being subjected to FGM themselves. In 2016/17 there were around 60 Wandsworth women who attended hospital who had undergone FGM at some point in their lives (although there is no indication that FGM had occurred recently or in this country). Mental health problems affect about 1 in 10 children and young people. They include depression, anxiety and conduct disorder and often a direct response to what is happening in their lives. An estimated 2,800 children aged 5-16 have mental health disorders in Wandsworth. Between 2011/12 and 2015/16, reports of domestic and sexual violence have soared by 80% and 100% respectively. A key contributor to this is a greater awareness and willingness for victims to engage but it remains an area that suffers from underreporting. Carers There are over 19,000 carers in Wandsworth, with almost 3,000 caring for 20-50 hours per week and almost 4,000 caring for over 50 hours per week. 12% reported ill health as a result of their caring duties. It is estimated that there are between 250 and 600 children who act as carers Homelessness The rate of family homelessness in Wandsworth has increased year on year from 4.7 per 1,000 households in 2011/12 to 6.3 per 1,000 in 2015/16. (Increased from 62 in 2011/12 to 96 in 2015/16). Diabetes Common Mental Health Disorders There are 15,000 residents in Wandsworth who are living with diabetes and another 25,000 who are on the verge of developing it. 80% of cases of Type 2 diabetes can be delayed or prevented by making simple changes like moving more, losing weight and eating healthy. An estimated 44,000 people aged between 16 and 74 have a common mental health disorder such as depression and anxiety. 9

Equality, Diversity and Inclusion Governance Wandsworth CCG is fully committed to ensuring that patients, carers, local residents, and staff have the right to be treated with dignity and respect and that everyone should be able to fulfil their potential without disadvantage. As tackling health inequalities remains a CCG priority, we want to account for equality and diversity at all levels within our organisational structure. Our Board The Wandsworth CCG Governing Body (our Board) oversees the delivery of our commissioning plan, leads and sets the strategy for the CCG, and is accountable for the delivery of our functions as a statutory body. All 40 GP practices are entitled, through their member representatives, to elect members to the Board. This means that members are represented and contribute clinical expertise at the highest level within the CCG. The Board also supports the CCG s Equality and Diversity Group, and ensures that equality, diversity, and inclusion are key factors when making overarching decisions at senior level. Managing Director The Managing director of Wandsworth and Merton CCGs is responsible for ensuring that equality, diversity, and inclusion considerations are embedded throughout both CCGs in a consistent, and sustainable manner. This includes the allocation of resources and leadership. The Managing Director also attends and conducts regular meetings with organisations across Wandsworth to discuss priorities and the CCG s performance in meeting its statutory duties, including equality and diversity. The Director of Quality and Governance As the equality, diversity, and inclusion lead for Wandsworth and Merton CCGs, the Director of Quality and Governance provides regular assurance and monitoring updates to our Governing Body, Integrated Governance Committee, Executive Management Team and the Clinical Quality Committee. This includes ensuring that delivery plans exist and are consistently implemented, and holding CCG staff to account for health inequality considerations. Director of Public Health The Director of Public Health helps to ensure that concerns relating to health and wellbeing are shared between the CCG and the local authority- Wandsworth Borough Council (WBC). Wandsworth CCG and the local authority are partners on the Health and Wellbeing Board. The aim of the Health and Wellbeing Board is to improve the health and wellbeing of the local population and reduce inequalities in health by ensuring that the key leaders in both the health and care systems work together. 10

Wandsworth Health and Wellbeing Board is made up of the following: local councillors, the Director of Public Health, Wandsworth CCG, Director for Adult Social Services, Director for Children s Services and a representative from HealthWatch. This year, the Health and Wellbeing Board has produced the Health & Wellbeing Strategy and the Joint Strategic Needs Assessment (JSNA) key strategies to help us alleviate health inequalities. Lay member, Patient and Public Involvement The Lay Member for PPI on the Governing Body actively champions the patient voice within the services the CCGs designs and delivers, and oversees the PPI Reference Group. This ensures that the overall aim of reducing health inequalities is supported with insight from the people that use our services. Patient and Public Involvement and Equality and Diversity team The PPI and E&D team is tasked with the operation responsibilities of the Public Sector Equality Duty. To deliver this, we seek input from internal and external stakeholders to gain a broader insight into commissioning decisions through the Thinking Partners Group, and share information about projects with major equality considerations with the Wandsworth and Merton Equality and Diversity Group. The team is also tasked with raising awareness and capability among CCG staff thorough training, support, and signposting to relevant policies. All staff All staff are responsible for championing quality, diversity, and inclusion within their projects and programmes. The PPI and E&D team supports commissioners and CCG staff to look at the impact their decisions might have on people with different protected characteristics, and how to minimise any potential negative impacts on these groups. Information about meeting General and Collective Public Sector Equality Duties and further detailed guidance is available on the intranet to all staff, alongside training modules on NHS Workforce. 11

Patient and public involvement Wandsworth CCG has a strong record of engaging patients and the public in the development of services and active engagement with patients is a common thread through all of our commissioning programmes. By really understanding what local patients, carers and residents need, the CCG is able identify, design, and deliver projects that help us to reduce health inequalities. Our aim is to ensure that patient and public involvement (PPI) is at the centre of everything we do as a CCG. This means that we systematically embed PPI and the patient voice at every stage of the commissioning cycle as illustrated by the examples shown in the diagram below. Building on best practice principles, the following diagram illustrates how PPI is a continuum and is made up for four distinct levels and processes. We use these levels or different approaches for PPI as indicators/standards for assessing PPI within each stage of the commissioning cycle. Informing Consulting Involving & engaging Partnership Informing is the first level of involvement and is a useful process to be clear, honest and transparent about what we are doing and about any plans or service changes. It is a one-way process to enable us to tell our stakeholders about our work/service or any changes to patients, carers and the public without involving them. Consulting is a two-way process which enables us to ask people and obtain feedback about their views; and gives us the ideal opportunity to build the patient voice/gain insights into projects or service improvements or new models of care. Involving and engaging is the logical extension of consulting which enables us to ensure that the patients and the public are actively engaged in our programmes. This is a useful process to ensure that we are taking patients, carers and public on the journey with us. An example of an enabler to our consultation process is the Customer Relationship Management (CRM) system we use. Developed by the PPI Team, the CRM system allows us to segment key stakeholders, identifying which inequalities they are most interested in knowing about. The CRM contains over 2000 of organisations and individuals, and enables us to create effective stakeholder mapping. Partnership This is when patients and the public are actively working with us to determine the outcomes of our programmes or shape services 12

CCG patient and public involvement groups Patient and Public Involvement Reference Group (PPI RG) Wandsworth CCG has aimed to provide our stakeholders with timely, appropriate, and accessible information about local health and care services that could affect them. Essential to this has been the PPI Reference Group, made up of members from Patient Participation Groups, Patient Consultative Groups, representatives from community and faith groups, and individual stakeholders. Achievements include: Long- Term Conditions Clinic Members discussed the role of family members, carers, patient transport, and the skillset needed to adequately service older people s healthcare. A key theme was perception, and the need to get the language right: the current Multi-Morbidity Clinic name, was rejected as being not user-friendly. Due to this feedback, the name has now been changed to the Long-Term Conditions Clinic. You said, we did Members advised that although the CCG spent a lot of time engaging with stakeholders, it did not always let them know how their input had made a difference. Due to this feedback, we have developed a you said, we did approach, ensuring that commissioners respond to the feedback they receive and provide examples of how their actions have been influenced. This will be promoted through our publications, meetings, and communications channels. 13

Thinking Partners Group (TPG) Equality, diversity, and inclusion play an important role in Wandsworth CCG s plan to reduce health inequalities. The Thinking Partners Group has been tasked with supporting these objectives, and is made of staff, patients, carers, local residents, Healthwatch Wandsworth, and community and voluntary sector organisations. PSED implementation is overseen by the Thinking Partners Group, which feeds into the Wandsworth and Merton Equality and Diversity Group. Achievements include: Wandsworth Joint Prevention Framework Members advised how topics such as empowerment, language, disability, and location can become barriers for people trying to make better healthcare decisions. Due to this feedback, the new Wandsworth Joint Prevention Framework will place a greater emphasis on these topics, and highlight how people can access support for resolving them. Voluntary Sector Coordination Project Members were encouraged to put forward ideas on how the CCG could strengthen its relationship with the community and voluntary sector. As a result of these ideas, we developed the Voluntary Sector Coordination Project alongside Wandsworth Care Alliance, led by a project manager. The project manager has encouraged CCG staff and community and voluntary organisations to share ideas, skills, and networks to positively influence local services. 14

Specific patient groups Voluntary sector HealthWatch Community Development Work Surveys / social media CCG Accountability Structures for PPI Other patient feedback LCG Wandsworth CCG Board PPI Reference Group (Chair: Lay member on Board) LCG LCG Other CRGs Thinking Partners Group Battersea Wandle West Wandsworth MGT PG MGT PG MGT PG GPs GPs GPs GPs GPs GPs GPs GPs GPs 15 Various forms of patient, carer, service user involvement at Practice level Key: CCG Clinical Commissioning Group CRG Clinical Reference Group LCG Locality Commissioning Group MGT Management Team PG Patient Group GP General Practice PPI Patient and Public Involvement

Clinical Reference Groups (CRGs) Led by GPs, our Clinical Reference Groups are where health and care professionals, patients, carers, and providers come together to develop projects. Over the past few years, the Patient and Public Involvement Clinical Lead has had discussions with groups on what support they require to reinforce patient and public involvement. The emerging themes included measuring patient and public involvement, cost-effective engagement, and the Accessible Information Standard. The evidence for each of the CRG s patient and public involvement activities can be seen in their own board reports. General Practice patient and public involvement Productive Patient and Public Involvement All 40 of our GP member practices provide input into how the CCG commissions services. To strengthen this involvement, the Public Involvement Clinical Lead held a workshop for primary care staff to gather their experiences of doing patient and public involvement. Responses from the workshop highlighted several positive and negative aspects of involving patients and the public. From this feedback, a plan has been developed for General Practice called Productive Patient and Public Involvement. Here, staff members are encouraged to consider the patients perspective of accessing healthcare, with the question What is it like for you to experience the service that I am giving you at this moment in time? The Productive PPI plan has also been expanded to include the practice s community and seldom heard group visits, patient participation groups, implementation of the Accessible Information Standard, and several other elements. The concept is represented by the Productive PPI Umbrella below. 16

Community and Seldom Heard Group GP Visit Programme Community and voluntary organisations have been crucial not only for the development of patient and public involvement but in providing clinical staff with opportunities to work with communities facing a variety of health inequalities. GP practices are encouraged to visit community and voluntary organisations to better understand the health and wellbeing concerns of hard-to-reach groups. So far, 29 GP practices have visited a total of 17 organisations, with evidence showing increased levels of enthusiasm alongside a better understanding of patient insight and community involvement. We are inviting carers to talk to us about accessible information needs the patients they look after may have, along with their own needs. We are developing a carer s newsletter, that details support information for them on a quarterly basis and linking them to external organisations such as Wandsworth Carers Practice staff member, 2017. Community Grant Scheme (CGS) The Community and Heard Grant Scheme has been set up to facilitate conversations between Wandsworth CCG and local organisations. The scheme has been supported by the Voluntary Sector Co-ordination Project, Wandsworth Care Alliance, and Wandsworth Community Empowerment Network. Through using an asset-based approach, we have looked at how the community can collaborate with the CCG in identifying and reducing health inequalities whilst promoting wellbeing. These groups have also become valuable engagement channels, allowing the CCG to cascade information to groups we often struggle to reach. Following feedback from last year that the CCG needed to do more to support grant recipients in applying for grants and measuring their outcomes, we have held a workshop in September to support these aims. 14 people attended the workshop. Currently, we have given grants to the following organisations: Wandsworth Vision Full Circle Therapies Generate Cedar House Nicholas Stewart Project Sen Talk The Venue Small Steps 17

Somali Community Advancement Organisation (SCAO) SCAO used funds from the Community Grant Scheme to hold a workshop to address specific issues such as mental health and female genital mutilation and designed to appeal to both Somali men and women. A total of 35 people attended the workshop, mainly women. They had a range of needs from lack of awareness of health issues (mental health, FGM) to isolation coupled with a lack of understanding of both the English language and UK systems which meant they did not access health services and had limited community involvement. Outcomes: Participants had an improved knowledge of mental health, the wellbeing of the patients, steps for supporting someone with mental health problems and how to access the support available. Participants appreciated the knowledge gained on UK laws regarding FGM, the health implications and expressed a willingness to talk confidently against FGM. People felt more comfortable discussing mental health and FGM. Participants learnt about support groups for diabetes, carers and mental health carers. Recommendations for Wandsworth CCG There is a need for more bilingual staff in the health sector as the language barrier is a problem when dealing with health professionals. Older members in particular may benefit from alternative methods to enable them to learn, such as group sessions. 18

Learning Lunches Last year we began an initiative to bring together community and voluntary organisations with Wandsworth CCG through lunchtime presentations. This has allowed commissioners to learn more about health inequalities, and how local organisations can help in reducing these. As community and voluntary sector organisations often have in-depth knowledge about certain conditions, cultures, and disabilities, staff are also encouraged to get more involved through planning their own visits. 2017 Learning Lunches: February 2017 Baked Bean Company April 2017 Wandsworth Community Empowerment Network April 2017 Aspire2Inspre Dyslexia November 2017 Macmillan/ Paul s Cancer Support The community groups have particularly been great in telling commissioners what does not work- which is just as important to save time and resources, while improving patient experience CCG staff member, 2017 CCG newsletter- Healthy Wandsworth The Healthy Wandsworth Newsletter will go out at least once a month to showcase local news, events, projects, and engagement opportunities- with a focus on good health promotion and ill health prevention. Healthwatch Assembly and Voluntary Sector Forum This year, we have forged a stronger relationship with Wandsworth Care Alliance, Healthwatch Wandsworth, and the Voluntary Sector Forum to ensure that we engage more within the local community. This has allowed us to discuss health inequalities on a much larger level, using well-established networks. Presentations have included: - STP: Debbie Baronti and Rebecca Wellburn - Wandsworth Self-Management Service Tisson Dulabdas - Expert Patient Programme Christine Monahan - Getting the most out of your GP services: Dr Aryan Jogiya - (Battersea Healthcare CIC) 19

Equality Delivery System 2 (EDS2) From 1 April 2015, the Equality Delivery System (EDS2) has been mandated in the NHS standard contract. The EDS2 is also being further embedded within the Care Quality Commission's inspection regime, and it features in the 2015/16 CCG Assurance Framework for CCGs. The 4 EDS2 goals are: Goal 1 - Better Health Outcomes Goal 2 - Improved Patient Experience Goal 3 - Representative and supportive workforce Goal 4 - Inclusive Leadership Through EDS2, the CCG is working to transform equality practices across the organisation, it has helped to: Identify the Thinking Partners Group as our partner organisation to help us deliver evidence of good practice across the organization Involve Community Groups in assessing our performance in equality and diversity and defining priorities for the localities. Continuously identify gaps or barriers within our services and the impact these may have on the nine protected characteristics so we can take remedial steps to address them Advance equality and diversity across all our core functional activities Capture the progress we make and to identify our equality and diversity priorities Strengthen our vision for equality and diversity to be mainstreamed and to become part of everyday practice within the CCG The four goals we graded our services against were: under-developed still have a very long way to go and no evidence available and no protected group fares well developing only a few protected groups are benefiting, and evidence is limited achieving most protected groups fare well as others in the community and there is evidence to support excelling all protected groups fare well, with evidence to support EDS2 external grading Workshop Acting on feedback form staff and stakeholders over the last year, we worked with Wandsworth Community Empowerment Network and DiverCT to deliver a workshop for goals 1 and 2. A Goals 3 & 4 workshop will be conducted in March 2018- as this focuses on internal grading, we will do this with our staff survey results. 20

By holding this workshop with local partners, clinicians, commissioners, and service providers, we were able to discuss how we can work together to improve services in two main areas: Latent Tuberculosis screening Improving access to psychological therapies (IAPT) Workshop participants came from a variety of organisations, including: Healthwatch Wandsworth Balham Autumn Rose Club St. George s Hospital KWA Africa Wandsworth Carer s Centre Wandsworth Care Alliance Muslim Network Citizens Advice Wandsworth CARAS New Testament Assembly Pastors Network Generate Age UK Wandsworth Putney Wellbeing Friends Wandsworth & Westminster MIND Mushkil Aasaan Muslim Network Diverse-CT Elays Network Wandsworth Borough Council Talk Wandsworth Below sets out the results of the workshop. It has been proposed that due to the current findings, the CCG should hole another workshop to investigate both services in more depth. This includes IAPT, which we were not able to fully grade in 2017-18. As we go into 2018, the CCG has discussed with our Thinking Partners group and local partners about how we deliver services. One agreed step forward will be in ensuing that we involve local partners in our event design and planning, so we can factor in their needs. We will also ensure that all nine protected characteristics are considered when creating any E&D plans/. 21

Latent Tuberculosis: Screening and Testing Goal 1: Better Health Outcomes Outcome Strengths Areas for improvement Grade 1.1 Services are commissioned, The fact that there is a such a targeted service is good for the Organisations that represented some of the targeted groups did not know about this Achieving procured, designed borough due to its population Promoting through community and voluntary and delivered to Helpful that it does not affect organisations could ensure higher take-up meet the health visas- which could put people Some people are simply not going to go to a needs of local off surgery- how to we ensure they know about this? communities Other groups that may be vulnerable include the homeless- what other ways can we attract highrisk patients? Stigma remains an issue in some of these patient groups- this should be addressed through community and voluntary sector 1.2 Individual people s health needs are assessed and met in appropriate and effective ways The Joint Strategic Needs Analysis has been consulted to support commissioners in understanding the make-up, health needs and inequalities of Wandsworth. This potentially limits the negative impact that More needs to be done to promote this service through areas where target groups tend to live, socialise, work Address what happens to people that may have latent TB- but fall outside the age group Each infectious case represents a risk of onward transmission- addressing TB early on during Achieving could be felt by patients Clear service expectations are contained within the specifications, focussing on the health needs of patients and ensuring that the service provider delivers to the needs of the individual. migration should be a priority Results do not clearly show which protected characteristics fare well or not Local organisations could assist with the minor tasks related to take up. however this would have patient safety and governance implications Look at model of WCEN/ GP health checks 22

1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone wellinformed As the IGRA test can also test for HIV, this can potentially assist with other long-term conditions. Images of pathway show effective and efficient route for screening and testing Making people aware of how easy it is to do this testing may make them less anxious- thus increasing take-up Patients may need translation service to ensure they are adequately informed Contact details should be clearer on leaflets Developing 1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse New E&D monitoring developed to record for specific groups of people with protected characteristics. Patient reports are monitored via serious incident reporting and meetings. Regular meetings take place with GP providers. Safeguarding reports are conducted when necessary. People need to know their options and their rights, especially if a mistake is made Practices must show their complaints policy in an accessible format- but also in other languages Service must make it clear that this does not affect visas Developing If a healthcare worker or NHS employee comes into contact with patients or clinical specimens, they are recommended to have a TB vaccination irrespective of age 1.5 Screening, vaccination and other health promotion services reach and benefit Programme has reached some communities- show by current testing results With the asylum seeker and refugee groups there is also often confusion about what patients are entitled to- from patients and clinicians Latent TB is expensive to treat and poses a serious public health threat Achieving 23

all local communities. Incidence rates within targeted age group have been rising- we must look at why Those at increased risk include the homeless, problem drug users and prisoners these must be factored in alongside people coming from abroad/ have been abroad Communities often have stigma attached to TB, so the health professionals need to be more aware of these risks- and their mitigation Some communities often live and work togetherdue to necessity. Must target people living in close quarters The hard to reach groups tend to be a highly mobile and transient group and are difficult to follow up. Patients may have multiple health and social problems. They may not therefore know how to manage their medication Goal 2: Improving Patient Access and experience Outcomes Strengths Areas for improvement Grade 2.1 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds. Times for samples to be checked through pathology service are not too long Available to some of Wandsworth s most vulnerable communities Positive to see that west Wandsworth may follow Wandle model Carer information is not easily available Most of the patients have been from one practice People find it difficult to take time out from work People with language issues need more time for consultations this can affect practice capacity It is necessary to invest in more TB awareness raising activities: Achieving 24

2.2 People are informed and supported to be as involved as they wish to be in decisions about their care 2.3 People report positive experiences of the NHS Leaflets available in multiple languages- focusing on high risk countries Leaflets dispel some myths. All Wandsworth practices now follow accessible information standard Patients able to access summary care record to view their results and medical information without booking appointment practice that handles most TB referrals has an overall good passive experience Topics on patient experience and are discussed at Thinking Partners Group/ PPI Reference Group Actions from this have included patients sharing their stories, using their experiences to Both within communities and with frontline health care providers in the areas of the borough most affected. Although there will be costs associated with these activities, these should be offset by reduced incidence of TB and in particular reduced incidence How to access this service if you are disabled? Support treatment completion in patients diagnosed with TB- many are not finishing cycles, leading to worse health outcomes Address stigma associated with a TB diagnosis amongst minority ethnic groups More promotion of accessible information standard at practice level raise awareness of TB amongst health care providers and the general population in order to achieve earlier diagnosis and to enhance case finding Lack of data to show positive patient experience Patients must know how to feed back- and why it is important Achieving Achieving 25

2.4 People s complaints about services are handled respectfully and efficiently develop and improve outcomes Accessible complaints policies in place All GP practices have Complaints processes advertised CCG has a serious incident monitoring framework The policy also has implications for providers of services to the CCG and they also have a duty to have a complaints. Need translated complaints policies Telling patients that making feedback/ complaints does not harm their service Getting back to patients in a timely manner once they complain Achieving 26

IAPT services: Talk Wandsworth Goal 1: Better Health outcomes Outcomes Strengths Areas for improvement Grade 1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities 1.2 Individual people s health needs are assessed and met in appropriate and effective ways The service offers a wide choice in terms of the range of interventions provided to meet a variety of needs. This includes both group and individual treatments Skype based therapy Interpreters can offer therapy in languages other than English. Service commissioned with local groups: BME mental health forum, Voicing Views, etc. Clients able to self-refer, which can lessen anxiety about going to practice to ask GP When people register, they are asked for demographic data Different locations available so people can access different services Social prescribing links to services offered The rest of the IAPT service s findings will be explored at a secondary workshop- estimated in summer 2018. More therapists with different language skillsespecially as new ethnicities come to Wandsworth How do disabled people get fair access? Needs to be clearer Early interventions needed for higher prevalence groups. i.e. black men There is a need to link with existing work that happens in the community- such as local faith groups, community centres, schools Making sure that families/ carers/ support networks are involved- as they can assist with support Staff must have adequate training on different cultures and needs Achieving Achieving 27

Key Commissioning Achievements Locality Commissioning Wandsworth CCG is formed from three localities; Battersea, Wandle and West Wandsworth, each with a clear understanding of the health and social care needs of their local population. As a membership organisation we place local clinicians, who are truly able to understand the needs of our patients, at the heart of our vision and decision making. The Wandsworth Health & Wellbeing Strategy has identified Healthy Places as a key enabler to addressing health inequalities and the CCG supports differential commissioning where it will deliver a health benefit. Locality commissioning groups, with their geographical focus, have a clear understanding of the health and social care needs and inequalities of their local population and can help reduce health inequalities and address health and social care issues that may be specific to their communities. The map below identifies the three localities and their constituent practices. Locality Commissioning Groups We passionately believe in real clinical leadership in all parts of the commissioning cyclethe priority setting, the planning, contracting, performance management and review of commissioned services are all undertaken under the leadership of the elected clinical leads. These groups have a detailed understanding of the health needs of their local populations and use this to develop programmes and projects to meet these needs. 28

Battersea Mental Health: Mindfulness Courses Battersea has high levels of mild mental health illness, including an incidence of depression higher than the Wandsworth average. Mindfulness and stress reduction courses have been shown to be beneficial to both psychological and physical well-being, reducing anxiety and low mood. The courses were initially started by Thurleigh Road practice for their patients and were then rolled out and made available to all the Battersea practices. Parenting Courses In 2014-15 the parenting course that had been developed by Thurleigh Road practice was rolled out to be available to all new parents in Battersea. The courses were delivered from four community localities across Battersea: St John s Therapy Centre, Thurleigh Road Practice, Katherine Low Settlement and STORM. Each course ran for five weeks and was aimed at new parents in the first year after birth. In the period January 2016 - March 2017 nine course were run with 40 new mothers. Following discussion with the course providers, GPs and the Battersea Patient Group the parenting classes were re-branded as Mum and Baby Club. It was felt that this would sound more supportive and be more likely to attract new parents. Patient Welfare Advice Service In January 2016 Battersea launched a Patient Welfare Advice Service (PWAS) that delivers non-medical advice and support to patients. This is delivered by Citizens Advice Wandsworth (CAW), Family Action and DASCAS, working closely together, ensuring an efficient and effective service for Battersea patients in need of social welfare support. Since its launch in January 2016 390 patients from nine Battersea Practices have been referred to the service. Of these, 112 have been referred on to Family Action and DASCAS. Two thirds of patients referred to the project in the period 1st April to 31st August 2017 had not previously used Citizens Advice Wandsworth (CAW) services. The project is therefore reaching local residents in need, and the referral from a trusted GP is a proven way to removing barriers to accessing support. 29

Wandle Childhood Obesity Public Health analysis shows Wandle has high levels of Childhood Obesity. Practices are taking part in a pilot where Nurses measure the children s Body Mass Index (BMI) when they attend for their pre-school immunisation booster. Training for health care professionals on measuring BMI in children and how to discuss the issue of child obesity in an effective, compassionate and motivating ways has been provided. From January 2017 to November 2017 250 children were weighed and measured. Latent Tuberculosis 143 Latent Tuberculosis tests carried out from January 2017-November 2017, with 18 patients identified as positive and referred for treatment Citizens Advice Bureau Delivery of the CAB service Wandle have commissioned a dedicated Community and Advice Referral Assistant. This enables all Wandle Practices to prescribe community advice with onward referrals where appropriate for their patients. Interventions are initially done by email and telephone with provision of space at two Wandle Practices for patients to be seen face to face. From January 2017 to November 2017 393 referrals were received: 30

West Wandsworth Patient Advice Service The Patient Advice Service launched in West Wandsworth in July 2016 and is currently being provided by Citizens Advice Bureau Wandsworth. The service intends to shift social support needs from GPs to more appropriate community based resources resulting in a reduction in the length of time GPs spend on non-clinical issues and a reduction in frequent attendances. The needs of the patient are assessed within 3 working days and they will be given information, advice and signposting via telephone. Where appropriate, a face to face appointment will be made to offer more specialist advice. During the first year of operation, 155 patients were referred to the service, of which 80% had a disability or long-term condition and over 60% had experience of a mental health issue. Benefits and tax credits are the most common issue that clients sought advice on, followed by housing issues and debt Latent Tuberculosis Tuberculosis (TB) rates in England remain high and are associated with significant morbidity, mortality and costs. The onset of TB can be difficult to detect with significant diagnostic delays. Late diagnoses are associated with worse outcomes for the individual, and in the case of pulmonary TB, with a transmission risk to the public. Following the successful pilot of a TB initiative in the Wandle locality, it has been decided to roll out the programme to the West Wandsworth locality. The aim of the initiative is to increase the number of people screened and treated for latent TB among eligible migrant at-risk populations in GP settings in order to improve early detection and reduce the incidence of TB in Wandsworth. Social Prescribing Clinic Pilot West Wandsworth are also engaged with a social prescribing clinic pilot. A Community Navigator from the Wandsworth Wellbeing Hub holds a social prescribing clinic once a week at Putneymead Medical Centre. The Community Navigator provides a face to face signposting service for patients who are referred from the Primary Care Team. The aims and objectives of this pilot are as follows; Develop an effective social prescribing pathway between Primary Care and the Wellbeing Hub. Improve the health and wellbeing of patients through providing access to nonmedical support. Increase social prescribing as a first line treatment for symptoms of mild anxiety and depression and other common mental health problems. Improve skill mix in Primary Care and reduce clinical workload by providing patients with community navigation in the most appropriate setting. Monitor patient outcomes and feedback to the CCG to inform future commissioning. 31

CCG/Wandsworth Council Joint Programmes Preventing Ill Health Promoting good health is one of our three strategic objectives. The aim of our Promoting Good Health Programme is to improve people s health through creating resilient communities by better supporting our voluntary sector. We have tried to achieve this through working closer with our local authority colleagues, exploring alternative and new ways of commissioning and designing specifications. This is currently being achieved by being less prescriptive about the design of the service and being more focused on the outcomes, thus allowing organisations to use their intelligence and experience to build services that are tailored to the needs of the local population and are accessible across the borough. The programme is made up of a series of smaller projects: The Wandsworth Wellbeing Hub A web portal designed to help patients and the public to find organisations and services to support their health and wellbeing. Over 1400 organisations services are accessible through the Wellbeing Hub. Developing Community Resilience The project focuses on supporting the local population of Wandsworth. Delivered in partnership with local voluntary organisations, the aim is to provide a range of activities to promote good health, reduce social isolation and increase resilience. Voluntary Sector Co-ordination Project (VSCP) Through the project, we have identified areas within our commissioning cycle that could be improved to make the way we commission voluntary sector services more effective and more collaborative. This has allowed us to have a more open and honest relationship with the sector, which we hope will lead to the commissioning of services that are more appropriate and that are based on the needs of the population, helping the prevention and early intervention agendas. Social Prescribing Wandsworth CCG are committed to working with Wandsworth Council to deliver the requirements highlighted in The Prevention Framework including; Making every contact count Focusing on those who need support most Building on e-solutions to make services more accessible Building a resilient voluntary sector Focusing more on self-management and self-care 32

Social Prescribing, Self-management and Community Resilience Example An Overview of Social Prescribing and Self-Management in Wandsworth The Wandsworth Wellbeing Hub The Wandsworth Wellbeing Hub is a social prescribing tool which aims to improve access to services that can aid self-management and develop personal capability and resilience. The Hub links primary care patients to a variety of local non-clinical services which promote wellbeing, encourage social inclusion, offer practical support, promote self-care, and can in turn, prevent ill health. The Wellbeing Hub provides an online and telephone signposting service run by Community Navigators. To reduce health inequalities, it is important not to focus solely on illness, but also provide a holistic response to social issues; the Wellbeing Hub and Community Navigators aim to facilitate this focus. During 2016/17, 366 calls to the Wellbeing Hub were received by the Community Navigators and the website was accessed over 7,500 times. As outlined below, 91 callers were signposted to the Talk Wandsworth service (previously IAPT) and 56 callers were referred on to a weight management service during 2016/17. 33

The Wandsworth Wellbeing Hub Primary Care Pilot From April 2017, the Wellbeing Hub will begin to pilot a face to face social prescribing model in Primary Care. Initially, a Community Navigator will be based at Battersea Fields Practice one day a week and will receive referrals from the Primary Care team. Over the last 12 months, the Wandsworth Self-Management Service (WSMS) has been challenged to deliver a multifaceted self-management service. This service has the following aims; To provide evidence-based courses to people living with long-term conditions and their carers. To create greater awareness of self-management and the services that are available within the third sector. To deliver a short course that acts as a taster for anyone who may be interested in developing their self-management skills. To work with Lifetimes to develop the Care4me database, ensuring it is user friendly, effective and responsive to user feedback. To support the Diabetes Champions to continue to help prevent Type 2 Diabetes in the community and promote the services of WSMS 34

Commissioning Programme achievements Planned Care Wandsworth CCG s planned care programme focuses on outpatient appointments in several areas and makes sure that patients receive the most appropriate care in the right place, seeing the best professional to meet their needs. During 2016/17 Wandsworth CCG worked with Merton CCG to establish a planned care programme, identifying what areas of work would be undertaken to start to make a big change in the way services are provided from St George s Hospital. The programme supports South West London s Five Year Forward Plan, which aims to reduce the number of outpatient appointments at hospital sites. We have redesigned a number of services in 2016/17 including phlebotomy, ear, nose and throat (ENT), gynaecology, musculoskeletal, diabetes and anticoagulant services, as described below. Blood Testing Many patients are referred by their GP for blood tests; until recently, most patients would have to travel to St George s Hospital to have their bloods taken, with only a few patients able to access blood tests at their GP or a neighbouring GP practice. In 2017, the CCG worked with the GPs to increase the availability of blood testing in primary care so all patients, where practical for the patient, could have their bloods taken closer to home. Now, when a GP refers a patient from blood tests, they can have the tests done quickly and easily at their own or a nearby GP surgery. Ear, Nose and Throat There are a great number of people who need to have ear wax removed, sometimes before having a hearing aid fitted, or before surgery, or sometimes just because they have blocked ears. Over 90 people a week are having their ear wax removed at St George s Hospital, a relatively straightforward procedure that could occur before the patient attends a hospital appointment. We are working with the hospital to develop a new pathway of care for patients so that they can have their wax removed before going to the hospital. This means valuable consultant time is not spent on undertaking straightforward work and some people will not need to visit the hospital at all, being able to receive all their treatment at their practice or a practice nearby. Diabetes Following a lengthy and extensive engagement and scoping exercise, the Wandsworth model for diabetes has been agreed by clinicians, patients, commissioners and public health. The model includes elements considered to be important by the Wandsworth Diabetes Patient Group. These include: A prevention plan Learning and refresher workshops for diabetes patients and home carers 35

Deliver a check-ups service outside of working hours/days for people who are of working age Build a personal healthcare plan for patients with long term conditions in general practices to include lifestyle change, motivation and advice and developing personalised care plans owned by the patient and home care Annual review of plans with all diabetes patients Digital pilot for Somalian diabetes patients The CCG has introduced a pilot digital education app/virtual tool for the Somalian population. A local GP practice was identified with a high Somalian population and targeted to test whether the population are more likely to access virtual education than the established group, face to face structured education. This allows clinicians to deliver diabetes patient education that is more accessible to people who are known to not usually access education. Gynaecology Many patients attend hospital appointments to access specialist advice and diagnostics. One of the objectives of the Planned Care Programme is to make sure that these services are provided in the most efficient and cost effective way. In gynaecology we have been looking at four different, common pathways that patients regularly follow: Acute pelvic pain Heavy menstrual bleeding Fertility Urinary incontinence We are working to ensure that, when people attend a hospital appointment, all the necessary information is available (for example test results and current medication) to reduce the need for multiple appointments. Example- Reintroducing urogynae services at the local hospital Currently women have to travel out of borough to access acute urogynae services. The re-introduction of urogynae services as St Georges Hospital will provide local specialist services to women with urogynae conditions. This ensures that patients do not have to travel as far to access services. Mental Health Our work in this area is overseen by the mental health clinical reference group. This comprises doctors, CCG and council mental health commissioners, service user and carer representatives, mental health providers and groups such as the Black and Minority Ethnic Forum. Through the services we plan and fund, our main aims are to promote prevention and mental wellbeing and improve the quality of services. 36

Achievements in 2016/17 Include: The new talking therapies service, called Talk Wandsworth, started in April 2017, provided from GP practices and from other accessible community sites including a new hub at Tooting Broadway. A new Primary Care Liaison service was launched within GP Practices in central Wandsworth in March 2017. The new service will better support people who have been discharged from mental health services to the care of their GPs, along with their families and carers. The launch of the psychiatric decision unit (Lotus Suite) at Springfield Hospital. The service allows those in mental health crisis to be seen and treated quicker and in the right place, thus improving their experience All mental health contracts including spot purchased placement and other mental health projects are contracted using the standard NHS contract which includes explicit expectations in relation to equalities requirements. Furthermore, all our mental health project contracts now have specific quarterly reporting requirements for those accessing the service for gender, age, ethnicity, disability and sexuality The mental health CRG continues to have key representation from service users, carers and the local BME Mental Health Forum. The CCG continues to commission Voicing Views to undertake service user involvement and has further commissioned Voicing Views to undertake a project seeking service user involvement specifically targeted at the LGBT community. Voicing Views is a mental health service user project that works with the Mental Health Trust, the Clinical Commissioning Group and Adult Social Services on matters relating to the delivery and development of mental health services. WCCG are commissioning a community lead evaluation of the Primary Care Plus project that will focus on impact within BME communities. The Primary Care Plus Project itself was commissioned with key involvement of service user, carers and community representatives, including full involvement in recruitment to PCP workers, input to extended community inductions and continued involvement in PCP Operational steering group. WCCG are working with SWLSTG and St. George s University to developmental health secondary care responses to Domestic Violence following an earlier commissioned report. A pathway for mental health services has been developed and during early 2018 an accredited training session will be undertaken by mental health staff at the Rose In-patient unit (women only unit) Other key achievements; 37

WCCG commissions and the mental health CRG s BME representation sub-group continues to develop projects targeted at BME communities Community Network for Family Care (Faith and Community Network) From Surviving to Thriving (including Community Champions) MH Ward Peer Support project (with Canerows) MH Awareness training targeting Muslim Women (with Muslim Women s Network) Secondary Care community links Older Peoples Acute Admission Avoidance (AAA) Pathway In 2016/17 we developed a rapid access clinic within the acute admissions avoidance (AAA) pathway. This clinic provides rapid assessment and treatment to prevent the need for a hospital admission, supporting patients to remain at home safely. It is an easy-toaccess alternative to A&E attendances and inappropriate acute admissions for our frail and elderly patients who do not have an acute/complex medical condition. The rapid access clinic launched in October 2016 and is now operating five days a week. To date, around half of all patients seen at the clinic have returned home safely with a package of care in place. Around 40% of patients were admitted to a short stay rehab bed, and only 10% required an acute admission. Case Study: Older People Multiple Long-term conditions service development What is the purpose of the service change? A single multi-ltc service is being developed to improve patient centred-care and reduce the fragmentation of care provision. The service aims to reduce the number of different appointments that a person will need to attend; enhancing existing geriatric service provision and replacing multiple consultant appointments. This will improve patient experience by creating an integrated care plan with one prescription. How is it trying to achieve this? New hospital are being developed to identify which patients would be better managed by a geriatrician and protocols developed with different clinical specialties. For example, in Rheumatology, protocols have been developed to redirect patients with osteoporosis to be seen by the Geriatrician. This redirection of a referral will be with the patient s permission and eventually in discussion with their GP. GPs will review their patients with more than two LTCs using a risk stratification tool and decide who could benefit from this holistic service. The geriatric service will be enhanced to further integrate services including physiotherapy, occupational therapy, nursing care and voluntary sector services, such as exercise groups to improve strength and balance, and social groups. The advantages of these new processes for increasing equality and diversity are that the GPs will use a risk stratification tool to identify patients with multiple LTC from their patient list. It does potentially preclude those patients that are not registered with a GP practise which is a small number. This could be picked up by patients attending A and E and then referred to the service. 38

Accessibility The location for the multi-ltc clinics will ensure easy access for our elderly population with good public and hospital transport links. This will improve ease of access to patients and their carers. Regular audits will be undertaken to embed patient feedback throughout the development of the service. This service is targeted at frail older people that have many long-term conditions such as diabetes, COPD and heart failure, who attend multiple outpatient appointments and receive multiple medications for those conditions. This service will benefit those patients who want to reduce the amount of time they spend at hospital appointments and maximise their time at home with their family and friends. People who may be disadvantaged from this development maybe those patients who have not previously accessed health care inputs for their long-term conditions and are not known to the health service. These patients would need to be picked up from A and E and then referred on to the MLTC service Care homes There are 11 nursing homes, 5 residential homes and 3 extra care housing establishments within Wandsworth. The Care Home Projects aims are for the care homes in Wandsworth is to: - To improve the coordination of and quality of care and outcomes for people living in nursing, residential and extra care housing in Wandsworth through proactive care planning, robust training and education programme, improve hospital transfers process and to reduce the number of unnecessary admissions into hospital through improved access to enhanced care and care planning in care homes. Two main groups have been set up to oversee the project and to ensure the aims are being met. Joint Working Joint Intelligence Group (JIG) The CCG Care Home Project Manager is leading on quality assurance for care homes. The Joint Intelligence Group (JIG) is chaired by the CCG Care Home Project Manager and has the aim of improving data intelligence sharing and joint working opportunities. The group brings together members from various organisations with a statutory responsibility for care homes and an operational role for quality and safety, enabling them to work collaboratively and share intelligence across the health and social care landscape Care Home Steering Group Project The Steering Group helps strengthen strategic partnerships with providers and commissioners across Wandsworth to improve integration. It brings together members from various organisations with the responsibility for care homes. The focus of the Care Home project is to promote a proactive and holistic approach to patient- centred care within care homes in Wandsworth. The key areas being: Deliver a planned programme of core education and training Deliver additional training according to the individual needs of the home to improve standards and reduce inequity across the borough. 39

Optimise transfer in and out of hospital for care home resident using the Red Bag scheme. Establish a responsive care home in reach team Reduction in London Ambulance Service (LAS) call-outs, LAS conveyances Accident and Emergency (A&E) attendances, emergency admission and length of stay. Improved resident experience. Red Bag Hospital Transfer pathway The CCG launched the Red Bag pathway on the 7th June 2017 All care homes in Wandsworth are currently using the Red Bag pathway this has helped to: reduce residents lengths of stay in hospital better communication between the hospitals and care homes more comprehensive medical history of residents facilitates better discharge planning. End of Life Care Work has continued to ensure that those patients who are nearing the end of their life receive joined up care from across the health and social care system enabling them, wherever possible, to be cared for and to die in the place of their choice. The Wandsworth End of Life Care Coordination Centre, based at the Royal Trinity Hospice, was set up as a pilot project in 2015 to provide a one-stop shop for patients, their families and those looking after them. Operating seven days a week, the Centre has supported more than 800 patients (to March 2017), coordinating the range of care providers looking after a patient at home, communicating with GPs and other clinicians, arranging equipment, delivering fast-track continuing health care packages and many other activities that can prevent a patient having to go into hospital as well as getting them home from hospital faster, if that is what they wish to happen. More than 75% of the people the Centre has supported have achieved their preferred place of death, where this was known. 40

ELC Coordination Centre aims To facilitate communications between providers and coordinate resources for the benefit of everyone Provide a single point of contact to support everyone engaged in caring for someone dying at home To free up clinical time To support patients to achieve their preferred place of care and death: to facilitate personal choice. Independent external evaluation demonstrated benefits to patients and families: improved communications Helped to raise awareness of services that HCPs, carers and family members might not have known about Intermediate Care or Reablement and Rehabilitation Intermediate care services are provided to patients, usually older people, after leaving hospital or when they are at risk of being sent to hospital and these services are put in place to avoid an unnecessary hospital admission. These services are also described as reablement in social services, or rehabilitation or maximising independence in health care. A team of hospital and community health nurses, therapists, social workers and the voluntary sector was set up at St George s Hospital in November 2016. The aim was to change the approach to discharge so more patients could go home sooner from hospital and be assessed at home rather than in hospital. A web-based dashboard has also been developed to identify patients who are medically stable and ready to go home. Integrated Urgent Care Service (NHS111/ GP Out of Hours) We successfully implemented our integrated urgent care (IUC) service across South West London. This aligns with the national integrated urgent care commissioning standards. The service aims to bring the current NHS 111 and GP Out-of-Hours (OOH) services closer together and will now include a virtual clinical hub formed of different types of clinicians (GP, pharmacist prescriber, nurses and paramedics). 41

Since the new service went live: 115,089 patients (across South West London) have called the service; 27% of calls were transferred to a clinical advisor (29,525) 8% of patients were recommended to attend A&E, and 11% were dispatched an ambulance Over 13,000 patients (12%) were not recommended to attend any further service; 48% of these patients were recommended home care and 11% of were given health information Child and Adolescent Mental Health Services (CAMHS) Wandsworth s Children and Young People s Transformation Plan 2015-20 reflects the Five Year Forward View priorities and expectations for transforming Children and Young People s Mental Health. Some of the achievements for Wandsworth over the last year have included: CAMHS Access Service continues to perform well working to a two to four week target for waiting times for first appointments and has reduced referrals to Specialist Tier 3 CAMHS by 33% Increased Place2Be counselling services in five more primary schools. The counselling is to build emotional resilience and self-esteem and to prevent emerging emotional wellbeing issues. This service works primarily with BME and disadvantaged families and has improved outcomes for 80-85% of families using the service An evidence-based parenting programme has been developed to build self-esteem, attachment and emotional resilience working successfully with 30-40 families from deprived areas in Wandsworth. The outcome measures are currently being evaluated by the Race Equality Unit Healthy Schools programme provides training and support for teachers and children in 22 primary schools in Wandsworth. It provides a time and space within the school curriculum for children to discuss their thoughts and feelings and to develop coping mechanisms to deal with difficulties they may be experiencing. It is expected in 2017/18 that an additional 2,000 children will benefit from this scheme CAMHS Transformation Plan monies have been used to increase the clinical capacity and capability of services to the under-fives. The service works with parents who due to life circumstances have a poor attachment with their child. The service has demonstrated improved outcomes for 75%-85% of the families seen and this is measured using the strength and difficulty questionnaire which looks at the level of emotional disturbance before and after the therapeutic intervention 42

Multispecialty Community Provider (MCP) a New Model for Care A major achievement for Wandsworth CCG in 2016 was the procurement of a Multispecialty Community Provider (MCP). The MCP will transform both Primary Care and out of hospital care across Wandsworth, and support delivery of the 17 specifications set out in the London Strategic Commissioning Framework for Primary Care: https://www.england.nhs.uk/london/wp-content/uploads/sites/8/2015/03/lndn-prim-caredoc.pdf The model will allow health and care professionals to work together with and for patients. Wandsworth GP Federation will ensure that agencies across health, mental health and social care are connected and coordinated to deliver multidisciplinary care for patients at home and in the community. The Federation will deliver the MCP specification for a seven-year period from 1 April 2017 using a phased approach. We expect the specification to evolve over time as we capture and evaluate learning from the initial model. Phase 1 (from 1 April 2017) will see the Federation deliver the following services: Primary Care Enhanced Services Planning all Care Together (PACT) The PACT enhanced service identifies patients at risk of hospital admission and resources GPs to proactively manage their care Primary Care Enhanced Services Diagnostics Four diagnostics services have been bundled into an overarching specification to ensure a standardised, efficient service, which all patients across Wandsworth can access: 24hr ambulatory blood pressure monitoring, 12-lead electrocardiogram, phlebotomy and spirometry Enhanced Care Pathway (ECP) The ECP provides multi-disciplinary support for the most vulnerable patients in Wandsworth, initially focusing on 500 of the most complex patients at the highest risk of deterioration. This service will be extended to support 800 patients in 2017 Primary Care Quality Contract This borough-wide contract operates at an individual practice level to identify and resolve gaps in quality, supporting GP practices to deliver high quality patient care Learning Disability Primary Case Management This service will reduce health inequalities by improving access to Primary Care for people with a learning disability, while ensuring that the care they receive is fully integrated with the wider health and care system 43

The CCG is currently supporting the Federation in the procurement and mobilisation of Phase 2 (from October 2017) and Phase 3 (from April 2018) services as below. The service specifications for Phase 2 and 3 are yet to be fully developed, and will require joint working from the Federation, the CCG and other local providers to ensure each service will be effectively integrated. Phase 2 Community Adult Health Services (CAHS) Better at Home Service Phase 3 End of Life Care Co-ordination Service (EOLS) Community Based Care Models for Long Term Conditions (LTCs) By embedding these services within the MCP and within Primary Care, the CCG will ensure that patients have access to joined-up services which operate proactively to meet the needs of patients and which are sustainable in the long term. Case Study: Enhanced Care Pathway An elderly man who had an external fixation frame on his leg following a tibial fracture, depression with agoraphobia after the death of a friend and bladder cancer which he did not want treating as he did not want to leave the house. The external frame was meant to have been removed 2 years previously but due to his agoraphobia he had not had it done. This patient was referred to the Enhanced Care Pathway (ECP). After an ECP referral and MDT discussion: The Complex Care team (Community GPs and Matrons) started the patient on an anti-depressant and referred onto the palliative care team who arranged domiciliary counselling (as he refused IAPT counselling). The domiciliary counsellor attends weekly and is encouraging him to start leaving the house. The Matrons visit regularly to offer encouragement and support so he would attend urology for treatment and orthopaedics for the removal of the frame and the subsequent wound care. The Voluntary Sector Coordinator has been supporting the gentleman to attend appointments by arranging transport to appointments. The coordinator also arranged a befriender to have regular contact and they are working towards the patient going out of the house for a walk to the local pub or coffee shop. The Social Services team has arranged for a Carer to attend three times a week to assist with personal tasks. As a result of the input of the MDT team, the gentleman has now had the external frame removed from his leg, his mental health is greatly improved and is now having active treatment for his bladder cancer. The team have seen a huge improvement to how they found him on their first visit, the patients has stated that he feels 1000 times better and he is currently doing well. 44

Looked After Children In meeting the health needs of this vulnerable group, health organisations need to focus on ensuring that Looked after Children are able to access universal services as well as targeted and specialist services where necessary. The NHS contributes to meeting the health needs of Looked after Children (LAC) by: Commissioning effective services Delivery through provider organisations Individual practitioners providing co-ordinated care for each child, young person and carer. There has been an increase in the number of LAC across Wandsworth which is line with the national profile. The Current population is 288 Health outcomes- Key Performance Indicators for children who have been in care for more than 12 months In regard to children in care for one year having their statutory review health assessments completed the LAC service achieved a strong performance 96.2 % review health assessments (RHAs) were completed 100% of under 5s received a developmental assessment 90.4% have up to date immunisations 78% have up to date dental checks Wandsworth Annual health assessment Up to date development assessment (under 5s only) Up to date immunisations Teeth checked by a dentist 2014-2015 2015-2016 2016-2017 Wandsworth (%) 91.9 98.4 96.2 Stat Neighbour England Wandsworth (%) 100.0 100.0 100.0 Stat Neighbour England Wandsworth (%) 91.1 82.0 90.4 Stat Neighbour England Wandsworth (%) 84.7 91.0 78.2 Stat Neighbour England 45

Improving Quality The drive to secure positive health outcomes for local people and continuously improve the quality of services is at the heart of the CCG s work. Quality is defined as: Patient safety: commissioning high quality care which is safe and prevents all avoidable harm and risks to the individual s safety, and having systems in place to protect patients Clinical effectiveness: commissioning high quality care which is delivered according to the best evidence as to what is clinically effective in improving an individual s health outcomes, and making sure care and treatments achieve their intended outcome Patient experience: commissioning high quality care which looks to give the individual as positive as possible an experience of receiving care, including being treated according to what the individual wants or needs, and with compassion, dignity and respect, and listening to the patient s own perception of their care We are working to ensure that all possible avenues are pursued to promote quality and monitor standards, holding providers to account through structured mechanisms. We have systems in place to monitor and review the quality of the services we commission to ensure that we are meeting the needs of our population. Learning from previous failures in quality across the NHS has emphasised the important role commissioners should play in preventing failures and driving improvements. We have developed a quality assurance process. The four stages are as follows: Stage 1: Quality Data Analysis Stage 2: Triangulation (comparing more than one source of information) Stage 3: Multi-Disciplinary Reviews Stage 4: Support Improvement We use dashboards and an integrated report to bring together a wide range of quality intelligence against the identified early warning quality outcome indicators in order to form a picture of the quality of each commissioned service. This includes on the ground intelligence such as site visits, and prioritises exploring patient experience to understand the reality behind the data. Where we identify areas of concern, these are addressed directly with providers to understand the causes and support improvements. The CCG holds providers to account for delivery of high quality care through the Clinical Quality Review Meetings (CQRMs) which are established through the NHS Standard Contract. The work of the CQRMs is reported to the Integrated Governance Committee, which provides assurance to the Board. We have established a Quality Group which reports to the Integrated Governance Committee which undertakes more in-depth scrutiny of quality issues, while ensuring that the work of the CQRMs is not duplicated. As we are part of the SWL STP, we will continue to implement and improve on the arrangements of quality monitoring as set out above working jointly with our partners. 46

Improving Quality and Safety In 2016/17 we focused on strengthening the existing processes and implementing more elements as set out in our strategy. We did this by building on work since the establishment of the CCG to help deliver our mission of putting quality at the heart of everything we do and ensuring we meet our statutory duties in respect of the quality of services we commission. Some of the achievements the CCG has made during the year include: Enhanced Quality Monitoring of Smaller Providers We have set up a process in place to improve quality assurance oversight of smaller providers by creating a standardised quality dashboard, reporting templates and formal discussion of the various groups of smaller contracts at our newly formed CQRG for directly contracted services. This work is still ongoing and continues to develop as we learn from the various types of contracts. Quality Monitoring of Primary Care From April 2016, Wandsworth CCG took on delegated commissioning from NHS England for the Wandsworth GP contracts, including responsibility for assessing and assuring quality and outcomes of these services. The delegation agreement between NHSE and the CCG sets out the expected responsibilities of the CCG with regard to quality in the management of GP contracts. The key responsibility is that the CCG must improve the quality of services and improve efficiency in the provision of the services. Wandsworth CCG has developed a process for identifying, reviewing and managing quality issues within primary care. This includes development of a Local Quality Tracker, a Practice Support Team and the Members Quality and Engagement Scheme. This is all overseen by the Primary Care Quality Review Group and involves working closely with other organisations, mainly NHSE, CQC and the GP Federation to assure the quality of primary care in Wandsworth. The Primary Care Quality Review Group meets on a monthly basis, monitors national and local quality standards as well as holding providers to account for any contractual requirements relating to clinical quality and safety of the services. This group reviews the work areas described above to direct areas of focus and inform decisions, or recommends where issues need to be escalated further for information or decision. The PCQRG reports to the Integrated Governance Committee, and where appropriate to the Primary Care Committee. 47

St George s Clinical Quality Review Meeting (CQRMs) These are formal dedicated monthly meetings with our major providers to monitor and discuss all aspects of the quality of care provided. CQRMs are chaired by GP leads and form part of our detailed quality oversight and scrutiny process. They allow a transparent and open discussion of issues to take place and improvements to be monitored. Wandsworth CCG is the lead commissioner in the contract with St. George s Hospital, and has responsibility for chairing the CQRM. A number of issues that the CQRM at St George s discussed in 2016/17 led to tangible improvements: Review into the process for cancer referrals and pathway management, in particular 100 day breaches Increased scrutiny into Serious Incident themes such as failure to follow up, unexpected death and delay in treatment in general Increased triangulation and visibility of complaints, incidents, quality alerts and other intelligence CQRG oversight and feedback from CQRG, monitoring CQC action plan progress, clinical harm process and patient safety and quality board Scrutiny into infection control processes, safeguarding and other quality areas such as staffing Attendance of Clinical Quality Review Meetings- Associate Commissioner The CCG is an associate commissioner for other providers such as Chelsea and Westminster NHS Foundation Trust, Kingston NHS Foundation Trust, and South West London and St George s Mental Health Trust. In order to have broader understanding and involvement in scrutiny of quality at these providers, the CCG has increased attendance at all these CQRGs. Improvement and Assessment Framework Clinical Priority Areas The Five Year Forward View and planning guidance set out national ambitions for transformation in several vital clinical priorities such as mental health, dementia, learning disabilities, cancer, maternity and diabetes. To reinforce collective efforts in these areas, NHS England is committed in the Government s Mandate to creating a separate clear rating for each of these six clinical areas, on a four point Ofsted-style scale. Our current rating for each clinical area is summarised below. 48

Make a Difference Alert System In 2013 we launched a quality alert system called Make a Difference. This enables care professionals to inform the CCG directly about quality concerns they may have from any of our commissioned services. In the year 2017/18 CCG has seen an increase in the use of this system. The themes from the alerts are discussed with providers at relevant platforms such as CQRG or contract meetings. These alerts have been a valuable source of soft intelligence. We have taken action as a result of these quality alerts, for example: Provided soft intelligence for use in design of pathways between secondary and primary care Provided early warning signs to a service within our main provider Triggered a provider review into technical system issues related to release of discharge summaries Provided continued awareness of the long-standing concerns with outpatients/referral issues with main provider Triggered proactive action and continued monitoring of our 111 SPOC service Some alerts escalated as potential serious Incidents Improved escalation of issues to other big providers where CCG is an associate commissioner Initiated quality inspection and deep dive into some services from a provider Work continues on improving how Make a Difference is used and this includes the launch of a reverse make a difference, where alerts are raised about our GP practices, improving how we escalate overdue alerts and increasing sharing of intelligence with other commissioners where we have common providers. 49

Workforce Race Equality Standard Wandsworth CCG is committed to improving the delivery of public services for everyone that used and works in the NHS. One way we have measured the views of the workforce has been through the staff survey. The standard comprises nine metrics four of which are specifically on workforce data and four are derived from the national NHS Staff Survey indicators. The aim is to compare the experience of BME staff and white staff with the objective of closing the gaps highlighted by those metrics. The survey results show that overall experience for BME employees is of a lower quality compared to white employees. The statistics also demonstrate the diversity of our workforce. However we acknowledge that we need to do more, particularly at senior levels. Respecting and valuing differences will help to ensure that our policies and services reflect the needs and experiences of the people we serve. To do this effectively, we need a workforce with the very best possible mix of existing and future talent. A WRES action plan will be created from the 2018 staff survey results to address overall challenges. Staff are encouraged to complete the staff survey, but more could be done to ensure staff populate their demographic data. This could be tied in with the Equality and Diversity Group, and could also incorporate certain organisational development outcomes, through working with OD Lead. The overall aim will be to embed our staff survey action into the implementation of our Organisational Development Strategy, including bespoke action for different tams; development and implementation of health inequality reduction. The plan must also detail actions to remove barriers and ensure that the best people progress in the NHS. The WRES also aims to address this inequality along racial lines and all providers, as holders of the standard contract 2015/16 except small providers of contracts less than 200,000 are required to implement the standard. 50