Patient and Public Engagement Event Wednesday 10 October 2018 - - PowerPoint PPT Presentation

Patient and Public Engagement Event Wednesday 10 October 2018 1:30pm for registration 1:45pm-5pm Executive Suite, Dugdale Centre, Enfield

Welcome

Teri Okoro Lay Member for Patient and Public Engagement

Housekeeping

• Please make sure you have signed in so that we can

add you to our mailing list.

• No fire alarm is planned today. If you hear the alarm,

please make your way outside

• Please turn your mobile phones off or put them on

silent

• Please help yourself to refreshments throughout the

event

• Feedback forms will be emailed to you after the

event.

• Please tell us what you what think of today’s event

and tell us about topics you would like to see at future events.

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• Join your GP practice’s Patient Participation Group (PPG). Ask your

practice if you can join. We have an active PPG network and an elected PPG representative Litsa Worrall who sits on the Governing Body

• Volunteer to be a patient representative and help us improve services

for local patients forms are available.

• Attend a Governing Body Meeting – dates are advertised on our

website, on Twitter and in the Enfield Independent

• Follow us on Twitter @EnfieldCCG
• Sign up to our mailing list – contact enfccg.communications@nhs.net
• Contact us if you would like someone to attend your voluntary or

community group meetings

• Visit our website www.enfieldccg.nhs.uk

How you can get more involved in the work of the CCG

Agenda

1:30pm-1:45pm Sign in, refreshments and networking 1:45-1:50pm Welcome Teri Okoro, Lay Governing Body member for Patient and Public Engagement 1:50-2:00pm Enfield CCG corporate update Dr Mo Abedi, Chair 2:00pm-2:30pm Primary Care Strategy Update Dr Chitra Sankaran 2:30pm-3:00pm Commissioning Intentions presentation Graham MacDougall Workshops 3:00pm-3:45pm Encouraging Self Care Clinical lead – Dr Mateen Jiwani, Medical Director Management lead – Paul Gouldstone, Head of Medicines Management 3:45pm-4:30pm NCL Orthopaedic Review workshop Anna Stewart, Programme Manager Colin Beesting, Communications and Engagement Lead 4:30pm- 4:45pm Questions and Answers session with the Governing Body 4:45pm Thank you and event closes Teri Okoro, Lay Governing Body member for Patient and Public Engagement 5

Enfield CCG Update

Dr Mo Abedi, Chair

• We have been under Legal Directions by NHS England since 10

August 2015. Historic underfunding has been a key contributory factor to the financial challenges and cumulative deficit.

• Enfield CCG delivered an in year deficit of £3.4m 2017/18

(Underlying position is £13.6m deficit after disregarding one off factors). In reaching this position, the CCG delivered £15.4m of efficiency savings, against a target of £22.5m. Of the achieved £15.4m of efficiencies made, £8.4m related to acute contracts and £7m related to non-acute productivity improvements, largely in prescribing services.

Corporate update

• In 2018/2019, Enfield CCG is planning a total spend of £462.725m and

needs to break even. This will be extremely challenging given that the CCG starts 2018/2019 with an underlying deficit of £13.6m and given the magnitude of local and system wide risks.

• In order for this to be achieved the CCG has to deliver an ambitious

programme of transformational changes and improvements of around £23.8m. Although the CCG has a developed and mature transformation programme, many of the easily achievable efficiency areas have already been adopted in recent years making programme delivery particularly challenging this year.

• North Central London commissioners and acute providers continue to

work collaboratively to develop and implement the Sustainability and Transformation Plan (STP) assumptions to ensure that the Enfield CCG and the North Central London wide control total is achieved.

2018/19 Financial Plan

North Central London (NCL) Primary Care Strategy

Dr Chitra Sankaran

General practice as the foundation of the NHS

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A strategy for North Central London

DRAFT

This strategy aims to consider what is important to andfor the people living in north central London, and sets outthe vision from a patient and system perspective. It recognisesthe challenges facing general practice in NCL and acknowledges that we must preserve the strengths of general practice, including continuity of care, a real understanding of the family

• r personal support network that patients are part of, and the

relative ease and accessibility of services.

Our story so far…

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DRAFT

General practice is facing unprecedented pressure.

Funding for general practice services, as a proportion of NHS funding has fallen, yet evidence suggests that demand has increased and is set to increase further as people live longerwith greater complexity and patient expectation grows. These pressures are further compounded by an aging workforce, fewer doctors and nurses choosing general practice as their destination of choice, and losing newly qualified general practice staff to other more attractive health services across the globe.

There are new and increased challengesin terms

• f building, recruiting and retaining sufficient numbers
• f healthcare professionals to work in general practice, and

more GPs are opting for salaried positions and portfolio careers, meaning a need to consider new and alternative employment models. There have been significant advances in technology, with the introduction and increased use of patient apps, the ability to book appointmentsonline, and products such as Symptom Checker.

The context and landscape have changed significantly since the previous strategy, including

an increasing financial challenge, with the ‘do nothing’ gap for north central London expected to be £811m deficit by 2020/21. Sources of information, advice and support regarding patients’ health and wellbeing are more varied, and patient expectations have changed with social and technological developments. General practice has a greater role in providing and coordinating care.

There is an increased focus oncollaboration,

both within general practice, and with other partners, and working at scale to deliver the best benefits for the population and for practices. There is an increased focus in general practice on quality improvement, with local investment in dedicated quality improvement support teams aiming to reduce unwarranted variation in each CCG area.

...the story so far

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DRAFT

The NHS was established 70 years ago at a time when

services were mainly provided to manage diseases in hospital. The roles of health and care services have changed significantly since then, and society is changing; there are over 15 million people with long term conditions in England and care for these people equals about 50% of all GP appointments and 70% of all inpatient hospital episodes.

Partners in north central London (NCL) have a history of collaborative working on primary care, including the production

• f previous strategies

for primary care. The previous NCL strategywas produced in 2012 and expired in 2016. In December 2017, leaders of the five clinical commissioning groups (CCG) and GPfederations agreed to nominate representatives to co-produce a refreshed strategy for NCL.

...the story so far

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DRAFT

Introduction: where we arenow

Instead of people only being able to access their own GP during core hours, people now have access to appointments with general practice from 8am-8pm seven days a week (since April 2017 in NCL). There may be opportunities to promote these services evenmore widely, so that everyone is aware

• f them. We also know that some

people still report dissatisfaction getting through to their practice

• n the phone, and there is more

progress to make in theseareas. There are six GP federations in NCL, four of which are co-terminous withthe borough, with two federations inCamden. Most practices now work in anintegrated way, to some extent, and many of the GP federations hold contracts ranging from Ear Nose and Throat and community gynaecology services to providing quality improvement support teams, or focusing

• n GP retention.

Also in place are Care and Health Integration Networks (health and care partners working together to deliver care to a cohort ofpatients). PLACEHOLDER: DIGITAL

Appointments with general practice available 8am-8pm seven days a week Most practices now work in an integrated way

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DRAFT

PLACEHOLDER: DIGITAL

Our context: the challenges facing generalpractice

Growing demand for services: many people

have more complex needs, health inequalities persist and there are high levels of long terms conditions and rising expectations of general practice. The population is growing and people are living longer but in poor health andwith greater complexity; older people in north central London are living their last 20 years of life in poor health, which is worse than the England average. The King’s Fund has shown how consultations are outstripping populationgrowth (source: King’s Fund- Strategic CommissioningFramework).

25%

A workforce under pressure

NCL faces significant challenges for its future workforce from GPs to general practice nurses and other primary care professionals. 25% of the GP workforce is over 55and therefore likely to retire within the next 10 years. A recent NCL Local Medical Committee (LMC) survey collected data showing that 45% of responding practices are due tolose

• ne or more GPs to retirement in the next three years.This,

along with an ever-growing and more diverse population, demonstrates the need to develop and grow the NCL GP workforce significantly over the next fewyears. Fewer GPs are looking for partnerships, and there are recruitment and retention challenges. There are low numbers of GPs per patient in Barnet, Enfield and Haringey, and low numbers of practice nurses in all CCGs in north central London. Low morale is not unusual; GPs, nurses and practice managers report being more stressed than ever

• before. We need to value the existing workforce and attract

and retain new professionals.

• f the GP workforce

is over 55 and likely toretire within the next 10 years There are poor indicators of health for children –childhood

• besity is high while immunisation levels arelow.

Investment has fallen and the unwarranted variation in

• utcomes and historical funding need to be addressed. We

will not be able to manage the expected growth in demand for healthcare if we do nothing.

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DRAFT

An evolving health and carelandscape

Sources of information, advice and support regarding patients’ health and well-being are more varied; patient expectations change in line with social and technological

• advances. There is renewed importance on the role of

general practice in providing and coordinating trusted accessible, proactive care that is integrated across all parts of an increasingly complex health and care system. Patients are being increasingly supported to self-care and there is more technology available to support this and health services more generally. More services are moving to being provided in the community (not inhospitals)

A financialchallenge

Unwarranted (unnecessary) variation, ranges from patient satisfaction in how easy it is to get an appointment to availability and use of technology for GP services, tounwarranted variation in clinical outcomes, e.g. identification and anticoagulation of people with atrial fibrillation. There is also variation in the historical levels of funding in primarycare, to variation in funding for locally commissioned services. There is variation in the condition

• f primary care estate e.g.only

23% in Islington is in good condition. There is also variability in ownership of the primary care estate across individual GPs, GP partnerships, private sector, NHS Property Services (NHSPS) and Community Health Partnerships(CHP).

...the challenges facing general practice

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DRAFT

Our context: patient experience of accessing generalpractice

100% 90 80 70 60 50 40 30 20 10 Barnet Camden Enfield Haringey Islington Highest performing practice inborough All boroughs in north central London offer access to primary care appointments between 8am-8pm seven days a week. The National GP Survey data shows that on average, two thirds of patients find it easy to get through to their GP practice on thephone. However, when we compare data at an individual practice level, there is lots of variation between practices, which tell us that some practices are performing much better than

• thers against this measure of patient

experience. Understanding the reasons behind this variation, and learning from the highest performing practices in each borough will be key to reducing this variation and making patient experience more consistent. Lowest performing practice inborough CCG average performance

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DRAFT

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Our context: patient experience of using online GPservices

Increasing patient awareness and uptake

• f online GP services is a priority area for

General Practice. Nationally there is still a long way to go to achieve this. Our results show that we are in line with the national averages for patients using online services, although we know that some of our NCL GP practices are much further ahead than the rest of the country. The survey tells us that there is a lack of awareness of online GP services across NCL, and improving this will be key to increasing their uptake amongst patients. However, there is also a cohort ofpatients who are aware of online GP services but choose not to use them, and more will need to be done to understand the experience of thisgroup.

Source: 2018 National GPSurvey

Patient awareness/uptake of online GP services to view medicalrecords Barnet Camden Enfield Haringey Islington Patient awareness/uptake of online GP services to bookappointments

Barnet Haringey Islington Barnet Camden Enfield Haringey Islington Patient awareness/uptake of online GP services to order repeat prescriptions

Camden Enfield

DRAFT

Our vision: what people wantnow

What would this looklike?

I want to be listened to andheard

• I won’t have to rely as much on my GP tointerpret

information for me

• I’ll be able to access the information and advice Ineed

to make more decisions for myself

• I’ll understand which services to use andwhen
• I can plan my care with people who work together

to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me Services will work better forme

• My health records will be up to date and servicesthat

help me will be able to accessthem

• I will tell my story once
• The professionals involved with my care talk to each
• ther; we all work together as a team

I’ll have easier access to the support I need to staywell

• I won’t have to go to hospital somuch
• Investigations such as blood tests and ECGs can be

done in alternative places to thehospital I’ll be able to do moreonline

• I can book and cancel appointments
• nline, when it suits me; I won’t haveto

visit the GP , miss appointments I don’t need or wait for the post to get my test results

• I can order repeat prescriptions online; I don’t need

to make a special trip to my surgery to place theorder

• I can see my health and care records and can decide

who to share them with. I can correct any mistakes in the information.

We want to do more for ourselves

We recognise the NHS is under pressure, but we can help by playing abigger role in looking after our own health andwellbeing

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DRAFT

Our vision: what we want todeliver

Given the needs of the local population and the challenges facing generalpractice,

• ver the next three years we want toachieve:

Resilient, sustainable and thriving general practice

Resilience: a systematic and data-driven approach to practice resilience, using local intelligence and NHSE data, reducing the need for CCG intervention – developed by GP federations working in partnership with theirCCGs At scale working: For federations to collaborate to develop at scale solutions to drive efficiencies and productivity, e.g. education and training, GP retention, back office functions, delivery of outcomes, population health management Resourcing: To be in the top x% ofSTPs nationally in our investment in primary care (£ per patient), working to reduce variation between boroughs in north central London

High quality, equitable andperson- centred safe care

Access: To use a Safer Staffing tool (or similar) to identify and agree on the minimum safe healthcare professional staffing levels in general practice, and work towards achieving these over the life of this strategy; to achieve (% of respondents reporting good on ease of access or telephone access to appointments) Quality improvement: For all NCL practices to be in the top 25% of best performing practices over xperiod

• n agreedmarkers

Estates: To keep services local in premises that are fit for purpose for the delivery of primary care services 2

DRAFT

...what we want todeliver

Proactive, accessible and coordinated care

Access: To see a step change in the roll out and uptake of digital technology in general practice (for patients and professionals), recognising the scope of digital technology to be used from ordering repeat prescriptions online, to online booking, the ability to check symptoms and have a consultation with a healthcare professional Strengths-based approach: GP practices to support people to address the social determinants of health, with the aim of everyone with a long term condition to have the opportunity for anannual care planningconversation

Integrated services that respond to the needs of the patient and thepopulation

Strengths-based approach: GP practices to support people to address the social determinants of health, with the aim of everyone with a long term condition to have the opportunity for an annual care planning conversation Resourcing: integrated working between GP practices and other community-based providers, supporting new roles into the wider GP team Prevention: To systematically embed high impact prevention interventions into everyday practice, in

• rder to prevent ill health andpromote

wellbeing, with a focus on smoking, blood pressure, overweight, physical inactivity, and alcohol

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DRAFT

Our vision: resilient, sustainable and thriving generalpractice

For GP federations to work in partnership with their CCGs to develop a systematic and data-driven approach to practice resilience, using local intelligence and NHSE data, reducing the need for CCGintervention For federations to collaborate to develop at scale solutions to drive efficiencies and productivity, e.g. education and training, GP retention, back office functions, delivery

• f outcomes, population health management

To be in the top x% of STPs nationally in our investment in primary care (£ per patient tbc), working to reduce variation between boroughs in north central London.

Additional skills and capacity in general practice– patients will benefit from increased availability of clinical time and resources Development of new employment models; the workforce will change; a greater role for specialist nurses, pharmacists, physicians’ associated, health care assistants, mental health workers and other healthcare professionals A valued and motivated workforce with training and development for a variety of roles including specialists and portfoliocareers Staff enjoy their work and achieve a good work life balance; NCL isthe destination of choice for healthcare professionals in training Collaborative and integrated working will deliver economies of scale and increased sustainability Increased security of service provision as a result of longer contracts, results stable primary care teams ”There is arguably nomore important job thanthat

• f the family doctor […] if

general practice fails, the whole NHS fails”

Simon Stevens, Chief Executive, NHS England,2016

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DRAFT

Our vision: high quality, equitable and safe, person-centred care

For all NCL practices to be in the top 25% of best performing practices over x period on agreed markers, reducing unnecessary variation in general practice so patients know what to expect from their GP , wherever they choose to accessservices GP practices to support people to address the social determinants of health, with the aim of everyone with a long term condition to have the opportunity for a care planningconversation.

Improved outcomes, experience and patient satisfaction Consistent high-quality care across general practice; safer, less (unwarranted) variability and better quality, consistent care delivered by highly trained GPs, nurses and other professionals, with appropriate continuity of care Care will be centred around each person so they won’t need to have multiple appointments about different long term conditions Patients will have the knowledge, skills and confidence to enable them to work in partnership with their health care professional All practices achieving good or excellent CQC ratings Shared good practice (policies, procedures, protocols) Technology used to support long-term conditions management and safe hospitaldischarge Staff enabled to work at the top of their licence, so increasing productivity and efficiency and avoiding duplication or waste Collaboration through partnership working with patients who are informed and engaged, will result in improved utilisation of GP services so ensuring health care professionals experience less demand and an improved work life balance 2 3

DRAFT

Our vision: proactive, accessible and coordinatedcare

A step change in the roll out and uptake of digital technology in general practice (for patients and professionals), recognising the scope of digital technology to be used from ordering repeat prescriptions online, to online booking, the ability to check symptoms and have a consultation witha healthcare professional To use a Safer Staffing tool (or similar) to identifyand agree on the minimum safe healthcare professional staffing levels in general practice, and work towards achieving these over the life of thisstrategy Keep services local in premises that are fit forpurpose for the delivery of primary careservices

Proactive care - supporting

and improving the health and wellbeing of the population,self- care, health literacy, and keeping people independent andhealthy

Accessible care - providing

a personalised, responsive, timely and accessible service

Coordinated care -

supporting and improving the health and wellbeing of the population,self- care, health literacy, and keeping people independent andhealthy 2 4

DRAFT

• We will:
• Develop care registries across networks; people

at risk of developing disease will beidentified

• systematically; those with medical conditions will

be supported to live longer in goodhealth

• Improve information sharing to support 24/7 access

to care

• Ensure that face to face appointments are offered to

those who need them; clinicians should assess the requirement for face to face appointments

• Encourage the use of programmes to for GPs to

manage demand and supply – a balancebetween access and continuity of care

• Encourage practices to work together to deliver a full

range of services to patients in their local community

• Improve access to general practice including

in person, on the telephone and digitally; making sure that everyone can access their GP surgery during the core hours (currently 8am-6.30pm) recognising that different people may prefer different means of access

• We will support the uptake of new technology to

improve access, and will ensure that services are well- publicised

• Ensure that 20% of all practice patients are registered

for GP Online, with 80% of all patients with repeat prescriptions registered for e-prescribing

• Ensure that new premises developments are designed

with the future of integrated general practice in mind (e.g. RCGP Roundhouse)

• In line with local priorities, we will support project

management, service charge tapers and paying off leases for general practice developments

• Continue to work closely with local authority and

public health partners to ensure a more effective prevention and healthy livingoffer

• Ensure that services provided within the

core and enhanced contracts are available to the population of north centralLondon, whether this is at a patient’s own practice,

• r nearby

...proactive, accessible and coordinatedcare

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DRAFT

...proactive, accessible and coordinatedcare

Better patient experience through more use of digital technology, with more responsive care, delivered in a range of ways, e.g. online, email and telephonenot just face-to-face - and improved access to general practice Improved (and less variable) access to general practice services People will be easily able to book their appointments Continuity of care for those patients that need itmost Patients will experience better management and care

• f long-term diseases; when they are frail and elderly,

and at the end of life – integrated services supported by shared access to clinicalrecords Unregistered patients wont fall through gaps Reduced duplication of activity through improved sharing of data, will result in improved productivity within general practice Through the development of closer working relationships with the wider MDT, GPs and their teams will feel supported in delivering care, so will feel more able to manage increasingcomplexity

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DRAFT

Our vision: integrated services that respondto the needs of the patient and thepopulation

To systematically embed high impact prevention interventions into everyday practice, in order to prevent ill health and promote wellbeing, with a focus on smoking, blood pressure, overweight, physical inactivity, and alcohol GP practices to support people to address the social determinants of health, with the aim of everyonewith a long term condition to have the opportunity for an annual care planning conversation Integrated working between GP practices and other community-based providers, supporting new roles into the wider GP team.

We will:

• Support the development of care and health

integrated networks through which teams of professionals and workers can provide innovative, proactive and person-centred care

• Work with our partners in the system, including other

health, local authority and voluntary/ third sector/ charity providers to develop more coordinated and integrated models of care, focusing on patient needs and around a sharedvision

• Take a proactive, person-centred approach to

delivering this care with our partners, through care and health integrated networks

• Provide general practice with the tools to support

patients to navigate their way through care, enabler easier access to appropriate care, with access to health, social care, lay and voluntaryorganisations

• Develop and use and share dashboards across all

providers for use at micro, miso and macro levels to support the reduction of duplication and unnecessary variation across the system

• Support the development of at scale provision,

including at network, neighbourhood, federation and borough level

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DRAFT

Peter is 12 years old and in Year 7 of secondaryschool. He has had asthma and eczema since earlychildhood.

He lives with his mother, who has mental health problems and a mild learning

• disability. She does not work. His asthma has previously been well controlled,

but he has missed a lot of school during the last year. He has gained weight and is missing sports lessons because of theasthma. Peter will have access to a nurse specialist in the community. At school he will be seen by an asthma nurse. This is more convenient, improves Peter’s ability to self-manage and involves less time inhospital. Peter and children like him will:

• require fewer A&E attendances and admissions
• become involved in care, and able tomanage
• be supported by people who know him and hisfamily
• miss less school
• have improved fitness and confidence

...integrated services that respond to the needs of the patient and the population

CASE STUDY

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DRAFT

...integrated services that respond to the needs of the patient and the population

Patients will be able to access more care locally from a range of service providers/ partners General practice will remain the gate keeper to care, but patients will be able to access a broader range of services through their GP Enhanced patient experience with as smooth and uncomplicated as possible a ‘journey’ through the health and care system Access to a broader range of clinical skills will enable a multi-disciplinary approach to caring for patients, releasing specialist medical resources Access to patient information broadened through a common clinical IT platform to enable seamless, integrated service provision Integration minimises the risk of duplication

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DRAFT

Our enablers

Workforce Focus on both the existing and new workforce –retain, recruit and develop a new skillmix Digital vision for digital – health and care information exchange and population health management IT, data systems and information sharing are critical to delivering integrated care and can help to co-ordinate care delivered by professionals across different

• rganisations and even across patients’ wider support
• networks. Population health management

Estates Delivery of our strategy relies our partners – including Local Authorities, CCGs, Trusts, and property companies. At the STP level, our focus is

• n collaboration and common prioritisationthrough
• ur Estates Board, whilst not superseding individual
• rganisational autonomy.

Working at scale Function over form ➞ what is the role we want the federations to play in the system? New ways of working and contracting Quality Improvement – what will the QISTSdeliver? CHINS The care and health integrated networkmodel

• Integration between different partners each year.

Virtual integration through digital systems; clinicians proactively working together around a register of patients/ local people Investing in primary care – investment demonstrating variation and primary care investment in the context of the system

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DRAFT

Commissioning Plans 2019-2020

Stephen Wells, Head of Performance & Planning

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What are Commissioning Intentions?

• Every year we produce commissioning intentions that describe to

local providers how we as an organisation intend to shape local healthcare services.

• Commissioning intentions describe what services we want to buy

and the health outcomes we wish to achieve for our local population.

• Our Commissioning Intentions demonstrate how we will respond to
• ur local population’s health needs, local clinical priorities and the

national priorities for the NHS as outlined by NHS England.

.

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Development of North Central London System Intentions for 2019/20

The strategic direction is focused on:

• NCL high-level priorities for 2019/20 seek to focus on what is best for the

population, rather than taking an institutional approach and seek to support the collective commitment to reduce system costs and to ensure that any unintended consequences of that for individual organisations are mitigated.

• System intentions are framed within the financial challenge faced by both

commissioners and providers in North Central London. Developing the Sustainability and Transformation Plan (STP) has led to a common understanding that we operate as a system in deficit. We need to understand the cost of delivering services and change the way we work to align incentives, reduce duplication, and take cost out of the system.

• Local CCG’s commissioning intentions to deliver CCG’s financial plans.

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Enfield CCG 2018/19

Enfield CCG continued in Financial Recovery in 2018/19 under NHS England Legal Direction, which means:

 The CCG is spending more than we are allocated,  Has an Aggressive financial recovery plan,  Ensure we engage and where necessary consult on difficult choices including proposed future service changes which may include the decommissioning of services.

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NCL System Intentions for 2019/ 20

Commissioning Intentions for 2019/20 will consist of the following:

• System intentions - Following on from the after action review for the 2018/19

contract round system intentions for 2019/20 seek to identify a few high-level priorities, agreed by all parties to the Sustainability and Transformation Plan (STP), that will then be translated into operating plans and provider contracts for the year;

• System intentions - will be influenced by the ten-year NHS plan (once

published in autumn 2018) and the national planning & contracting guidance that will flow from this;

• Commissioning intentions – that provide a more detailed view of how system

intentions will be delivered locally, plus any local intentions for CCGs that sit

• utside of the STP;
• Pivotal to intentions for 2019/20 will be delivery of jointly agreed STP priorities

signed off by the Health and Care Cabinet incorporating priorities from each STP workstream;

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Strategic Challenges in NCL (1)

• Further developing integrated care systems across health and care services as

part of our move to population based health models and to better tackle the broader determinants of health;

• A focus on prevention to tackle the broader determinants of health and reduce

health inequalities, and to deliver this extend the scope of work with the third sector and utilisation of community assets;

• To support our move to population based health models this redefine community

services contracts to an outcomes based approach for future years allowing greater flexibility in service redesign to support the development of Care and Health Integrated Networks (CHINs), and establish integrated services across health and care for admission avoidance and discharge from hospital;

• Building resilience in general practice including developing primary care at scale
• n a geographic basis alongside the emerging GP Federations;
• The redesign of outpatient pathways building on service models developed in

2018/19 including Clinical Advice and Navigation;

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Strategic Challenges in NCL (2)

• Continuing to deliver value and reduce variations in care, building on the work to

date in both primary care and secondary care to reduce unwarranted variations in care:

• This will include implementing a common service model for core 24-hour

mental health liaison services across NCL;

• To deliver investment in prevention and primary care will require historic growth

in acute contract baselines to be halted. Aligned to this, system intentions are designed to deliver offsetting cost reductions for acute providers. This will be supported by:

• Joint work on provider cost improvement plans and CCG QIPP programmes

to help providers reduce their costs;

• Joint development of system incentives;
• Development of NCL-wide plans and capacity for direct access pathology

(including pricing) and imaging services (including the re-procurement of the community diagnostic service);

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Strategic Challenges in NCL (3)

• Trialling new system incentives and contract forms to promote a reduction in

system costs and better align incentives to the service models being developed through the Sustainability and Transformation Plan:

• To support STP service developments with a focus on outpatient and

elective pathways, community services outcomes, and GP streaming in emergency departments to support urgent treatment centre designations and winter resilience;

• CCGs will also work with providers on opportunities for whole contract form

changes for adoption in 2019/20 or future years;

• In preparation for contracts in 2019/20 and onwards, CCGs would like to

shadow-run alternative contract forms in 2018/19 to ensure that any changes support delivery of the STP and balance risk equitably across the system.

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Strategic Challenges in NCL (4)

The delivery of key enablers including:

• Roll-out of the Health Information Exchange across North Central London;
• Provider collaboration initiatives including opportunities for common procurement,

repatriation of activity, and exploring further opportunities for mutual aid cross providers to support delivery of NHS Constitution targets for cancer, referral-to- treatment times, and A&E;

• Delivery of the estates strategy for NCL based on the one-public estate approach

to support the development of a place-based approach to our community estate and increase operational efficiency;

• Workforce, including the work by Community Education Provider Networks

(CEPN), to develop the workforce to support our strategic service changes with a focus on skill-mix, recruitment and retention, collaboration across providers including “passporting”, and portfolio careers.

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NCL System Intentions for 2019/20

Priorities from previous local engagement with stakeholders in 2018/19

In 2018/19, engagement with local people across North Central London CCGs, identified priorities for delivering health and care services that included:

• The need to invest in prevention and primary care;
• Better co-ordination of care for the individual supported by making general

practice the centre of co-ordinated care through health and care teams working around the practice;

• Co-production of care and helping people manage their own care;
• Improving the quality of, and reducing the variation of, primary care and

secondary care services.

Do any of these priorities need to be revised for 2019/20?

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Commissioning Intention Impact Reason for Implementation

Early Diagnosis Introduction of FIT test for low risk symptomatic colorectal patients in primary care Cancer World Class Outcomes = a strategy for England 2015-2020 CCG Improvement & Assessment Framework GPs to have urgent direct access to key investigative tests (Chest x-ray, ultrasound, MRI, CT and endoscopy) Reduce number of patients diagnosed following an emergency admission and improve patient experience Cancer World Class Outcomes = a strategy for England 2015-2020 CCG Improvement & Assessment Framework Improve first appointment for 2 week wait referrals and Cancer 8 waiting time standards Contributes to sustainable achievement of cancer waiting time standards Delivery of NHS cancer 8 waiting time standards Cancer World Class Outcomes = a strategy for England 2015-2020 CCG Improvement & Assessment Framework Living with and Beyond Cancer Implement the Breast stratified pathway Planning Guidance and UCLH Cancer Collaborative Breast Pathway Board Living with and Beyond Cancer Develop recovery package – health and well being interventions Planning Guidance FYFV Primary Care Stratified pathway – stable prostate cancer Reduce demand on Urology outpatient clinics and deliver a pan London primary care at scale approach NICE NG 195 FYFV TCST

Commissioning Intentions for Cancer - Q3 2018/2019 to Q4 2019/2020

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Enfield CCG’s System Intensions for 2019/20

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Enfield CCG’s Local Commissioning Intensions 2019/20 (Examples 1)

Programme Area Objective Outline of CCGs’ System Intentions

Delivery of Optimal Integrated Urgent & Emergency Care, Ambulatory emergency care and supported discharge Hospital Based Admission Avoidance

• To increase the number of patients ambulated rather than admitted to

hospital following a non-elective admission Delivery of Optimal Integrated Urgent & Emergency Care, Ambulatory emergency care and supported discharge Urgent Treatment Centres

• The CCG will continue work undertaken in 2018/19 to be a lead area

for NHS England's drive to designate local Urgent Treatment Centres. Delivery of Optimal Integrated Urgent & Emergency Care, Ambulatory emergency care and supported discharge Emergency Department Streaming and Re- direction

• To increase the number of patients streamed into Tier 3 and Tier 4

and to support presentation to A&E through GPs and/ or Nurse led activities. Delivery of Optimal Integrated Urgent & Emergency Care, Ambulatory emergency care and supported discharge London Ambulance Service

• To increase the effectiveness and coverage of London Ambulance

Service appropriate care pathways and to increase by 10% the number of patients conveyed to appropriate services rather than an Emergency Department. Delivery of Care Closer to Home Integrated Networks (CHINS) Development of CHINS services

• To develop at scale services as part of Care Closer to Home

Integrated Networks for three clinical priority areas;

• Frail Elderly in West Locality
• Respiratory in North East Locality
• Diabetes in the South East Locality

Delivery of Care Closer to Home Integrated Networks (CHINS) Reducing A&E attendances from Care Homes

• Undertake a review of A&E attendances from Care Homes in

2018/19 to inform the development of Clinical Nurse training and GP support to Care Homes in order to reduce the number of patients attending A&E departments in 2019/20.

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Enfield CCG’s Local Commissioning Intensions 2019/20 (Examples 2)

Programme Area Objective Outline of CCGs’ System Intentions

Mental Health and Physical Health Rehabilitation Integrate physical health rehabilitation services

• It is the aim of NCL CCGs to have a unified and consistent

commissioning and contracting approach to Mental Health Liaison Services for 2019/20 onwards. Notice is therefore given to all acute providers and mental health providers that current arrangements will cease and a new approach will be commissioned from April 2019. That approach need to ensure that:

• Current investment levels across NCL are maintained
• Commissioning process is streamlined and there is a single

process across NCL

• Contracting is on same footing as main NHS standard

contracts, is aligned to same national and NCL timescales and is on a more sustainable footing for providers

• The model of commissioning ensures integrated governance

approach across mental health and acute providers and CCG commissioners.

• Budgets are pooled at a level that makes sense to achieve the

above. Deliver financial recovery in ways that transform the care system to reduce costs and create efficiencies at all

• pportunities

Diabetes

• To implement the East London diabetic service model in order to

improve the management of diabetic patients in primary care and provide further education and training for GPs building on the previous scheme in 2018/19 informed by the Royal London Hospitals Diabetologist MDTs (attended by DSN’s ; HV’s; third sector/VCO’s; GPs & others).

• This scheme will also link to the A&E High Intensity Users work to

identify frequent diabetic’s in crisis attending A&E departments. Children with Disabilities and Complex Needs Children & Young People

• To commission a new service model for children with disabilities and

complex health needs based on a care group/ outcomes focussed approach in 2019/20. The service model will be developed in partnership with London Borough of Enfield Joint Service for Children with Disabilities. The CCG also expects that as a result of commissioning the new service that a business case for additional community paediatricians and other associated clinicians would be developed in the second half of 2019/20.

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Enfield CCG’s Local Commissioning Intensions 2019/20 (Examples 3)

Programme Area Objective Outline of CCGs’ System Intentions

Deliver financial recovery in ways that transform the care system to reduce costs and create efficiencies at all

• pportunities

Cardiology (including community heart failure service)

• To commission a community based cardiology programme of care to

ensure that there is seamless and patient centred delivery of community based cardiology services with an emphasis on driving prevention (including secondary prevention), self-care management and reduction of

• inequalities. The CCG will redesign the cardiology model of care and re-

procure and commission community outpatient services in 2019/20 in

• rder to enhance the management of patients in primary care and review,

validate and streamline pathways with secondary care providers. Deliver financial recovery in ways that transform the care system to reduce costs and create efficiencies at all

• pportunities

Respiratory

• To commission community based respiratory services that ensures all

health professionals undertaking spirometry must be appropriately certified as competent and follow the recommended standards for quality assured spirometry in 2019/20. (Benchmark - Healthcare professionals currently performing and interpreting spirometry have until 31 March 2021 to ensure they have been assessed and entered on to the National Register of certified healthcare professionals. This will require time for all necessary professionals to comply within the target date. Deliver financial recovery in ways that transform the care system to reduce costs and create efficiencies at all

• pportunities

Community Pain Service

• To commission and deliver a Community pain service in 2019/20 for

patients with a history of chronic pain to reduce there reliance on long term pain injections and the new care pathway will include the development of psychological support for this patient cohort. Enfield CCG will also look to repatriate existing patients on the acute pathway into the community pain service pathway. Deliver financial recovery in ways that transform the care system to reduce costs and create efficiencies at all

• pportunities

MSK service

• Enfield CCG to review and re-procure the MSK service in 2019/20 with

the intention to establish an integrated service care provide model, including SPA, Triage, Self Referral, Pre Op Assessment and MDT.

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Questions

Workshop sessions

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3:00pm - 3:45pm

How can we encourage more patients to self care?

Clinical lead – Dr Mateen Jiwani, Medical Director Management lead – Paul Gouldstone, Head of Medicines Management

3:45pm - 4:30pm

NCL Orthopaedic Review workshop

Anna Stewart, Programme Manager Colin Beesting, Communications and Engagement Lead

Encouraging self care

• National picture
• NHS winter campaign – Help Us to Help you

Focus on self-care and visiting your pharmacy

• Limited NHS resources
• Recent NHS England consultation on

reducing the prescribing of the counter medicines

• Review of minor ailments scheme
• Patient education around self-care

Encouraging self care in Enfield

• GPs in Enfield reducing over the

counter prescribing

Medicine cabinet

Discussion point

How can we encourage more patients to self-care?

We are reviewing planned adult orthopaedic surgery in north central London and we’d like your views

Barnet, Camden, Enfield, Haringey and Islington

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About North London Partners in Health and Care

• Our sustainability and transformation partnership (STP),

brings together health and care commissioners and providers across five boroughs

• We work together to provide joined-up health and care

across the area

• All partners are united behind a clear set of priorities,

based on the needs of local people

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Improve the health of the local population Reduce health inequalities Maximise care

• ut of hospital

Ambitions of the STP

A partnership of the NHS and local authorities, working together with the public and patients where it’s the most efficient and effective way to deliver improvements.

Ambition for the STP is built on existing CCGs, Local Authorities and Providers values and strategy

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Context Within the planned care workstream of the STP there are four MSK projects of which this review is one

• Single point
• f access

First contact practitioners Pain management Adult elective

• rthopaedic

surgery

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About the review

• We think there may be opportunities to improve adult elective
• rthopaedic surgery in north central London by consolidating services
• nto fewer sites
• We are undertaking a review of these services to see if these

improvements can be achieved

• The review has been established by North London Partners in Health

and Care

• A review group led by local clinicians is coordinating the development
• f how this kind of care could be delivered in the future
• Clinical commissioners will make decisions on where and how this

happens

• The review covers services in Barnet, Camden, Enfield, Haringey and

Islington

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Stages of the review

Stage 1 Engage to get feedback on the draft case for change Propose a service model describing how services might be delivered in future, informed by feedback Stage 2 Clinical commissioners consider the feedback from the engagement, agree a service model Produce a pre-consultation business case

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• Patients & residents
• Providers
• Clinicians
• Clinical Commissioners

engagement

What we want to achieve

Make efficiencies as a consequence of these improvements; value for money Improve quality and efficiency of services by reducing unwarranted variation Improve

• utcomes and

experience for patients

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The benefits for patients

Less time spent in hospital

Much less risk of

• perations

being cancelled Shorter waiting times for an

• peration

Improved clinical

• utcomes

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Principles underpinning this review

• Co-production (everyone working collaboratively)
• Evidence based service model (using evidence from trusted sources)
• Clinically led collaborative approach which enables meaningful

engagement with all stakeholders, particularly front line clinical staff and the public (people involved in delivering and receiving care)

• Independent experts to provide challenge and advice
• Sharing what we learn
• Clear separation of decision-making functions
• Flexible timelines to ensure we are properly engaging with

stakeholders and the public

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Leadership and Review Group

Chair: Professor Fares Haddad (UCLH) CEO Sponsor and Project SRO: Rob Hurd (RNOH) Review Group Members:

Clinical representatives from each of the five largest providers of adult orthopaedic services Two clinical commissioning representatives from NCL CCGs NHS England Specialised Commissioning Two patient and public representatives (recruited by Healthwatch) NHS England Strategy and Reconfiguration

In attendance:

Trust management leads from each of the five largest providers of adult orthopaedic services Programme Director and Programme Manager Other workstream leads as required 61

Adult elective orthopaedic surgery

• In 2016/17, north central London hospitals carried out over

23,000 adult elective orthopaedic operations across 10 sites

• Adult elective orthopaedic surgery is planned (non-

emergency) surgery of bones and joints, such as hip and knee replacements

• There are already many areas of good practice in adult

elective orthopaedic care in north central London – falls prevention schemes, how people access musculoskeletal care, people staying in hospital for a shorter time

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Adult elective

• rthopaedic surgery

currently takes place at ten different hospital sites in north central London Around 23,000

• perations each year

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Opportunities for improvement

• Patients report different experiences and outcomes at different hospitals
• Some hospitals carry out small numbers of some operations, leading to inconsistent approaches (ie
• elective knee replacements in those who had an arthroscopy )
• Variation in ‘revision rates’ (ie – a follow-up procedure being needed if the first one didn’t work as

expected)

• Variations in the length of hospital stay, following an operation
• Readmissions vary (but are low) (ie– a patient who has been discharged is admitted back to

hospital)

• Infection rates vary (but are low)
• Waiting times vary and targets are being missed

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Our current thinking

Learning from the best, we believe that by consolidating adult elective orthopaedic surgery from multiple hospitals to a smaller number of larger units we could further improve care.

Separate emergency and planned care

Elective surgery split from non-elective emergency surgery for efficiency and quality improvements Elective beds separated from non- elective beds to prevent cancellations and reduce the incident of hospital acquired infections

Expansion of ‘joint school’

improve quality of care through greater patient engagement and education leading to faster recovery and improved patient experience

Best possible after-care

for faster recovery better

• utcomes

less time in hospital

Co-located specialist high dependency unit

enables all cases to be done on one site

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Aiming for excellence

The International Society of Orthopaedic Centres considers a centre of

• rthopaedic

excellence meets the following criteria:

Source: www.isocweb.org Performs more than 5,000

• rthopaedic

procedures each year Conduc exhib commitm basic clini resea

Functions as an academic centre (i.e. has residents

• r fellows in

training)

Has orthopaedic staff of more than 20 surgeons who collectively publish more than five articles in peer i d

Is either a dedicated

• rthopaedic

specialty hospital

• r large

department within a hospital 66

Rationale supporting change

“Separating elective care from emergency pressures through the use of dedicated beds, theatres and staff can… achieve a more predictable workflow, provide excellent training

• pportunities, increase senior supervision of complex /

emergency cases, and therefore improve the quality of care delivered to patients”

The Royal College of Surgeons

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Rationale supporting change

“there is evidence that separation of the elective surgical workload can improve efficiency and avoid the cancellation of elective activity. However, the efficiency gains can be affected by patient case-mix and demand. Evaluation of the operation of the independent sector treatment centres has also suggested separating elective surgical care from emergency services could improve the quality of care”

The King’s Fund and Nuffield Trust qualitative analysis of National Clinical Advisory Team reviews

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Ideas from around the country….

In South London they created SWLEOC – South West London Elective Orthopaedic Centre:

– surgeons from local hospitals use the centre for all their planned routine procedures – day cases take place at local hospitals – all preoperative, post operative and emergency care happens locally – opened in 2004 – 14 years in operation

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South west London GP on their experience with the South West London Elective Orthopaedic Centre

SWLEOC

The centre has revolutionised the management of joint surgery and has reduced the waiting time enormously

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Ideas from around the country….

Manchester is exploring a ‘layered’ approach with:

– one ‘very specialist’ centre doing the most complex

• perations only

– two ’specialist’ centres doing complex and routine care – local hospitals doing routine care only

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Experience and evidence from….

– The Royal College of Surgeons (RCS) report Separating Emergency and Elective Surgical Care: Recommendations for practice (2007) – GIRFT literature review – National Orthopaedic Policy Unit – Economies of Scale and Scope in Hospitals, July 2017 – Separate and Concentrate: Accounting for Patient Complexity in General Hospital, July 2017

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What do you think? Patients and residents

• 1. What are your views on our ideas?
• 2. What are the advantages and disadvantages of consolidating
• nto fewer sites?
• 3. What are the top three considerations to take into account

when thinking about how these services are delivered in the future?

• 4. If you have used these services (or know someone who has)

please tell us whether the challenges set out in this draft case for change reflect those experiences?

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Ways to feed back

Please feed back by 19 October 2018*

• Read the full case for change on our website:

www.northlondonpartners.org.uk

• Email us: nclstp.orthopaedics@nhs.net
• Complete our online questionnaire
• Write to us: North London Partners in Health and Care,

5th Floor, 5 Pancras Square, London N1C 4AG

*Additional time will be allowed to hear more views if required

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Some definitions

• “adult elective orthopaedic surgery”

– Planned (non-emergency) surgery of bones and joints, such as hip and knee replacements

• “north central London”

– Barnet, Camden, Enfield, Haringey and Islington

• “North London Partners in Health and Care - STP”

– a partnership which represents clinical commissioning groups (CCGs), health providers and local authorities in north central London

• “elective / emergency”

– Elective care is planned in advance. Emergency care is not planned

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Ask us anything!

Panel questions and answers session

Key dates for your diaries

Governing Body Meetings 21 November 2018 1:30-3:30pm, Holbrook House, Cockfosters Road, Barnet, EN4 ODR 23 January 2019 1:30-3:30pm, Millfield House, Silver Street, London, N18 1PJ 20 March 2019 1:30-3:30pm Holbrook House, Cockfosters Road, Barnet, EN4 0DR Patient and Public Engagement Meetings The dates and venues for 2019/2020 are to be confirmed. Patient Participation Group (PPG) network meetings For Chairs and members of PPGs and staff at member practices who support patient groups only. Tuesday 4 December 2018 1-4pm Conference Room 1, Dugdale Centre, Thomas Hardy House, London Road, Enfield, EN2 6DS Please email enfccg.communications@nhs.net to be added to our stakeholder list and be notified

• f news and events.

All events are advertised on our website: www.enfieldccg.nhs.uk; Twitter @EnfieldCCG and in local newspapers.

Thank you for attending today’s event For more information

www.enfieldccg.nhs.uk Follow us on Twitter @EnfieldCCG Contact: enfccg.communications@nhs.net 0203 688 2814

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