South East London Sector

A meeting of NHS Bromley CCG Governing Body 24 September 2015

ENCLOSURE 6

Update on Developing our local strategy & Commissioning Intentions

SUMMARY: The purpose of this document is to update the Governing Body on how we have arrived at our current set of nine strategic priority areas, including providing an overview of the process undertaken and the different types of engagement that have been built into the process in order to inform and shape the development of our draft commissioning intentions.

KEY ISSUES: The process of prioritizing our current list of nine strategic priority areas began with a Joint SMT/Clinical Lead away day in May which identified the need to review/refresh our strategic priorities. This soon led to a series of planning discussions which involved revisiting the CCG’s vision, mission statement and current commissioning priorities as reflected in the CCG’s Initiatives Register. It was agreed that the June GB seminar should be used as an opportunity to start the iterative process of priority setting beginning by comparing our existing commissioning portfolio against the broad range of strategic themes emerging from a wide range of external sources including:

• OHSEL • JSNA • Better Health for London • 5 Year Forward View • New Assurance Framework • H&WB Strategy

The GB seminar itself therefore focused on engaging the group in a high level prioritization exercise, in order to consider which priority themes & sub-themes should be among our top priorities - based on a high level assessment of Impact and Importance.

Clinical Chair: Dr Andrew Parson 1 Chief Officer: Dr Angela Bhan

High Impact; High Importance themes then underwent a high level assessment against the following criteria:

• Strategic fit with the CCG’s vision and mission • Potential to improve services and patient experience • Potential impact on health outcomes & strength of link to key HWB/JSNA priorities • Quality benefits • Potential to deliver best value • Alignment & fit with:

o Assurance framework/statutory requirements o OHSEL/London strategy o Top 8 NHSE areas

• Level of urgency It was agreed through the CCGs SMT that the process of iteratively developing and sense checking our local priorities should be as inclusive as possible. To ensure engagement and ownership internally within the CCG this led to the establishment of the Strategy Ops Group and through the process and schedule of activities summarized in the Plan on a Page approved by Exec on 30th July, for external stakeholders it was agreed that membership engagement (via Clusters) and patient and public engagement should form an essential part of our approach to developing our local strategy and commissioning intentions. The consolidation of the priority themes and sub-themes showing the strongest consensus among GB members led to an exercise to demonstrate alignment against the full range of strategic sources, the outcome of which was discussed by the CCG SMT who agreed that nine key themes would be shortlisted as potential high priority areas for strategic focus, both for 16-17 and beyond, but on the understanding that this shortlist must be sense checked by engaging patients, members of the public and our membership to capture feedback and to establish whether we are missing any other local priorities that are important for Bromley. This has therefore led to the development of a set of ‘summary statements’ that have been developed in partnership with CCG clinical and commissioning leads in each area and which have been reviewed separately by Lucy McCulloch at LBB from a carer’s perspective and subsequently refined. These will form the initial basis for developing Commissioning Intentions for the following nine key areas, together with condensed versions more suitable for patient and public engagement and separately membership engagement, via Clusters:

1. Urgent Care 2. Cancer 3. End of Life Care 4. Maternity 5. Children and Young People 6. Planned Care 7. Primary care

Clinical Chair: Dr Andrew Parson 2 Chief Officer: Dr Angela Bhan

8. Mental Health 9. Self Management & Prevention (cross-cutting themes being incorporated throughout

other priority summary statements) Input from the CCG’s Head of Nursing and Safeguarding has also led to the development of an overarching, all-encompassing quality objective which is currently being finalized but which will ensure there is a ‘quality golden thread’ running through the priority areas to ensure that high quality services are commissioned across both public and private sectors and that vulnerable people (children and adults) are safeguarded by working with partner agencies to protect them from avoidable harm. The process of translating the more detailed statements into clear objectives in each area that are prioritized for 16-17 - in order to link into contracting and QIPP processes for next year – will be coordinated through individual working groups and the Strategy Ops Group. The Plan on a Page process for developing our local strategy and commissioning intentions is provided in appendix 1 followed by a condensed version of the statements shown in appendix 2 and appendix 3 is the summary of the Governing Body’s initial prioritisation. Further work is required to not only incorporate feedback from PPE and Cluster engagement but also to align statements, where appropriate, to relevant reports including 2015 JSNA and outputs from Impower and McKinsey. OVERALL RISK ASSESSMENT

COMMITTEE INVOLVEMENT: • Early stage discussion held at GB seminar • CEG is sighted on the overall process • The detail around developing the statements and other parts of the broader strategy

development process are discussed at Strategy Ops Group (chaired by Mark Cheung), which provides ongoing input and support.

PUBLIC AND USER INVOLVEMENT: As well as incorporating input received to date, the aim is to use the more detailed summaries to create condensed versions to enable patient and public engagement in working up and sense checking our local priorities so that our intentions can incorporate and reflect patient and public feedback .

IMPACT ASSESSMENT: The intended outcome is to raise awareness at GB and to ensure that the ongoing process remains inclusive and enables iterative development and refinement of our local commissioning intentions, underpinned by key principles and minimum standards in key areas including quality and safeguarding.

Clinical Chair: Dr Andrew Parson 3 Chief Officer: Dr Angela Bhan

RECOMMENDATIONS: The Governing Body is asked to:- • Discuss the set of priority summaries and to Note the development process undertaken to

date ACRONYMS PPE – patient and public engagement DIRECTORS CONTACT: Name: Mark Cheung Email: mark.cheung@nhs.net Telephone: Tel: 01689 866104

AUTHOR CONTACT: Name: Peter Wade Email: peter.wade3@nhs.net Telephone: 01689 866546

Clinical Chair: Dr Andrew Parson 4 Chief Officer: Dr Angela Bhan

Appendix 1

Clinical Chair: Dr Andrew Parson 5 Chief Officer: Dr Angela Bhan

Proposed process for developing our local strategy and commissioning intentions

High level Plan on a Page

1) SUMMARY STATEMENTS for our local priority areas

Here we will need a brief compelling local story / statement under each of our core priority areas

Maternity CYP Cancer Planned Care

Urgent Care

CBC (incl LCNs )

To form a strong basis for developing CIs, each statement should include (as a minimum):

• Brief summary of our biggest local challenges & local population needs (JSNA)

• Other points that support the case for change • Key areas where we need the whole system to

work differently in future • What services will look like in 5 years’ time • Benefits – including what changes patients will

notice • Key questions as part of engagement (PPE focused)

Activity (incl Engagement) 2015 Indicative Timeline

July Aug Sept Oct Nov Dec Establish planning group Agree workstream leads Approve process with Exec

Engagement with Programme Boards - Urgent Care and CBC

Engagement with Contract Boards Incorporate McKinsey and Impower work

Liaison with SE London Draft Summary Statements for comment early Sept

Membership Engagement on Cis (via Clusters)

Patient & Public Engagement on Cis (AGM & PAG) 21st

AGM

Governing Body, H&WB & LCB engagement 24th

GB

Full CIs (incl clear objectives) Membership meeting

2) ENGAGEMENT

3) STRATEGIC FIT

4) COMMISSIONING INTENTIONS & Key

Enablers (incl. Provider engagement)

5) QIPP

6) CONTRACTING CYCLE (CSU)

7) DELIVERY PLANS

Informed by Population need, OHSEL, Impower & McKinsey work

E.g. Alignment with 1 or more of: OHSEL, JSNA, Better Health for London, 5 Year Forward View, New Assurance Framework and H&WB Strategy

Cross cutting priorities : • End of Life Care; Mental Health (part of CBC) • Self Mgmnt & Prevention • Overarching quality objective (incl. safeguarding)

Primary Care

Including Outcomes / KPIs – How we will measure success

Mental Health

APPENDIX 1

SUMMARY STATEMENT Strategic Priority – Cancer Our biggest local challenges & local population needs (JSNA) In London Borough of Bromley (LBB):

• Cancer accounts for approximately 30% of mortality in LBB. • Over 10,000 cancer deaths have occurred in LBB in the last 10 years.

In general, survival rates are improving, mortality is falling and cancer patients were observed to more likely die at their preferred place of death than other terminal patients (JSNA, 2014). However, incidence continues to increase which suggests good prevention strategies are required. Cancer screening rates are significantly lower in the most deprived areas of the borough. Of the 22 wards of Bromley, 8 were observed above the standardised mortality ratio for cancer in the UK (PHE, Local Health, 2014 in JSNA, 2014). There is less uptake for bowel cancer screening in deprived areas, and Cray Valley, predominantly home to a traveller community, has higher than average cancer mortality rates for LBB.

All cancer incidences in Bromley are consistently lower than in London and England, except breast and colorectal cancer which was shown to be higher - although the difference is not significant (JSNA, 2014). Further work needs to be done locally engaging with people including carers, through both our Patient Advisory Group and in conjunction with Bromley Health Watch. The National Cancer Patient Experience Survey results locally show there is still much to be done to improve patient experience.

Table 1 - There are eight monitored cancer wait standards. The ninth standard is reported against but there is no set target. The table below sets out Bromley CCG’s performance against the national cancer wait standards, by quarter, for

2014/15.

Standard Target Quarter 1 Quarter 2 Quarter 3 Quarter 4 Cancer two weeks 93.0% 84.4% 91.2% 92.6% 94.2% Breast symptoms two weeks 93.0% 80.5% 96.4% 97.3% 96.3% Cancer first definitive treatment 31 days 96.0% 97.5% 97.9% 98.3% 98.3% Cancer subsequent treatment 31 days, surgery 94.0% 95.7% 96.3% 92.4% 89.3% Cancer subsequent treatment 31 days, drug 98.0% 99.4% 100.0% 99.5% 100.0% Cancer subsequent treatment 31 days, radiotherapy 94.0% 96.0% 97.9% 98.2% 95.5% Cancer first treatment 62 days, excludes rare cancers ,GP Referral 85.0% 79.8% 76.1% 81.7% 76.0%

Cancer first treatment 62 days, Screening 90.0% 100.0% 100.0% 97.3% 100.0% Cancer first treatment 62 days, Consultant upgrade (monthly)

None set 87.5% 75.0% 66.7% 50.0%

APPENDIX 2

Key points that support the case for change Macmillan has conducted extensive economic research which suggests large decreases in treatment costs if patients are diagnosed sooner. If our visions (detailed below) are met, early diagnosis could allow 8,000 more patients a year to live longer than 5 years after diagnosis (in SEL). The NHS Five Year forward view outlines that patients don’t always have the information they need and, crucially, the support they need to understand it. In a study seen in Cancer CGL Deep Dive (2015):

• 87% of patients want to know more about their illness • 50% forget key information within minutes of consultation • 37% found the support system confusing – a more clearly structured system is required

Obesity levels in Bromley are the third highest of all London boroughs which has been shown to contribute to the incidence and progression of cancer (JSNA, 2014). Key areas where we need the whole system to work differently in future We must proactively lead, facilitate and support discussion that encourages the whole system to streamline services and improve patient journey. This will include working with secondary care to streamline the referral process for suspected cancer to minimise to possibility of any delays What services will look like in 5 years’ time Our future vision for Cancer services is firmly aligned to the Cancer element of Our Healthier South East London (OHSEL), including the following key features: Early Detection Our local focus on improving services and support for patients living with cancer will include achievement of relevant standards of care including ensuring access to specialist treatments on time and achievement of key targets such as implementation of 2 week wait pathways and treatment in 62 days. Treatment and Transition

• Access to appropriate information and support for patients and carers Living with and beyond Cancer Specific priorities for patients living with and beyond Cancer, aligned to OHSEL, are outlined below:

• Implement stratified pathways of care • Better care for those living with adverse consequences of cancer treatment • Comprehensive support for carers

End of Life Care - improving services for patients dying of cancer:

• Ensure a dignified death irrespective of setting • Ensure dying in a place of choice • Ensure Consistent use of coordinate my care (CMC) • Advance Care Planning

Supporting Care at home:

• We will build on the current success of the Bromley Care Coordination Service to enable people with progressive and advanced illness or frailty to receive timely and well-

APPENDIX 2

coordinated care to maximise the proportion of patients in EoL stage who wish to, are able to die at home.

Benefits – including what changes patients will notice

• Reduced treatment cost, influenced by preventative measures and early diagnosis • Approaching equal service provision across LBB geography and age groups • Reduced burden of ill health due to lung cancer • Open and honest regular dialog across the whole NHS system • Better trained professional team, especially those in primary care • A new serious but unspecified symptoms pathway

Patients will notice:

• An improved awareness of cancer issues, treatments and screenings in their community • Increased support offered for accessing information • Factors that influence cancer incidence – e.g. sun, smoking, obesity – and hopefully work to

impede these contributors • A sense of engagement with their LCN • Appropriate waiting periods • Improved mental wellbeing support at all stages • Their careers are more confident and informed • The stigma of discussing end of life care is reduced, which is comforting and improves

confidence through feelings of empowerment Self-Management & Prevention In some instances too few patients are active partners in their care; they require empowerment to self-manage and to help others do the same. Bromley CCG looks to:

• Improve “supported self-management” to develop a system in which personalised pathways have the ability to emerge based on patient choices.

• Ensure routine use of the Cancer Recovery Package to improve the feeling of empowerment among patients

In achieving our aims in relation to self-management and prevention in this area, patients will notice an improved awareness of cancer issues, treatments and screenings in their community while better preventative measures will also reduce treatment costs. Link to Mental Health 25% of patients suffer psychological distress after one year. Specialist psychological intervention will prove extremely beneficial and present better care for those living with adverse consequences of cancer. Mental wellbeing should be considered at all stages – St Christopher’s service includes a mental health element. Key questions that need to be raised as part of engagement (PPE focused) • Are there any other commissioning priorities that you would wish us to consider in the future?

o If yes what are they? • Do you have any other ideas around how we can meet the health and care needs of the people

living in Bromley (bearing in mind limited resources and increasing demand)? o If yes what are they?

APPENDIX 2

CHILDREN AND YOUNG PEOPLE SUMMARY STATEMENT

The following forms the initial basis for developing Commissioning Intentions for the above key priority area Brief summary of our biggest local challenges & local population needs (JSNA)

Nearly 1 in 4 children (23%) aged 0-18 years are presenting with complex health needs and this number is expected to increase. Our current provision for these children could be much better: there is considerable variability in primary care services and in how much of a service is provided across primary care, and the interface between acute sector and community and primary services needs further development. E.g. integrated care pathways for asthma, diabetes, ADHD and ASD. The conversion rate (attendance to inpatient) for children is low, suggesting that health needs could be supported more within primary and community services. Specific challenges are as follows:

• High number of children with a Statement of Educational Needs (SEN) or EHC Plan (n=1691) of which there are greater than expected numbers with Speech and Language Therapy needs.

• High number of children/young people with a SEN that also have Autistic Spectrum Disorder and/or specific and moderate learning difficulties compared with other boroughs

• Admission rates and length of stay for diabetic children could be shorted if more active specialist support in place.

• A&E attendance for children under 4 is worse than England average but lower than London rate

• Timeliness in completion of Initial Health Assessments for Looked After Children is an issue Other key points that support the case for change

• OHSEL work on the development of a community based care model and integration of

services via Local Care Networks and Children’s Integrated Community teams. • SEND (Special Educational Needs and Disability) reforms focus more on outcomes rather

than what services are being provided. Outcomes include the Preparing For Adulthood outcomes including employment and community engagement/ involvement.

• London Children’s Strategic Clinical Network is looking at a number of specific pathways that include paediatric asthma and changes to how services are delivered to meet needs of children and young people with disabilities as set out by the SEND reforms.

Key areas where we need the whole system to work differently in future

• Local Care Networks and Children’s Integrated Community teams to provide better integrated services

• ‘No Wrong Door’ policy and what it means in practice for Bromley

What services will look like in 5 years’ time

• More integrated acute, community and primary care services via a Local Care Network • Standard pathways around asthma, diabetes, ADHD • Increased access to primary care provision

• Reduction in A&E attendance among children and young people, especially very young children

• Greater service user involvement in how services are shaped and managed • Better outcomes for children and young people evidenced

Better assessment and support of young carers and reduction in inappropriate caring roles undertaken by children. Benefits – including what changes patients will notice

• Improved patient navigation through the health system so children and young people are better able to receive the care they need more quickly and seamlessly

• Improved outcomes for children and young people including those with long term conditions Self-management and prevention The 2015 Our Health South East London Issues Paper recognises that we need to get better at supporting families to keep children and young people physically and mentally well. For example, we need to support children and young people in preventing obesity / self-managing their health to reduce obesity. The specifics of self-management and resilience are being explored through the OHSEL strategy. Links to mental health One in ten children needs support or treatment for mental health problems. These range from short spells of depression or anxiety through to severe and persistent conditions that can isolate, disrupt and frighten those who experience them. Mental health problems in young people can result in lower educational attainment and are strongly associated with behaviours that pose a risk to their health, such as smoking, drug and alcohol abuse and risky sexual behaviour (Future in Mind, NHSE, 2015).

• 75% of mental health problems in adult life (excluding dementia) start by the age of 18. • Failure to support children and young people with mental health needs costs lives and

money. • Early intervention avoids young people falling into crisis and avoids expensive and longer

term interventions in adulthood.

What services will look like in 5 years’ time (these are explained in detail in the Mental Health Summary Statement):

• Mental health will be embedded throughout the whole CYP system model • Children’s mental health integrated community teams will improve mental health

integration and support the principle of ‘no wrong door’ for children. • Extended GP hours to allow rapid access for CYP to paediatric specialists for CYP with long

term mental health conditions Key questions that need to be raised as part of engagement (PPE focused)

• How do we communicate and work with other providers across the health system? • How do we develop a model of patient-led services that include active patient and public

involvement in design? • How do we integrate care pathways across the six SEL boroughs?

SUMMARY STATEMENT Strategic Priority – End of Life Care Brief summary of our biggest local challenges & local population needs (JSNA)

As our local JSNA (2015) indicates, good quality end of life care is critically important in giving the individual patient and their family a positive experience of care at a difficult time in their lives. Bromley’s JSNA 2015 indicates that at any one time, 0.59% of Bromley’s population would be identifiable by healthcare professionals as being within the last 12 months of life. Key points from the 2015 JSNA, specific local challenges and other key areas that need addressing locally are highlighted below: • Bromley identifies a lower percentage of patients with a palliative care need than some other

South East London boroughs (2014 JSNA). Therefore a higher proportion of patients will not have an agreed care plan in place and are less likely to achieve their preferred place of death.

• 58% of non-cancer deaths occur in hospital compared to 39% of cancer deaths (Figure 11.8 JSNA 15). Therefore non-cancer deaths are still more likely to occur in hospital than cancer deaths. Appropriate End of Life Care should be available and given to all those identified as in the last 12 months of life.

• There are inconsistent levels of training in identification and management of EOLC in the acute sector and primary care. Training of staff could lead to earlier recognition of patients, a jointly agreed care plan, more effective and meaningful palliative care register systems, asking about needs and preferences, improving communications between consultants/GPs/nurses and reducing hospital stays and death rates.

• Dementia – Currently St Christopher’s staff receive training in line with the National Dementia CQUIN for 2015-16, which includes dementia awareness

• Bromley has the highest number of deaths from dementia than that any other London borough: 546 in 2012 and percentage of death is 21 % which is higher than national average of 17.3% (conservative figure as dementia under diagnosed and under reported and frequently a co-morbidity). However there are currently small numbers of patients with advanced dementia accessing EOL services in Bromley.

• Referrals into Bromley Co-ordination Care – in the context of patients in hospital, better identification of those at end of life will lead to increased numbers of appropriate referrals. In addition, we will increase identification of end of life patients through enhanced engagement with community providers and general practice (in line with engagement CQUIN 15-16).

• There is an ongoing need for training in primary care in recognising deterioration and signs of impending terminal phase and patients (such as the use of GSF Prognostic Indicator Guidance)

• A review of St Christopher’s Bereavement service capacity to ensure the individual’s families’ and carers’ are offered immediate and ongoing bereavement, emotional and spiritual support appropriate to their needs and preferences.

Other key points that support the case for change Identification of end of life care patients is essential to ensure they receive the right co-ordinated care from the appropriate services and that their care preferences are recorded and communicated to the variety of care providers they may encounter. Research shows that if given the choice, most people prefer to die at home and the least preferred place of death is in hospital. The major limitation of the current end of life provision is not being able to exploit the benefits (both financial and non-financial) which derive from early referral and the potential for more integrated and coordinated health and social care:

• Increased EOL identification • Avoidance of hospital admissions • A smooth and speedy transition from hospital to home • Increasing further patient and carer satisfaction

Our vision is to develop a co-ordinated approach for all End of Life patients and their families or carers, whereby an advanced care plan is jointly agreed and where choice and personal wishes are discussed and documented. If the appropriate group of patients are linked in with local end of life services, the additional benefits will include: • Improved access to end of life care for those who previously would not have had this – i.e.

those with non-cancerous diagnoses. • More patients dying at home and achieving their preferred place of care and death • Reducing unnecessary use of hospital services Key areas where we need the whole system to work differently in future

In our End of Life vision we identified 5 key areas in which End of Life Care could be improved, either through services that we provide or better joint working across the health and social care economy, not least given the importance of improving coordination and integration beyond traditional organisational and professional boundaries. Identification & Patient support

• Early identification of and support for patients in their last year of life is everyone’s responsibility – in Primary Care, Community Care and Secondary Care. This should be based on close collaboration between health and social care services supported by accurate patient information and a common understanding of patient centred end of life care.

Communication • To provide choice to people (delivery of care and care environment) supporting individuals

to maintain control of their care and be involved at each aspect. Workforce Support

• To support staff across health and social care so that they have the knowledge, competence and confidence necessary to communicate effectively and sensitively with the patient and

their families / carers, placing them at the centre of any decision, plan or action for their care or treatment.

Family and carer support • Review of St Christopher’s Bereavement services capacity to ensure the individual’s families’

and carers’ are offered immediate and ongoing bereavement, emotional and spiritual support appropriate to their needs and preferences.

Co-ordination and integration with locally provided services such as Care Networks (CNs)

• Improve integration beyond traditional organisational and professional boundaries, so front-line staff can work effectively and flexibly together to deliver seamless care.

• CNs will play a vital role in enabling delivery of more seamless, integrated services for EoL patients, based on their needs and preferences

• Delivery of Community Based Care (CBC) through the platform Care Networks will be achieved in line with seven confirmed Characteristics of Care. These characteristics below a number of which will support the future development and delivery of EoLC services:

o Timely and prompt assessment o Proactive and empowering care o Seamless co-ordinated care o Multidisciplinary holistic care o Continuity of care professional

What services will look like in 5 years’ time Alignment with National and SEL Strategy In 5 years’ time we would have hoped to improve care for dying people and meet the important and sometimes neglected needs of their relatives and carers. Five priorities agreed by GP Alliance for the care of dying people

1. The possibility that a person may die within the next few days or hours is recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly.

2. Sensitive communication takes place between staff and the dying person, and those identified as important to them.

3. The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants.

4. The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible.

5. An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, coordinated and delivered with compassion.

Benefits – including what changes patients will notice Patients will benefit from:

• A co-ordinated approach for all End of Life patients and their families or carers, whereby an advanced care plan is jointly agreed and where choice and personal wishes are discussed and documented.

• For all End of Life patients to achieve their preferred place of death. • Patients and carers are involved in decisions about treatment and care to the extent that the

dying person wants. This should include advanced care planning and DNAR decisions. • Continued improvement of patient and their carers experience through all stages and in all

settings as the patient approaches the end of their lives. • An empowered End of Life Care workforce across care settings, achieved through training

and support, enabling them to deliver high quality care with compassion, competence and confidence.

• Increased awareness from patients and professional of end of life issues and the availability of end of life services.

Link to Mental Health We recognise that it is quite common for patients at the end of life to have additional complex learning or mental needs which are important to identify in order to respond appropriately with appropriate care. Many people experience unnecessary psychological and spiritual (as well as physical) suffering which can prevent them from living out their final days in a preferred place of care and often has a negative impact on how family and friends cope during the bereavement phase. Through anticipating the above issues, we will therefore aim to ensure that this vulnerable group are given the support that they need including the following (several of which also support and enable self-management):

• Signposting to voluntary groups and self-help services to help patients better manage symptoms and to help reduce anxiety

• Optimising the use of current services – e.g. IAPT, stroke counselling • Ensuring early stage discussions are held with individuals living with dementia to ensure that

whilst they have mental capacity, they can discuss how they would like the later stages managed

• Encouraging greater use - across all faith groups - of resources such as the inter-cultural spiritual care directory to ensure access to appropriate guidance

Key questions that need to be raised as part of engagement (PPE focused) • Are there any other commissioning priorities that you would wish us to consider in the future?

o If yes what are they? • Do you have any other ideas around how we can meet the health and care needs of the people

living in Bromley (bearing in mind limited resources and increasing demand)? o If yes what are they?

MATERNITY SERVICES SUMMARY STATEMENT

Brief summary of our biggest local challenges & local population needs

More children are being born in Bromley each year and this figure continues to rise. In 2012 there were 22% more births than in 2002. Last year, around 4,700 babies were born at the Princess Royal University Hospital. The London context:

• Over 130,000 live births in London in 2014. • 1.74 children born per woman in London on average. • Compared to other regions in England, London has the lowest birth rate for women aged

under 45 and highest birth rate for women aged over 45. • Across London there are 21 maternity services providing maternity care over 28 sites; 3

standalone birth centres and 21 co-located birth centres. • Approximately 10% of women in London deliver their baby in one NHS trust but receive

postnatal care in another area. • London has the worst perceived maternity care in England (CQC survey 2013).

Key areas where we need the whole system to work differently in future In line with Our Healthier South East London Strategy, maternity services for Bromley women and their families will be safe, evidence-based and of high quality, delivered at the right time, in the right place and by a planned, educated and trained workforce. This requires whole system changes to ensure that:

• The transition from pregnancy to parenting and family life is supported through high quality services that are woman and family centred.

• Women and their families are able to access a full range of antenatal, intrapartum and postnatal care, taking account of individual choice and clinical need.

• Women are given evidence-based information and advice about all stages of their pregnancy.

• Continuity of care is delivered across the maternity pathway. • Maternity care provision is flexible, appropriate and accessible to women. • Service providers work in partnership to deliver community based multi-professional care

across organisational and geographical boundaries to deliver seamless services. What services will look like in 5 years’ time Specific outcomes at KCH to be achieved in 2016-17 will include the following:

Outcome Source / standard Current position at KCH 1. Obstetric units to be staffed to provide 168 hours a week (24/7) of obstetric consultant presence on the labour ward.

RCOG (2007) Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour ROCG (2011) High Quality Women’s Health Care: A proposal for change RCOG (2012) Tomorrow’s Specialist

94hrs labour ward cover.

1

2. Midwifery staffing levels to ensure that there is one consultant midwife for every 900 expected normal births.

RCOG (2007) Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour

Approx 40% of KCH births are normal births, which is around 4000 and we have 2.6 WTE consultant midwives. This is one CM for every 1538 births

3. Obstetric units to have access 24 hours a day, 7 days a week to a supervising consultant obstetric anaesthetist who undertakes regular obstetric sessions.

Obstetric Anaesthetists’ Association/ Association of Anaesthetists of Great Britain and Ireland for Obstetric Anaesthesia Services (2005) Guidelines for Obstetric Anaesthesia Services Clinical expert panel consensus

Not in place

4. Number of women seen by a midwife or maternity healthcare professional, before 12 completed weeks of pregnancy. Or within 2 weeks of referral if this is received after 12 completed weeks of pregnancy.

90% London Standards

80%

12. Obstetric and midwifery cover and specialist mental health training for workforce

2 WTE mental health specialist midwives as part of perinatal mental health case load service at KCH. Offered as part of maternity higher tariff per woman

Not in place

*Preconception Assisted conception is not a maternity service – it is a planned care pathway

Benefits – including what changes patients will notice A safer and more accessible service for local women, babies and their families in planning pregnancy, during pregnancy and labour, and in the period following the baby’s birth. Link to Mental Health The MSLC were closely involved in the development of a business case for a new perinatal mental health service. The service aims to improve knowledge and awareness of mental health issues during pregnancy and post-natal, improve care for women who experience mental health problems, and implement the NICE and RCPysch guidelines. Self-Management & Prevention Women are given evidence-based information and advice about all stages of their pregnancy – antenatal, screening, intrapartum and postnatal.

Key questions that need to be raised as part of engagement (PPE focused) • Are there any other commissioning priorities that you would wish us to consider in the future?

o If yes, what are they?

• Do you have any other ideas around how we can meet the health and care needs of the people living in Bromley (bearing in mind our limited resources and increasing demands for care)?

o If yes, what are they?

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Strategic Priority - SUMMARY STATEMENT MENTAL HEALTH

Brief summary of our biggest local challenges & local population needs (JSNA) Good mental health and resilience are fundamental to our physical health, our relationships, our education, our training, our work and to achieving our potential. Some mental health problems can be long lasting and can significantly affect the quality of people’s lives, especially if they are not treated. Some people only experience a single episode of mental ill health. Mental health problems affect a large proportion of the population, one person in six has a mental health problem at any one time, and one in four will have a problem during their lifetime. Approximately 158 people per 1,000 of the Bromley population aged 16 to 74 years suffering from a mild to moderate disorder (i.e. anxiety and/or depression). Suicide rates in Bromley have been consistently lower than in London and the national average. In 2012, there were 22 deaths from suicide and undetermined injury. However, the percentage of >18s with depression is significantly higher in Bromley (6%) than both England (5.8%) and London (4.4%) (JSNA, 2014). Children and Young People’s Mental Health One in ten children needs support or treatment for mental health problems. These range from short spells of depression or anxiety through to severe and persistent conditions that can isolate, disrupt and frighten those who experience them. 75% of mental health problems in adult life (excluding dementia) start by the age of 18. Failure to support children and young people with mental health needs costs lives and money. Mental Health and Older People Bromley has the highest number of 65+ and 85+ in London and this number is expected to grow. People over 65 in Bromley make up approximately 17.74% of the population in 2014, of which 4,205 were estimated to have dementia (Dementia Prevalence calculator, 2012), this is expected to rise year on year with an increase of nearly 300 people in the next four years. Other key points that support the case for change Links to Physical Health and Long Term Conditions Mental health problems such as depression are also much more common in people with physical illness, and having both physical and mental health problems delays recovery from both. Children with a long term physical illness are twice as likely to suffer from emotional or conduct disorder problems. Links to substance misuse Alcohol misuse is related to mental ill health, and alcohol dependence is associated to an increased rate of mental disorders. 26% of people in Bromley regularly consume enough alcohol to damage their health.

Drug misuse damages mental health. In 2012-13 estimates suggest 15,000 in Bromley had abused substances. In the same time period there were 318 admissions through primary and secondary diagnosis of drug related mental health and behavioural disorders. Key areas where we need the whole system to work differently in future Improving Mental Health Support within Primary Care An approach across primary care and community care that looks to support patients to manage their own and their loved ones’ mental wellbeing, additionally and importantly working to remove the stigma/taboo of discussion and awareness of mental ill health in the community

• Identification • Responsiveness • New ways of working across primary and secondary care • Development of local care networks • Mental health support to those with long term conditions • Links to Primary Care Plan

Improving access to psychological therapies for individuals with anxiety and depression (IAPT) In recognition of the burden of mental ill health caused by moderate depression and anxiety disorders, there is a current strategy for improving access to psychological therapies (IAPT) known to be effective in treating these disorders.

• Increasing recognition and detection in primary care • Improving access to the service and methods of engagement • Continuing to promote self awareness and self referral • Reducing waiting times • Improving recovery rates • Linking closely with long term condition care pathways

Improving Mental Health Crisis Response • Urgent care pathways • Increasing mental health liaison services • Crisis Care concordat • Preventing crisis admissions • Links to Urgent Care Plan

Supporting those with Dementia

• Raising awareness in the community • Increasing access to diagnosis • Increasing access to post diagnostic support services • Increasing support to carers • Links to End of Life Plan

Improving Child and Adolescent Mental Health Services

• Transformation of child and adolescent mental health services • Promoting resilience, prevention and early intervention.

• Increasing accessibility of services for children and young people. • Development of community Eating Disorder Services • Improving awareness in schools and local communities • Link to Children and Young People’s Plan

Development of specialist community perinatal mental health services

• Increased support to women in the ante-natal and post-natal period who experience mental health problems.

• Increased education and awareness of mental health conditions to the range of professional supporting women and their families.

• Link to Maternity Plan

Improving the links between physical health and mental health • Addressing health inequality and early mortality • Improve annual health check take up • MH CQUIN • Increased recognition of the mental health needs of those with long term conditions

and other physical health problems. • Links to Planned Care Plan

What services will look like in 5 years’ time Our vision for Mental Health services closely aligns to the vision of OHSEL and so will be explored corresponding to key priority areas: CYP Mental health is embedded throughout the whole CYP system model Prevention of self harm and suicide will require a whole population approach and targeted approach to high risk groups.

• Multi-systematic family based therapy

Children’s mental health integrated community teams will improve mental health integration – support the principle of “no wrong door” for children

• CAMHS will be linked to the community Team, providing: o psychiatric casework and clinical advice; o support such as talking therapies and cognitive behavioural therapy (CBT); and o support for mental health conditions such as self-harm, depression, and anxiety.

Extended GP hours to allow rapid access for CYP to paediatric specialists for CYP with long term mental health conditions Urgent and Emergency Care An interface will exist between the urgent and emergency department and mental health services, allowing for: • earlier identification of mental health cases (including Dementia) reducing length of stay

and enabling quicker streaming to specialities for mental health patients by having Psychiatric Liaison nurse and Triage joint assessments

Maternity Each woman having a named midwife, particularly those with pre-existing mental health issues • This provides continuity of care. • Makes patients feel more confident to disclose mental health issues Cancer Specialist psychological intervention will present better care for those living with adverse consequences of cancer. • Mental wellbeing will be considered at all stages of the cancer pathways – St

Christopher’s service includes a mental health element • Carers will be aware of and have access to the option of counselling support EoLC For patients in EoLC, mental health services will achieve:

• signposting to voluntary groups and self-help services to help patients better manage symptoms and to help reduce anxiety

• Optimisation of current services – e.g. IAPT, stroke counselling

Benefits – including what changes patients will notice • Equitable, accessible and consistently good quality mental health provision • Reduced suicide rate • Reduced DSH hospital admissions • Mental health problems that inflate the number of A&E frequent attenders could be

absorbed by improved primary care services • Sustainable treatment for dementia patients • Higher life expectancy for patients with mental illness • Concurrent improvements in physical health and indirect beneficial consequences,

e.g. less obesity/smoking related costs to NHS • Improved confidence and ability to discuss mental ill health

Self-management and prevention Generally: • Prevention and awareness of depression/anxiety and common mental ill-health in the

general population and promotion of IAPT o Including targeted prevention of depression in the elderly population which may

require complex and personalised approaches Key questions that need to be raised as part of engagement (PPE focused) • Are there any other mental health commissioning priorities that you would wish us to

consider in the future? o If yes, what are they?

• Do you have any other ideas around how we can meet the health and care needs of the people living in Bromley (bearing in mind our limited resources and increasing demands for care)?

o If yes, what are they?

SUMMARY STATEMENT Strategic Priority – Planned Care

Brief summary of our biggest local challenges & local population needs (JSNA) Our four main biggest challenges are related to cardiovascular disease, hypertension, stroke and diabetes.

1) Circulatory disease is the largest cause of mortality in Bromley (32%). CVD is a priority. Early CVD mortality has decreased 39.7% in the last 10 years. However, there are differences in the borough associated to gender and deprivation: • Male (182.9) CVD mortality rates are higher than females’ (108.5). • In the most deprived quintile the CVD mortality rate is 1.2 times higher than the overall

LBB mortality rate and 1.6 times greater that the mortality rate in the least deprived areas.

2) The prevalence of recorded hypertension is higher in Bromley than the national average. However, recorded prevalence of hypertension in Bromley is only 44.9% of the estimated prevalence (this figure is 46% for England and 41.5% for London). Hypertension places the sufferer at higher risk of stroke.

3) The observed prevalence for stroke in Bromley is 65.5% of the estimated prevalence (this compares to 68.4% for England and 52.6% for London). Of those people diagnosed with stroke, a lower proportion has monitoring and control of blood pressure and cholesterol in Bromley than the England average.

4) Diabetes represents a continuing challenge in Bromley. The number of people affected has almost tripled in 10 years, rising from 4,846 in 2002 to 13,681 in 2012. For those people diagnosed with diabetes, control of the associated risk factors for circulatory disease is less effective than nationally.

In addition to these key clinical areas, there is an unwarranted variation in access to and quality of care leading to varying patient outcomes and experiences.

• GP and consultant access to diagnostics is varied. Non-standardised diagnostic pathways leads to costly waste and inefficiency in the system, delays, and unnecessary duplication of tests.

• Carers can find it difficult to access planned care because of lack of services and/or lack of availability at the ‘planned’ time to look after the cared for person

Other key points that support the case for change • Cancer incidence is increasing suggesting a need for an improved preventative strategy. A

significant proportion of cancers are diagnosed outside the two week referral pathway, leading to later diagnoses, which will adversely impact survival rates, as will the low cancer screening uptake in the more deprived parts of the borough.

• Smoking is a major risk factor of CVD, stroke and cancer. Smoking accounts for about one seventh of CVD deaths. In Bromley the adult smoker population is 43,192 and prevalence has been rising since 2010.

• Obesity is associated with CVD and obesity levels in Bromley are the third highest of all London boroughs.

• An ageing population is resulting in a significant increase in the number of people presenting with long term conditions such as heart disease, diabetes and hypertension.

Key areas where we need the whole system to work differently in future

• Establish a bold and clear vision for transforming the whole system - not just the reorganisation of individual planned care pathways

• Lead, facilitate and support discussion to encourage the whole system to streamline services and improve the patient journey

• Embrace technology and effective use of IT • Improve communication among primary and secondary care and patients

What services will look like in 5 years’ time The CCG’s vision for planned care over the next 5 years is based on the principle of “consistently good, quality care for all”, whereby patients see the right professional, receive the right treatment or diagnostic test, at the right time and in the most clinically appropriate local setting. Patients and referring clinicians are enabled to access a choice of cost-effective provision according to clinical need. Our future vision for planned care services is firmly aligned to the planned care element of Our Healthier South East London (OHSEL) and includes the following key features: Standardisation

• Co-development of high level standards across pathways (from referral to discharge) to reduce variation in access and outcome. This will be done through high level mapping of patient journeys and careful consideration of what best practice looks like and what patients say they want at each step. Ethnography studies and PPE “I” statements will inform the standards.

• Targeted prevention through Wellness Public Health (delivered by LCN) • Use of Clinical Decision Support Tools • Standardised referrals e.g. MSK pathway self-referral practice (delivered by LCN) • Consistent use of e-referral (Choose and Book) across SEL to promote patient choice • Every patient will be involved in developing their own holistic care plan (social, mental,

physical, health, emotional) • Evidence-based standardised rehabilitation programmes

Diagnostics

• Enhanced patient management by GPs through rapid access to diagnostics • Evidence-based standardised clinical pathways. Explore potential impact of local innovation

programmes, for example TOHETI aims to improve patient outcomes and health sector cost-effectiveness by changing the way in which imaging is used as a diagnostic and therapeutic tool

• Serious but unspecified systems pathway – a pilot diagnosis strategy to influence cancer outcomes through earlier diagnosis and easier access to treatments. The strategy accommodates what the GPs recognise as alarm symptoms (the obvious cancer suspicion), non-specific symptoms (the difficult diagnosis) and vague symptoms (the common symptom).

• Shared results across the system supported by integrated IT systems Elective Care Centres (ECCs) for high volume specialities

• Provider collaboration will create centres of excellence for high volume specialities that have driven up quality of service provision and improved outcomes for patients.

• ECC for orthopaedics (hips and knees) has the potential to highly impact length of stay, emergency re-admissions within 30 days of discharge and cancelled operations

• The clinical pathways for urology, neurosurgery, nephrology, gynaecology and dermatology will have been reviewed. The reviews will highlight any opportunities for standardisation, consolidation and testing new models of patient care

Neurology

• Initial focus on improving the current service models for Multiple Sclerosis, Parkinson’s and Epilepsy

• Options for procuring the community rehabilitation element of the neurology service are currently being explored within the broader context of community rehab including stroke patients

Stroke

• Implement NICE Stroke Rehabilitation guidelines and commission appropriate services in line with Sentinel Stroke National Audit Programme

• Primary care engagement to promote and enable seamless coordination of stroke services through advice and support services, support for initiatives that foster active citizenship including self-management programmes and better integration with voluntary and community organisations

Cardio-vascular disease (CVD)

• Improve the current service model across the entire health pathway with a particular emphasis on appropriate use of diagnostics within primary and community care

• Encourage patients to self-manage their health care through supported training and education programmes

Diabetes

• Support early diagnosis of patients within primary care • Educate patients in diabetes care and encourage self-management of their health care

needs • Patients to receive the same high standard of care regardless of where they enter the

system and the eight NICE care processes for diabetes.

The governance required to mobilise the programme needs to be robust. This will be achieved through:

• A Local Commissioning Board at PRUH to avoid overreliance on CSU • Organisational buy-in at a corporate level with KCH • Whole system buy-in to CCG plans or proposed change processes

Benefits – including what changes patients will notice

• A clear set of high level standards that can be worked towards • Systematic engagement with integrated governance processes • Stronger, consistent clinical leadership, governance and delivery arrangements • An alliance approach that engages all providers in the health and social care economy across

a pathway • A standard access pathway that is efficient, equitable, consistent, high quality and managed

according to clinical priority in line with National Access Targets and the NHS Constitution. It will be able to meet demands for treatment

• Less risk and error in diagnostic pathway and thus improved patient safety • Better use of imaging as a diagnostic and therapeutic tool • Lower operation cancellation rates and a reduction in post-operative complications

• Lower procurement costs Patients will notice:

• Being fully informed of test results • Greater support in maintaining optimum health and empowerment to make informed

choices concerning their care • Care plans that are personalised to their needs and preferences • More coordinated and consistently high quality planned care services that are visible across

the system • Recovery plans that involve family and carers better • Lower waiting times for treatment, fewer delayed discharges and a reduction in length of

stay Self-Management & Prevention

• NHS Health Checks to reach more of the eligible population aimed to prevent heart disease, stroke, diabetes, chronic kidney disease and vascular dementia o Cardiovascular risk assessment tool to assess high risk citizens and prescribed

interventions o Diagnosed individuals can now receive treatment to reduce CVD risk and prevent

disease progression • Support the Public Health Smoking Cessation service • Reduce obesity by supporting services that encourage the local population to adopt

healthier lifestyles • Work is necessary both to prevent diabetes in high risk patients and to improve

identification of diabetes to inform future commissioning Links to Mental Health Having mental ill health increases the risk of physical ill health. People with mental health problems, for example schizophrenia or bipolar disorder, have higher rates of CVD and are less likely to benefit from mainstream screening and public health programmes. It is vital that our physical and mental health services are joined up and support each other. The Improving Access to Psychological Therapies (IAPT) strategy references the importance of linking closely with pathways for patients with long term conditions. Improved take-up of the annual health check-up will help with early diagnosis of both mental and physical conditions and assist in joint management. Key questions that need to be raised as part of engagement (PPE focused) • Are there any other commissioning priorities that you would wish us to consider in the future?

o If yes, what are they? • Do you have any other ideas around how we can meet the health and care needs of the people

living in Bromley (bearing in mind our limited resources and increasing demands for care)? We would especially like any feedback on how we can best support people with cardiovascular disease.

o If yes, what are they? • How can we support carers to be more involved in delivering our vision for planned care

pathways?

SUMMARY STATEMENT

Strategic Priority – Primary Care

The following forms the initial basis for developing Commissioning Intentions

Alignment with Our Healthier South East London (OHSEL) Ultimately we intend primary care services to be consistently excellent and for there to be an increased focus on prevention, with safer, less (unwarranted) variability and better quality care delivered closer to home by highly trained GPs, nurses and other professionals. In line with the wider South East London strategy for primary care that we are working with neighboring boroughs to achieve, the development of primary care in Bromley will incorporate the three dimensions of accessible, proactive and coordinated care and will feature the following specific delivery priorities: • ACCESSIBLE - with greater patient choice, longer opening hours and greater continuity of care:

Patient Choice Contacting the practice Routine opening hours Extended opening hours Same day access Urgent and Emergency Care Continuity of Care

• PROACTIVE - looking at the whole health and wellbeing of the person and preventing ill-health:

Co-Design Developing assets and resources for improving health and wellbeing Personal conversations focussed on an individual's health goals Health and wellbeing liaison and information Patients not currently accessing primary care services

• CO-ORDINATED - working alongside other agencies to improve care planning for patients and

support self-management: Case finding and review Named professional Care Planning Patients supported to manage their health and wellbeing Multi-disciplinary working

A number of these key OHSEL delivery priorities for transforming primary care are outlined in more detail in the following section. Transforming Primary Care to address our biggest local challenges Locally, our biggest challenges can be summarised within the following key themes:

Capacity of general practice: In order to meet the future, changing needs of our local population through transforming care, effective workforce capacity development and management will be essential to identify specific changes required to workforce numbers, skills and roles in order to bolster the primary care workforce. Continuity: We recognise the need, as defined by our patients, to provide improved continuity of care which means addressing the challenge of ensuring practices are able to organise themselves so that patients have a named GP accountable for their care and responsible for overseeing delivery of the care plan and providing an ongoing relationship for care coordination and care continuity.

Access: A key part of our future strategy is to work towards making GPs more accessible through the development of Care Networks and by changing the way in which GPs are able to consult. Health promotion and prevention: GPs and primary care teams have a crucial role to play in promoting health and preventing disease, reducing health inequalities and developing community resilience given the significant potential to detect early warning signs that could prevent illness and disease and to deliver health-promotion and disease-prevention strategies to identified populations. Coordinated care: Patients are changing, both in the complexity of their conditions and in their expectations and therefore the remit of GPs is changing every year. In line with OHSEL and the London Strategic Commissioning Framework, the coordinated care dimension will feature the following specific delivery priorities:

• Case finding and review – practices will identify patients who would benefit from coordinated care and continuity with a named clinician

• Named professional - patients identified as needing coordinated care will have a named professional who oversees their care and ensures continuity

• Care Planning • Patients supported to manage their health and wellbeing • Multi-disciplinary working

Reducing A&E attendances: There is evidence to suggest improving/developing primary and community care services could reduce the numbers of frequent attenders to A&E. Factors such as access to primary care in terms of proximity, longer opening hours, more appointment slots and continuity of care (seeing the same GP) would reduce A&E rising attendance rate, although these studies are contested. Key areas where we need the whole system to work differently in future

• GP practices working collaboratively to share resources, ideas and contracts will deliver better healthcare across localities, not just to their own patient lists.

• Will reduce variation in the quality of care and raise patient experience of their GP practice. • Transition involves no loss of sovereignty for individual GPs • Identify opportunities for innovation and areas where practices can collaborate. • Integration of services into a single system of leadership and delivery will be vital for

providing a patient experience that looks at the whole person To establish an integrated single system leadership and management would include:

• United leadership & common Voice (formal/informal leadership development programmes, local learning sets)

• Access to Expertise (governance, structure development, legal support, business development and new models of care)

• Direct Management Support (coaching/mentoring, management/admin staff) • Facilitated events and engagement across the network • Greater Peer Working & Support and sharing of ideas and solutions – including relating to

enabling strategies, e.g. workforce, IM&T, Estates and across networks Community Based Care will be delivered through Care Networks. This will be a universal service covering the whole population ‘cradle to grave’. A Care Network, underpinned by clear governance and decision-making arrangements, will involve primary, community and social care colleagues working together and drawing on others from across the health, social care and the voluntary sector to provide proactive patient-centred care. Other elements of our aspiration for strengthening future joint working with other key parts of the local system include:

• Implementation of the Mental Health Strategy and CCG Mental Health Programme over the next few years, in particular the development of Primary Mental Health Care Services.

• Continuing to increase uptake of NHS Health Checks among those eligible in the borough through campaigns to improve awareness and support our local prevention agenda.

• Continuing to work with NHS England to maximise the effectiveness of co-commissioning arrangements for primary care services

• Improving care of the vulnerable and elderly in primary care, leading to reduced hospital attendances and admissions. Increasing medicine prescribing efficiency:

Key aims of future primary care services & Links to other strategic priorities Our future vision of general practice is a service that operates without borders and in partnership with the wider health and care system as part of a multidisciplinary effort to deliver patient-centered, coordinated care. To achieve this, our local health system needs to be primary care orientated. Specific aims of future primary care services

• Improve quality and safety in general practice, requiring a collaborative approach leading to shared systems for peer review and a culture of developmental and supportive learning in order to improve patient safety, clinical quality and outcomes for all practices involved.

• Improve ease of access to primary care during maternity to reduce risk and better support the patient. Ensure pregnancy fits within an appropriate wider social infrastructure, supported by developing links within the LCN.

• Reduce variation (level up) in primary care management of long term conditions for children and young people. Children’s Integrated Community Team will work across primary/community care, emergency departments, urgent-care centres and paediatric assessment units to ensure children and young people are cared for in the community.

• Implementation of Co-ordinate My Care o Support for professionals to access and use CMC o Ensure consistent use of CMC across the borough; monitor and audit

• Unplanned, reactive care delivered in an acute/secondary setting is to shift – by adopting a more proactive approach – to care and support delivered in primary/community care or in the elderly patient’s home environment

Benefits – including what changes patients will notice

• Patients will be better supported to be more in control of their health and have a greater say in their own care.

• Patients will be able to live independently for longer and will know what to do if their health deteriorates or incidents happen.

• Patients with more complex needs will have to go to fewer appointments in different locations and see different clinicians as services become co-located, integrated and records are shared amongst professionals.

Some of the main benefits we will aim to deliver through transforming primary care:

• A more seamless, accessible and responsive service that empowers patients to make positive choices regarding their health

• Improved mental health services that promotes better understanding of mental wellbeing • Reduced waiting times and reduced number of hospital admissions and frequent attenders

to A&E • Less avoidable illness and mortality from pertussis in infants • Better capacity to treat and support those identified with learning disabilities • Better medicine prescribing efficiency, cutting costs, reducing waste and more effective

treatment • Primary care system more supported and thus capable of coping with anticipated increase in

workload • Reduced health inequalities • Community based care will be proactive, accessible, coordinated and provide continuity;

with a flexible, holistic approach to ensure every contact counts. • CMC puts the patient at the centre of health care delivery, giving them choice and improving

quality of life • Patients will perceive a greater level of control over their own health

Self-Management & Prevention

• Proactively engaging in personal conversations focused around an individual’s health goals • Supporting patients to manage their own wellbeing • Promoting patient understanding of the services and resources available to help them to

stay well and to look after themselves • All of primary care services to place increased emphasis on prevention • Improve uptake of maternal pertussis vaccination to prevent unnecessary illness and

mortality from pertussis in infants • The SHIP training programme: designed to support primary care staff in promoting HIV

awareness and testing

Link to Mental Health

• Primary care is fundamental to delivering high quality mental health care

• Implementation of the Mental Health Strategy and CCG Mental Health Programme over the next few years, in particular the development of Primary Mental Health Care Services.

• Mental health problems that inflate the number of A&E frequent attenders could be addressed by improved primary care services

• A view to support patients to manage their own and their loved ones’ mental wellbeing

Key questions that need to be raised as part of engagement (PPE focused)

• Are there any other commissioning priorities that you would wish us to consider in the future?

o If yes, what are they? • Do you have any other ideas around how we can meet the health and care needs of the

people living in Bromley (bearing in mind limited resources and increasing demand)? o If yes, what are they?

• How could your experience of your GP practice be improved? Think about getting an appointment, the practice and staff, and the care provided by your GP.

URGENT CARE SUMMARY STATEMENT

Brief summary of our biggest local challenges and local population needs

A King’s Fund report on transforming the health care system highlights some of the current problems that contribute to the burden of urgent and emergency care, all of which are relevant to local Bromley challenges to varying degrees: • Highly fragmented urgent care services generate confusion among patient with regard to how

and where to access care • Lack of alternative options leads to the admission of patients even when it is not clinically

required • Poor sharing of information as patients move between providers causes failures of care Locally, our main challenges for urgent and emergency care are summarised as follows: • 60% of breaches in current Emergency Department performance were due to ineffective /

inefficient patient flow • Inability to undertake robust evaluation (e.g. no robust method of measuring numbers of

patients delayed and numbers of bed days lost) • Reactive not proactive approach including inability to take timely and appropriate action prior

to transfer decisions • Lack of accountability: organisations have not agreed on who is accountable for what and who

accountability is to • Insufficient management infrastructure and lack of robust governance and performance

management arrangements between acute and community providers • Barriers to trust and effective relationships: strained relationships and disagreement exist due

to organisations not working together effectively and disagreement on the architecture of key processes and performance management

Key local challenges around our 2014-15 and 2015-16 YTD performance in urgent and emergency care are highlighted below: • Attendance vs. admission ratio remains above the London average, although comparable to the

SEL average Patient perspective: Based on their experience of our local services and some of the current challenges, local patients and residents have identified the following requirements in order for urgent and emergency care services to meet their current and future needs:

• More central points of access and discharge to services • Better joined up care from providers in Bromley • Clinicians given access to clinical information – especially GPs having access to hospital results • Extended access to GPs and urgent care • Option of telephone calls with professionals rather than face to face interactions • Improved discharge from hospital process with information available to the patient and their GP,

particularly about medicines

Key areas where we need the whole system to work differently in future

Across the Bromley health and social care economy there is a need for improved integrated multi-agency governance and operations. This includes: • More intelligent use of the information we have about people who are frail or have a LTC,

including removal of artificial boundaries and data collection that adds no value. • Establishment of an integrated governance arrangement across the whole system, to oversee

the design and implementation of the improvement programme for ED (as illustrated below)

• Building and maintaining effective relationships based on trust and collaboration to ensure that the right culture and robust leadership are in place

• Creating an environment that supports innovation – including new collaborations with private sector

• Pathway development • Addressing workforce needs

What services will look like in 5 years’ time Our future vision for local urgent and emergency care is firmly aligned to the urgent and unscheduled care part of Our Healthier South East London (OHSEL), and includes the following key features: • Implementing the London Quality Standards for EDs, UCC and other emergency care • Enhanced access to unscheduled care outside hospital, including access to specialist services in

the community • Integration of the 111 service into "Integrated Urgent Care Services" which will continue to

provide advice and signposting but will also incorporate out of hours GP provision and onward referral to the London Ambulance Service. This will result in a smoother, more efficient and "seamless" service for patients.

Bromley health and social care economy are proposing to implement the Integrated Transfer of Care Bureau model of care:

• It will operate initially to improve the flow of patients through the urgent and emergency care pathway.

• Expand to include admissions prevention and the use of integrated systems (111, GP Alliance, community services and acute clinicians working in the community) to improve the care of patients in Bromley’s 60 care homes and reduce admission to hospital in particular.

• Will match patient need for an urgent response with the supply of the most appropriate community based service. It will have the authority to act on behalf of all local organisations, thus simplifying transfer processes, at any point along the urgent care pathway.

Benefits – including what changes patients will notice

Patients will notice the following key changes: • More support for family and carers • Shorter hospital visits • Increased support at home to prevent or respond to “crisis” • Improved prioritisation based on need • A reduction in average delay from 5 days to 0 for patients with complex and supported discharge

needs • More seamless care between providers Key benefit of Integrated Transfer of Care Bureau: • Clearer and more effective governance and financial decision-making Self-Management & Prevention Remove A&E as default point of entry to healthcare system by proactively researching and developing alternative urgent care services for attendances relating to conditions that might be better dealt with in settings other than A&E. E.g. intramuscular or intravenous injections, catheter problems, blood tests, feeding tube problems. Tackle issues relating to child admissions to A&E (higher than the national average):

• Reduce the patients presenting minor ailments who can self-manage • Reduce Deliberate Self Harm in children by implementation and uptake of:

o Psychological wellbeing programmes o Gatekeeper training for key frontline staff in places where children may present. This

is being taken forward in secondary schools, CAMHS and A&E at PRUH • Reduction of teenage pregnancy

Key questions that need to be raised as part of engagement (PPE focused) • What are your views on the use of technology – e.g. robotics - to aid daily functions, including:

o use of robotics to assist tasks of daily living o at which point do people feel able to compromise – e.g. machine to get patient up once

ready versus human visit at prearranged time • What support do family members, carers and friends need to prevent crises, especially at

weekends and during the night? Generic (all priority areas) • Are there any other commissioning priorities that you would wish us to consider in the future?

o If yes, what are they? • Do you have any other ideas around how we can meet the health and care needs of the people

living in Bromley (bearing in mind limited resources and increasing demand)? o If yes, what are they?