SOUTH WEST LONDON HEALTH AND CARE ......• Our six Local Authorities: Croydon, Kingston, Merton,...

SOUTH WEST LONDON HEALTH AND CARE PARTNERSHIP: ONE YEAR ON. 1

SOUTH WEST LONDON HEALTH AND CARE PARTNERSHIP: ONE YEAR ON.

Discussing with you how we deliver better health and care for local people

START WELL, LIVE WELL, AGE WELL


FOREWORD

LocalNHSclinicalcommissioninggroups,providertrusts,localauthoritiesandpatients'representativesacrossSouthWestLondonmakeuptheSTP’sSouthWestLondonHealthandCarePartnership.

Thepartnersare:

• OursixClinicalCommissioningGroups(CCG)of:Croydon,Kingston,Merton,Richmond,SuttonandWandsworth

• OursixLocalAuthorities:Croydon,Kingston,Merton,Richmond,SuttonandWandsworth

• OurAcuteandCommunityProviders:CentralLondonCommunityHealthcare,CroydonHealthServicesNHSTrust,EpsomandStHelierUniversityHospitalsNHSTrust,HounslowandRichmondCommunityHealthcare,KingstonHospitalNHSFoundationTrust,RoyalMarsdenFoundationTrust,StGeorge’sNHSFoundationTrustandYourHealthcare

• OurtwoMentalHealthProviders:SouthWestLondonandStGeorge’sMentalHealthNHSTrust,SouthLondonandtheMaudsleyNHSFoundationTrust

• TheGPFederationsineachofthesixboroughs

• TheLondonAmbulanceService

• Healthwatch

We’velistenedtolocalpeople,ourpartners,politiciansandexpertsliketheKing’sFund,andhaveworkedtogethertorefreshourvisionandstrategyforsouthwestLondon.Thishadbeenbroughtthistogetherinthisdiscussiondocument.

Thisdocumentisfordiscussionwithlocalorganisationsandstakeholdersandisnotafinaldocument.

WewillcontinuetoworkwithLocalAuthorities,thevoluntarysector,localHealthwatchgroupsaswellastheNHStoproduce“Localhealthandcareplans”inJune2018.Theseplanswillprovideclearanddetailedactionstoaddressthelocalchallengeswehavesetoutinthisdiscussiondocument.


CONTENTS Page number 1. Introduction 4

2. Contents 7

3. Servicequality 11

4. Ourfinancialposition 12

5. Workinginpartnership 16

6. SocialCare 18

7. Oneyearon:ourprogresssofar 19

8. Whatlocalpeoplehavetoldusaboutourservices 20

9. OurHealthandCarePartnershipcommitments 24

10. LocalTransformationBoards:Alocalfocusonimprovement 25

• Croydon 27

• MertonandWandsworth 41

• KingstonandRichmondandEastElmbridge 51

• Sutton 59

11. SouthWestLondon-wideimprovements 68

• HealthPromotionandPrevention 69

• Cancer 71

• MentalHealth 75

• UrgentandEmergencyCare 79

• PrimaryCare 84

• Maternity 87

• LearningDisabilitiesand/orAutism 90

• ChildrenandYoungPeople 92

• OurWorkforce 94

• HarnessingTechnology 97

• OurBuildingsandEstate 99

• Supportingourlocalcommunities 101

12. Appendices

Appendix1:ClinicalqualitystandardsforacuteservicesprovidedinSouthWestLondonoroperatedbyaSouthWestLondonTrust

Appendix2:ClinicalqualitystandardsforacuteservicesprovidedinSouthWestLondonoroperatedbyaSouthWestLondonTrust:currentpositionandgapanalysis

Appendix3:Reportsdetailingfeedbackfromlocalpeopleandpatients


1. INTRODUCTION

TheSouthWestLondonSustainabilityandTransformationPlan(STP)waspublishedinNovember2016.ItsetouthowhealthandcareorganisationswouldworktogethertoimprovecareandservicesforpeopleinSouthWestLondon.

TheSouthWestLondonHealthandCarePartnership:Oneyearonprovidesanoutlineoftheprogresswehavemadeinthefirstyearandoutlinesfordiscussionourplansforthenexttwoyears.TheprogresswehavemadeissummarisedinSection6andshowsthatbyworkingtogetherandindifferentways,wehavealreadydeliveredimprovementsforlocalpeople.Thankyoutoallthosewhohavebeeninvolvedinthefirstyearofourdelivery.

Overthepastyear,wehavebeentalkingtolocalpeopleacrosssouthwestLondon.Wetalkedtoover5,000peopleandhavein-depthreportsthathaveanalysedtheirfeedback.Someoftheconsistentandcorethemesthatpeopletoldusaboutwere:theywanttobeabletogetcarewhentheyneedit;thattheywantorganisationstoworkwelltogethertoprovidethatcare,inparticularjoiningupmentalhealthandphysicalhealthservices;thatwhenthereisdifficultnewstotellabouttheirhealththatitisgivensensitivelyandfurthersupportoptionsareexplained;andthatweencouragepeopletoleadhealthierlifestyles,particularlychildrenandyoungpeople.

Aswellaslisteningtolocalpeople,wehavelearnedalotoverthelastyearfromourpartnersandstakeholders,andasaresultourfocusoverthenexttwoyearswillbeonthefollowing:


• Alocalapproachworksbestforplanning:Aftertalkingtolocalpeopleandcommunities,webelievealocalapproachworksbestforplanninghealthandcare.WehavesetupfourlocalhealthandcarepartnershipsinCroydon,Sutton,Merton/WandsworthandKingston/Richmondtodrivetheimprovementofservicesatlocallevel.

• Careisbetterwhenitiscentredaroundaperson,notanorganisation:Cliniciansandcareworkerstellusthis:Thesefourhealthandcarepartnerships,areabouttheNHSandLocalAuthoritiesinthoselocalareas,comingtogethertolookatwhatservicestheirlocalpeopleneed,ratherthancontinuingtoprovideserviceswithintraditionalorganisationalboundaries.

• Bottom-upplanningatboroughlevel,basedonlocalpeople’sneeds:Theselocalhealthandcarepartnershipsatboroughlevelarelookingatwhereisthebestplaceforpeopletoreceivetheircare.Forexampleinthecommunity,theirlocalhospitals,theirGPpractice,orthelocalpharmacy.Theyaremakinglocalplanstoworktogethertoprovidemorejoineduphealthandsocialcareservices,andhowtomaketheselocalsystemsclinicallyandfinicallysustainable.

• Strengtheningourfocusonpreventionandkeepingpeoplewell:thegreatestinfluencesonourhealthandwellbeingarefactorssuchaseducation,employment,housing,healthyhabitsinourcommunitiesandsocialconnections.Wewanttostrengthenthefocusonreducinghealthinequalities,andkeepingpeoplehealthyathomebytreatingthemearlier.Wewanttostoppeoplefrombecomingmoreunwellandgivethemtherightsupportathomesothattheydon’tneedtobeadmittedtohospital.

• Thebestbedisyourownbed:Wewillworktogethertokeeppeoplewellandoutofhospital.Workingtogether,oneormoreofourfourhealthandcarepartnerships,maywanttoprovidesomeservicestogetherwhereitmakessenseforpatients,forexamplemusculoskeletalservicesforconditionsthataffectthejoints,bonesandmuscles.

• Likelytomeanchangestoserviceslocallytoimprovecareforlocalpeople:wewillneedtochangehowsomeservicesaredelivered,andwewillofcoursebeopenandtransparentaboutthisandinvolvelocalpeople.Wewillcontinuetoneedallourhospitalsthoughwedonotthinkeveryhospitalhastoprovideeveryservice.


TransformingcareinSouthWestLondonoccursthroughbothlocalandSouthWestLondonwidetransformationprogrammes.Inthesectionsthatfollowweidentifyhowwewillcontinuetodobothoverthenexttwoyears.

Itisimportantthatwemakesurethatourplanscontinuetoreflecttheneedsoflocalpeopleandservices.Todothiswewillreviewourtransformationplanseverytwoyears.Thediagramsbelowshowhowwewilldothis:

Theyearsaheadwillundoubtedlybechallenging,butbyworkingtogetherandfocusingontheneedsoflocalpeoplewewilldelivertheambitionsoutlinedinthisdocument.

SarahBlow DrAndyMitchell,MBBSFRCPCHSeniorResponsibleOfficerforSouthWestLondon ConsultantPaediatricianandChairmanHealthandCarePartnership oftheSouthWestLondonHealthandCarePartnership

SouthWestLondonwidetransformationprogrammesUrgentandEmergencyCare:MentalHealth;PrimaryCare;Maternity,Cancer,LearningDisabilitiesand/orAutismseesection10ofthedocumentfordetailsoftheseprogrammes

LocaltransformationTransformingourmodelforhealthandcarelocallyincludingthemostappropriateplacetoreceivecareseesection9ofthedocumentfordetailsoftheseprogrammes


2. SOUTH WEST LONDON IN CONTEXT

Croydon

Kingston Merton

Richmond

Sutton

Wandsworth

Key facts about Croydon

The population of Croydon is expected to grow significantly by 2027, particularly the younger population. Life expectancy has increased however there are very big differences in the health for our residents across the borough.

Compared to the average Londoner, people in Croydon ...

The population in Croydon ...

The Croydon Transformation Board is a partnership of the NHS, Croydon Council and Healthwatch Croydon.The LTB includes CCG, CHS, Croydon Council, SLAM, GP Collaborative and Healthwatch.

Your health and social care in Croydon

Key facts on health in Croydon

inequality in life expectancy,

high number of people who are obese

high prevalence of diabetes, a growing and diverse population

supporting more people to stay healthy and active for as long as possible and able to live as independently as possible

early detection and diagnosis of health conditions such as diabetes,

support older people to keep well and stay in their home

has more woman then men

Is one of the most diverse in

London with over has lots of older people, and lots

of teenagers

Population of over

380,000and rising by over

There are

57GP practices in Croydon

Main health challenges for Croydon today

123

Over the next three years, the LTB will focus on...

over next 5 years6%

women

men

56%44% 90 languages

spoken

...are more obese as children

... have higher rates of diabetes and

heart disease

...are less likely to smoke as teenagers

...take more exercise,

especially walking

Life expectancy is

9.7years lower for men and 6.1

years lower for women in the most deprived areas of Croydon than the least deprived areas.


Key facts about Kingston & Richmond

The residents of Kingston and Richmond are, on average, less deprived compared to other borough in London. The number of over 65 year olds is projected to increase by over 50% in the next twenty years.

Compared to the average Londoner, people in Kingston & Richmond ...

The population in Kingston & Richmond ...

Produced by the Kingston & Richmond Local Transformation Board (LTB) 2017The LTB includes Kingston & Richmond Clinical Comissioning Group and Kingston & Richmond council.

Your health and social care in Kingston & Richmond

Key facts on health in Kingston & Richmond

Too many people die too early of cancer

Too many people are developing diabetes and heart disease

Too many people, especially young people, are suffering with mental health problems

... early diagnosis and treatment of cancer

....more community support to prevent long term diseases

... more specialist mental health care, especially for young people

...supporting older people to keep well in their own homes.


of 75 year olds in Richmond live

alone

has lots of older people, and lots

of teenagers

Population of around

420,000in Kingston & Richmond including East Elmbridge

There are about

57GP practices in Kingston & Richmond

Main health challenges for Kingston & Richmond today

123


women

men

56%44%

over half


... have lower rates of diabetes…. But this is a

leading cause of illhealth



especially walking

Life expectancy is

81.8years for men and 85

years for women which is slightly above the

national average


Key facts about Merton & Wandsworth

The residents of Merton and Wandsworth are, on average, less deprived compared to other boroughs in London. However significant health and social inqeualities in both boroughs with an associated gap in life expectancy.

Compared to the average Londoner, people in Merton & Wansdworth...

The population in Merton & Wandsworth...

Produced by the Merton & Wandsworth Local Transformation Board (LTB) 2017The LTB includes Merton & Wandsworth Clinical Comissioning Group and Merton & Wandsworth council.

Your health and social care in Merton & Wandsworth

Key facts on health in Merton & Wandsworth


... have higher rates of diabetes and

heart disease


Too many people die too early of cancer

Too many people are developing diabetes and heart disease



....more community support to prevent diseases, like diabetes


...supporting older people to keep well in their own homes.


There’s a particularly

high proportion of 25-39 year olds

in Wandsworth

has lots of older people, and lots

of teenagers

Population of over

585,000There are about

65GP practices in Merton & Wandsworth

Main health challenges for Merton & Wandsworth today

123


women

men

56%44% (39%)


especially walking

In Merton over

5,900over 75 year olds live alone

Life expectancy is

9.3years lower for men and 4.5

years lower for women in the most deprived areas

of Wamndsworth than the least deprived areas.


Key facts about Sutton

Sutton residents live in one of the healthier boroughs in England, and has an increasingly young population. People living in Sutton live longer than average and are less likely to have illnesses like diabetes. However, there are big differences across the borough.

Compared to the average Londoner, people in Sutton ...

The population in Sutton ...

Produced by the Sutton Local Transformation Board (LTB) 2017The LTB includes Sutton Clinical Comissioning Group and Sutton council.

Your health and social care in Sutton

Key facts on health in Sutton

.. live longer ... have lower ratesof diabetes and

heart disease

... do less than the recommended amount

of exercise each day

... are more likely to be aged either 5-19

or 30-49

Too many people die too early from cancer

There are big differences in how long you live across the borough



....giving everyone across the borough the same high standard of support to live well


supporting older people to keep well in their own homes.

... are positive about their health. In a recent survey,

75% said they feel in good or very good

health.

... can feel lonely, with one in ten

people saying they do not get enough

social contact

... is younger and less diverse than the

London average.

Sutton is hometo around

200,000people

There are over

25GP practaces in Sutton

Main health challenges for Sutton today

123

Over the next three years, the L TB will focus on...

There are over

1,800careers in Sutton

Life expectancy is

80.8years for men and 83.5

years for women which is slightly above the

national average


3. SERVICE QUALITY

Wefirmlybelievethatfortransformationandimprovementtobesuccessfulitneedstobelocal,respondingtolocalneeds,issuesandcontext.So,inearly2017wesetupfourLocalTransformationBoardstoworktogethertotransformcareandservicesforlocalpeople.MadeupofrepresentativesfromtheLocalNHS,LocalAuthorities,patientrepresentativesand,insomethevoluntarysector,LocalTransformationBoardscometogethertoplanhowbesttomeettheneedsoftheirlocalpopulation;ataboroughandwiderleveltotransformhealthandcareservices.

TheSouthWestLondonHealthand CarePartnershiparecommittedtocontinuouslyimprovingthestandardsofcareinhospital,specialistandcommunitysettingsandtoreduceinappropriatevariationincareacrossSouthWestLondon.ThissectionoutlinesevaluationsintothestandardofsomecareinhospitalsacrossallfourLocalTransformationBoardareas.

InOctober2017,theSouthWestLondonClinicalSenateagreedasetofclinicalstandards(seeappendix1)forsixclinicalservicesinhospitals:emergencydepartment;acutemedicine;paediatrics;emergencygeneralsurgery;obstetrics;andintensivecare.HospitalsinSouthWestLondonwereaskedtoself-assesstheirservicesagainsttheagreedclinicalstandardsandtofeedthisworkintotheirlocaltransformationboardsastheyprogresstheirlocalhealthandcareplans.ThisisthefirststageofwiderevaluationworkintosustainabilityineachofourlocaltransformationboardareasacrossSouthWestLondon.ThisassessmentprovidesaclearpositionforthesespecificclinicalservicesforeachoftheSouthWestLondonhospitalsites.

WiththeexceptionofEpsomandStHelierUniversityHospitalsNHSTrust,hospitaltrustsbelievethattakingthisself-assessmentintoaccount,withtheirknowledgeoftheirindividualstaffing,estatesandoperationalissuesandplansthattheyareclinicallysustainableinthesesixclinicalservices.

Takingalloftheseareasintoaccount,EpsomandStHelierUniversityHospitalsNHSTrusthaveclearlysetoutacaseforchangeandascaleofchallengethatstatesthattheyareunabletodeliveralloftheseserviceswithoutalevelofchangetotheirclinicalmodel.Throughanengagementexercise,heldbetweenJulyandSeptember2017,theTrusthassetouttheirviewsonpotentialscenariosforthefuture.

NodecisionhasbeenmadeonthefutureofEpsomandStHelierUniversityHospitalsNHSTrust.LocalclinicalcommissioninggroupswilldevelopaformalprocesstoconsiderthefutureofservicesatEpsomandStHelierUniversityHospitalsNHSTrust,andotherissuessuchastheirestate,andhowtheywillbeabletodeliversustainableservicesforthelocalpopulation.Commissionersandthelocalsystemarefullycommittedtoconsultationwiththepublicifthisprocesssuggestssignificantchange.

FurtherinformationonthisevaluationcanbefoundintheLocalTransformationBoardsections.Acopyofthefullevaluationsummaryisgiveninappendix2.

Localhealthandcarepartnershipswillcontinuallyevaluatethequalityofservicesacrosscommunity,primarycare,mentalhealthandhospitalservices.


4. OUR FINANCIAL POSITION

Nationally,thehealthandcaresystemfacesachallengingfinancialpositionasitworkshardtokeepserviceprovisioninlinewithservicedemand.SouthWestLondonisnodifferenttothis

andwehaveanumberofchallengingfinancialpressureswithinourpartnership.

TheNHSinSouthWestLondoncurrentlyspends£2.7billionacrossarangeofservicesashighlightedintheanalysisbelow.

Inthecurrentfinancialyear(2017/18)NHSprovidersandcommissionersintheSouthWestLondonHealthandCarePartnershiphaveidentifiedanunderlyingdeficitof£166millionwithafurtherriskof£38millionwhichtheyaremanagingthroughanumberofoneoffmeasuresandcentralNHSsupport.TheSouthWestLondonHealthandCarePartnershipisworkinghardtoimproveourfinancialpositionduringthecurrentyearandwilltakestockofourachievementsandreviewourunderlyingpositiongoingforward.WhilewewillhavedeliveredasignificantelementofthePartnership’s£560millionsavingtarget(providersandcommissionersshareonly)therewillbeanunresolvedgapwhichwillneedtobeaddressedgoingforward.

Inthenexttwoyears,basedoncurrentNHSallocationprojectionssouthwestLondonislikelytoreceiveafurtherincreasetoitsfundingof£220millionby2020/21.However,basedonourcurrentestimateswethinkourcostsprovidingservicesoverthoseyearsarelikelytoincreaseby£422million.Thisisaresultof:

• Increasedactivityfromlocalpeopleneedinghealthservices

• Costincreasesduetoinflation

• Technologicalandmedicaladvancements-suchasnewdrugtherapiesandinnovativenewtreatmentsmeetingnewandbetterqualityofcarestandardsforourpatientsandtostrengthenclinicalsustainability


Investmentsinkeyserviceareassuchasurgentcare,mentalhealthandcancer

WearealsoreviewinghowotherfactorssuchasdeliveryofNHSnationalpolicies,removalofthe

publicsectorpaycap,theimpactoftheNovember2017Chancellor’sbudgetstatementtheimpactofBrexitonourworkforceandrisingcostsandinflationmayimpactonourfinancialpositiongoingforward.

Increasingfinancialchallengeofc£365millionby2020/21

Thetableaboveshowshowthegapbetweenincomeandexpendituregrowsiflocalprovidersandcommissionersdonotfindfinancialsavingsoverthenextfouryears.ThetableexcludesthechallengefacedbyspecialisedservicesinSouthWestLondonwhicharecommissionedbyNHSEngland.IntheoriginalSTPthiswascalculatedatrisingto£99millionby2020/21.

LocalAuthoritysocialcareinsouthwestLondonfacesanequallychallengingfinancialpositionasdemandfor,andcostsof,providingsocialcareservicesincreasesandgovernmentfundingdecreases.SouthwestLondonboroughsmade£250millionsavingstotheirsocialcarebudgetsbetween2011/12and2016/17andareestimatedtoneedtomakeafurther£163millionsavingsbetween2017/18and2020/21.

WhilesouthwestLondonhashistoricallymadesignificantsavingseachyear,werecognisethat

wewillneedtotakeadifferentapproachtodeliversavingsby:

• organisationsworkingmorecloselytogethertoavoidduplication:

• sharingback-officeservicestoreducecostswhereitmakesense

• organisationscomingtogethertobuyproductsandservicesmorecheaplytogether

• re-designingthewayweprovideclinicalcare,firstlytoimprovecareforpatientsandsecondlytoreducecosts

• reviewingwherehospitalscanworkclosertogethertoprovideclinicalservicesacrosssouthwestLondonmoreefficiently

• developingearlyinterventionandpreventioncaremodelstosupportpeopletoliveindependentlivesandreducetheirneedtoaccessservices

Underlying GAP % 6.5%GAP Increase % 2.2% 2.6% 2.6%

£billion

£2.6bn £2.6bn £2.7bn £2.8bn£2.7bn £2.8bn £3.0bn £3.2bn

2017/18 2018/19 2019/20 2020/21

Income Spend

£0.2bn £0.2bn £0.3bn £0.4bn

2017/18 2018/19 2019/20 2020/21

GAP


• usingnewtechnologytosupportself-careforthepopulation,newwaysforpatientsandserviceproviderstointeractandshareinformation,andforproviderstooperatemoreeffectively

• reviewingthebuildingsweuseandunder-useinthepublicsectortomakethemostofthebuildingsandmoneywehave

• takingwasteout,bydeveloping“lean”processestofree-upthetimeofourskilledhealthandcarestafftofocusonpatients

• developingnewworkforcemodelswhichmakesureourmostskilledhealthandcarestaffcanfocusonthepeoplewhohavethehighestneed

• lookingattheday-to-dayrunningcostsinallorganisationstomakesurewearemakingthebestuseofthemoneywehave

• comparingwhatwedoagainstlocalandnationalbestpracticetoseewherewecanimproveservicesandbecomemoreproductive

AspartoftheLocalTransformationBoardsLocalHealthandCarePlans,eachLocalTransformationBoardwillworkthroughthelocalfinancialpressures,ataboroughandwiderlevel,tounderstandthechallengesthesystemfacesandthelocalsolutionstoresolvethese.


Capital ThehealthandcareservicesacrosssouthwestLondonoperatefromanumberofdifferentsitesacrossLondonincludinghospitals,GPpractices,communityandcarefacilities.Eachofthesefacilitiesneedtobeaccessibletothepublic,safe,fitforpurposeforrunningtherequiredservicesandcosteffective.

EachindividualhealthandcareorganisationretainsresponsibilityformanagingthisbutwerecognisethatweneedtoworkbettertogetheracrosssouthwestLondontomakesurethatwemakemosteffectiveuseofourhealthandcareestate.

TheoriginalSTP(publishedinNovember2016)estimatedthatweneeded£1.3bntodeliverourplanstoimproveourbuildingsandestate.WearenowreviewingthisrequirementataLocalTransformationBoardlevelsothateachareacanreviewitscombinedorganisationalcapitalplansalongsideitsdevelopinghealthandcaremodels.Thiswilllookathowwecurrentlyuseourbuildingsagainstfuturerequirementsandseewhereweneedtoinvest,andequallywhereweareabletodisposeofbuildingstoprovidefundsforre-investmentinnewandupgradedfacilities.

Thiswillprovideuswithbroadtypesofcapitalexpenditure:

• Maintainingourexistingbuildingstoahighstandard

• Buildingnewfacilitiesoradaptingcurrentfacilitiestomeanwecanchangethewayweprovideorlocalservices

• MajortransformationalschemeswhichrequireawidersouthwestLondonorevenLondonperspective.Thetimescalesfordeliveryoftheseschemeswillbeafter2020butthepreparationandplanningworkneedstostartnow

WearedevelopingapipelineofschemesforsouthwestLondoninlinewithLocalTransformationBoardLocalHealthandCarePlans.Wethinkthatdoingthismayincreasetheidentifiedneedforcapital.Whilewewillreleasefundstosupportthisfromthesaleofunwantedbuildings,weknowthatthiswillnotbesufficienttomeetourcapitalfundingrequirements.Wewillthereforeneedtosecureadditionalcapitalfunding.WhiletherewillbesomeNHScapitalfundsavailable,inthecurrenteconomicclimatethesemaybelimitedandthereforealternativefundingsourceswillneedtobeexplored.

SouthwestLondonisplayingafullpartinthedevelopmentoftheLondonEstatesBoardwhichhasbeencreatedaspartoftheLondondevolutionprocessandwewillworkwiththeBoardtoidentifyandsecuretherequiredcapitalstreamstohelpusrealiseourwiderplans.


5. WORKING IN PARTNERSHIP The South West London Health and Care Partnership LocalNHSclinicalcommissioninggroups,providertrusts,localauthoritiesandpatientrepresentativesacrossSouthWestLondoncametogethertoformtheSouthWestLondonHealthandCarePartnership.

SouthWestLondon’sHealthandCarePartnersare:

• OursixClinicalCommissioningGroups(CCG)of:Croydon,Kingston,Merton,Richmond,SuttonandWandsworth

• OursixLocalAuthorities:Croydon,Kingston,Merton,Richmond,SuttonandWandsworth

• OurAcuteandCommunityProviders:CentralLondonCommunityHealthcare,CroydonHealthServicesNHSTrust,EpsomandStHelierUniversityHospitalsNHSTrust,HounslowandRichmondCommunityHealthcare,KingstonHospitalNHSFoundationTrust,TheRoyalMarsdenFoundationTrust,StGeorge’sNHSFoundationTrust,andYourHealthcare

• OurtwoMentalHealthProviders:SouthWestLondonandStGeorge’sMentalHealthNHSTrust,SouthLondonandtheMaudsleyNHSFoundationTrust

• TheGPFederationsineachofthesixboroughs

• TheLondonAmbulanceService

• Healthwatch

• OurHealthandSocialCarePartnershipworkstogetherinanumberofdifferentways:

• HealthandWellbeingBoardsineachboroughthataremadeupoflocalcouncillors,seniorclinicians,NHSandsocialcaremanagers,

publichealthexpertsandHealthwatch.Theirroleistoplanhowtomeettheneedsoflocalpeopleandtotackleinequalitiesinhealth.

• TheClinicalSenatethatismadeupofseniorCliniciansacrossallsouthwestLondonorganisations,andrepresentativesfromtheRoyalCollegeofNursing,theLocalMedicalCommittees,AlliedHealthProfessionals,NHSEnglandandthePatientsandPublicEngagementSteeringGroup.TheSenatehaveoversightoftheimplementationoftheSouthWestLondonclinicalmodel,driveforwardtheworkprogrammeforspecificclinicalpathwayswhichithasagreedshouldbeconsideredacrossSouthWestLondonaswellasadhocmattersinrelationtoclinicalmodels.

• FourLocalTransformationBoards(LTBs)inCroydon,MertonandWandsworth,KingstonandRichmondandSuttonthataremadeupofrepresentativesfromtheLocalNHS,LocalAuthorities,patientrepresentativesand,onsomethevoluntarysector.LTBsbringleadersoforganisationstogetherto:planhowbesttomeettheneedsoftheirlocalpopulation;andtransformhealthandcareservicestodeliverjoinedupservicesthatimprovecareandreducehealthinequalities.LTBswilldevelopLocalHealthandCarePlansforhealthandcareservicesintheirarea.Theseplanswillreflectandincorporateindividualboroughlevelplansfordelivery.

• LocalOverviewandScrutinyCommittees(OSCs)thataremadeupoflocalcouncillorstooverseeandscrutiniselocalhealthservicesonbehalfoftheelectorate.Wheremajorservicechangeisbeingconsidered,representativesof


eachOSCmayformaJointHealthoverviewandScrutinyCommitteecoveringmorethanoneborough.

• PatientandPublicEngagementSteeringGroupthatismadeupofHealthwatch,thevoluntarysectorandpatientrepresentativesfromeachborough,whoseroleistooverseeandadvisetheSouthWestLondonHealthandCarePartnershiponpatientandpublicengagement.

• Clinicalnetworksincludingurgentandemergencycare,cancer,mentalhealth,maternity,learningdisabilities,andplannedandprimarycare,thataremadeupoflocalclinicians,NHSandlocalauthoritymanagersandpatientrepresentatives.Theirroleistodevelopplansandproposalsfortheirclinicalarea,fordiscussionandagreementbyLocalTransformationBoardsandtheClinicalSenate.

Thediagrambelowsummarisesthegovernancearrangements:


6. SOCIAL CARE Adult Social Care AdultsocialcareisavitalpartofthesouthwestLondonhealthandcaresystemsupportingpeopletokeepwellandindependentintheirownhomesandcommunities.Itoffershelpandcaretopeoplewithawiderangeofneedsarisingfromage,disability,illnessorotherlifesituationshelpingthemtokeepwellandliveindependently,protectthemfromharmandprovideessentialhelpattimesofcrisis.In2015/16thesixsouthwestLondonboroughsprovidedlongandshorttermsupporttoover25,000peopleandspent£464milliononadultsocialcare.

Adultsocialcarefocusesonthewholepersonandtheiroveralllife,andenablestheirfamilysupportandcommunitynetworks.Itsupportscarersintheirveryimportantrolesotheycanlivetheirownlives,remainwellandavoidstressandcrisis.Itworkscloselywiththecommunityandvoluntarysectortosupportpeopletoliveintheirownhomesandbeactiveintheirowncommunities.

Byfocusingonprevention,providingearlyandshorttermsupportinpeople’sownhomesandcommunitiessocialcareisacriticalcomponentinmanagingthedemandforhospitalandNHSservices.Adultsocialcarealsoprovideslongtermsupportforsomeofourmostvulnerable

residentsenablingthemtolivefulfillingandasindependentlivesaspossibleintheircommunities.Ithelpspeopletonavigatethecomplexhealthcaresystemandaccesstheservicestheyneed-attherighttimeintherightplace.

Socialcareneedstobeattheheartofintegratedcommunitybasedhealthandsocialcare.IndevelopingLocalHealthandCarePlanslocalauthoritiesandtheNHSwillworkwiththeirvoluntaryandcommunitysectorpartnerstobuildthispartnershipandensurethatcontributionofsocialcareisfullyreflectedindevelopinghighqualityintegratedandholisticcommunitybasedhealthandsocialcaresupport.

Children Services TheabovefocussesonadultsocialcareandwewillworktogetherwithDirectorsofChildren’sServices,DirectorsofPublicHealthandother

partnerstoensurechildren’sneedsareaddressedindevelopingthelocalhealthandcareplans.


7. ONE YEAR ON: OUR PROGRESS SO FAR

The NHS and local authorities accross the six boroughs of South West London are working togther to improve care and support for all our residents.

This is a top priority as we know how important it is to see a GP quickly. We are investing to make it easier for you to see a GP quickly. If you need an appointment at short notice, you may not see your usual GP, but one as close to where you live as possible.

Extending GP hours from 8am – 8pm in every borough to ensure patients have access to an additional 15,000 appointments per month

Residents in Merton, Wandsworth, Kingston and Richmond can now pre-book appointments on line as well as by phone

Getting the right advice and care in an emergency really matters. We are working hard to get this right. Getting it right means fewer people, especially older residents, having an unplanned overnight stay in hospital when they don't need one.

Helping older people stay well in their own home In Sutton, if an older person has to go to hospital, they take a red bag with all their relevant information, medicines and personal belongings. This speeds up care, so they get off the ward and back home four days earlier on average.

More mental health support Investing in a 24/7 safe house to look after people suffering a mental health crisis in Kingston and Richmond has meant nine out of ten visitors return home without needing to stay in hospital. Every hospital in SW London now has 24/7 psychiatric support in place.

Here’s an update on our progress in 2016/17

Making it easier to see a GP

Better urgent and emergency care

111 has more doctors and nurses at the end of the

phone to give advice

Expert clinicians on hand for care homes and ambulance crews to get the right care for older

residents

Did you know? - SW London has the best

ambulance response times in London for the most

serious calls

4days

Get home

sooner

Personal independence co-ordinators providing support for older people with long term health conditions in Croydon, as part of a partnership between Age UK, local GPs, the NHS and Croydon Council.

Teams of doctors, nurses, mental health experts and therapists across Merton and Wandsworth working together to respond rapidly when older people are taken ill – and to help them to be treated in their own home when possible

An additional

£400,000 of funding for NHS 111, with

more doctors and nurses available to give advice to patients, care homes and

the ambulance service over the phone


8. WHAT LOCAL PEOPLE HAVE TOLD US ABOUT OUR SERVICE

Itisessentialthattheviewsandexperiencesoflocalpeopleareattheheartofourplans,drivingforwardthechangesneededtoimprovelocalservices.Webelieveinon-goingconversationsandmakingsurethattheneedsoflocalpeoplearecentraltowhatwedo.Nobodyknowsmoreabouthowwecanmakethingsbetterthanthepeoplewhouseourservices.

Overthelastyearwehavespokentoover5000localpeople,includingthosewholessoftensharetheirviewsaboutourplansandtheirexperiencesofservices.Weranapubliceventineachboroughwhichwasopentomembersofthepublic,aswellasrunninganextensiveprogrammeofgrassrootsoutreachworkdeliveredinpartnershipwithlocalHealthwatchorganisations.Theseeventsallowedustohavein-depthconversationsandthefeedbackhasbeenindependentlyanalysed,writtenupandpublishedonourwebsite.Thisfeedbackhasbeenintegraltoshapingthisdiscussiondocument.Wehavesummarisedtheheadlinefindingsbelow,butmoredetailcanbefoundthroughoutthisdocumentandinappendix3.

Overarching themes Severalcommonissuesemergedwhicharecommonacrossworkstreamsandlocalareas:

• Concernsaboutaperceivedlackoffundingandresourcestoinvestinservicechanges,particularlyinthelightoflocalservicesalreadybeingchanged.

• Capacityconcernsthatthecurrentlocalserviceswouldnothavethecapacitytotake

• onadditionalworkinordertoreducetheburdenonhospitalservices.

• Improvingandincreasingsignpostingtoservicestomakethepublicawareofservicesinthearea,aswellaseducatingpeopleabouthealthcarechoices.Anddifficultyinchangingbehaviourofthepublicandstaff.

• Concernsoverqualityofservicesandofequalityinaccessingtheseservices.

• Theneedtoimprovestaffcommunicationskillssothatpatientsandcarersaretreatedwithempathyandrespect,especiallythosewithcomplexoradditionalneeds.

• Theneedformorejoined-upITsystemstoaidcommunicationbetweenservicesandavoidpatientshavingtorepeatthemselves.

Work stream specific themes Sevendayhospitalservices-WhilepeopleagreedwiththeaimtoreducethenumberofpatientsusingAccidentandEmergency(A&E),therewereconcernsaboutwhatalternativeswouldbeavailable.TherewaslowawarenessofNHS111,andthosewhowerefamiliarwithitwerenotconfidentitwouldreducedemandonA&E.ItwasalsofeltthatGPaccesswasasignificantissue,andpotentiallydrivingperceivedmisuseofA&E.

Somefeltexistingurgentandemergencycareandacuteservicesneedtobeimprovedtoensuretheyareinclusiveandmeettheneedsofdiverseusers.Therewereconcernsaboutmentalhealth


crisiscare,andlackofmentalhealthawarenessinA&E.

Morecareclosertohome-Overall,whiletheideaofhavingmorecareclosertohomewassupportedquestionswereraisedaboutthefeasibilityofextendingout-of-hospitalservices,whentherearealreadyinsufficientstafftocoverthecurrentprovision(especiallyGPs).PeoplegaveexamplesofdifficultiesgettingappointmentsandwiththeaccessibilityofGPservices.Also,peopleoftenfeltthatreceptionistswereputinthepositontobegatekeepers.

Theintroductionofnewrolessuchascarenavigatorswerepositivelyreceivedbutmanywantedmoredetailabouthowtheseteamswouldsupportlocalpatientcareinpractice.

Preventionandearlyintervention-Mostpeople,althoughtheysupportedtheincreasedfocusonprevention,thoughtitwouldbechallengingtoachieve.Specifically,theyfeltitwouldbeunder-resourced.Peopleemphasisedthatcommunicationiskeytoensuringchangeinbehaviourforprevention,andparticipantsagreedtheNHSmustimproveitsoutreachandlinkswiththevoluntaryandcommunitysectorforthistobesuccessful.

Mentalhealth-Overall,therewaslowconfidenceincurrentmentalhealthservicesduetoperceptionsofpoorquality,closures,longwaitingtimes,underfundingandinabilitytocope.Peoplesupportedaholisticapproach,incorporatingphysicalconditionsandcoordinatingwithmultipleorganisations,butquestionedhowthiswouldworkinpractice.ItwasfeltthatsignificantinvestmentintrainingandadditionalskillswouldbeneededforGPs.Therewasaconsistentviewthatthereneedstobe24/7crisissupportforpeoplewithmentalhealthconditionsandtheirfamilies.

Learningdisabilities–Peoplefeltthatthereshouldbemoreawarenessofannualhealthchecksforchildrenwithlearningdisabilities,includingremindersfromtheGPsurgery,andthatpeopleshouldbeofferedlongerappointmenttimesifnecessary.Itwasstronglyfeltthatstaffneedtocommunicatemoreclearlywiththosewithlearningdisabilities,andinvolvethemintheircare(notjusttheircarers).

Children’sservices–OverallitasfeltthattheNHSneedstopromoteawarenessandsignpostingtoavailableservices.Therewasalsoadesireformoreeducationandinformationtosupporthealthylifestylesforchildrenandfamilies–bothinsideandoutsideschool.Peoplebelievedthattoreducetheburdenonhospitalservices,moreflexibleGPservicesareneeded.

Maternityservices–Peoplewereconcernedabouttheshortageofmidwives–particularlyasmanysawthebenefitsinhavingaconsistentpointofcontactthroughtheirmaternityjourney.Post-natalcarewashighlightedasaservicethatrequiredimprovement.Communicationandattitudesofstaffwereseenasvariableandinneedofimprovementinordertoadequatelysupportwomengivingbirthandtheirfamilies.

Cancercare–Peoplefeltmoreworkcouldbedonetoincreaseuptakeofscreening,andtoincreasepreventativecareandguidancetothoseathigherriskofcancer.Itwasfeltthatdeliveringnewsofadiagnosisshouldbedeliveredwithempathyandsensitivity.TherewasadesireforNHSsouthwestLondontosetthe‘goldstandard’forcancerdiagnosis,treatmentandcare,includingbeingproactivelyinvolvedintrialsandnewtreatments.

Plannedcare–Peoplefeltthattheyweremorepreparedtotravelfornon-urgentelectivecare,buthighlightedthatensuringappropriatetransportationwouldbeimportant.Itwasfeltthat


thereisscopeforcurrentpracticesarounddischargeandaftercaretobeimproved.Manypeoplenotedthereshouldbeimprovedinternalandexternalcommunicationbetweenservices,includingGPs,hospitalsandsocialcareproviders.

Local Transformation Board Area specific issues ManyoftheissuesraisedwerecommonacrosssouthwestLondon.ThefeedbackbelowhighlightsspecificcommentsorperceptionsthatwerefeltmorestronglyineachLTBarea.

CroydonLocalTransformationBoardArea-Therewasafeelingthat,inCroydon,localcircumstancesexacerbateaneedforchangestothehealthservice(e.g.Croydonhasalargeanddiversepopulation).Therewasalsoafeelingthattheplanswerenotrealisticinthecontextoftheresourcesavailable.Concernswereraisedaroundmentalhealthservices,ofnoteinsufficientcapacityinImprovingAccesstoPsychologicalTherapiescurrentlyleadingtolongwaitingtimesand,morebroadly,thelocalboroughnotreceivingtheir‘fairshare’offundingforMentalHealthservices.Itwasfeltthatchildren,particularly,benefitfromseeingthesamehealthcareprofessionalandthatthisisoftencompromisedasthereisahighstaffturnover(forexampleinoccupationaltherapy).Itwasfeltthattherewasmorescopetoencouragechildrentohavehealthierlifestylesbothinandoutofschool.OveralltherewasageneralconsensusthatCroydonUniversityHospitalhadimproved.

KingstonandRichmondLocalTransformationBoardArea–OverallpeoplefeltthattheSTPpublishedin2016wastoohighlevelandaspirational,theywantedtoseemoredetailed

plans,figures,modellingandtimelines.TherewereconcernsaroundmoneyandhowtheNHSwouldbalancefundsbetweenhealthandsocialcare.Peoplefeltthatpublichealthandeducatingandinformingthepublicwasveryimportantinordertosupportthepreventionagenda,includingfurtherworkingwiththevoluntarycommunitysectorandincreasingtheuseoftechnology.Peopleweremoreconfidentinpharmacists,thaninotherareas,butfeltthatinordertoreducetheburdenonGPservices,pharmacistswouldneedtoreceivefurthertrainingandadapttheirservices.

MertonandWandsworthLocalTransformationBoardArea-ThreediscussiontopicswereverypopularinMertonandWandsworth:careclosertohome,preventionandearlyintervention,andmentalhealth.Formanypeople,theirprimaryconcernwasuncertaintyinNHSfunding.OtherswereconcernedabouthowstaffwouldbeattractedandretainedespeciallyinlightofupcomingchangessuchasBrexitandtheriseoflivingcostsinLondon.Concernswereraisedaboutthehospitalbedreductiontargetsandhowthesewouldbeachieved.Peoplesupportedtheideaofencouragingindividualstotakemoreresponsibilityfortheirownhealthandlifestylesbutemphasisedthatacultureshiftisrequiredforthistobesuccessful.

SuttonLocalTransformationBoardArea–OverallpeoplefeltthatproblemswithcapacityarelikelytobeexacerbatedbyagrowingpopulationinSutton.TherewerelocalconcernsthatthereisinsufficientcapacityinA&Eandthatanymovetoreduceserviceswouldexacerbatewaitingtimes.Peoplesuggested,thatinsteadoftryingtochangeA&Eandhowitisused,itwouldbeworthconsideringco-locatingGPsandsocialcarethere.TherewasstrongsupportforStHelierHospitalalthoughsomeconcernsaboutcommunication


withinStHelier,andbetweenStHelierandotherorganisations.TherewasscepticismaboutalternativestoseeingaGPorattendingA&E,withmanypeoplefeelingthattheywouldnotgotoapharmacistasafirstchoiceforcare.TherewassupportforlocalGPswithmanysharingtheirpositiveexperiences.Peoplewereworriedthat

despiteanidentifiedneedtoaddressmentalhealthmoreholistically,severalmentalhealthcentresintheSuttonareahaveclosedandconcernswereraisedastherewasn’talocalmentalhealthcrisiscentre.PraisewasgivenforSouthWestLondonElectiveOrthopaedicCentre.


9. OUR HEALTH AND CARE PARTNERSHIP COMMITMENTS

Overall, the South West London Health and Care Partnership are committed to delivering joined-up services for local people and through this improving their health and care. Specifically over the next two years we will focus our joint efforts on the following:

We will strengthen our focus on prevention and on keeping people well, and will take into account that the greatest influences on people’s health and wellbeing are factors such as education, employment, housing, healthy habits and social connections

We are committed to improving services for people when they are at their sickest and are in need of urgent or emergency care ensuring that, for those with non-life threatening but urgent needs, they are treated as close to home as possible, and for those with more serious or emergency needs that they are treated in centres with the very best expertise and facilities, in order to maximise their chances of survival and a good recovery.

We are committed to using technology to be the “electronic glue” which helps health and care organisations work better together, enables our frontline staff to provide the best care possible and enables people to make the best lifestyle and health choices

ABOVE ALL… The Health and Care Partnership are committed to working together to improve health and care services and outcomes for people in South West London, and to ensuring that our organisational boundaries do not get in the way of providing the very best care for local people.

We are committed to ensuring that general practice is accessible and co-ordinated with community and social care services. This will mean people receiving the right care closer to home, so that they can live healthy and independent lives for as long as possible.

Prevention

Urgent and Emergency Care

Harnessing technology

Primary Care

We are committed to making South West London a great place to work so that we attract and keep our excellent staff Workforce

We are committed to improving how we prevent, support and care for people experiencing mental health problems and make sure we treat their physical and mental health together

Mental health

We are committed to transforming services for people with learning disabilities and/or autism so that they are supported in the community to live fulfilling and independent lives

Learning Disabilities and/or Autism

Buildings and estate We are committed to improving our buildings so that we can deliver high quality care from all south west London sites

Maternity We are committed to improving maternity services so that women have choice about where to have their baby, that every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances

Cancer We are committed to improving cancer survival rates, ensuring that more people are diagnosed and treated earlier and that we provide the highest quality of care and support for people living with and beyond cancer

Hospital, Specialist and Community

We are committed to continuously improving the standards of care in hospital, specialist and community settings and to reducing inappropriate variation in care across south west London

Money We are committed to being efficient, using our money wisely and making sure that we get best value from every public sector pound

We are committed to helping children have the best start in life and to supporting children as they develop into adults Children and young

people


10. LOCAL TRANSFORMATION BOARDS: A LOCAL FOCUS ON IMPROVEMENT

Wefirmlybelievethatfortransformationandimprovementtobesuccessfulitneedstobelocal,respondingtolocalneeds,issuesandcontext.So,inearly2017wesetupfourLocalTransformationBoards(LTBs).

ThefourLocalTransformationBoardsinSouthWestLondonare:

• Croydon

• MertonandWandsworth

• KingstonandRichmond

• Sutton

MadeupofrepresentativesfromtheLocalNHS,LocalAuthorities,patientrepresentativesand,onsomethevoluntarysector,LTBsbringleadersoflocalhealthandcareorganisationstogetherto:planhowbesttomeettheneedsoftheirlocalpopulation;andtransformhealthandcareservicestodeliverjoinedupservicesthatimprovecareandreducehealthinequalities.

Thisdocumentidentifiesanumberofchallengesforthelocalhealthandcaresystems.BetweenDecember2017andJune2018,LTBswilldrawupLocalHealthandCarePlans.LocalHealthandCareplanswilloutline:

• TheLTB’svisionforhealthandcarelocally

• Theirmodelforhealthandcarelocally

• Theirlocalcontextandthechallengestheyface,includinganyfinancialandclinicalsustainabilityissues

• Theirplantoimprovehealthinequalitiesinordertoaddressthewiderdeterminantsofhealth(Healthinequalitiesaresystematic,avoidableandunjustdifferencesinhealthandwellbeingbetweengroupsofpeople)

• Theirpriorities,actionsandfocustomeetthehealthandcareneedsoftheirlocalpopulationandplanstoaddressanyfinancialandclinicalsustainabilityissues.ServicesaredeliveredandmanagedatdifferentscalesacrosssouthwestLondonandLTBswillworktogethertoidentifythebestscaletodevelopourplans.

• Whatwillbedifferentforlocalpeopleintwoyears’time(measurableoutcomes)

• WhereLTBscovermorethanoneborough,individualLocalBoroughHealthandCarePlans(thatwillbenamedbylocalareas)willbewrittensothatboroughlevelissues,prioritiesandplansareidentified.BoroughlevelLocalBoroughHealthandCarePlanswillthenbebroughttogethertocreatetheLTB’soverarchingHealthandCareplan.


11. LOCAL TRANSFORMATION BOARDS IN FOCUS


Croydon Local Transformation Board Our joint vision Wehaveaclearvisioninthat:

• Wewantpeopletolivelonger,healthierlives

• WewanttoreducehealthinequalitiesandimprovehealthoutcomesforCroydonpeople

• Wewillsupportlocalpeopletolookafterthemselvesandthosetheycarefor

• Wewillmakesurelocalpeoplehaveaccesstohighquality,joinedupphysicalandmentalhealthandcareserviceswhenandwheretheyneedthem

• WemustdothiswithintheresourcesavailabletousforthepopulationofCroydon.

Indeliveringthisvisionwerecognisethat,atthesametime,weneedtoworkwithinthecontextofagrowingandanageingCroydonpopulation.Thismeansthat,whileaveragelifeexpectancyincreases,thehealthandcaresystemneedstosupportindividualsandcommunitiestobeashealthyandindependentastheycanbe,ifwearetoensurethatincreaseddemandforcarecanbemetwithintheresourcesavailabletous.WealsoknowthatwithinourCroydonpopulationawiderangeofhealthinequalitiesalreadyexistsandthat

theboroughisbecomingincreasinglydiverse,sochangingthehealthneedsofpeopleintheborough.Variationalsoexistsinthequalityandperformanceofourservices,leadingtovaryingexperiencesofcareandoutcomesforpeople.AlloftheseissuesestablishthecontextwithinwhichwewishtotransformservicestobebetterabletosupportCroydonpeople.

WewillachieveourvisioninCroydonby:

• Joiningupcareseamlesslyaroundtheneedsoftheindividual

• Transformingandjoininguphealthandsocialcareacrossprimary,communityandhospitalsettingstoprovideproactive,safeandhighqualitycareforalllocalpeople

• Supportingpeopletolivehealthyandindependentlives

• Workinginpartnershipacrossorganisationalboundaries,acrossboththestatutoryandvoluntarysector

• Exploringinnovativeandradicalwaysofworkingtoplanforthefuture

Our model for health and care Health,socialcareandvoluntarysectorpartnersareworkingtogethertoachieveamorepersonalisedandjoined-upapproachtohealthandcareservicesforthepeopleofCroydon.

Croydon’sOutcomes-BasedCommissioningprogramme(OBC)isaradicallydifferentapproachtothefundinganddeliveryofservicesdesignedtogetthebestvalueoutofthehealthandcare

sectorsinCroydon,whilstdeliveringtheoutcomeslocalpeoplewant.

Thenewwayofworkingisaresultofanallianceagreementbetweensixorganisationsintheborough–CroydonClinicalCommissioningGroup(CCG),CroydonCouncil,CroydonGPCollaborative,CroydonHealthServicesNHSTrust,


theSouthLondonandMaudsleyNHSFoundationTrustandAgeUKCroydon.

Thepartnershipwillmeanasingle,joined-upserviceforpeopleover65needinghealthandsocialcaresupport,fromhelpwithleadingahealthierlifestylethroughtoavoidingunnecessaryhospitalstaysandsupportingpeopleintheirownhomesandcommunity.

Themainprincipleistomovetowardsfundingpeople’scarebasedonthedeliveryofsuccessfuloutcomes,helpingthemtolivemoreindependentandactivelivesforaslongaspossible.

Thelaunchfollowsengagementwiththelocalover-65communityduringwhichtheyidentified

thosethingsthatmatteredmosttothem,fromstayingindependenttoreceivingtailoredsupport.

Weaimtoextendthismodelandapproachbeyondtheover65stoencompassservicesforthewholeoftheCroydonpopulation,includingchildrenandfamilies,workingageadultsandpeoplewithdisabilities,includingseriousmentalillness.

Thisallianceofcommissionersandprovidersfromhealth,socialcareandthethirdsectorinCroydonisbeingcalledOneCroydon.EachorganisationhasitsowncultureandhistorybutweshareacommongoaltoimproveoutcomesforpeopleinCroydon.

Vision:‘Workingtogethertohelpyoulivethelifeyouwant’

OneCroydonalliancepartnersarecomingtogethertodeliverasharedvisionwithasinglesetofoutcomesoperatingfromonebudget.

ProblemTitle

• Accesstodecisionmakingtools• Improvedpersonalactivation• Singlecommunicationchannel• Regardedasacommunityasset• Seamlesssystemnavigation

TheCroydonWay

• Peertopeersupport/buddies• Vibrantvolunteersector• Assetbaseddevelopment• Socialprescribing• Timebanking• Communityvolunteeringactivities• Communitybuilders

Resilientcommunities

• Betterconnectedthroughtechnology.• Oneteam,onebudgetapproach.• GPnetworkbaseddeliverymodel• Groupcoaching/consultation• Coachingandconversations• Preventativetele-consultations• Integratedtraininganddevelopment

Primary,community&socialcare• Alignedbehaviours• Transfersofcare(notdicharge)• Communityfacing• Digitalconnectivity

Hospital

Inspiringbehaviour changeandempoweringindividualstotakebettercontroloftheirhealthandwellness.

TheCroydonWay

Buildingcommunityresources&assetsasastrong,complimentaryresource:

Resiliencecommunities

Workingtogetherasonetode–medicalise themodelofcare,takingapersoncentred approach.

Primary,community&socialcare

Achangedlandscape.

TheCroydonWay

• Iwanttostayhealthandactiveforaslongaspossible.• Iwanttobesupportedasanindividualwithservicesspecifictome.• Iwantsupportfrompeoplewiththerighttrainingandknowledge.• Iwantaccesstothequalityofcarethatallowsmetostayindependent.• Iwantgoodclinicaloutcomes.

What’sinitforme?


Our health and care partners • CroydonClinicalCommissioningGroup• CroydonCouncil• CroydonGPCollaborative• CroydonHealthServicesNHSTrust• SouthLondonandtheMaudsleyNHS

FoundationTrust

• HealthwatchCroydonAgeUKisalsoapartneroftheCroydonHealthandCareAllianceBoardandtheAllianceagreementforOneCroydon.

Our context and challenges • SignificantpopulationgrowthOverthenext

fiveyears,Croydon’spopulationisexpectedtogrowby6%,fromapproximately380,500in2015to403,500by2022,

• Deprivation:Croydonisthe17thmostdeprivedboroughinLondonoutof33.10,261ofCroydonresidentsliveinthe10%mostdeprivedareasinthecountry.ThewardsofNewAddington,FieldwayandBroadGreenarethemostdeprivedwardsinCroydon.

• Ethnicdiversity:OverhalfoftheCroydonpopulationarenon-WhiteBritish.Thisfigurerisesto62.9%fortheunder18population.Amorediversepopulationleadstomorediversehealthneeds.

• Inequalityinlifeexpectancy:InthemostdeprivedareasofCroydon,lifeexpectancyissignificantlylowerthanfortheleastdeprivedareas:

• 9.7yearslowerformenat75yearsoldratherthan84yearsoldformen;and

• 6.1yearslowerforwomenat80yearsoldratherthan86

• Obesity

• DiabetesCroydonhasahigherprevalenceofpeoplewithdiabetesthanLondon.

• Smoking:SmokingprevalenceinCroydonislowerthanthenationalaverage.JustoveroneineightadultsinCroydonsmoke,whichislowerthanthenationalaverageofaroundoneinfive.

• HealthScreening:Breastandcervicalcancerscreeningratesarebothsignificantlylowerthanthenationalaveragewhichcanleadtoworseoutcomesifcancersarenotdetectedatanearlystage.


• TheprevalenceofseverementalillnessinCroydonissignificantlyhigherthanthenationalaverage,butsimilartoLondon.Admissionsformentalhealthconditionsforunder18sishigherthanLondonandnationalaverages.

• Employment:Croydon’sunemploymentrateis5.2%,whichisthe15thlowestrateinLondon.ThemediangrosspayinCroydonis£602.80

perweekwhichisthe11thlowestinLondon(AnnualSurveyofHoursandEarnings,2016).

• Housing:InCroydon,inJune2017therewere2,406householdsintemporaryaccommodation,whichisthe8thhighestboroughinLondon.

• SocialIsolation:Lonelinesscanhaveseriousconsequencesformentalandphysicalhealth.Itislinkedtoobesity,smoking,substanceabuse,depressionandpoorimmunity.

Care and quality challenges • LondonQualityStandardsweredevelopedto

addressvariationsfoundinservicearrangementsandpatientoutcomesbetweenandwithinhospitals,andbetweenweekdaysandweekends.ThestandardsrepresenttheminimumqualityofcarethatpatientsshouldexpecttoreceiveineveryacutehospitalinLondon.Ofthe172applicableLondonQualityStandards,CroydonHealthServicesmet99standardsanddidnotmeet61standardsin2016.

• CroydonCounciltookimmediateactiontoimproveitsChildren’sServicesafteranOfstedinspectionratedsomeareasoftheserviceinadequateearlierthisyear.Thecouncilacceptedthefindingsandisworkingwith

Ofstedtomakethenecessarychangesneededtodeliverbetterservicesforchildrenandyoungpeopleintheborough.Thecouncilisaddressingalltheissuesraisedasapriority.Ithasalreadyinvestedfurtherfundingtohelpsupportandmoderniseworkingpracticesforallitschildren’ssocialworkersandfrontlinestaff.

• AcrossGPpracticesthereareanumberofvariationsinqualityandperformance,includingratesfordiagnosisandreferrals,whichleadstoavaryingexperienceofcareandoutcomesforpeopleacrosstheborough.

• NHSRightCareisanationalNHSEngland-supportedprogrammecommittedto


deliveringthebestcaretopatients,makingtheNHS’smoneygoasfaraspossibleandimprovingpatientoutcomes.Aspartofthis,CroydonCCGhasbeenbenchmarkedagainstsimilarCCGsacrossthecountryfordifferentserviceareas.Throughthiswefoundthat18%ofinpatientswithdementiacouldhaveavoidedadmissiontohospitalandafurther39%couldhavebenefittedfrombeingdischargedhomeearlier.WehavesinceincreasedpostdementiadiagnosissupportintheboroughthroughinvestmentinanOlderAdultHomeTreatmentTeam.Thisteamworkswiththosewhoareacutelyunwelltoavoidinpatientadmissionsaswellassupportingthemtobedischargedearlier.

• 44%ofthehospitalspendisonpatientsattendinghospitalsoutsideofCroydon.We

believethatatleast17%ofthiscouldberepatriatedtoCroydonHealthServicessothatpatientsaretreatedclosertohomeandthelocalhospitaltrustcanbecomemorefinanciallysustainable.

• Independenceandindependentliving.

• Patientslivingathome:Thepercentageofolderpeoplestillathome91daysafterdischargefromhospitalintore-ablementandrehabilitationservicesdecreasedby3%to84.7%in2015/16andisbelowtheLondonaverageof85.4%.

• Socialcare-relatedqualityoflifePeoplereportedqualityoflifescorein2015/16was18.6comparedto18.4thepreviousyearandthenationalaverageof19.1.

Patient experience Analysisofusersurveyssuggeststhatreportedsatisfactionwithservicesisagoodpredictoroftheoverallexperienceofservicesandquality

• AccesstoGPservices:PatientexperiencefeedbackforhoweasyitistogetanappointmentwiththeirGPhasrisenbyhalfapercentto72.3%in2015/16.However,itremainsslightlybelowthenationalaverageof73.4%.

• Communitymentalhealth:Patientexperiencehasfallenduring2014fromascoreof8.75to7outof10.Thecommunitymentalhealthoverallpatientexperiencescoreisacombinedscoreincludingaccessandwaitingandsafe,highquality,coordinatedservices.

• Hospitalcareforinpatients:Patientexperiencehasimprovedfor2016/17to71.8%from70.6%.Itishoweverbelowthe


nationalaverage76.7%.Inpatientoverallpatientexperiencescoreisacombinedscoreforareasincludingaccessandwaiting,clean,friendlycomfortableplacetobeandsafe,highquality,coordinatedservices.

• Carerwithsocialservices:Satisfactionin2014/15hasfallenfromtheprevioussurvey25.5%from29.2%andremainsbelowthenationalaverageof41.2%.Thismeasuresthesatisfactionwithservicesofcarersofpeople

usingadultsocialcare,whichisdirectlylinkedtoapositiveexperienceofcareandsupport.

• Peoplewhouseserviceswiththeircarerandsupport:Satisfactionhasfallento53.2%in2015/16from59%thepreviousyear.Itremainsbelowthenationalaverage64.4%.Thismeasuresthesatisfactionwithservicesofpeopleusingadultsocialcarewhichisdirectlylinkedtoapositiveexperienceofcareandsupport.


Size and shape of health and care services

NHSCroydonCCGisresponsibleforthelocalNHScommissioningbudgetofaround£489million.Thereare57GPpracticesintheboroughdividedintosixLocalities–Mayday,ThorntonHeath,WoodsideandShirley,NewAddingtonandSelsdon,PurleyandEastCroydon.Whilehavingarangeofsinglehandedpracticesandsomechallengingestatesissues,82%ofpatientssurveyedratedtheirexperienceoftheirGPsurgeryasfairlyorverygoodinthisyear’sGPpatientsurvey.

Thereisan‘extendedhours’serviceinplace,meaningthatpatientscanbooktoseeaGPbetween8amand8pm,sevendaysaweek,attwohubsintheborough.TheextendedhoursprimarycareserviceisprovidedbyCroydonGPCollaborative,afederationofGPpracticesintheborough.

Residentsareservedbyonemainacutetrust,CroydonHealthServicesNHSTrust,whichalsoprovidescommunityservicesfortheborough.PatientsrequiringspecialistacutecareincludingstrokeandtraumaservicesaremainlytreatedattertiarycarecentressuchasStGeorge’sUniversityHospitalsNHSFoundationTrustinTooting,Guy'sandStThomas'NHSFoundationTrustincentralLondonandKing'sCollegeHospitalNHSFoundationTrustbasedinCamberwell.CommunityandacutementalhealthservicesareprovidedbytheSouthLondonandtheMaudsleyNHSFoundationTrust.

LocalandspecialistcancerservicesareprovidedbytheRoyalMarsdenNHSFoundationTrust.TheCCGalsocommissionsservicesfromarangeoflocalvoluntaryandthirdsectorproviders.


Service quality

InOctober2017,theSouthWestLondonClinicalSenateagreedasetofclinicalstandardsforsixclinicalservicesinhospitals:emergencydepartment;acutemedicine;paediatrics;emergencygeneralsurgery;obstetrics;andintensivecare.MedicalDirectorsfromeachHospitalTrustwerethenaskedtoself-assesstheirservicesagainsttheagreedclinicalstandardsseeappendix1.Thisevaluationprovidedanassessmentofcurrentconsultantstaffingagainsttheclinicalstandardsfortheseagreedsixcorehospitalservices.

Theevaluationhighlightedthat,CroydonUniversityHospitalisclinicallysustainableinthosesixcoreservices,inregardtoconsultantstaffing.Theevaluationshowedthattherearegapscurrentlyinanumberofthesixcoreservices,butthatthesearerelativelysmallandbeingmanagedbytheTrustthroughadedicatedcommitmenttoongoingrecruitmentandretentionefforts,andsupportedthroughtheuseoflocumstaffing.Withitsknowledgeoflocalservicesandwiderstaffingissues,CroydonHealthServicesNHSTrustisconfidentthatitcanrecruitthenecessaryadditionalconsultantsandthattheyarethereforeclinicallysustainableinthesixcorehospitalservices.Acopyofthefullevaluationsummaryisgiveninappendix2.

TheCroydonLocalTransformationBoardwillcontinuallyevaluatethequalityofservicesacrosscommunity,primarycare,mentalhealthandhospitalservices.

Our progress one year on

OverrecentyearsCroydonhasbeenonajourney,withlocalpartners,totransformarangeof

servicesthatwillleadtomoreeffectiveandsustainablehealthandcareservicesthataddresstheneedsofCroydonresidentsmoreproactively,improvetheirexperienceofcareandsupportandaddresscarequality.Animportantelementofthisissupportingpeopletobettermanagetheirhealthrisksandtheimpactoftheiridentifiedhealthconditionsandinsodoingsupportthemtoremainindependentandintheirownhomes.

Ourtransformationprogrammeshaveincludedoutcomes-basedcommissioningfortheover65s,enhancedcommunity-basedservices,includinginGPpractices,forpeoplelivingwithlongtermhealthconditions,servicesforchildren,youngpeopleandfamilies,bettersupporttopeoplelivingwithmentalhealthconditions,andforthosepeopleneedingcareurgentlybetterandfasteraccesstolocalservices.

Ourapproachtoredesigningservicesistomakethemmoreeffectiveandimplementnew,innovativeservices,thusbetterintegratingcareintothesystemandimprovingservicesforlocalpeoplewhilstalsotacklingourresourcechallenges.


Hospital services • Wehavereducedunnecessaryreferralsto

hospitalby9%andoutpatientattendancesby7.9%

• Wehaveseenareductionof3.2%innon-electiveactivityanda6.9%reductioninA&EattendancesforpatientswhocouldbebettertreatedbytheirGPoratoneoftheborough’snewGPhubs

Mental health services • Wehavereducedtheaveragelengthofstay

forCroydonpatientsinamentalhealthbedfrom58to35days,supportingpeopletogohomeearlier

• Wehavereducedthenumberofdelayeddischargesfromapeakof22toseveninNovember2017

• Wehavereducedthenumberofpatientsinoutofboroughbedsfromapeakof36tozeroinNovember2017

Primary care GP access • Wehaveincreasedaccesstoprimarycare

throughthenewurgentcareGPhubsinPurley,NewAddingtonandEastCroydonwhichopenedinApril2017andprovidesamedaypre-bookableandwalk-inaccessforpatients8amtill8pm,sevendaysaweek.

• WehaveimprovedpatientreportedaccesstoGPs

Herearesomeoftheschemeswehavesuccessfullyimplementedduring2016/17:

• Prevention,sharedcareandshareddecisionmaking

• WehaveimplementedatrainingprogrammeacrossallCroydon’sGPpracticestosupportclinicianstodelivershareddecisionmaking.Shareddecisionmakingiswhenhealthprofessionalsandpatientsworktogether.Thisputspeopleatthecentreofdecisionsabouttheirowntreatmentandcare.

• Outcomes-basedcommissioning

• Wehavedevelopedsixintegratedcommunitynetworks,onearoundeachofourexistingGPnetworks.Anintegratedcommunitynetworkisateamofhealthandsocialcarepractitionerswhoworktogetherinajoinedupwaytosupportpatientsandserviceuserswiththegreatestneedsormostcomplexclinicalorsocialproblems.Thenetworksaimtosupportindividualstomanagetheirowncare,helpthempreventillnessandpromoteindependence.Professionalshaveregular“huddles”inGPpracticestotalkabouthowtobestsupportpatientswiththegreatestneeds.

• WenowhavesixPersonalIndependenceCoordinators(PICs)workingintheboroughtosupportelderlypeoplewithchroniclong-termillnesseswhohavebeenhospitalisedinthepastyear.PICsmakehomevisitsandprovidethelinkbetweenvariousagenciesaswellasofferingisolatedpeopleaccesstocommunitygroupsandvolunteeringopportunities.ThePICProgrammeisajointinitiativebetweentheNHS,CroydonCouncilandAgeUKCroydonsignallingashifttowardsofferingmorecareclosertopeople’s


homes.GPsinitiallyidentifytheirmost‘atrisk’patientsandlaterusetheinformationgatheredbythePICstogainabetterunderstandingofpatients’circumstances.EachPICworkswiththreeGPsurgeriesandweplantorollthisouttothewholeboroughoverthenextsixmonths.

• LivingIndependentlyforEveryone,(LIFE),isanintegratedservicethatbringstogetherintermediatecareandrehabilitationservicesfromacrosshealth,socialcareandthevoluntaryandprivatesector.LIFEaimstoreducehospitaladmissionsandcarehomeplacementsaswellashelpingsupportpeopletoreturnhomequicklyandsafely.

• Urgentandemergencycaresystem

• PeopleinCroydonnowhaveaccesstoawiderangeofurgentcareservices,includingGPappointmentsavailablefrom8amto8pm,sevendaysaweek.Three'GPHubs'openedinApril2017acrosstheboroughtotreatchildrenandadultswithurgentcareneeds.ThishascontributedtoCHS’sA&Ehavingachieved90%targetandaboveforpatientsbeingseenwithinfourhoursofarrivalsinceSeptember2017.

• GPhubsarebecomingmoreandmorepopularasthepublicbecomemoreawareoftheirservices,witha37%increaseinthenumberofvisitorssincetheyfirstopenedinApril2017.CroydonnowhasanintegratedambulatorycareservicewhichallowstheLondonAmbulanceService(LAS)toreferpatientswhodon’tneedtobeadmittedtohospitaldirectlytotheGPhubsandtotheRapidAssessmentUnitattheEdgecombeUnitatCHS.ThishasreducedattendancesatA&Esothat

patientscanbeseenintherightplacethefirsttimeandimprovesthequalityofservices.

• Adultcommunityservices

• WehaveimplementedaGProvingservicewhichprovidesurgenthomevisitsforlocalresidentswhichalsosupportspatientsbeingdischargedhomeovertheweekend.

• Plannedcare

• Wearefocussingontransformingplannedcareservicestobringthemclosertothehomesoflocalpeople,makethemeasiertoaccessandimprovequality,patientexperienceandoutcomes.Thespecialtieswearefocussingonaremusculoskeletal,gynaecology,dermatology,ophthalmology,digestivediseases,diabetes,respiratory,cardiologyandneurology.ThesehavebeenselectedasspecialtiesthatwhenbenchmarkedagainstotherCCGsofferopportunitiestoreducethenumberofunnecessaryhospitalappointmentsforpatientsandalsooffercontractualopportunitiesforbettervalueformoneyfortheNHS.Aspartofthisprogrammewewillalsobeworkingtosupportlocalpeopletochangetheirbehaviourtoimprovetheirhealthandwell-being,lookingatthecultureandstructureoftheworkforceandintegratingcliniciansfromacrosssecondaryandprimarycare.

• Croydon’sGPpracticeshaveapeerreviewsystemwhereGPsineachpracticeregularlypeerreviewtheirassessmentsofsomepatientssothattheycanmakesurereferralstohospitalarealwaysbestoption


fortheindividual.Wehavealsobeenpromotingandincentivisingtheuseofe-ReferralstoGPswhichcombineselectronicbookingwithachoiceofplace,dateandtimeforfirsthospitalorclinicappointments.

• InordertosupporttheconnectionbetweenGPsandconsultantsatCroydonHealthServicesweareintroducingtheSpecialistAdviceandGuidancefeatureonthee-Referralsystem(eRS),thisautumn.ThisisanopportunitytoimproveaccessbetweencliniciansinPrimaryandSecondaryCarebyusingexistingdigitalconnectivitytobenefitpatientsandavoidingpatientshavingtotraveltohospital.

• Primarycareandprimarycarevariation

• Workingtowardtheimplementationofall17standardsforprimarycaresetoutintheGPFiveYearForwardViewwhichincluded:

• pilotingagroupconsultationmodeltosupportpatientswithlong-termconditionstodeveloptheknowledge,skillsandconfidencetomanagetheirownhealthandcarewhichhasshowedsignificantsuccesssofar

• introducingGPpeerreviewprogrammewhereGPcolleaguesrevieweachother’sassessmentforsomepatientswhichhasreducedunnecessaryreferralratestohospitalandreducedinappropriateattendancesatA&E

• implementinganumberofsocialprescribinginitiativessothatGPsandpracticestaffcanconnectmoreeasilywith

thecommunity.Socialprescribingisawayoflinkingpatientsinprimarycarewithsourcesofsupportwithinthecommunity.ItprovidesGPswithanon-medicalreferraloptionthatcanoperatealongsideexistingtreatmentstoimprovehealthandwell-being.

• Mentalhealth

• Wehaveintroduceda24-hourmentalhealthcrisistelephonelinestaffedbyclinicianstoprovidesupportattimesofcrisisforlocalpeople.Itisalsoavailabletousersofservicesandstatutoryorganisations,includingthepoliceandTheLondonAmbulanceService.Theservicereceivesapproximately140callstotheCrisisLineeachmonthandsupportstheneedsandcareofthoseindividuals.

• Croydonnowhasa24-hourHometreatmentteamthatoffersanalternativetomentalhealthinpatienthospitalcare.ThismeansthattheHometreatmentteamcanmakeanassessment24hoursadaytomakesurethatallcommunityoptionsareexploredbeforeapersonisadmittedasaninpatient.Theteamwillthenworkwiththepatienttoplantheircareandrecoverysothattheycanbetreatedintheirownhome.Careisplannedandagreedandindependenceispromoted.

• Childandadolescentmentalhealthservices(CAMHS)

• Thenumberofchildrenandyoungpeopleagedunder-18withadiagnosablementalhealthconditionreceivingNHScommunityservicestreatmentincreasedfrom16.8%in2015/16to32%in2016/17.Weexpecttobeabletosustainthislevelandimproveitinthecomingyear.


• Wehavemetthewaitingtimestandardforchildrenandyoungpeoplewitheatingdisorderssothattreatmentstartswithinamaximumoffourweeksfromthefirstcontactwithadesignatedhealthcareprofessionalforroutinecasesandwithinoneweekforurgentcases.

• Wehavemetthewaitingtimestandardforearlyinterventioninpsychosisservicessothatmorethan50%ofpeopleexperiencingfirstepisodepsychosisaretreatedwithaNICE-approvedcarepackagewithintwoweeksofreferral.

• Wehaveincreasedaccesstothecrisisteamforyoungpeopleunder18whoareexperiencingamentalhealthcrisis.

• CAMHSinCroydoncanbeaccessedthroughaSinglePointofAccesswhichbringstogetherallthelocalservicesofferingemotionalsupport,counselling,mentalhealthassessmentandparentingsupport.Representativesallmeettomakesurereferralsforchildren,youngpeopleandtheirfamiliesareofferedthemostappropriatespecialisthelpbasedontheirpresentingconcerns,needsandreferralinformation.

• Diabetes

• DiabetesisaparticularfocusforourpopulationandwehaveimplementedandpromotedtheNationalDiabetesPreventionProgrammethatfocussesonsupportingpatientswhoareathigherriskofdevelopingthediseaseandthosewhoareclassifiedas“pre-diabetic”.Throughcommunityoutreachsessions,CroydonVoluntaryActionhelpusidentifypeopleatrisk,aswellasthroughtheirGPsandthecouncil’sJustBeprogramme.Wecurrently

have60placesontheprogrammeandhopetoexpandthisto105places.Attendeesofthe18monthprogrammearethengivenonetoonesessionswithahealthadvisortosupportthemtounderstandtheimpactoftheirdietandexerciseandhowmakingsimplechangescanreducetheirriskofdevelopingdiabetes.


How we have involved patients and residents Therehavebeenextensivelocalandinnovativeengagementactivitiesoverthepastyear.

• IntheBigIdeasinitiative,theCCGaskedpatientandpublicrepresentatives,staff,partnersandstakeholdersforideasabouthowtheNHScanaddressfinancialchallenges.Therewere2,229observationscapturedfrom155participantswhoattendedoneofthefourevents.

• AcrossthesouthwestLondonCCGsheld88grassrootsoutreachsessionsalongsidelocalHealthwatches,11ofthesewereinCroydon,andahealthandcareforumineachboroughfocussingonpatientexperienceandthetransformationofhealthandsocialcaretohelpinformtheSustainabilityandTransformationPartnershiprefresh.

Hundredsoflocalpeopleacrossarangeofcommunitieshavecontributedtothefeedback,providingthousandsofobservationsandcomments.Thesehavebeendistilledintokeythemesandkeyissuesbelow:

GrassRootsAccesstoGPswasasignificantissue

GeneralconsensusthatCroydonHospitalhasimproved

Frustrationswithreceptionists

LongwaitsforImprovingAccesstoPsychologicalTherapyServices

Needaholisticphysicalandmentalhealthapproach

SupportforChildrenandYoungpeopletoleadhealthierlifestyles

‘BigIdea’ThemesDigitaldevelopments

Medicationwaste

Communication–signposting

Access–convenience

Self-care–independenceandwellbeing

Integration–system,funding,data

Supportnetwork–voluntarysector

Workforce–trainingandintegration


Our focus

Wehavesetoutsomeofourmanysuccessestohelpsustainablyimprovehealthandwellbeingandimprovecareandqualityofservices,howeverwerecognisethatthereisstillmuchtodooverfutureyears.

Whilstwewillbuildontheourcurrentprogrammeswewillconsiderhowwecouldextendthepositiveresultsfromouroutcomesbasedapproachtobeyondover65stobenefitthewholepopulationofCroydon,acrossbothphysicalandmentalhealth,includingchildrenandfamilies,workingageadultsandpeoplewithdisabilities.

TheCroydonHealthandCareAllianceforolderpeopleishelpingtoremovebarrierstocommissionersandprovidersworkingtogetheralongsideanoutcomes-basedcontract.InadditiontheGPengagementisbeingstrengthenedthroughdevelopingtheCroydonGPCollaborative,whichwillallowforgreaterflexibilityinhowprimaryandcommunityservicescometogether.

Transformingthehealthandcaresystemthroughtransformationalchangewillrequirefundamentalchangestothewayhealthandcareservicesareprovided.Ourworkforcewillneedtobetrained,recruitedanddeployedaccordingly.Staffwillberequiredtoworkindifferentandmoreflexiblewaysandtodelivernewcarepathwaysthatwillbepredominantlyinacommunityorprimarycaresetting.Therefore,aplannedshiftofservicesand

teamsfromacutetoprimaryandintermediatecaresettingswillberequiredwiththecreationofmorejointworkingandrolesacrossagencieswithintheCroydonsystem.

AswemovetowardawholepopulationprogrammetheCroydonTransformationBoardwillbeconsideringthedevelopmentofanaccountablecaretypearrangementsthatwillhelppartnersinCroydontakeonclearcollectiveresponsibilityforpopulationhealthinCroydonandensuringwecancollectivelymaximisethevalueoftheresourceswecollectivelydeployonbehalfoflocalpeople.

Ourfocuswillbetoimproveoutcomesby:

• supportingmorepeopletostayhealthyandactiveforaslongaspossibleandabletoliveasindependentlyaspossible

• earlydetectionandaccuratediagnosisofserioushealthconditionsandillnesses

• qualityofcareandpatientexperience

• worksatisfactionofourhealthandcareprofessionals

• makingsureweachievefinancialsustainability

ThiswillbethefocusaswedevelopourLocalHealthandCarePlanbetweennowandJune2018.


Merton and Wandsworth Local Transformation Board

Our visionOuragreedjointvisionistoenablethepeopleinMertonandWandsworthtolivehealthy,independentlivesforaslongaspossible.

Ourvisionistohavehealthandcareserviceswhere:

• weworktogethertopreventillhealthandreduceinequalities

• healthandcareareco-ordinatedaroundtheneedsoftheindividual

• theexperienceofusinghealthandcareservicesisseamless–webreakdownbarriersbetweenprimary,community,socialandmentalhealthservices

• weensurepromptaccesstoserviceswhichmeanthatpeoplearetreatedascloseto

homeaspossibleandthatonlythepeoplewhoreallyneedtogointohospitaldoso

• careforpatientswithlong-termandcomplexneedsistailoredtotheindividualsothatthecaretheyreceivemeetstheirpersonalneeds

• hospitalservicesareaccessible,highqualityandjoinedupwithotherhealthandcareorganisations

• localpeopleareconfidenttomanagetheirownhealthandwellbeing

• peoplereceiveaconsistentserviceandweensurethosewiththegreatestneedsgetaservicethatfullyreflectstheirchallenges

Our model for health and care Thiswillbeachievedthrough:

• Generalpracticeworkingtogetherinnetworksalignedtothelocaldeliverymodelforintegratedcare.Deliveringresilient,responsiveandsustainableprimarycare.

• AMultispecialityCommunityProviderapproachineachboroughwhichisresponsibleforintegrationofprimarycarenetworks,communitycareandsocialcareprovisionalongwiththirdsectorinputtodeliverproactive,co-ordinatedmanagementofindividualswithlongtermconditions,

complexneeds,riskofphysicalormentalhealthcrisisorwhoareattheendoflife.

• Thehospitalasthecentreofspecialistphysicalhealthexpertiseandcare–forpeoplewhohaveanidentifiedneedforspecialistinterventionandrequirediagnosis,stabilisationandtreatment.Inbothplannedandemergencycare,thismeansthatthehospitalworkforcewilloperateacrosshospitalandcommunitysettings,providingspecialistexpertisetogeneralist-ledservicesaswellashighquality,accessibleservicesinthehospitalsettingusingmodernservicemodels.St


George’shospitalwillplayacriticalSWL-wideroleinensuringthatthereisasustainable,networkedapproachtoacutecareacrosstheSTPandwillcontinuetodevelopitsvisionforlocalsystemintegration.

• Mentalhealthservicesintegratingwitheachelementofthesystemandprovidingspecialistintervention–diagnosis,stabilisationand

treatmentaswellasintegrationwithphysicalhealthservices

• Acommissioningsysteminhealthandsocialcarewhichmovesintoastrategicrole,aligningincentivestosupporttransformationincludingresourceallocation/shiftsbetweenMCP,hospitalandMentalHealth

• Weknowthisvisionrequiresfurtheriterationanddevelopment:

• PatientsintheLTBareaaccessacuteservicesatStGeorge’s,EpsomandStHelier,ChelseaandWestminsterandKingstonHospitalandsoourtransformationvisionmustreflectthis.MertonCCGwillworkcloselywithpartnersinSuttonandSurreyDownstoaddresstheservicequalityissuesatEpsomandStHelierraisedelsewhereinthisdocument

• Inbothboroughs,HealthandWellbeingBoards(HWBBs)areresponsibleforjointhealthandwellbeingstrategiesatboroughlevel.ThestrategyoftheLTBneedstoalignto

eachHWBB,reflectingareasofsharedchallengebutalsodistinctdifferencesineachborough.ThecontextforeachHWBBistheJointStrategicNeedsAssessmentineachborough,whichhasinformedthe‘contextandchallenges’sectionbelow.

• Althoughwehaveabroadaspirationtointegratephysicalandmentalhealthcare,weneedtoworkthroughthedetailofhowmentalhealthservicescanbefullyintegratedineverypartofourproposedmodel

• Weneedtoensurethatthisvisionandstrategyisfullyownedacrosshealthandsocialcareandreflectsappropriately,asocialcare


viewofthechallengesfacingthatsectoroverthemediumtolongterm.Weknowthatthehealthandcaresectorsareco-dependentand

werelyoneachbeingsustainableandeffectiveforthewholehealthandcaresystemtoflourish

Our health and care partners: • CentralLondonCommunityHealthcare

• LocalMedicalCommittee

• LondonBoroughofMerton

• LondonBoroughofWandsworth

• LondonSpecialisedCommissioning

• MertonClinicalCommissioningGroup

• MertonGPFederation

• MertonHealthwatch

• SouthWestLondonandSt.George’sMentalHealthTrust

• StGeorgesUniversityHospitalsNHSFoundationTrust

• WandsworthClinicalCommissioningGroup

• WandsworthGPFederation

• WandsworthHealthwatch

Our context and challenges Acrossthetwoboroughswehave

• 65practices

• Apopulationof585,000people

• FiveGPlocalities

ThehealthofpeopleinMertonisgenerallybetterthantheLondonandEnglandaverage.Lifeexpectancyishigherthanaverageandratesofdeathconsideredpreventablearelow.ThisislargelylinkedtothelowerthanaveragelevelsofdeprivationinMerton.Wehavearangeofcommunityassetsthatareimportanttohealth;therearemanygreenspaces,educationalattainmentishighandwehavehighlevelsofvolunteering.

ThepopulationsofMertonandWandswortharepredictedtogrowoverthenext10years.InMertonweexpectittoriseby10%(20,000morepeople)andinWandsworthweexpectittoriseby

7%(24,000morepeople).Thegreatestincreaseswillbeseeninolderagegroups:

• 65-84yearoldsareprojectedtoincreasebyaround20%inbothboroughs

• 85+yearoldsareprojectedtoincreaseby22%inMerton(800morepeople)and34%inWandsworth(1,300morepeople)


• Minimalchangesareexpectedinthenumbersof0-4yearoldsintheboroughs

Thisgrowthinthepopulationswillhavethebiggestimpactonservicesforolderpeople,e.g.homecare,carehomes,falls,dementia,emergencycare,rehabilitationandreablement(Reablementinvolves,intensivesupporttohelppeoplerecoverindependencefollowingcrisisorhospitaldischargesothattheyareabletoliveasindependentlyaspossible).Inaddition,growthinolderpopulationshasasignificantimpactonhowwespendourresources,asoutlinedintheNHSFiveYearForwardView“itcoststhreetimesmoretolookaftera75yearoldandfivetimesmoretolookafteran80yearoldthana30yearold”.Weknowwewillneedtosupportolderpeopletolivemoreindependentlyforlonger,withgreaterabilitytomanagetheirownhealth.Moreintegratedhealthandcareinthecommunitywouldmakeuslessreliantonhospitals,whichcouldthenfocusonhelpingpeopleinneedofspecialistcare.SignificantsocialinequalitiesexistwithinMerton.Theeasternhalfhasayounger,lessaffluent,andmoreethnicallymixedpopulation.Thewesternhalfismoreaffluent,withahigheraverageage.ThelifeexpectancygapbetweenthemostandleastdeprivedwardsinMertonis6.2yearsformenand3.9yearsforwomenandnearlytwiceasmanypeopledieprematurelyintheEastoftheboroughthantheWest.6%ofthepopulationofMertonhasdiabeteswhichplacespressureonprimarycareservicestoensurepatientsreceiveoptimaltreatment.

Wandsworthisavibrantandwell-connectedborough,withmanycommunityassets,attractionsandfacilitiesthatsupportandcanbefurtherutilisedtoimprovehealthylives.BlackandMinorityEthnic(BME)groupsmakeup29%ofthepopulation,whichisanimportantconsiderationin

theplanningofservicesandBMEchildrenmakeup69%ofthosewhoareChildrenLookedAfter(CLA).Thepopulationisgrowinganddiverse,providedforbygoodschools,accessibleparksandgreenspacesandthrivingbusinesses.TheCouncilisworkinghardtoensurethatitsambitiousregenerationschemescreateopportunitiesforresidentstoleadmoreprosperous,activeandhealthylives.

However,theboroughhasanumberofchallenges.Thereisasignificanthealthburdenfrompoorairqualityandhomelessnesshasincreasedbyathirdinfiveyears,linkedtorapidlyrisinghousingcosts.Thegapoflifeexpectancybetweenthemostandleastdeprivedwardsis9.3yearsformenand4.5yearsforwomen.WandsworthhasthehighestlevelsinLondonofalcoholconsumptionaboverecommendedlevelsand15,000peoplehavediabetes(4.8%).39%ofthoseover65livealoneandthisissettoincreasefurther,whichincreasesthechallengesinprovidingco-ordinated,proactivecareforolderpeople.Itisunsurprisinginthiscontextthatratesoffallsbyolderpeoplearesignificantlyhigherthannationalandregionalaverages.


Service quality InOctober2017,theSouthWestLondonClinicalSenateagreedasetofclinicalstandardsforsixclinicalservicesinhospitals:emergencydepartment;acutemedicine;paediatrics;emergencygeneralsurgery;obstetrics;andintensivecare.MedicalDirectorsfromeachHospitalTrustwerethenaskedtoself-assesstheirservicesagainsttheagreedclinicalstandards(seeappendix1).Thisevaluationprovidedanassessmentofcurrentconsultantstaffingagainsttheclinicalstandardsfortheseagreedsixcorehospitalservices.

StGeorge’sHospital

TheevaluationhighlightedthatStGeorge’sHospitalisclinicallysustainableinthosesixcoreservices,inregardtoconsultantstaffing.The

evaluationshowedthattherearegapscurrentlyinanumberofthesixcoreservices,butthatthesearerelativelysmallandbeingmanagedbytheTrustthroughadedicatedcommitmenttoongoingrecruitmentandretentionefforts,andsupportedthroughtheuseoflocumstaffing.Withitsknowledgeoflocalservicesandwiderstaffingissues,StGeorge’sNHSFoundationTrustisconfidentthatitcanrecruitthenecessaryadditionalconsultantsandthattheyarethereforeclinicallysustainableinthesixcoreacuteservices.

EpsomandStHelierHospitals

TheevaluationhighlightedclinicalsustainabilityissuesintwoofthesixclinicalservicesthatwereassessedatEpsomandStHelier.Thesearesummarisedinthetablebelow:

Table:CurrentconsultancystaffingagainststandardsatEpsomandStHelier

Hospitalservice

Currentconsultantworkforce

ClinicalStandardsRequirement

Gap

ED Currentconsultantheadcount 14 24(12foreachsite) 10

Obstetrics Currentconsultantheadcount(consultantswiththecompetenciestocoveracuteobstetricsoncalls1)

26 22(Epsom–categoryA,StHelier–categoryB)

Nogap

Emergencygeneralsurgery

Currentconsultantheadcount(consultantswhocontributetotheemergencygeneralsurgeryrota)

10 10 Nogap

Paediatrics Currentconsultantheadcount(consultantswiththecompetenciestocoveracutepaediatricsoncalls)

262 24(12ateachsite,asactivitylevelsarelower)

Nogap

Acutemedicine

Currentconsultantheadcount–dedicatedacutecarephysicians

11 24(ontwosites) 13

Currentconsultantheadcount–totalnumberofconsultantswhocontributetotheacutemedicalrota(includesacutecarephysiciansandnon-acutecarephysicians3)

30 24(ontwosites) Nogap

Intensivecare

Currentconsultantheadcount(consultantswhocontributetothecriticalcarerota(s))

7 9(forHDUatEpsomandICUatStHelier)4

2

1Notethatgynaecologyworkmayalsobeasignificantpartofsomeoftheseconsultants’jobplans.

2Thisincludes8WTEacutepaediatricconsultantswhomanagethepaediatricEmergencyDepartmentserviceonbothsites3Giventhecomplexityoftheacutemedicalrota,wehaveincludedthefiguresfordedicatedacutecarephysiciansandforthetotalnumberofconsultantswhocontributetotheacutemedicalrota(includesacutecarephysiciansandnon-acutecarephysicians).Therequirementismetbyacombinationofdedicatedacutecarephysiciansandnon-acutecarephysicians.4EpsomHospitalhasanadultcriticalcarefacilitythathastheabilitytotreatandstabiliselevel3patients.ThereisanexpectationthatsuchpatientswilleitherstepdownorbetransferredtotheintensivecareunitatStHelieriftheyrequireongoinglevel3care.Inaddition,thereisaPACU,staffed24/7byconsultantintensivists,ontheEpsomsite(withinSWELEOC).


ThetableshowsthatEpsomandStHelier,ascurrentlyconfigured,meetsthestandardsforobstetricandpaediatricservices.

ForIntensiveCare,EpsomandSt.HeliercurrentlyoperatesaservicewherebyLevel1and2criticalcareisprovidedwithinEpsom’sHighDependencyUnit,andLevel3patientsarestabilisedandtransferredtoSt.Helier,whichhasaLevel3IntensiveCareUnit.Thetrusthasconfirmedthatthecurrentgapof2intensivecareconsultantsismanageablewithinthecontextofthisservicemodelandplanstoappointafurthertwoconsultantsatStHelier.

ForEmergencyDepartmentservices,thefiguresdemonstratethattheTrustdoesnotcurrentlymeetthestandards.Ithasagapof10consultantsbetweenitscurrentstaffingandtheagreedqualitystandards.

TheTrustalsofacesparticularworkforcepressuresinacutemedicine.Epsom&StHelierhasthefewestnumberofdedicatedacutecarephysiciansperacuteinpatientsiteandacurrentgapof13consultantsagainsttheagreedclinicalstandards(ifonlyacutecarephysiciansaretakenintoaccount).

TheTrustcurrentlymanagestheimplicationsoftheseshortfallsonadailybasistoensurecareissafeacrossthetwosites,inanumberofwaysincluding:usingamixofstaffrotations;temporarystaff;andconsultantscoveringformiddlegradedoctorvacancies.ButthesizeoftheEmergencyDepartmentandAcuteMedicineconsultant

workforcegapsisconsiderableandthechallengesforthetrustwillincreaseasthemovetofullydelivera7dayservicemodelintensifies.

AcopyofthefullevaluationsummaryisgiveninAppendix2.

EpsomandStHelierhaveclearlysetoutacaseforchangeandascaleofchallengethatstatesthattheyareunabletodeliveralloftheseacuteserviceswithoutalevelofchangetotheirclinicalmodel.Throughanengagementexercise,heldbetweenJulyandSeptember2017,theTrusthassetouttheirviewsonpotentialscenariosforthefuture.

NodecisionhasbeenmadeonthefutureofEpsomandStHelierUniversityHospitalsNHSTrust.MertonclinicalcommissioninggroupwillworkwithlocalcommissionerstodevelopaformalprocesstoconsiderthefutureofservicesatEpsomandStHelierUniversityHospitalsNHSTrust,andotherissuessuchastheirestate,andhowtheywillbeabletodeliversustainableservicesforthelocalpopulation.Commissionersandthelocalsystemarefullycommittedtoconsultationwiththepublicifthisprocesssuggestssignificantchange.

TheMertonandWandsworthLocalTransformationBoardwillcontinuallytoevaluatethequalityofservicesacrosscommunity,primarycare,mentalhealthandhospitalservices.


Our achievements Cardiology • Wehaveimprovedaccesstoservicescloserto

homefollowingarecentreviewofGPreferralswhichhasledtotheoptimisationofdiagnosticswithinprimarycare

• WehaveimprovedpathwaysforthetransferofthemanagementofAmbulatoryBloodPressureandAnti-Coagulationservicestoprimarycare

Dermatology • Shorterwaitingtimesarebeingexperienced

bypatientsasaresultofnewdermatologyserviceswehaveputinplacethisyear

• Communitydermatologyservice-Cliniciansaredevelopingacommunity‘OneStopShop’andtele-dermatologyservice

• WehaveimproveddermatologypathwaysbyprovidingclearadviceandreferralpathwaysforGPs

Ambulatory Emergency Care Ambulatorycareiswhereapatientistreatedandstabilisedathospitalwithoutbeingadmitted.Itensuresrapidaccesstospecialistexpertisewhilstmaintainingapatients’independenceandsupportnetworkathome.

• In2016/17ouraverageperformanceforambulatorycareroseto22.6%(ofallpotentialcarewhichcouldbemanagedthisway)whichisanimprovementofnearly5%overtheyearcomparedtotheyearbeforewhenitwas18%

• InFebruary2018,StGeorge’sHospitalwillopennewambulatorycarecapacitywhichisprojectedtotakeperformanceabove30%

Diabetes• Diabetesclinicshostedinpracticeswithvideo-

consultantcallinginonceamonthwiththepatients:ConsultantsupportinprimarycareisunderwayaspartoftheGPFederationworkinWandsworth,learningwillbesharedacrossthebothboroughs

• RapidaccessforprofessionaladviceandguidancebyGPsisnowavailableviaourcommunityspecialistnurses

• SpecialtyoutreachintoGPpracticestodiscussatriskpatients,reviewreferrals,holdvirtualclinics

Ear, Nose Throat (ENT) • Shorterwaitingtimesarenowbeing

experiencedbypatientsthroughournewENTservices

• Virtualclinics-PatientsarenowreceivingimprovedaccesstoENTfollowupappointmentsthroughournew‘virtualclinics’

Musculoskeletal services • AninnovativeSinglePointofAccessservicein

Mertonnowacceptsself-referralaswellasmanagingMusculoskeletalpathwaysinthe


borough.Thishashelpeddirectpatientstothemostappropriatecareincludingphysiotherapyratherthanahospitalappointmentwherenotappropriate.ThismodelisalsobeingputinplaceinWandsworth.

Neurology • GPDirectAccessHotClinics-GPsarenow

abletoreferpatientswhoarerapidlydeterioratingtoanUrgentNeurologyClinicinsteadofanEmergencyDepartment

• WehaveputinplaceOpenAccessfollowups–thisiswherepatientscanrequestafollowupappointmentwhentheyexperiencesymptomsratherthanhavearegularbookedfollow-upwhichmaynotcoincidewithfeelingunwell.Thishasledto:

• Reductioninreferralstoacuteheadacheclinics

• Reductioninwaitingtimesandbacklogs

• Reductioninattendancesandre-admissionsthroughEmergencyDepartment/AcuteMedicalUnit

• Reductioninattendanceswithinprimarycare

Intermediate Care, Discharge to Assess and Rapid Response • Athreemonthpilotforasinglehealth&social

carere-ablement/rehabilitationpathwaystartedinAugust2017atStGeorge’sHospitalonthreewards.Thisusesa‘DischargetoAssess’principlei.e.allagenciesensurethesupportisputinplaceforthepatienttogo

home,andassessmentsforcarearemadeinthepatients’homeratherthanhospital.Theimpacthasbeenthatallsocialcarereferralsmadebypilotwardshavebeenrespondedtowithin2hours,withadecision.Thismodelisbeingrolledoutacrosswards

Enhanced Support to Care Homes • In-reachnurseshavetaughtapprox.60

nurses/carersinoverhalfofthecarehomesinWandsworththeirtrainingsessionsfocusedonhowtorecogniseadeterioratingpatient,chronicobstructivepulmonarydisease(COPD)andasthmamanagement.

• The“RedBag”schemeimplementationunderwayinbothboroughs

• AMertonJointIntelligenceGrouphasbeenestablishedwhichnowmeetsmonthly.Thegroupbringstogetherarangeofprofessionalsandorganisationsacrosshealthandsocialcaretoshareinformationrelatingtothequalityofcarebeingdeliveredincarehomes.Areasofpotentialriskareidentifiedsothatwecanrespondquicklytoconcernsandagreeactionplanswhereappropriate.

Extended Access to Primary Care • Thereisnow7day,8am-8pmaccessto

PrimaryCareinWandsworthandMerton.ThisisprovidedthroughacombinationofindividualpracticeextendedopeningandPrimaryCareAccessHubswhichlaunchedinApril2017(Merton)andMay2017(Wandsworth).


• Mertonhas2PrimaryCareAccessHubswhichprovideprimarycareservicestocover4.00pm-8.30pmonweekdaysand8amto8pmweekendsandBankHolidays(1hubopensonaSunday).Thehubservicealsooffersawoundcareclinicfordailydressingneeds.Wandsworthhas3PrimaryCareAccessHubswhichprovideaprimarycareservicetocover6:30-8:00pmonweekdays,8am-8pmonweekendsand8am-8pmonbankholidays(notallhubsareopenatalltimes).TheyoperatealongsideextendedhoursschemesinpracticeswhichmeansomePracticesarealsoopenuntil8pmonweekdaysandonSaturdaymornings.

• PracticesinbothBoroughsarealsosigneduptodeliverurgentonthedayappointmentswithin4hours,whereitisdeterminedthatapatienthasaclinicalneedforsuchanappointment.

• PracticesinbothBoroughsaresigneduptoacceptpatientsredirectedbytheAccident&Emergency(A&E)navigatorbetween9am–

3pm.PlanstodevelopdirectbookingfromA&Eareinprogress.

• Intotalthismeansthatthereareapprox.6000additionalprimarycareappointmentsavailableeachmonthacrossWandsworthandMerton.Utilisationiscurrentlyaround75%thereforecapacityisavailabletomanageincreaseddemand.

Mental Health • TheLocalTransformationBoard(LTB)works

withpartnersacrossSouthWestLondontoprogressthetransformationofmentalhealthservicesandinordertofocuseffortonthesesystem-widechangeshasnotestablishedaseparateworkstreamatLTBlevel.However,significantlocalchangehasbeenachievedwiththeinstitutionofimprovedpsychiatricliaisonservicesatStGeorge’sHospital,theopeningofCrisisCafesandSinglePointofAccessmodelsformentalhealth.

Developing Local Health and Care Plans

TheinformationcontainedinthissectionwillbeusedaswedevelopourLocalHealthandCarePlanbetweennowandJune2018.

AsourLocalTransformationBoardcoverstwoboroughs,wewilldevelopindividualLocalHealthandCareBoroughPlans(thatwillbenamedbylocalareas)sothatboroughlevelissuesand

prioritiesareidentifiedandplansdevelopedtoaddressthese.

OurtwoindividualBoroughlevelLocalHealthandCareBoroughPlanswillthenbebroughttogethertocreateourLocalTransformationBoardHealthandCareplan.


Kingston, Richmond and East Elmbridge Local Transformation Board

Our joint vision Todeliverimprovementsinthehealthandwell-beingofpeoplelivinginKingston,RichmondandEastElmbridgeandfocusontheprioritieslaidoutintheJointStrategicNeedsAssessmentsandbytheHealthandWell-BeingBoards.

ThepopulationofKingston,RichmondandEastElmbridgeishealthywiththelifeexpectancyforbothfemalesandmalesabovethenationalaverage.However,thepopulationisageingandwiththiscomesthechallengesofcaringforincreasednumbersofpeoplewithill-healthandmultiplelong-termconditions.Wearealsoseeinggrowthinthenumberofchildrenandyoungpeoplewholiveandstudyacrossthethreeareas.ToensurewemeetthediverseneedsofagrowingpopulationtheLocalTransformationBoard(LTB)hasagreedtoimprovethefollowingareas:

• Improvepreventionandsupportpeopletoliveindependentlivesforlonger

• Improvedoutcomesforchildrenwhoexperiencesignificantmentalhealthchallenges

• Reductionsinthetimepeoplespendinhospitalinthelastyearoftheirlivesandhelpthemtodecideontheirpreferredplaceofdeath

• Puttinginplacehealthandcareservicesthatareperson-centredwhilstbeingbothfinancialandclinicallysustainable

Todeliverthesekeyareas,theLocalTransformationBoardhasagreedtobuildupon

theprinciplesoftrustandpartnershiptoenableimprovedcareoutcomesandfinancialsustainability.

Our model for health and care TheLocalTransformationBoardisdevelopingthedetailonhowthevisionwillbeachievedandthekeymetricsforsuccess.Theareasthatwewillbefocusingoninclude:

• Developingalocalityteamapproachbasedaroundpopulationsof50,000thataresimpleandcoherent,toensureconsistencyandbasedonsharedmodelsandbestpractice

• Primarycareatscalewithpracticesworkingtogetherasnetworks,andthroughthethreeGPFederations,sothatcareisprovidedinajoined-upwayforpatientsandthataccessto,andresilienceof,GPpracticesareimproved

• Bringingtogetherphysicalandmentalhealthtoimproveoutcomesforpeoplewithlongtermconditionsandreducethehealthinequalitiesinpeoplewithseriousmentalhealthillness

• BuildingonfoundationsalreadyinplaceacrossKingstonandRichmondboroughstofocussupportforthosewithlearningdisabilities

• Enablingaworkforcethatisempoweredtoworkacrossorganisationalandprofessional


boundaries,toprovidehighqualityandsafecareforthepopulation

ThediagrambelowshowsthehealthandcaresysteminKingstonandRichmond.

Our health and care partners ThehealthandsocialcarepartnersinKingston,RichmondandEastElmbridgeare:

• Chelsea&WestminsterNHSFoundationTrust

• CSHSurrey

• HounslowandRichmondCommunityTrust

• KingstonGPChambers

• Healthwatch–KingstonUponThames

• KingstonHospitalNHSFoundationTrust

• KingstonVoluntaryAction

• NHSKingstonCCG

• NHSRichmondCCG

• NHSSurreyDownsCCG

• RichmondCouncilforVoluntaryService

• RichmondGPAlliance

• Healthwatch-RichmondUponThames

• RoyalBoroughofKingstonUponThames

• LondonBoroughofRichmondUponThames

• SouthWestLondonandStGeorge'sMentalHealthNHSTrust

• SurreyandBordersPartnershipNHSFoundationTrust

• SurreyCountyCouncil

• Healthwatch-Surrey

• SurreyMedicalNetwork

• YourHealthcare


Our context and challenges


The populations and demand on services TheregisteredpopulationoftheLocalTransformationBoardisbrokendownasfollows:

• Kingston 207,000

• Richmond 215,000

• EastElmbridge 65,000

Thepercentageofover65slivingintheLocalTransformationBoardareaishigherthanmostofLondon(13%forbothKingstonandRichmond)withaprojectedincreaseof50%acrossKingstonandRichmondby2035.

Whilstpeoplearelivinglongerthereisanincreasedincidenceofpeoplewithlivingwithoneormorelongtermconditions.NearlyoneinthreepeoplehavealongtermconditioninKingstonandRichmondandnearlyoneintenpeoplearelivingwiththreeormorelong-termconditions.

CoronaryheartdiseaseinKingstonispredictedtobe3.2%,inRichmonditispredictedtobe3.4%,comparedtotheEnglandaverageof4.6%.AlthoughtheprevalenceislowerthanEnglandcoronaryheartdiseaseistheleadingcauseofdeathinmen.

DiabetesprevalenceinKingstonis6.6%,inRichmonditis6.8%,comparedtotheEnglandaverageof8.5%.AlthoughtheprevalenceratesarelowerthanEngland,diabetesisaleadingcauseofillhealthintheboroughs,andthereisalargenumberofpeoplestillundiagnosedinourcommunity.

Oneinfourpeoplewillexperiencementalillnessinanyyear.Oneinsixpeoplehaveacommonmentalhealthdisorderatanypointintime.Mostcommonmentalhealthdisorderstaketheformofanxietyand/ordepressionwhichareexperiencedby10%

ofpeopleinbothKingstonandRichmondatanypointintime.

Tomeetthesechallengesourplanshavetoensurethattheservicesweputinplacearebothclinicallyandfinanciallysustainable.

Size and shape of health and care services TherelativelylargenumberofthehealthandcareorganisationsintheLocalTransformationBoardregionmeansthatservicesandrelationshipstodelivercarearemorecomplexthanmanyhealthandcareeconomiesandhasresultedinfragmentedservicedelivery.ThishasbeenrecognisedandisinpartbeingaddressedthroughprogrammeslikeKingstonCo-ordinatedCareandRichmondOutcomeBasedCommissioning.

General Practice AcrossKingston,RichmondandEastElmbridgethereareatotalof57GPpractices(Kingston21,Richmond28andEastElmbridge8).Generallywehaveagoodqualityofprimarycareacrossallthreeareaswithalargenumberofpracticesreceivingaratingof“Good”fromtheCareQualityCommission.OurpopulationalsogenerallyratethequalityoftheGPserviceshighlyasdemonstratedbytheresultsofthenationalGPsurveywithmanyoftheresponsesratingtheservicesequaltoorabovenationalaverage.

WealsohavethreeGPFederationsworkingacrosstheLocalTransformationBoardarea,whichsupportustodelivercareinajoined-upwayforpatientsandimproveaccessto,andtheresilienceof,GPpractices.


Hospitals WhenhospitalcareisrequiredthepopulationofKingston,RichmondandEastElmbridgeaccesstwohospitals–KingstonandWestMiddlesexHospitalinthemajorityofinstances.SometimeswhenmorespecialisthospitalcareisrequiredpatientsmaytraveltotertiarycentressuchasStGeorge’sUniversityHospitalsNHSFoundationTrustorImperialCollegeHealthcareNHSTrust.

Service quality InOctober2017,theSouthWestLondonClinicalSenateagreedasetofclinicalstandardsforsixclinicalhospitalservices:emergencydepartment;acutemedicine;paediatrics;emergencygeneralsurgery;obstetrics;andintensivecare.MedicalDirectorsfromeachHospitalTrustwerethenaskedtoself-assesstheirservicesagainsttheagreedclinicalstandardsseeappendix1.Thisevaluationprovidedanassessmentofcurrentconsultantstaffingagainsttheclinicalstandardsfortheseagreedsixcorehospitalservices.

Theevaluationhighlightedthat,KingstonHospitalisclinicallysustainableinthosesixcoreservices,inregardtoconsultantstaffing.Theevaluationshowedthattherearegapscurrentlyinanumberofthesixcoreservices,butthatthesearerelativelysmallandbeingmanagedbytheTrustthroughadedicatedcommitmenttoongoingrecruitmentandretentionefforts,andsupportedthroughtheuseoflocumstaffing.Withitsknowledgeoflocalservicesandwiderstaffingissues,KingstonHospitalNHSFoundationTrustisconfidentthatitcanrecruitthenecessaryadditionalconsultantsandthattheyarethereforeclinicallysustainableinthesixcoreacuteservices.Acopyofthefullevaluationsummaryisgiveninappendix2.

TheKingstonandRichmondLocalTransformationBoardwillcontinuallyevaluatethequalityofservicesacrosscommunity,primarycare,mentalhealthandhospitalservices.

Community care AcrossKingston,RichmondandEastElmbridgecommunitycareisprovidedbythreecommunityproviders–CentralSurreyHealthHounslow,HounslowandRichmondCommunityHealthcareandYourHealthcare.

Social Care SocialcareisprovidedbyEastElmbridgeBoroughCouncil,LondonBoroughofRichmondandtheRoyalBoroughofKingstonUponThames.

Voluntary and Community Sector Support WearefortunateinourLocalTransformationBoardareatohaveastrongvoluntaryandcommunitysector(VCS)whichprovidesarangeofsupportthatcanhelppeopletoliveindependentlyinthelocalcommunityandmakesasignificantcontributiontopreventingillhealthandmaintainingpeople’swellbeing.Increasinglywearelookingforopportunitiesforjointworking;forexamplethereisVCSinvolvementintheRichmondoutcomebasedcommissioningprogrammeandtheKingstonCoordinatedCareprogrammewhereVCSgroupsareinvolvedinthemultidisciplinaryteammeetingsinNewMalden.


Our progress so far – one year on Improving care for people in crisis OverthelastyearwehavepilotedanewserviceinKingstonandRichmondintroducinganalternativetohospitaladmissionforpeopleexperiencingamentalhealthcrisis.Now,peoplelivinginKingstonandRichmondwhoareexperiencingamentalhealthcrisishaveaccesstoa“safehaven”residentialhomeinthecommunitywheretheycanstayforuptofivedays.Thehouseisstaffed-byspecialistsupportworkers24hoursadaywhoprovidepersonalisedsupportwhichfocusonhelpingthepersontostabiliseandrecover.Theserviceislinkedtocommunityandhometreatmentteamsforclinicalsupport.BetweenJuly2016andFebruary2017over100peopleaccessedtheservice,withover80%ofthemreturninghomewithoutneedingadmissiontohospital.S136detentions(knownas“sections”undertheMentalHealthAct)forKingstonandRichmondresidentshavedroppedby32%comparedtotheaveragefortheprevioustwoyears.

Improving Access to Psychological Therapy InRichmondwehavepilotedexpandedourImprovingAccesstoPsychologicalTherapyservicestosupportpeoplewithlongtermconditionssuchasdiabetesandchronicobstructivepulmonarydiseasetohaveeasieraccesstotalkingtherapies,togivethemmoresupporttoself-managetheirconditionstohelpimprovetheirhealthoutcomes.

Working together to provide joined-up Community Care AspartofKingstonCo-ordinatedCareinKingstonwehaveimplemented:

MTDsandLocalityteams:Amulti-disciplinarylocalityteam(MDT)thatmeetsmonthlywitheachGeneralPracticetoreviewindividualpatientswhohavehighunplanneduseofservicesandcomplexproblems,basedontheirhealthandcareneedsandbuildsacareplanforeachpatienttoimplementandaddresstheseneeds.Progresssofarincludes:

• ThreemonthsofMDT’sinNewMaldenineachofthe5practicecluster.

• Learningonriskstratification,supportrequirements,systemrequirements.

• MDTcommencedwithKingstonHealthCentreatthebeginningofNovember.

• Furtherinterestfrompracticesinotherlocalitiestoroll-outtheapproach.

AccessandTriage:YourHealthcareduty/triagefunctionsandRoyalBoroughofKingstonAdultSocialcaretriagefunctionshavebeenco-locatedtocreate‘Access’teamwhohavebeen:

• Undertakingprocessredesigntoreduceduplicationbetweenservices

• Identifyingopportunitiestoworkmoreeffectivelyasawholeteam.

• ConductingworkshopswithMentalHealthservicestoreviewexistingprocesses.

WorkforceDevelopment:StaffworkshopstoidentifyandtrialnewwaysofworkingbasedonpopulationcohortshavetakenplacethroughoutOctoberandNovember.


AroleframeworkhasbeendevelopedtomapcapabilitiesandrolesscopedforHealthEducationEnglandfundingincluding:

• LocalityCoordinator

• TrustedAssessorfunction

• CommunityReferrer

• BoundaryWorkers

InformaticsandEvaluation:developmentandutilisationofKingstonCareRecord(KCR)withaTaskandFinishgroupfocussedon:

• CarePlaninKCR(visibletoall)

• Flaggingtosupportevaluation

• Summarypage

• Utilisation

• Riskstratification

• GP’ssupportaccesstofreetextinformationtosupportintegratedsingleviewofcareplaninKCR.

InRichmondtheOutcomeBasedCommissioningapproachhasbeendeveloped,withanestablishedgovernanceframeworkacrosshealthandsocialcare,todelivernewintegratedmodelsofcareandimproveoutcomesforpatientsandtheircarers.

Examplesinclude:

• RapidredesignoftheinpatientunitpathwayatTeddingtonMemorialhospitaltoensureagreaterfocusonrehabilitationsothatpeopleregaintheirindependenceinasupportedenvironmenttosupportthemtogethomefaster.Theresultisthatpeoplestayforlesstimeandwehavecreatedcapacitytoallowstepupfrompeople’shomesiftheyarenotcopingwhichavoidsanadmissiontohospital.Wearetreatingthesamenumberofpatients

inlessbedswhichhasreleasedmoneytobereinvestedelsewhereinthelocalhealthsystem.

• Thelocalitymodel,whichispremisedonstrongresearchevidencethatmorepersonalisedcarecanbedeliveredtopopulationsofaround50,000,isbeingdevelopedandtestedinTeddington&Hamptonlocality.Bycombiningthecapacity,skillsandknowledgeofGPs,communitystaffandsocialservicesatthislevel,wehavedemonstratedthatpatientscanbebettersupportedintheirownhomesthroughjoinedupcare.Themodelwillbeextendedtotheremainingthreelocalitiesoverthenextsixmonths.

• Longtermconditionspecialistpathwayshavebeenredesignedbecauseitwasevidentthattoomanypatientswerebeingreferredtohospitalforongoingcarewhentheexpertiseexistsinthecommunitytoprovidethatcareandsupport.Diabeteshubclinics,communityheartfailureclinicsandincreasedcardiacrehabilitationprovisionhavebeenimplemented.

• NewrespiratorypathwayshavebeenestablishedandBREATHeducationclassesareinplacetosupportpatientstoself-managetheircondition.Theoutcomesoftheseinterventionsarecurrentlybeingmeasured.

• Ahospitaltransferpathway‘redbagscheme’hasbeenrolledoutacrosscarehomesinRichmondwiththeanticipatedimpactofa2-3dayreductioninlengthofstayforpatientsbasedofevidencefromtheSuttonCareHomesVanguard.


Primary Care AcrossbothKingstonandRichmondwehavemadeimprovementsinprimarycareaccess.Wenowofferseven-dayaccesstoaGP,betweenthehoursof8amand8pm.WehavealsointroducedonlineservicesacrossallGPpracticessothatpeoplecannowbookappointments,orderrepeatprescriptionsandaccesstheirhealthrecordsonline.

GPservicesarenowco-ordinatedbythreeGPfederationsthatworkacrosspracticestoshareinformationanddriveimprovementsincarethatisbestprovidedclosetohome.

Wearealsodevelopingprimarycare-ledurgentcareservicesinbothboroughs.WeareredesigningtheWalkinCentreatTeddingtonMemorialhospitaltobecomeanurgenttreatmentcentre.Thiswillensuresevendaywalk-inandbookableservicesprovidedbyamixofGPandurgentcarepractitionerstomeettheexpressedneedsofthelocalpopulation.Theservicewillalsosupportthepublictoadoptsaferandhealthierlifestylesandtousethebroadrangeofservicesinthecommunitytomanagetheirhealthsuchaspharmacies,opticiansandthevoluntarysector.Itwillcontinuetheemphasisonlocalservicesforlocalpeople.AlinkedserviceforpeopleintheEastoftheboroughisalsobeingexplored.

ThisserviceisalreadysupportedbytheRichmondrapidresponseteamwhichcombines,communityandsocialservicesstaff(supportedbyaGP)torespondtourgentrequestsforhome-basedinterventionandongoingcare.Theteamrespondstothemajorityofrequestswithin2hoursandcanarrangemedical,socialcareandhomeadaptations

whichsupportpeopletostayathomeandavoidhavingtobeadmittedtohospital.

Social Prescribing InbothKingstonandRichmondwehavestartedrollingoutsocialprescribingacrossourcommunitiesthroughpilotschemesthataredeliveredinpartnershipwiththevoluntaryandcommunitysector.InRichmondwehavestartedinBarneswiththefocusonimprovingpeople’swellbeingbyprescribingsocialandleisureactivitiesandvolunteeringopportunities,aswellasaddressingothernon-medicalneeds.InKingston,inpartnershipwithMacmillan,wearefocusingonprovidingsocialprescribingtopeoplelivingwithandbeyondcancer

Developing Local Health and Care Plans TheinformationcontainedinthissectionwillbeusedaswedevelopourLocalHealthandCarePlanbetweennowandJune2018.

AsourLocalTransformationBoardcoverstwoboroughs,wewilldevelopindividualLocalHealthandCareBoroughPlans(thatwillbenamedbylocalareas)sothatboroughlevelissuesandprioritiesareidentifiedandplansdevelopedtoaddressthese.

OurtwoindividualBoroughlevelLocalHealthandCareBoroughPlanswillthenbebroughttogethertocreateourLocalTransformationBoardHealthandCareplan.


Sutton Local Transformation Board

Our joint vision TheSuttonLocalTransformationBoard(LTB)hasendorsedavisionofintegratedworkingforthepopulationofSuttonthroughthedevelopmentof“SuttonHealthandCare”.SuttonHealthandCare(SHC)isanambitiousprogrammetointegrateservicesaroundtheneedsofpeople,particularlyfrailolderpeopleinthefirstinstance.Theprogrammeisplannedtoencompassallelementsofcare-prevention,proactiveplannedcareandreactivecrisiscare-withtheaimofsupportingpeopleintheirhomestobeasindependentandhealthyaslongaspossible.

Our model for health and care TheSuttonHealthandCaremodelhasbeendevelopedthroughmultipleengagementeventswithstaff,patientsandthepublicusingthestoriesof‘BobandBarbara’,twoSuttonresidentsintheireightieslivingindependently.AsBobandBarbaraageandbecomeincreasinglyfrail,engagementeventshavemodelledthecurrenthealthandcarepathwaysthatsupportthecouplethroughspecificepisodes.

Thereiswidespreadagreementthat,despiteindividualservicesandstaffmembersprovidinghighquality,compassionatecaretoBobandBarbara,thesystemisfragmentedandduplicative,leadingtopooreroutcomesandincreaseddependencyforolderpeople.Thesame

engagementeventsidentifiedthewaywecollectivelywanttoworktogetheraroundBobandBarbara,offeringintegrated,responsiveandpersonalisedcare,withimprovedoutcomesandindependenceforolderpeople.

DeliveringbetteroutcomesforBobandBarbaraalsotransformstheefficiencyandeffectivenessofservices,makingthehealthandcaresysteminSuttonsustainableforthefuture.

Thefirstfocuseson‘reactive’care,therapidresponseservicesthataimtoavoidanadmissionorenablesafasterdischargefromhospitalsothatolderpeoplecanliveathomeforlonger.


Our health and social care partners• LondonBoroughofSutton

• SuttonHealthwatch

• SuttonClinicalCommissioningGroup

• EpsomandStHelierUniversityHospitalsNHSTrust

• TheRoyalMarsdenNHSFoundationTrust

• SuttonCentreforVoluntaryServices(CVS)

• SouthWestLondonandStGeorge’sMentalHealthNHSTrust

• SuttonGPServices

• Sutton(LBS)PublicHealth

Our context and challenges

ThepopulationofSuttonisgrowingandlocalpeoplearetendingtolivelonger;however,thereareasignificantnumberofpeoplelivingwithoneormorelong-termmedicalcondition.InadditionSuttonexperiencesahighlevelofmentalhealthproblemsforchildrenandyoungpeople,anareaofparticularfocusforus.Meanwhilemedicaltechnologycontinuestoadvanceasneworimprovedtreatmentsandmedicinesaremadeavailabletopatients.

Thismeansthatthereismoredemandthaneveronourhealthservices,andthisdemandiscontinuingtoincrease.TheSuttonLocalTransformationBoardrecognisesthatweneedmoreandbetterservicesprovidedoutsideofhospital–inGPsurgeries,communityservices,socialcareand,whereappropriate,athome.People,inparticulartheolderpopulation,needtobesupportedtolivehealthierlives,toavoidbecomingillandtomaintaintheirindependence.

Moreintegratedhealthandcareinthecommunitywouldmakeuslessreliantonhospitals,whichcouldthenfocusonhelpingpeopleinneedofspecialistcare.Thereissubstantialevidencethatafocusonpreventionandproactivecare,alongsidehighqualityrapidresponseservicesinacrisissituation,leadstobetteroutcomesforpatientsandgreatersystemsustainability.




Size and shape of health and care services SuttonCCGisresponsibleforthelocalNHScommissioningbudgetofaround£240million.

Therearetwenty-fiveGPpracticesintheboroughwitheverypracticereceivingaCQCratingofGoodintherecentinspections.ThepracticesaredividedintothreeLocalities–Carshalton(8practices),SuttonandCheam(10practices)andWallington(7practices).Whilehavingarangeofsinglehandedpracticesandsomechallengingestatesissues,primarycareinSuttonalsocameourasthetopperformer,orwithinthetopthreeresponsesinLondon,inanswersgivenbylocalresidentstothenationalGPpracticepatientsatisfactionsurvey.Thereisan‘extendedhours’serviceinplace,meaningthatpatientscanbooktoseeaGPbetween8amand8pm,sevendaysaweek,attwohubsintheborough.TheextendedhoursprimarycareserviceisprovidedbySuttonGPServices,afederationofGPpracticesintheborough.

Residentsareservedbyonemainacutetrust(EpsomandSt.HelierUniversityHospitalNHSTrust,withpatientsmainlyaccessingservicesontheStHeliersite)withcommunityservicesprovidedbytheRoyalMarsdenNHSFoundationTrust,viaSuttonCommunityHealthServices.PatientsrequiringspecialistacutecarearemainlytreatedatStGeorge’sUniversityHospitalsNHS

FoundationTrustinTooting.CommunityandacutementalhealthservicesareprovidedbytheSouthWestLondonandSt.George’sMentalHealthTrust,whichisalsoaproviderinanalliancecontractfortheSuttontalkingtherapiesservicecalledUplift.LocalandspecialistcancerservicesareprovidedbytheRoyalMarsdenNHSFoundationTrust.TheCCGalsocommissionsservicesfromarangeoflocalvoluntaryandthirdsectorproviders.

SocialcareservicesareprovidedbytheLondonBoroughofSutton.

Service quality InOctober2017,theSouthWestLondonClinicalSenateagreedasetofclinicalstandardsforsixclinicalservicesinhospitals:emergencydepartment;acutemedicine;paediatrics;emergencygeneralsurgery;obstetrics;andintensivecare.MedicalDirectorsfromeachHospitalTrustwerethenaskedtoself-assesstheirservicesagainsttheagreedclinicalstandardssee(appendix1).Thisevaluationprovidedanassessmentofcurrentconsultantstaffingagainsttheclinicalstandardsfortheseagreedsixcorehospitalservices.


TheevaluationhighlightedclinicalsustainabilityissuesintwoofthesixclinicalservicesthatwereassessedatEpsomandStHelier..Thesearesummarisedinthetablebelow:

Table:CurrentconsultancystaffingagainststandardsatEpsomandStHelier

Hospitalservice Currentconsultantworkforce

ClinicalStandardsRequirement

Gap

ED Currentconsultantheadcount

14 24(12foreachsite) 10


26 22(Epsom–categoryA,StHelier–categoryB)

Nogap



10 10 Nogap

Paediatrics Currentconsultantheadcount(consultantswiththecompetenciestocoveracutepaediatricsoncalls)

266 24(12ateachsite,asactivitylevelsarelower)

Nogap

Acutemedicine Currentconsultantheadcount–dedicatedacutecarephysicians

11 24(ontwosites) 13


30 24(ontwosites) Nogap

Intensivecare Currentconsultantheadcount(consultantswhocontributetothecriticalcarerota(s))

7 9(forHDUatEpsomandICUatStHelier)8

2

5Notethatgynaecologyworkmayalsobeasignificantpartofsomeoftheseconsultants’jobplans.6Thisincludes8WTEacutepaediatricconsultantswhomanagethepaediatricEmergencyDepartmentserviceonbothsites7Giventhecomplexityoftheacutemedicalrota,wehaveincludedthefiguresfordedicatedacutecarephysiciansandforthetotalnumberofconsultantswhocontributetotheacutemedicalrota(includesacutecarephysiciansandnon-acutecarephysicians).Therequirementismetbyacombinationofdedicatedacutecarephysiciansandnon-acutecarephysicians.8EpsomHospitalhasanadultcriticalcarefacilitythathastheabilitytotreatandstabiliselevel3patients.ThereisanexpectationthatsuchpatientswilleitherstepdownorbetransferredtotheintensivecareunitatStHelieriftheyrequireongoinglevel3care.Inaddition,thereisaPACU,staffed24/7byconsultantintensivists,ontheEpsomsite(withinSWELEOC).


ThetableshowsthatEpsomandStHelier,ascurrentlyconfigured,meetsthestandardsforobstetricandpaediatricservices.

ForIntensiveCare,EpsomandSt.HeliercurrentlyoperatesaservicewherebyLevel1and2criticalcareisprovidedwithinEpsom’sHighDependencyUnit,andLevel3patientsarestabilisedandtransferredtoSt.Helier,whichhasaLevel3IntensiveCareUnit.ForIntensiveCare,EpsomandSt.HeliercurrentlyoperatesaservicewherebyLevel1and2criticalcareisprovidedwithinEpsom’sHighDependencyUnit,andLevel3patientsarestabilisedandtransferredtoSt.Helier,whichhasaLevel3IntensiveCareUnit.ThetrusthasconfirmedthatthecurrentgapoftwointensivecareconsultantsismanageablewithinthecontextofthisservicemodelandplanstoappointafurthertwoconsultantsatStHelier.

ForEmergencyDepartmentservices,thefiguresdemonstratethattheTrustdoesnotcurrentlymeetthestandards.Ithasagapoftenconsultantsbetweenitscurrentstaffingandtheagreedqualitystandards.

TheTrustalsofacesparticularworkforcepressuresinacutemedicine.Epsom&StHelierhasthefewestnumberofdedicatedacutecarephysiciansperacuteinpatientsiteandacurrentgapof13consultantsagainsttheagreedclinicalstandards(ifonlyacutecarephysiciansaretakenintoaccount).

TheTrustcurrentlymanagestheimplicationsoftheseshortfallsonadailybasistoensurecareissafeacrossthetwosites,inanumberofwaysincluding:usingamixofstaffrotations;temporarystaff;andconsultantscoveringformiddlegradedoctorvacancies.ButthesizeoftheEmergencyDepartmentandAcuteMedicineconsultantworkforcegapsisconsiderableandthechallengesforthetrustwillincreaseasthemovetofullydeliverasevendayservicemodelintensifies.

AcopyofthefullevaluationsummaryisgiveninAppendix2.

EpsomandStHelierUniversityHospitalsNHSTrusthaveclearlysetoutacaseforchangeandascaleofchallengethatstatesthattheyareunabletodeliveralloftheseacuteserviceswithoutalevelofchangetotheirclinicalmodel.Throughanengagementexercise,heldbetweenJulyandSeptember2017,theTrusthassetouttheirviewsonpotentialscenariosforthefuture.

NodecisionhasbeenmadeonthefutureofEpsomandStHelierUniversityHospitalsNHSTrust.SuttonclinicalcommissioninggroupwillworkwithlocalcommissionerstodevelopaformalprocesstoconsiderthefutureofservicesatEpsomandStHelierUniversityHospitalsNHSTrust,andotherissuessuchastheirestate,andhowtheywillbeabletodeliversustainableservicesforthelocalpopulation.Commissionersandthelocalsystemarefullycommittedtoconsultationwiththepublicifthisprocesssuggestssignificantchange.

TheSuttonLocalTransformationBoardwillcontinuallyevaluatethequalityofservicesacrosscommunity,primarycare,mentalhealthandhospitalservices.

Our progress so far – one year on LocalSuttonhealthandcareserviceshaveseensignificantimprovementsoverthelastyear.Highlightsinclude:

ExtendedHoursGPAccess.SuttonCCGcommissionedthelocalGPFederation,SuttonGPServices,toprovideprimarycareservicesfrom8amto8pm,sevendaysaweek,fromtwohubs(OldCourtHouseSurgeryandWrytheGreenSurgery).Theservicedeliversmorethan1100


additionalappointmentsaweek,hasalowDNArateandaveryhigh(90%)patientsatisfactionrate.

EnhancedCareinCareHomes.BuildingonthesuccessoftheSuttonHomesofCareVanguardthemainpillarsofserviceimprovement(stafftraining,careplanning,medicinesreview)havebeenextendedfromnursinghomestoresidentialhomes,allowingmorecarehomeresidentstoaccesstheimprovementsdeliveredbytheVanguard(areductioninnon-electiveadmissionsof20%andareductioninlengthofstayinhospitalsperadmissionofaroundfourdays)

SuttonHomesofCareVanguard–redbag.Weworkedwithcarehomes,theAmbulanceService,socialservicesandhospitalstoprovidemorejoinedupcaretopeoplelivingincarehomes.Nowwhenacarehomeresidentneedsanemergencyhospitaladmissiontheyaretransferredwitha“redbag”whichcontainstheirhealthandsocialcareinformation,theirmedicinesandpersonalbelongings.The“redbag”pathwayhasimprovedpatientcareandcommunicationbetweenthehospitalandthecarehome.Ithasalsohelpedimprovethedischargeprocessandresultedinreducedlengthofstayinhospitalby4days.Increasedmultidisciplinaryworkingandtraininghasledtoasignificantreductioninunnecessaryambulancecalloutsandhospitaladmissions.Theservicehasreceivednationalacclaimandsupport.

Musculo-SkeletalPathway(MSK).SuttonCCGhasimplementedanewMSKpathwaythatensuresallpatientsaccessurgentphysiotherapyassessmentandtreatmentinadvanceofanydecisionaboutsurgicalintervention.Thisensuresthatpatientshavetherapeuticsupportassoonaspossible,reducingpainandmorbidity,aswellasensuringonlyappropriatepatientsgoontorequirehospitalservices.Thishasresultedinasignificant

reductionofpeopleneedingsecondarycarereferalsandtreatmentwithawaitingtimereducedfrom9to4weeks.Significantsavingshavebeenreleasedtobeinvestedelsewhereinservices

ChildrenandAdolescentMentalHealthServices(CAMHS).Respondingtoanincreaseinidentifiedneedintheborough,SuttonCCGhasworkedwiththeLondonBoroughofSuttonandSouthWestLondonandStGeorge’sMentalHealthNHSTrusttoincreasetheresponsivenessofCAMHSservices.ThishasincludedincreasedhoursofseniorpsychiatricCAMHSliaisonsupportattheStHelierEmergencyDepartmentandincreasednursesupporttotheSinglePointofContactreferrallineformulti-agencyreferrals.Theservicewillbereviewedtowardstheendof2017/18toseehowtheoverallserviceconfigurationcanbeaddressedtodeliverservicesatthetimesandplacesneededbypatientsandfamilies.

Newprimarycareestates.WearebuildingtwonewpracticesinSutton,oneatSouthSutton(thesiteoftheformerHendersonhospital)andthesecondatHackbridge(aspartofanewresidentialdevelopment).

SocialPrescribing.WorkingwiththeLondonBoroughofSuttonandlocalvoluntaryandthirdsectorproviders,SuttonCCGhasledthedevelopmentandimplementationofasocialprescribingpilot(usingtheHealthyLondonPartnershipframeworkanddefinitionofsocialprescribing).Startingwithonepractice,thepilothasbeenusedtodemonstratethataGPcanusealimitednumberofwell-establishedthirdsectorproviders(startingwiththeCitizen’sAdviceBureau)toreferapatientforspecificsupportandtracktheoutcomesforthepatient.Oncethepilotiscomplete,itisexpectedthatthesocialprescribingreferralprocesswillberolledoutacrossSutton(firstlywithonepracticeineach


locality,thenincreasednumbersineachlocality,untilthereiscomprehensivecoverage).

HealthChampions.SuttonCCGandtheSuttonCentreforVoluntaryServiceshavedevelopedahealthchampionsprojecttodevelopandtrain30localpeopletosignpostpatientstoappropriatehealthservices.TrainingstartedinSeptember2017andchampionswillbeinplacefromOctober2017throughtoMay2018.

Developing Local Health and Care Plans TheinformationcontainedinthissectionwillbeusedaswedevelopourLocalHealthandCarePlanbetweennowandJune2018.


12. SOUTH WEST LONDON-WIDE IMPROVEMENTS


Health Promotion and Prevention

Healthpromotionistheprocessofenablingpeopletoincreasecontrolover,andtoimprove,theirhealth.Itmovesbeyondafocusonindividualbehaviourtowardsawiderangeofsocialandenvironmentalinterventions.

Healthpromotionanddiseasepreventionprogrammesaredesignedtokeeppeoplehealthy.Healthpromotionengagesandempowersindividualsandcommunitiestoengageinhealthybehaviours,andmakechangesthatreducetheriskofdevelopingchronicdiseasesandothermorbidities.Whilediseasepreventionfocusesonpreventionstrategiestoreducetheriskofdevelopingchronicdiseasesandothermorbidities.

MembersoftheHealthandCarePartnershipinSouthWestLondoncoverallaspectsofhealthaswellasinfluencethewiderdeterminantsofhealth(suchaseducation,employment,housing,healthyhabitsinourcommunitiesandsocialconnections)andbyworkingtogetheronasmallnumberofprioritiescanmakeasignificantdifferencetogether.

TheSouthWestLondonHealthandCarePartnershiphasthereforemadeajointcommitmenttochampionchildrenandyoungpeoples’mentalhealthandwell-beingasasharedhealthpromotionandpreventionpriority.Thisisbecause:

Nationally,weknowthat50%ofallmentalhealthproblemsareestablishedbytheageof14,rising

to75%byage24.Oneintenchildrenaged5-16hasadiagnosablementalhealthcondition,suchasconductdisorder,anxietydisorder,attentiondeficienthyperactivitydisorder(ADHD)ordepression.Wealsoknowthatweneedtoimprovecareforyoungpeoplewitheatingdisorders.

AcrossSouthWestLondonweknowthat:

• Suttonhasalargerthanaveragenumberofchildrenwhoself-harmcomparedtootherLondonboroughs.Therateofadmissionforself-harminSuttonhasbeenincreasingyearonyearandatafasterratethanmostadjacentboroughs.

• InRichmondself-harminthoseaged10-24years,equatestothe4thhighestrateinLondon.Thehighestratesofself-harmrelatedA&Eattendancesandhospitaladmissionsareinfemalesaged15-24years,mostlyduetoself-poisoning(92%).Increasinglevelsofself-harmisanissueineachofourBoroughs.

• TheprevalenceofseverementalillnessinCroydonissignificantlyhigherthanthenationalaverage,butsimilartoLondon.Admissionsformentalhealthconditionsforunder18sishigherthanLondonandnationalaverages.

• KingstonhasoneofthehighestestimatedprevalenceratesforbothEatingDisordersandADHDintheolderagegroup(16-24).

We will strengthen our focus on prevention and on keeping people well, and

will take into account that the greatest influences on people’s health and

wellbeing are factors such as education, employment, housing, healthy habits


• ChildadmissionsformentalhealthinWandsworthwerehigherthaninLondonandEngland.

• Mertonhasthesecondhighestrateofchildmentalhealthadmissionscomparedtocomparativeboroughs(122.7per100,000,equivalentto56admissions,2014/15).ThisisthehigherthantheaverageforEngland(87.4per100,000)andLondon(94.2per100,000).

WewillworktogetherasaHealthandCarePartnershipsothatcollectivelywesupportchildrentohavethebeststartinlife.

Ourjointfocusonchildrenandyoungpeoples’mentalhealthandwell-beingwillnotdetractfromtheexcellenthealthpromotionandpreventionactivities,thattakeplaceineachofourhealthandcareorganisationsineachBoroughincludingstoppingsmoking,alcoholandobesity.AswedevelopLocalHealthandCarePlanswewillidentifytheyearoneactionswewilltakeandtheactionsthatindividualorganisationswilltaketoimproveourcareforchildrenandyoungpeoplewithmentalhealthneeds.


Cancer

Oneinthreeofuswillbediagnosedwithcancerinourlifetime.Fortunatelyhalfofthosewithcancerwillnowliveforatleasttenyears,whereasfortyyearsagotheaveragesurvivalwasonlyoneyear.ButcancersurvivalisbelowtheEuropeanaverage,especiallyforpeopleagedover75,andespeciallywhenmeasuredatoneyearafterdiagnosiscomparedwithfiveyears.Thissuggeststhatlatediagnosisandvariationinsubsequentaccesstosometreatmentsarekeyreasonsforthegap.

ThenationalIndependentCancerTaskforcehasproducedahelpfulreport(AchievingWorldClassCancerOutcomes-AStrategyforEngland2015-2020)inwhichitsetsoutsixprioritiesthatcouldsave30,000livesintheUKayearby2020.Thesearearoundprevention,earlydiagnosesandtreatment,andabetterexperienceforpatients:

• Aradicalupgradeinpreventionandpublichealth

• Anationalambitiontoachieveearlierdiagnosis

• Establishpatientexperienceonparwithclinicaleffectivenessandsafety

• Transformourapproachtosupportpeoplelivingwithandbeyondcancer

• Makethenecessaryinvestmentsrequiredtodeliveramodern,high-qualityservice

• Ensurecommissioning,provisionandaccountabilityprocessesarefit-for-purpose

TheFiveYearForwardViewsettheoverallgoalsandoutcomesforCancer,theseinclude:

• Significantlyimprovingone-yearrelativesurvivaltoachieve75%by2020forallcancerscombined(upfrom69%currently)

• Patientsgivendefinitivecancerdiagnosis,orallclear,within28daysofbeingreferredbyaGP

AcrosssouthwestLondon:

• CancerisoneofthetopthreecausesofprematuredeathacrossallsixsouthwestLondonCCGs

• ThereisapredictedincreaseinprevalenceofcanceracrosssouthwestLondonduetotheageingpopulationandmorecomplexcareneeds.

• Uptakeforbreast,bowelandcervicalscreeningacrosssouthwestLondonisgenerallybelownationalaveragesandthereissignificantvariationacrossCCGs,withourbreastscreeningratesbetween33%and53%(againstanationalaverageof67%)andourbowelscreeningratesbetween68%and93%(againstanationalaverageof85%)

• PatientexperienceinCancerservicesisgenerallygoodinsouthwestLondon,withanaverageoverallpatientsatisfactionscoreof8.75outof10*.HoweverthereisvariationandimprovementrequiredaroundpatientsfeelingsupportedbyGPsandnursesduring

We are committed to improving cancer survival rates, ensuring that more

people are diagnosed and treated earlier and that we provide the highest

quality of care and support for people living with and beyond cancer


theircancertreatment.(*NationalCancerPatientExperienceSurvey,2016).

• Overthelastyear,thereweresignificantimprovementsacrosssouthwestLondoninthenumberofpeoplereceivingadefinitivediagnosisandtreatmentforcancerwithin62daysandworkcontinuestoachieveandmaintainthis.

LocalpeoplehavetoldusabouttheirviewsandexperiencesofCancerservices.Wehavelistenedtotheseviewsandhaveadaptedourplansandprioritiesgoingforwardtoreflectwhattheyhavesaid.Thefullsummaryofwhatpeoplehavesaidisinsection7.Insummary,thecommonthemesacrosssouthwestLondonareexplainedbelow:

• Localpeopletoldus…thatgettinganearlydiagnosisisreallyimportantinordertoavoidtheneedformoreaggressiveformsoftreatmentandtoimprovetheirchancesofgettingbetter.Peoplevaluedscreeningprogrammesandfeltthattheyworkedwellforthemostpart,butmorecouldbedonetoreachallpartsofourdiversecommunity.OncediagnosedpeoplefeltthattheNHSprovidesexcellentclinicalcare.However,furthertrainingcouldbegivenarounddeliveringnewssensitively.Whilstpeoplevaluedthespecialisttreatmenttheyreceived(forexampleattheRoyalMarsden)manyfeltthattheywouldpreferhavingalloftheirtreatmentinoneplace–ratherthangoingbetweensites.PeoplealsofeltthattheirGPcouldplayagreaterroleintheirfollow-upcare–signpostingthemtoothersupportandofferingcancerreviewsthatcouldpickupontheirphysicalandmentalwellbeing.

OverthenexttwoyearswehavesetthefollowingprioritiestoimproveCancercareandservices:

Improving screening and early diagnosis Wewillimprovetheuptakeofcancerscreeningtestssothatmorepeoplearediagnosedearlierandthereforehaveearlieraccesstotreatment.Weknowthatearlierdiagnosisofcancersignificantlyimprovessurvivalrates.

AcrossSouthWestLondon,bowelscreeningratesarelowerthanthenationalaverageandthereissignificantvariationacrossCCGs.Bowelcancerscreeninginvolvesatesttolookforhiddentracesofbloodinstoolsandaimstodetectbowelcanceratanearlystagebeforesymptomsdevelop.

WewillworktogethertoimprovetheratesofbowelcancerscreeningthroughimplementingaBowelCancerScreeningCommunicationService.ThisservicewillworkwithCCGs,CancerResearchUKfacilitators,MacmillanGPs,existingscreeningservices,GPpracticesandtheirstaff,totelephonepeopledirectlyandtotalkthemthroughthebowelscreeningprocess;whyitisimportantandaddressanyconcernstheymayhave.TheservicewillworkcloselywithGPpracticesandtheirstaffinordertoensuretheyareengagedandsupportedtoencouragepeopletoundertakethebowelscreeningtest.ThiswillbeaservicedeliveredacrosssouthwestLondonandnorthwestLondonacrossacombinedpopulationof3.6millionpeopleandwillbelaunchedfromJanuary2018.

Clinicalcommissioninggroupswillcontinuetodriveimprovementsinscreeningratesforbreastandcervicalscreeningbypromotingtheseteststopatientsandthepublicthroughthenational“BeClearonCancer”campaigns.

InKingston,wearetestingwaysinwhichtotargetcancerscreeningforpeoplewhomaynoteasily


accessthetests,inparticularpeoplewithlearningdisabilities.

Cancer waiting times Theincreasingandageingpopulation,andmorepeoplecomingforwardforinvestigativetestsmeansthatthehealthcaresystemneedstoenablequickeraccesstotherightdiagnosticservicesandtreatmentwhenitisrequired.

AllhospitalTrustsacrossSouthWestLondonwillcontinuetoworkinpartnershiptoensurethatmorepeoplehavetimelyaccesstodiagnosisandtreatment.Specificallywewillfocuson:

• Improvingcarefromdiagnosistotreatmentforprostatecancerpatientsbyprovidingfasteraccessandensuringmoretestsareprovidedinafewernumberofhospitalvisits.Thiswillalsohelppatientstoaccessdiagnostictestsmorequickly.ThisisbeingtestedatStGeorge’sHospitalandStHelierHospital.Ifsuccessful,thiswillberolledoutacrossotherhospitalsinsouthwestLondon.

• ReviewingwheretreatmentsareprovidedacrosssouthwestLondonforpeoplewithheadandneckcancerssothattheycanaccesscareclosertohome,quickly.

• Speedingupdiagnostictestsandbiopsiesforpeoplewithsuspectedlungandcolorectalcancerssothatclinicianscaninterpretthetestsquicklyandthatpatientscanreceivetheirresultsandstarttreatmentsooner.

• Improvinghospitalsystems,processesandcommunicationsbetweencliniciansandcancermultidisciplinaryteamstoensureminimaldelays,thatpatientsareadequatelyreviewedandthattheircareisplannedforappropriately.

• Improvingtheprocessesforpatientsstartingtheircancercarewithonehospital,butrequiringfurtherspecialisttreatmentatanotherhospital,sothatdelaysandlatereferralsareminimised.

Supporting people living with and beyond cancer Everyonewhogetscancerisdifferent,andthecareandsupportpeopleneedtolivewithacancerdiagnosiswillbedifferenttoo.Wewanttoacceleratesupportavailableforpeopleaffectedbycancertoliveashealthyandashappylivesaspossible.

Wewillimprovethesupporttopeoplelivingwithandbeyondcancerthrough:

• Puttinginplaceafollow-upprogrammeforprostatecancerpatients.Thisisaprogrammeforpatientswhohavehadsuccessfultreatmentforprostatecancer,andwhoseconditionisstablefortwoormoreyears.GPsandpracticenurseswillregularlyfollow-upcareandmonitorpatientssothattheydonotneedtoattendhospitalforunnecessaryhospitalappointments.ThisprogrammeisalreadyinplaceinCroydonandSuttonandhasbeenshowntoimprovecareandpatients’experience.WeplantorollthisoutacrosssouthwestLondon.

• Rollingouta“RecoveryPackage”.Overthelastfewyears,theNHSacrosssouthwestLondonhasworkedtoimplementthe‘RecoveryPackage’thatmakessuretheindividualneedsofallpeoplegoingthroughcancertreatmentandbeyondaremetbytailoredsupportandservices.TheRecoveryPackageisaboutthepatientandtheirlead


clinicianworkingthroughthecareandsupportthepatientwillneedoncetheirhospitaltreatmenthasfinished.Thepackageissharedwiththepatient’sGPandwillexplainthetreatmenttheyhavereceivedinhospital,thesupporttheywillneedoncethepatientisathome,andincludetheoptionofattending‘healthandwellbeingevents’.

• PatientswillbeofferedanannualcancercarereviewwiththeirGPaftertheirtreatment.Thiswillincludeaconversationregardingtheperson’shealthandmentalwell-beingneeds.

ThisiscurrentlyinplaceinWandsworthandRichmondandwewillimplementthisacrossallotherCCGsoverthenexttwoyears.

• Trainingourprimarycarenursestobettersupportpeoplewithcancer-Overthenext2years,wewillputinplaceaMacmillanPrimaryCareNursingLeadershipteamtoworkacrosssouthwestLondontodevelopnursesandequipthemwiththeexpertiseandconfidencetobettersupportpeoplelivingwithandbeyondcancer.


Mental Health

TheNHSFiveYearForwardViewforMentalHealthsetsoutthe‘must-dos’fortransformingandimprovingmentalhealthcareandstatesthat“TheNHSneedsafarmoreproactiveandpreventativeapproachtoreducethelongtermimpactforpeopleexperiencingmentalhealthproblemsandfortheirfamilies,andtoreducecostsfortheNHSandemergencyservices”.Itoutlinesthat:

“Mentalhealthproblemsarewidespread,attimesdisabling,yetoftenhidden.PeoplewhowouldgototheirGPwithchestpainswillsufferdepressionoranxietyinsilence.Oneinfouradultsexperiencesatleastonediagnosablementalhealthprobleminanygivenyear.Peopleinallwalksoflifecanbeaffectedandatanypointintheirlives,includingnewmothers,children,teenagers,adultsandolderpeople.MentalhealthproblemsrepresentthelargestsinglecauseofdisabilityintheUK.“

InsouthwestLondon,weknowthat:

• Weneedtodomorearoundpreventionandearlyintervention,tohelpkeeppeoplewellandgetthemthesupporttheyneedasearlyaspossible

• WeneedtoimprovesupportforpeoplewithLongTermConditions,whosementalhealthisoftennotdealtwith,ordealtwithseparatelyfromtheirphysicalhealthneeds.

• Weneedtoprovidebettercareforbothyoungpeopleandadultsexperiencingamentalhealthcrisis,includingalternativestoadmissionandimprovedpathwaysforthosepeoplewithamentalillnesswhoareremovedfromapublicplacebyeitherthepoliceorbymedicalservices(knownasthes136pathway),andensuringpeopleexperiencingfirstepisodesofpsychosisreceivetimelytreatment

• Weneedtoprovidebettersupportforthe3-5%ofwomenwhoexperiencemoderatetoseverementalhealthproblemsduringtheperinatalperiod

• Weneedtoimprovesupporttopeopleatriskofsuicide

• LocalpeoplehavetoldusabouttheirviewsandexperiencesofMentalHealthservices.Wehavelistenedtotheseviewsandhaveadaptedourplansandprioritiesgoingforwardtoreflectwhattheyhavesaid.Thefullsummaryofwhatpeoplehavesaidisinsection7.Insummary,thecommonthemesacrossSouthWestLondonareexplainedbelow:

• Localpeopletoldus…thattheywereworriedthatnotenoughmoneyisbeinginvestedinmentalhealthservicesinordertomeetthegrowingdemand.Peoplefeltthatmoreshouldbedonetoprovide24/7crisissupportforadultsandchildrenwithmentalhealthconditionsandtheirfamilies–theyagreedthatAccidentandEmergencyServicesarenotthebestplace

We are committed to improving how we prevent, support and care for people

experiencing mental health problems and make sure we treat their physical

and mental health together


toreceivethiscare.Itwasalsofeltthatweneedtosupportpeopletomaintaintheirhealthandwellbeingsotheydon’treachacrisispoint.PeoplefeltthatthereisstillalackofparitybetweenthetreatmentofphysicalillnessandmentalhealthillnessbytheNHS,withphysicalhealthconditionstreatedbeforementalhealth,orwiththeconditionsbeingtreatedcompletelyseparately.Parentstoldusthattheyfoundithardtonavigatethesystemandknowwheretofindhelp-morecouldbedonetosignpostthemtolocalsupportservicesandhelptheirchildrentransitionsmoothlytoadultservices.


Improving care for children and young people

50%ofallmentalhealthproblemsareestablishedbytheageof14,risingto75%byage24.Oneintenchildrenaged5-16hasadiagnosablementalhealthcondition,suchasconductdisorder,anxietydisorder,attentiondeficienthyperactivitydisorder(ADHD)ordepression.Mostchildrenandyoungpeopledonotgetenoughsupportforthisand,forthosethatdo,facelongwaitingtimes.Wealsoneedtoimprovecareforyoungpeoplewitheatingdisorders.Toaddressthiswewilltakethefollowingactions:

• ChildrenandyoungpeoplewithadiagnosablementalhealthconditionwillreceivetreatmentfromanNHS-fundedcommunitymentalhealthservice.ThenationaltargetfortheNHSofreachingatleast70,000morechildrenandyoungpeopleannuallyfrom2020/21isexpectedtodeliverincreasedaccessfrom25%to35%ofthosewithadiagnosablecondition.

• By2020/21themajorhospitalsinsouthwestLondonwillhavementalhealthliaisonteamsinplaceinemergencydepartmentsandin-patientwards.Thefundingwillbeusedtoincreasethenumberofhospitalswherechildrenandyoungpeoplewillhaveaccessto24/7crisisresolutionandliaisonmentalhealthservices.

• ChildrenandyoungpeoplewillhaveaccesstoanimprovedneurodevelopmentalpathwaybyApril2019/2020.Thepathwaywillberedesignedwithparentstoimproveassessmentandwillofferindividualsupportforparentsaswellaspeergroupsupport.

• Wewillspeedupthetimeittakesforchildrenandyoungpeoplewithaneatingdisorderto

receivetreatment,seeingthemajorityofthosewithurgentneedswithinoneweekofreferralandallotherswithinfourweeksofreferralinlinewithNationalAccessandWaitingTimestandards.

• Wewillinvestincommunitybasedeatingdisorderteamstoreducetheneedforchildrentobeadmittedintospecialistin-patientwards.

• SouthwestLondonmentalhealthnetworkiscurrentlyreviewingthefuturementalhealthworkforcewithanexpectationofrecruitingnewspecialiststaffandputtingpackagesinplacetoretainourexpertstaff.

Improving prevention and early intervention • Peoplewithacommonmentalhealth

problem,suchasanxietyanddepression,willreceiveearlyintervention.Wewilldothisthroughexpandingtalkingtherapyservices,withaparticularfocusonensuringthattalkingtherapiesareintegratedintocareforpeoplewithlongtermconditionstoensuretheirmentalhealthneedsaremetalongsidetheirphysicalhealthcareneeds.Wearealsolookingathowtoincreaseaccesstohighqualityinformationonline,throughmakingbestuseoftheLondon-wideGoodMindswebsite

• Wewillincreasethenumberofphysicalhealthchecksweoffertopeoplewithsevereandenduringmentalhealthinprimarycare,andinsecondarycarementalhealthsettingssothattheyhavebetterphysicalhealth.

• SpeedingupdiagnosisandtreatmentforpeoplewithDementia.Peoplesuspectedofhavingdementiawillbediagnosedandstart


treatmentwithinsixweeksofreferralforexampleSouthWestLondonandStGeorge’sMentalHealthNHSTrustarereviewingtheirmemoryservicessothatpeoplecanbeseenandtreatedfaster.

• LocalAuthoritiesareputtinginplaceupdatedsuicidepreventionplansbytheendof2017.TheseplanswillincludeworkingwithGPstosupportthemtoidentifythoseatriskofsuicide.Planswillalsoincludeactivitiessuchasworkingwiththerailandrivernetworkstoreduceaccesstomeansofsuicide.

• WewillalsoremainengagedwiththeThriveLondonProgramme,andbuildonthislocallytopromoteaconversationaboutmentalhealthwithourpopulation.

• Weareseekingnationalfundingsothatwomenexperiencingmentalhealthproblemsduringtheperinatalperiodwillbesupportedbynewspecialistperinatalcommunitymentalhealthteams,withphasedimplementationfromApril2018.Thesenewteamswillsupportwomenandtheirfamilies,andworkwithotherhealthcareprofessionalstoprovideeducationandtrainingaroundperinatalmentalhealth.

Improving support and services for people in mental health crisis

• Wewanttomakesurethatpeoplewhoarebeingtreatedinanin-patientserviceareasclosetotheirhomeaspossible.Wearereviewingallourpatientswhoarereceivingtreatmentoutoftheirlocalareatoplantoseeifwecanmovepeopletoaserviceclosertohome.

• Hospitalswillhave24hourpsychiatricliaisonservicesinplacetoensurethatpatientswithamentalhealthcrisisareseenbytheappropriateexperts.ThisisalreadyinplaceinSt.George’s,CroydonwillbeinplacebyDecember2017andKingstonandEpsom&St.HelierbyApril2018.

• Subjecttofullpublicconsultation,anewpan-Londonpathwayforpatientsexperiencingmentalillnesswhoareremovedfromapublicplacebyeitherthepoliceorbymedicalservices(section136)willbeimplementedin2018sothatpeopleexperiencingamentalhealthcrisisaretreatedinhighqualityservice.

• Wewillreviewourcommunitymentalhealthservicestounderstandhowwewillmeettheneedsofpatientsinthefutureandmeetnationalstandards.AnexampleofthisisunderstandingtheadditionalcapacityneededtoensurethatallCrisisResolutionHomeTreatmentTeamscandelivercare24/7.

• Wewillimproveourserviceforpeopleexperiencingafirstepisodeofpsychosisbyputtinginplacemoreexpertcarewithintwoweeksoftheirepisode.


Urgent and Emergency Care

UrgentandemergencycareinsouthwestLondonismadeupofanumberofcomplementaryparts:NHS111;improvedaccesstoGPpractices,theLondonAmbulanceService;UrgentTreatmentCentres,AccidentandEmergencydepartments(A&E)aswellashospital,communityandsocialservices.

InsouthwestLondon,A&Eattendanceshavestabilisedoverthelastfewyearswithfewerpeaksandtroughsthanwereseeninthepast.Despitethis,performanceagainstthe4hourA&Estandardhasdeterioratedwhichislikelytobeduetoincreasednumbersofverysickpatientsaswellascomplexandvariableprocessesinhospitalsystems.EmergencyadmissionsintohospitalshaveinturnincreasedacrosssouthwestLondonyearonyear.Between2012and2017,therehasbeenalmosta50%increaseinthenumbersofpeopleadmittedtohospitalinanemergency.TherearealsomanypatientsstayinginhospitallongerthanisnecessarywhichaffectsflowresultinginlessbedsavailableforsickpatientscomingintoA&E.Theonlyhospitalthathasmanagedtoconsistentlymeetthe4hourtargetisEpsom&StHelier;thelearningfromtheimprovementstheyhavemadeisbeingsharedacrossSWL.

SouthwestLondon’sdemandontheLondonAmbulanceServicehasalsorisensteadilyoverthelast4yearssince2013affectingtheirabilitytorespondtopatientsquickly.Despitethis,wehaveseenthehighestperformanceofresponsetimestoCategoryAcallsinLondon,whichistoreachemergencycalls.Thissectionoutlineshowwewillimproveinalltheseareasoverthenexttwoyears.

• LocalpeoplehavetoldusabouttheirviewsandexperiencesofUrgentandEmergencyCareservices.Wehavelistenedtotheseviewsandhaveadaptedourplansandprioritiesgoingforwardtoreflectwhattheyhavesaid.Thefullsummaryofwhatpeoplehavesaidisinsection7.Insummary,thecommonthemesacrossSouthWestLondonareexplainedbelow:

• Localpeopletoldus…thattoomanypeopleuseAccidentandEmergency(A&E)becausetheycan’tgetanappointmentwiththeirGPortheydon’tknowwhereelsetogo–veryfewpeoplehadheardofNHS111.Peoplethoughtthatevenwithclearinformation,itwouldbehardtochangepeople’sbehavioursandtheiruseofA&E,andsuggestedthatinsteadweconsiderco-locatingotherservicesinA&Edepartments.PeoplefeltthatA&Eserviceswerealreadyoperatingabovecapacityandthatchangingthenumberofsiteswouldonlyexacerbatetheproblems.Concernswerealso

We are committed to improving services for people when they are at their

sickest and are in need of urgent or emergency care ensuring that, for those

with non-life threatening but urgent needs they are treated as close to home as

possible, and for those with more serious or emergency needs that they are

treated in centres with the very best expertise and facilities, in order to

maximise their chances of survival and a good recovery.


raisedaboutdischargefromhospital–somepeoplebeingdischargedlateatnightwithproblemsoccurringbecausecarepackageswerenotinplacewhentheygothome.ItwasfeltthattheNHSneedstoworkmorecloselywithlocalauthorities.

Accessing urgent healthcare in the most appropriate place Wewanttohelpourresidentsaccessthemostappropriateurgentcarefortheirneedsasnotonlywillthisreducethepressuresonouraccidentandemergencydepartments,itwillalsoenablepatientstohavebetterhealthoutcomesbyhelpingthemtostayathomeandaccessingthemostappropriateservicesmorelocally.

Thereareanumberofwaysthatwewillachievethis:

• Weareintroducinganextended111servicetohelpourresidentsreceivethemostappropriatehealthcare.Itwillbethefirstpointofcallforpatientstoaccessurgentcareservicesprovidingaccesstoadvice,onwardreferralincludingappointmentsanddirectbookingintootherhealthservices.Thisnewservicewillbeinplaceduring2018.

• Wearedevelopinga111onlineservicewherepatientscanentertheirsymptomsandreceivespecificadviceontheirhealthneedsoracallbackfromahealthcareprofessionalsothatweofferanincreasinglypersonalised,andfasterexperiencetopatients.

• Wewillemploymorecliniciansinournew111servicesothatoverhalfofour111callsarehandledbyaclinicianbyMarch2018.Thiswillmeanthatmorepatientsgetafullresponseto

theirconcernswithouttheneedtoseekfurtherhelp.

• WehaveheardourresidentstellusthattheyarefrustratedwhentheycannotgetaGPappointment.ToresolvethisissuewehavealreadyprovidedmoreGPcapacityineachofourboroughstoensurethatourresidentscanaccessGPservicesfrom8am-8pm,7daysaweekatoneoftheGPhubsthatexistineachborough.Intotal,wehavecreatedmorethan15,000additionalappointmentspermonth.WeareontracktoopentwoadditionalhubsinCroydonbytheendof2017.Thisadditionalcapacitywillsupportpeopletoaccessprimarycarewhentheyneedit,andweareworkingtoimprovethelinksbetweenprimarycarecapacityandotherpartsofthesystem.Forexample,wearepilotingasystemsothatwhenpeoplecall111,theycanbebookedanappointmentdirectlyinprimarycare.WearealsoimplementingsystemssothatstaffinA&Edepartmentscanbookpatientsprimarycareappointments,ifthisisthebestplaceforthemtobeseen.ThiswillgoliveatStGeorge’sHospitalbyDecember2017.

• WewillcontinuetoworkwiththeLondonAmbulanceService(LAS)toreducethenumberofpatientsusingtheirservicesinappropriatelysothatitisavailableforthepatientswhoreallyneedanemergencyresponse.Everyclinicalcommissioninggrouphasputinplaceservicesthatmeeturgentcareneeds,suchasmulti-disciplinaryteamrapidresponseforolderpatientswhohavefallenathomeandcanbehelpedtosafelyremainathome.LAScanquicklyreferpatientstotheseservicesratherthantakethemtoAccident&EmergencyDepartments.

• Weknowthatitissometimesconfusingforresidentstounderstandwhaturgentcare


servicesareprovidedwhere.TohelpresolvethiswearereviewingcurrenturgentcareservicesacrosssouthwestLondonsothattheymeetthenewLondonspecificationforUrgentTreatmentCentres.UrgentTreatmentCentreswillcovereverythingthatusedtobedonebyMinorInjuriesUnits,Walk-InCentresandUrgentCareCentres.UrgentCareCentresarecurrentlyalreadyinplaceatCroydonHospital,StHelierHospitalandStGeorge’sHospitalandanewUrgentCareCentreopenedatKingstonHospitalinNovember2017.OuraimisforallfourUrgentCareCentrestobedesignatedasmeetingtheUrgentTreatmentCentresservicespecificationbytheendof2017.Overthenexttwoyears,wewillalsoagreeandimplementfutureplansforurgentcareservicestobeprovidedatQueenMary’sRoehamptonMinorInjuriesUnit,ClaphamJunctionWalk-InCentreandTeddingtonMemorialHospital.

• Whereanemergencyhasresultedina999callforanambulancewewillimplementanewwayofassessingpatientsandsendingambulancestooursickestpatients.TheAmbulanceResponseProgrammewillensureearlyrecognitionoflife-threateningconditions,particularlycardiacarrest.Anewsetofquestionswillbeaskedsothatwhenyoudial999thosepatientsinneedofthefastestresponseareidentified.Newnationallysetresponsetimeswillfreeupmorevehiclesandstafftorespondtoemergencies.Forastrokepatientthismeansthattheambulanceservicewillbeabletosendanambulancetoconveythemtohospital,whenpreviouslyamotorbikeorrapidresponsevehiclewould‘stoptheclock’butcouldnottransportthemtoAccident&Emergency.Fromnowonstrokepatientswillgetto

hospitaloraspecialiststrokeunitquickerbecausethemostappropriatevehiclecanbesentfirsttime.

Improving urgent and emergency services • Someurgenthealthconditionscanbetreated

withouttheneedforanovernightstayinhospital.Thisiscalledambulatoryemergencycare(AEC)andinsouthwestLondonallourhospitalsoffersomeAECservices.ThisisaserviceforpatientswhowouldotherwisehaveneededtostayinhospitalbutwithAECcanreceivespecialisthelpandreturnhomethesameday.WewillexpandAECdeliveryacrosssouthwestLondontoensurethattheyareopen14hoursaday,sevendaysaweek.StGeorge’sisseekingtoexpanditsAECUnittoincreasetheiropeninghoursto16hoursadayeveryday.

• TheNHSconstitutionmandatesthat95%ofpatientswhoaccessemergencyservicesathospitalshouldbeseenwithin4hours.Oneofourhospitals,EpsomandSt.Helier,hasconsistentlyachievedthistargetandwewillsharelearningsacrossprovidersinsouthwestLondontodeliverybestpracticeforhospitalflowandpatientreviewsothatallourhospitalsseeallpatientswithin4hours.

• SouthwestLondonhospitalsconsistentlylooktoimprovehowtheycarefortheirpatients.Theyarecurrentlyworkingtoimplementbestpracticetoensurethatpatientsaresupportedtogetwellasquicklyaspossible.Thisisreferredtoasthe“SAFERbundle”andmeansthatpatientswillhaveareviewbyaseniorclinicianbeforemidday,allpatientswillbegivenanexpecteddateofdischargesoonafteradmission,patientswillbeadmittedasearly


aspossibleinthedayfromtheassessmentunitsandwillbedischargedbeforemiddaywhereverpossible.Wherepatientsstayinhospitalformorethansevendaystheywillbeassessedbyamulti-disciplinaryteamwithaclear“homefirst”mind-set.TheSAFERbundleaimstogetpatientstotherightplaceassoonaspossible,includinghome,toavoidunnecessarydelayswhichleadtopoorerhealthandsocialoutcomesforpatients.OurintentionacrosssouthwestLondonisthatallhospitalwardswillhaveimplementedtheSAFERbundleduring2018.

• Allofourhospitalscurrentlyhave24hourall-agepsychiatricliaisonservicesandwearenowworkingtowardshavingenhancedservicestoensurethatpatientswithamentalhealthcrisisareseenbytheappropriateexperts.ThisisalreadyinplaceinSt.George’s,CroydonwillbeinplacebyDecember2017andKingstonandEpsom&St.HelierbyApril2018.

Improving discharge and support after hospital Werecognisethatsometimesweareunabletodischargepatientswhoaremedicallyfitorwhonolongerneedtobecaredforonahospitalwardandthatthismayhaveanadverseimpactontheiroverallhealth.Thiscouldsometimesbehelpedbyorganisationswho,together,haveresponsibilityforapatient’scareworkingmorecloselytogether.Wewillcontinuetoworktogethertoenhanceservicesinthecommunityincludingproactivemanagementforthemostcomplexpatients,ensuringgoodcrisisresponseandonfacilitiestoprovideintermediatecare,sothatpatientscanbedischargedassoonastheyarewellenoughto

leavehospital.ThisworkisbeingundertakenbyourfourLocalTransformationBoards.Thereareanumberofwaysthatwewillreducethelevelsofthesedelayeddischarges:

• ToensurethatpatientsdonotspendanylongerinhospitalthantheyneedtonewlocalityteamswillbeestablishedacrosssouthwestLondon.Thesenewteamswilloffermultidisciplinarysupportbothtopatientswithalongtermconditionandalsothosewhoaredischargedfromhospitalandneedadditionalsupport.Aspartoftheseteamstherewillbe‘inreach’teamswhoactivelygointohospitalstoensurethatpatientswhoarereadytogohomearenotdelayed,freeingupvitalbedspaceandalsoensuringthatpatientsdon’tspendanylongerinhospitalthannecessary.

• NHScontinuinghealthcare(CHC)isafreepackageofcareforpeoplewhohavesignificantongoinghealthcareneeds.Delaystoassessmentsbeingcarriedoutcanleadtodelaystofundingandcarebeingreceivedbythosewhoneeditmost.TochangethisacrossSouthWestLondonwewill:

• ReducethenumberofCHCassessmentscarriedoutinhospital(byusingDischargetoAssess)sothat,byMarch2018only15%ofallCHCassessmentswillbecarriedoutinhospital,areductionfromthecurrent47.4%acrossSouthWestLondon.

• IncreasethespeedwithwhichwecarryoutCHCassessmentssothat,byMarch2018,80%ofassessmentswillbecarriedoutwithin28daysofreferral.Thiswillbeanimprovementagainstthecurrent42.4%.

• Coupledwiththeabove,wehavebeenworkingacrosssouthwestLondontoensurethatbothhealthandsocialcareservices,includingcommunitynursing,rapidresponse


andearlysupporteddischargeservicesareavailablesevendaysaweek.Sevendayserviceswillhelpensurethatpatientsare

dischargedfromhospitalassoonastheyareable,andshouldnotbedelayedbecauseitistheweekend.


Primary Care

GeneralPractice,andotherprimarycareservicesarethefirstpointofcontactapersonhaswiththehealthservice,andareessentialtodeliveringexcellenthealthcare.Primarycareservicesensurewetreatpeopleinthebestplaceandthattheyonlygotohospitalwhentheyabsolutelyneedto.

Wehaveanumberofchallengesingeneralpractices(GP):

Increaseddemandforservices,duetoagrowingandagingpopulationwithincreasingfrailtyandhealthneed.

• Extendingtheservicesofferedthrough,oralongside,primarycareofferstheopportunitytoprovideagreaterrangeofintermediate/complexcareco-ordinatedthroughapatient’sGPpracticeandinaplaceclosertohome.Inordertofulfiltheambitiontooffermoreservicesinprimarycare,workforceandotherimplicationswillneedtobeconsidered.

• WhilstmostofourGPpracticesperformwelltherearesomewhichneedtobeimproved.ThevariationinthewayprimarycareisdeliveredacrossSWLresultsinvaryingpatientexperienceandoutcomes.

• WehavemanystaffvacancieswithalargenumberofGPsandnursesapproachingretirement(insouthwestLondon21.8%ofGPsand39%ofnursesareovertheageof55).

• Someofourprimarycareestateisoutdatedandnotfitforpurpose;thereisalargevarianceinpremisesincosts,sizeandqualityacrosssouthwestLondonandsomepotentiallyunder-utilisedspace.

• Weknowthatwewillneedadditionalcapacity,particularlyinhighgrowthareassuchasCroydonandNineElms,Vauxhall.

• Wecoulddomoretousetechnologytosupportbothpatientsandourprimarycarestaff.

OurprimarycareprioritiesinsouthwestLondonarefocusedondeliveringthekeyaimssetoutintheGeneralPracticeForwardView,andarealsoinformedbythepublicationfromNHSEnglandLondonregion:StrategicCommissioningFrameworkforPrimaryCare,whichsetsout17specificationstodeliveraccessible,coordinatedandproactivecareinprimarycare.

LocalpeoplehavetoldusabouttheirviewsandexperiencesofGPservices.Wehavelistenedtotheseviewsandhaveadaptedourplansandprioritiesgoingforwardtoreflectwhattheyhavesaid.Thefullsummaryofwhatpeoplehavesaidisinsection7.Insummary,thecommonthemesacrosssouthwestLondonareexplainedbelow:

• Localpeopletoldus…thattheystruggletogetanappointmentwithaGPandthat,ideally,theywouldlikeconsistencysothattheycanbuildtrustandnothavetorepeattheir

We are committed to ensuring that general practice is accessible and co-

ordinated with community and social care services. This will mean people

receiving the right care closer to home so that they can live healthy and

independent lives for as long as possible.


stories.Peopleoftenfeltlikereceptionistswereputinthepositontobegatekeepers.Ingeneralpeopleacceptedthatotherhealthcareprofessionals,suchaspharmacists,couldplayabiggerroleinprimarycare,butthatmorewouldneedstobedonetoraisepublicawarenessandbuildconfidenceintheirskillsandroles.Manypeople,includingcarers,saidthattheyfindthehealthsystemdifficulttonavigateandwelcomednewroles,suchascarenavigators,particularlyiftheirjobincludespatientliaisonandsupportforbothpatientsandcarers.

Ourfocusoverthenexttwoyearswillbe:

Improving access to GP practices and services Wehavealreadymadesurelocalpeoplehavegreateraccesstosamedayappointments8am-8pm,sevendaysperweek.Wewanttofurtherimproveaccesstoourprimarycaresothatpeoplecanbeseenbythehealthcareprofessionalwhocanbestmeettheirneeds.

Improving the quality of our primary care services Weareworkingwithindividualpracticestostrengthentheirservices.PracticeswhowouldmostbenefithavebeenidentifiedacrossSWLandwillreceivetailoredsupport.Examplesofsupportinclude:

• Tailoredinvestmentandresourcetosolveindividualissuese.g.recruitmentofkeystaff,premisesrelocation,clinicalaudit

• Peersupportaroundtheworkforcetosupportpractices:toreviewandplanstaffing,improverecruitment,andintroducenewinitiativessuchasnursementorship

• Supportingpracticestostreamlineback-officesystems

• ITsupport–practiceleveltrainingandsupportonITandclinicalsystems

Ensuring that we have enough primary care staff in the future GeneralPracticefacesunprecedenteddemandandinLondonitisestimatedthat20%ofpatientsconsulttheirGPforwhatisprimarilyasocialproblem(LowCommission,2015).Overthenexttwoyears:

• Weareworkingtoextendourprimarycareworkforce.WeareseekingtoincreasethenumberofGPsworkingwithinGeneralPracticethroughactivitiestosupportretention,suchasmentoringandpeersupportprogrammes,aswellasexploringinternationalrecruitment.Wearealsoincreasingthenumberofphysicians’associates,clinicalpharmacists,medicalassistantsandcarenavigatorsthatwehavewithingeneralpractice.InthefuturesouthwestLondonresidentswillhaveagreaternumberandrangeofpeoplewhocanprovidecare,referralandadviceworkinginaprimarycareteam.

• SupportimplementationofhighimpactactionsthathavebeenidentifiedasincreasingtheabilityofGPs,nursesandotherpracticestafftoimprovecareanddevelopservices

• SupportimplementationofGPNurse10pointplan.Thisisanationalactionplanwhichaimstoincreasethenursingworkforcewithin


generalpracticeinresponsetotherisingdemandbyattractingnewrecruits,supportingexistinggeneralpracticenurses,andencouragingreturntopractice.

• WeareintroducingsocialprescribingwhichsupportsprimarycarebyofferingGPsreferralandsupportoptionsforpeoplewithpredominantlysocialneeds.Forexample,wearecurrentlypilotinganumberoflink-workerrolesinsomeGPpracticesinsouthwestLondon,forexampleforcancersurvivorsinKingston.Link-workerstalktopatientsandagreea‘socialprescription.Thisisaplanthatmeetstheirsocial,emotionalorpracticalneeds,oftenusingnon-clinicalservicesprovidedbythevoluntaryandcommunitysector.

Improving care through the use of technology Generalpracticesalreadyusetechnologytocareforpatientsandtohelpthembewell-organised.Wewanttoincreasetheuseoftechnologytohelppatientsaccesstheircaremoreeasilyandtohelphealthcareprofessionalsofferbettercare.Forexample,wewillincreasetheopportunitiesforpatientstouseonlineservicestoaccesshealthadvice,tobookandcancelappointments,tocontacttheirGPandtomanagetheirprescriptionsandhealthrecord.FurtherinformationonourplansisgivenintheHarnessingTechnologysection.


Maternity

y

In2016/17therewerearound19,000birthsinSouthWestLondon.AsignificantproportiononmothersinSouthWestLondonareovertheageof35yearsold.Thisishigherthanthenationalaverage.

InSouthWestLondonweknowthat:

• TheCareQualityCommission’snationalmaternitysurveyin2015indicatedthatSouthWestLondonperformedinthelowestquartileforwomen’sexperienceofmaternityservices.

• Thestillbirthrateper1,000livebirthsinsouthwestLondonwas4.9%.Thisislowerthanthenationalaverageandthereissomevariationacrossourclinicalcommissioninggroups.

• 5.4%ofwomensmokeatthetimeofgivingbirth,comparedtoanationalaverageof12%

Localpeoplehavetoldusabouttheirviewsandexperiencesofmaternityservices.Wehavelistenedtotheseviewsandhaveadaptedourplansandprioritiesgoingforwardtoreflectwhattheyhavesaid.Thefullsummaryofwhatpeoplehavesaidisinsection7.Insummary,thecommonthemesacrosssouthwestLondonareexplainedbelow:

• Localpeopletoldus…thattheircarewouldbeimprovediftheyhadthesamemidwifethroughouttheirmaternityjourney.Theyfeltthatnotonlywouldthishelpthemtobuildtrustandhaveconfidenceintheircare,itwouldalsoenablethemidwifetogettoknowthemandpickuponthesoftersignsoftheirphysicalandmentalwellbeing.Peoplewantedtobeempoweredtohavemorechoiceintheirmaternitycare.However,somequestionedwhatchoicereallymeantandwhetheritextendedpassedwhathospitalstheygavebirthin.Aboveall,peopletoldusthattheirsafety,andthesafetyoftheirchildwasofparamountimportance.Peoplewanthighqualityandconsistentcarethroughouttheirpregnancy,birthandpost-birth,tailoredtotheirculturalandclinicalneeds.

WeareworkingtoensurethatallmaternityservicesacrosssouthwestLondon:

• Preparewomenandtheirpartnersforpregnancy,labour,birthandparenthoodthrougheducationandup-to-date,evidence-basedinformation

• Providecaretowomenasindividuals,withafocusontheirneedsandpreferences

We are committed to improving maternity services so that women have choice

about where to have their baby, that every woman has access to information

to enable her to make decisions about her care; and where she and her baby

can access support that is centred around their individual needs and

circumstances


• Investinimprovingcontinuityofcareandcarer,withastrongemphasisonmidwifery-ledcarefornormalpregnancyandbirth

• Providecarewhichmeetshighclinicalqualitystandardsforallwomenandtheirbabies

• Valueandtakeonboardfeedbackfromwomen,theirfamiliesandthelocalcommunitytodrivecontinuousimprovementinthequalityofcare

Overthenexttwoyearsourfocuswillbeon:

Supporting choice and personalisation of maternity care Wewantwomentofeelpositiveabouttheirexperienceofcarewhentheyarepregnantoriftheyhavejusthadababy.Wewillachievethisby:

• Makingsurethatmostwomenseethesamemidwifeorteamofmidwives,throughouttheirmaternitycare.Weexpecttoachieveimprovedclinicaloutcomesasaresultofmidwifery-ledcontinuityofcarer;reducedepisiotomiesorinstrumentalbirths,increaseinspontaneousvaginaldeliveryandanincreaseinbirthsinmidwiferyunitsorathome.

• EnsuringwomenandfamiliesfeelmoreinformedaboutthechoicesavailableinmaternityservicesacrossSouthWestLondonsothattheycanmakemoreinformeddecisionsabouttheircare.WehavestartedthisbypilotingMyMaternityJourneyinSWLwhichsummarisesalltheservicesavailabletowomenwhentheyarepregnantaswellasprovidingconsistentinformationaboutwhattoexpectfrommaternityservicesduringandafterpregnancy.Weplantomakethis

availabletoallwomenacrossSWLaswellasdevelopingthisintoaweb-basedresource.

• Trainingandcoachingmidwives,GPandotherhealthprofessionalsinvolvedindeliveringmaternitycaretoimprovetheconversationstheyhavewithwomenandfamilies,sothattheyunderstandthechoicesthatareavailabletothemandthattheyareabletomakeinformeddecisionsandtakecontroloftheirmaternitycare,forexample,keepinghealthyduringpregnancyandmakingthechoicesthatarerightfortheirneeds.

• Helpingwomenaccessmaternityservicesearlier.

Improving perinatal mental health SouthwestLondondoesnotcurrentlyhaveaspecialistperinatalcommunitymentalhealthserviceandweneedtoprovidebettersupportforthe3-5%ofwomenwhoexperiencemoderatetoseverementalhealthproblemsduringtheperinatalperiod.Weareseekingnationalfundingsothatwomenexperiencingmentalhealthproblemsduringtheperinatalperiodwillbesupportedbynewspecialistperinatalcommunitymentalhealthteams,withphasedimplementationfromApril2018.Thesenewteamswillsupportwomenandtheirfamilies,andworkwithotherhealthcareprofessionalstoprovideeducationandtrainingaroundperinatalmentalhealth.Additionally,wearecommittedtoensuringthatallwomenwhomayrequireemotionalsupportduringandafterpregnancycanaccesstherightlevelofcare,throughimprovingsignpostingtoservicessuchasaccesstopsychologicaltherapiesormorespecialistsupportthroughspecialistmidwiferyteams.


11.6.3Improvingsafetyofservices

Wearecommittedtodeliveringthenationalambitiontoreducetheratesofmaternaldeaths,stillbirths,neonataldeathsandbraininjuriesthatoccurduringorsoonafterbirthby20%by2020and50%by2030.AllofourmaternityprovidersarefullyengagedinthedevelopmentsandimplementationofthenationalNHSImprovementMaternalandNeonatalhealthsafetycollaborativeoverthenexttwoyears.Thisprogrammewillhelphospitalsmakeimprovementstothesafetyoftheirmaternityservicesbyassessinglocalservicesanddevelopingspecificactionplansforimprovementsineachhospital.

AllourorganisationswillcontinuetoinvestigateandlearnfromincidentsandsharethislearningthroughtheLocalMaternitySystemwhereallprovidersarerepresented.

Toreducevariationinthequality,safetyandexperienceofmaternityservices,weareimprovingthewaywemonitorthequalityandsafetyofmaternityservicesacrosssouthwestLondonsothathospitalsandcommissionersunderstandwherethereisbestpracticeaswellasthoseareasrequiringimprovement.Asetkeyofmeasureshasbeenagreedandthiswillbe

developedintoafullmaternityqualityandsafetyframeworkforsouthwestLondon.

Improving post-natal care Thecarethatwomenandtheirbabiesreceiveaftertheygivebirthhasasignificantimpactonthelifechancesandwellbeingofthewoman,babyandfamily.FeedbackfromwomenandfamiliesinsouthwestLondonisthatourpostnatalcareneedsimproving.Weareimprovingthewaytheprovidepostnatalcarefocusingonthecontinuityofmidwiferycarer,developingpersonalisedcareplans,reviewingandmakingthepostnatalcarepathwaymoreconsistentacrosshospitals,andensuringwehavetherightstaffinplacetoprovidethatcareincludingMaternitySupportWorkers.

Duringwinter2017furtherworkwillbeundertakentodefineadditionalactionstodeliverthesouthwestLondonvisionformaternityservices.


Improving care for people with Learning Disabilities and/or Autism

In2011theDepartmentofHealthledareviewintheimmediateaftermathoftheexposureofseriousabuseofpatientswithlearningdisabilitiesatWinterbourneViewhospital.TheGovernmentandleadingorganisationsacrossthehealthcaresystempledgedtoimprovecareandsecurebetteroutcomesforallpeoplewithlearningdisabilitiesand/orautismandbehavioursthatchallenge,byshiftingservicesawayfromlearningdisability/mentalhealthhospitalinstitutionalcaretowardscommunity-basedsettingsandreducerelianceonin-patientbeds.

Localpeoplehavetoldusabouttheirviewsandexperiencesoflearningdisabilityservices.Wehavelistenedtotheseviewsandhaveadaptedourplansandprioritiesgoingforwardtoreflectwhattheyhavesaid.Thefullsummaryofwhatpeoplehavesaidisinsection7.Insummary,thecommonthemesacrossSouthWestLondonareexplainedbelow:

• Localpeopletoldus…thatdoctors,pharmacistsandreceptionistsneedmoretraininginhowtheyspeaktopeoplewithLearningDisabilities.Peoplewithlearningdisabilitiestoldusthattheywantdoctorstospeaktothemandnottheircarers,andforinformationtobesenttotheminEasyReadformatorexplainedtotheminperson.Peoplefeltverystronglythatannualhealthchecksareveryimportant–butnotroutinelyoffered.TheyfeltthatallGPsshouldbeawareofthem

andshouldofferthemtoallpatientswithaLearningDisability.

Thenationalplan,“BuildingtheRightSupport”document(October2015)supportedthecreationof48TransformingCarePartnershipsacrossEngland.InApril2016,SouthWestLondonTransformingCarePartnershippublishedourplanonhowwewouldrealisetheaimsofprogramme.Overthenexttwoyearswewill:

• Workwithpatientsandtheirfamiliestoreducethenumberofpeoplelivinginalearningdisabilityormentalhealthinstitutionbytransferringpatientsintoacommunitysetting

• Ensurethatstaffaretrainedinpositivebehaviouralsupport(PBS)sothatstaffcaringforpeoplewithlearningdisabilitiesand/orautism,withbehavioursthatchallenge,canassess,preventandrespondtoincidentsofchallengingbehaviour.Thiswillminimiseescalationofissuesandreduceharmtothepatient(s)andothers.

• WewillseektoimprovesouthwestLondoncrisismanagementsupporttoprovidepatientswithaplacetostayduringcrisis,wheretheycanbesupportedbyexpertstaff,inasafeenvironment,withtheaimtosupportthepatienttomovebackintothecommunity.Thiswillalsoreduceadmissionsandre-admissionsintolearningdisabilityormentalhealth

We are committed to transforming services for people with learning disabilities

and/or autism so that they are supported in the community to live fulfilling and

independent lives


institutionsandalsoofferaplaceofrespiteforfamilies,atatimeofcrisis.

• WorkwithHealthEducationEnglandtodevelopaworkforceplansothatwehavetherightstaff,withtherightskills,tomeettheneedsofpeoplewithlearningdisabilitiesnowandinthefuture.

• Usetheinformationgainedfromourhousing/accommodationneedsanalysis,

todevelopahousingplantosupportcurrentandfutureaccommodationneedsofpeoplewithlearningdisabilitiesand/orautism,withbehaviourthatchallenges.


Children and Young People

Initially,ourchildren’sprogrammesarefocusedontwoareas:improvingsupportforthosewithamentalhealthneedandensuringthatweenhanceoursupportforchildrenwhoneedurgentandemergencycare.LocalTransformationBoardsthroughtheirlocalhealthandcareplanswillidentifylocalprioritiesforchildrenandyoungpeople.

InsouthwestLondon,weknowthat:

• Weneedtodomorearoundpreventionandearlyintervention,tohelpkeeppeoplewellandgetthemthesupporttheyneedasearlyaspossible

• Weneedtoprovidebettercareforbothyoungpeopleexperiencingamentalhealthcrisis,includingalternativestoadmissionandimprovedpathwaysforthosepeoplewithamentalillnesswhoareremovedfromapublicplacebyeitherthepoliceorbymedicalservices(knownasthes136pathway),andensuringpeopleexperiencingfirstepisodesofpsychosisreceivetimelytreatment

• Weneedtoimprovesupporttopeopleatriskofsuicide

Localpeoplehavetoldusabouttheirviewsandexperiencesofchildrenandyoungpeopleservices.Wehavelistenedtotheseviewsandhaveadaptedourplansandprioritiesgoingforwardtoreflectwhattheyhavesaid.Thefullsummaryofwhatpeoplehavesaidisinsection7.Insummary,thecommonthemesacrossSouthWestLondonareexplainedbelow:

• Localpeopletoldus…thattheysupportedtheideaofreducingthenumberofunnecessaryvisitstoA&E.However,itwasfeltanxiousparentsoftendonotthinkthereisaflexible,highqualityalternative.ImprovingaccesstoGPswasthereforeconsideredtobefundamentaltoreducingthenumberofchildrenunnecessarilyinA&E.Peoplefeltthatmoreneedstobedonetosupportchildrenandyoungpeoplewithmentalhealthconditions.Diagnosisneedstobequicker,andmoreneedstobedone,insideandoutsideschools,toprovideearlysupportandpreventconditionsfromescalating.Itwasfeltthatthewaitingtimestoreceive

• supportthroughCAMHSweretoolong,theprocessisconfusing,andthethresholdsforsupportaretoohigh.

Concernswerealsoraisedaboutthetransitionbetweenchildandadultmentalhealthservices–peoplefeltthatorganisationsneedtoworkbettertogetherinordertobettersupportpeoplethroughthischange.

Assetoutinandearliersection,wehaveidentifiedchildrenandyoungpeople’smentalhealthasourPartnership’shealthpromotionandpreventionpriorityforthenexttwoyears.Thiswillbuildontheworkalreadyunderwaytotransformchildrenandadolescentmentalhealthserviceswhichwillensurethat:

We are committed to helping children have the best start in life and to

supporting children as they develop into adults


• Childrenandyoungpeoplehaveaccessto24/7crisisresolutionandliaisonmentalhealthservices

• Theneurodevelopmentalpathwaywillbeenhancedtoimproveassessment

• Wewillspeedupthetimeittakesforchildrenandyoungpeoplewithaneatingdisordertoreceivetreatment

Wherechildrenandyoungpeopleneedurgentandemergencycarewewillensurethattheyandtheirparents/carerscanaccessthemostappropriateservicesthattheyrequire,asclosetohomeaspossiblethrough:

• AccesstourgentcareadviceanddirectbookingtoprimarycareandurgentcarefacilitiesifrequiredthroughNHS111.Thismayincludeadvicetovisitapharmacistforself-care.Forthosewithmoreseriousconditionsrequiringtheinputfromaspecialist

children’sdoctorornurses,theywillbereferredtotheappropriatehospitalservices

• AccesstoextendedaccesstoGPs,8am-8pm,7daysperweek

• Accesstourgenttreatmentcentresasrequired

• Improvedaccesstoambulanceservicesforthemostlifethreateningconditions

• Improvedaccesstohospitalcareforthemosturgentandemergencycarewhereinputfromspecialistchildren’sdoctorsandnursesarerequired

• Improvedservicesinthecommunityforchildrenandyoungpeopletoavoidunnecessarystaysinhospital,particularlywithlongtermconditionssuchasasthma


Workforce

OurhighlyskilledpeoplethatmakeupthecombinedNHSandsocialcareworkforcewithinsouthwestLondonareessentialtothedeliveryofhighqualitycareandtransformationofservices.

Inthe“LondonWorkforceStrategicFramework”theHealthyLondonPartnershipstatethat“Thehealthandsocialcaresystemisfacingmanychallenges.Greaterdemandonservicesisfuelledbyanincreasinglyagedandfrailpopulation,whilstpatientexpectationofservicescontinuestogrow.Growingdemandcontinuestoputpressureoncurrentservices,increasingcostsandthedemandsontheexistingmedicalandnon-medicalhealthandsocialcareworkforce.Itiswidelyrecognisedthatservingthisgrowthindemandisnotsustainable,ifwecarryonthewayweworknow.Achangeinapproachisneededifwearetodelivertheconsistenthighqualityofcarepatientsexpectnowandinthefuture.”

InsouthwestLondonwehaveover25,000peopleworkingacrossthementalhealth,primarycare,community,andhospitalsettingsandafurther29,000jobswithinsocialcare.TogetherthemembersofthesouthwestLondonhealthandcarepartnershipfaceanumberofstaffingchallenges:

• Newmodelsofcareandinitiativestomeetpatientandpublicneedswillcontinuetoneedtobedeveloped,andtodeliverthesenewmodels,changestoworkforcenumbers,skillsandwaysofworkingarelikelytoberequired

• WithinsouthwestLondonourworkforcechallengesareaccentuatedbyhighercostsof

living,availabilityofaffordablehousingaswellasthecompetitionfortalentedstaff

• RecruitingandretainingstaffacrosssouthwestLondonisachallengeforus,andnationallythereisashortageofsomequalifiedprofessionsincludingGPs,seniorandmiddlegradehospitaldoctors,nurses,paramedics,specialistchildren’sdoctorsandsocialcarestaff

• ManyoftheworkforcewhotraininLondonsubsequentlychoosetomoveaway,andwecertainlyexperiencehealthcareprofessionsleavingsouthwestLondonwithinafewyearsofqualifying

• WhilstwedonothaveanimmediatechallengewiththenumberofGPsandprimarycarenursesinsouthwestLondon,thereareasignificantnumberthatarenearingretirementagewhichwillcreateanissueforusinthenearfuture(insouthwestLondon21.8%ofGPsand39%ofnursesareovertheageof55)

• StaffturnoverisrecognisedasbeinghigherinLondonthaninotherregions

Weknowthat,ifdemandforourservicescontinuestoriseandwecontinuetodelivercareinthesameway,withoutfocussingonourpeoplewemaynothaveenoughstafftodeliverthecarethatisneeded.

Localpeoplehavetoldusabouttheirviewsaboutourworkforce.Wehavelistenedtotheseviewsandhaveadaptedourplansandprioritiesgoingforwardtoreflectwhattheyhavesaid.Thefullsummaryofwhatpeoplehavesaidisinsection7.

We are committed to making South West London a great place to work so

that we attract and keep our excellent staff.


Insummary,thecommonthemesacrosssouthwestLondonareexplainedbelow:

• Localpeopletoldus…thatweneedtodomoretoencouragestafftostayinsouthwestLondon.PeoplefeltthatGPsandnursescanbeoverworkedandunderpaid.Peopletoldusthatweneededtolookafterourstaffbetter.Peopletoldusthat,inthesamewaythatweneedtolookafterourstaff.Itwasfeltthatweshouldbetryingtorecruitpeoplefromdiversebackgroundssothattheycanrelatetotheculturalneedsoflocalpeople.Itwasfeltthatmoreinvestmentwasneededtotrainourstaff–particularlyontheir‘bedsidemanner’andinhowtheytreatpeoplewithdifferentneeds(forexamplepeoplewithmentalhealthconditions,childrenandyoungpeopleorpeoplewithlearningdisabilities).

Overthenexttwoyearswewillworktogetherto:

• Makesurewehavetherightnumbersofstaff,intherightroles,withtherightskillstoprovidesafeandeffectivecarenowandinthefuture:througheffectiverecruitmentandworkforceplanning.Specificactionsinclude:

• ImprovinglocaluptakeoftheCapitalNurseinitiative.CapitalNurseisaprogrammeofcollectiveactionfromemployersanduniversitiesinLondon,HealthEducationEngland,NHSEnglandandNHSImprovement.It’saimsare:toensurethecapitalhastherightnumberofnurseswiththerightskillstodeliverhighqualityperson-centredcare;andtomakeiteasierforemployerstorecruitandretainnurseswithinthecapital

• Developajointemployer‘offer’forsouthwestLondon,incorporatingacommonsetofcommitments

throughoutamemberofstaff’scareer-beforeandatthepointofjoining,inthefirstyear,developingtalent,andhelpingstafftoworkforaslongastheywantto

• Evaluatedifferentapproachestoflexibleworkingincludingpilotingself-rosteringinahospitalenvironment

• DevelopandsupporttheimplementationofsouthwestLondonWorkforcePlansforPrimaryCare(underway),MentalHealth(underway)andCancer(expectedin2018)

• Developingrecruitmentcampaignsthattargetpeoplefromdiversebackgroundssothatourorganisationsarerepresentativeofthecommunitiesweserve

• Helpingemployerstoworktogethertoimplementarangeofapprenticeshipschemestosupportpeopleintoemployment

• Makethebestuseofourscarceresources:collaboratingwhereitisrighttodoso:workhasalreadycommencedacrosshospitalsinsouthwestLondontoimplementthefirststageofajointstaff“bank”(a“bank”isagroupoftemporarystaffwhoworktofillshorttermgapsinrotas).The“bank”iscurrentlyavailableforstaffnursesandhealthcareassistantsinthreeNHSorganisations.Wewillexpandittocovermorestaffgroupsinmoreorganisations.

• Careforourstaff:supportingtheirhealthandwellbeing,havingahealthyworklifebalanceanderadicatinganybehavioursthatdiscriminate,harassorintimidate.Inadditiontoactionsthatindividualorganisationsare


takingintheseareasacrosssouthwestLondonwewill:

• SupportemployerstoprogressthroughtheGreaterLondonAuthorityHealthyWorkplaceCharterbackedbytheMayorofLondontomakeourworkplaceshealthierandhappierforourpeople.TheHealthyWorkplaceCharterisasetofstandardsthatorganisationsmeetinordertoreceiveanofficialaccreditation(andaward).Asleadingorganisationsinthepublicsectorwewillalsopromotethisinitiativeoutsideourorganisationsbecausethebenefitsfromsuchworkplaceinterventionswillnotonlyhelpemployersandtheirpeopleitalsohelpssocietyasahealthierworkingpopulationprovideshealthandeconomicbenefits

• Supportourpeopletodevelop:sharingbestpracticeandputtinginplaceshareddevelopmentsotheycancontinuallylearnandimprovetheirpractice.Specificactionsinclude:

• ‘Growingourown’seniornursesandAlliedHealthProfessionalsbyimplementingastructuredprogrammetoequipstaffwiththeskillsandknowledgetoprogressthroughthegradesfromjuniorpoststoseniorroleswithinsouthwestLondon

• WewillcontinuetoworkwithHealthEducationEngland,localacademicinstitutions

andeducationproviderstoensurethattheirtrainingprogrammesfitwithourchangingpopulationhealthneeds.Bydoingthiswewillhaveasustainableworkforcewiththerightskillsandcompetenciesthatarerightfortodayaswellasourpopulationsfuturehealthneeds

• Establisharangeoftrainingprogrammestobuildskillsinpreventionofmentalillhealthinotherchildrenandyoungpeople,suchasyoungpeople’shealthchampions,peersupport,communitynavigators

• Involveourstaffinimprovingservices:engagingourstaffwhoknowourservicesandpatientsbest,tohelpustransformandimprovethewaywework.WewillstrengthenclinicalleadershipandinvolvementacrosssouthwestLondonandlocalhealthandcarepartnerships.OverthenextfewmonthstheClinicalSenatewillreviewwhatclinicalleadershipandinvolvementmeansacrossSouthWestLondon,howwewilldevelopclinicalleadersandhowwewillreleasetheircapacitytolead

• WorkforceDirectorswillcometogetherinJanuary2018toreviewourworkforceprioritiesandplanstoensuretheyaresufficienttomeetourchallengesgoingforward,andtodiscusswhetherajoinedupapproachtoworkforceissuesacrosshealthandsocialcarewouldbebeneficial.


Harnessing technology

Technologyisacriticalenablerofmanyoftherecommendationsthatarebeingmadeinthisplan.Weknowthatsharinginformationbetweendifferenthealthandsocialcareservices,iskeytodeliveringmorejoined-upcare.Wealsoknowwecanusetechnologytosupportpatientstolookafterthemselvesandmanagetheirownconditionsandmonitorsymptomsremotely.

Localpeoplehavetoldusabouttheirviewsaboutouruseoftechnology.Wehavelistenedtotheseviewsandhaveadaptedourplansandprioritiesgoingforwardtoreflectwhattheyhavesaid.Thefullsummaryofwhatpeoplehavesaidisinsection7.Insummary,thecommonthemesacrosssouthwestLondonareexplainedbelow:

• Localpeopletoldus…thatitcanbefrustratingwhenyouhavetotellyourstoryoverandoveragaintodifferentpeopleandthattheywouldwelcomebettercommunicationbetweenGPs,communityservices,hospitalsandsocialcare(aslongastheirdataisusedconfidentially).ManypeoplevaluedexistingadvancesintechnologysuchastextremindersfromtheirGPsandtelephoneconsultations.Howeverpeoplefeltthatnewtechnologyshouldcomplement,notreplace,facetofaceappointments.Andwhilechildrenandyoungpeoplewelcomedtheideaofmoreonlinesupport,theyalsohadconcernsaboutwhethertheyhadenoughstorageontheirphonestousedifferentapps.

WeaspiretobeaGlobalDigitalExemplar.AGlobalDigitalExemplarisanNHSorganisationthatusesworld-classdigitaltechnologyandinformation.Exemplarswillsharetheirlearningandexperiencestoenableotherstofollowintheirfootstepsasquicklyandeffectivelyaspossible.

Wewillworktowardsapaper-freehealthandcarepartnershipsothatourfront-linestaffareabletoaccessinformationinasecure,timelyandreliablemanner.Thissupportseffectivedecision-makingtoimprovehealthoutcomesforpeopleanddeliverhighqualitycare.

Goingpaperlessisahighpriorityasourcontinueddependenceonpaperrecordsandmanualprocessesmeansthereisunnecessaryduplication,makescarelessefficientandriskspatientsafety.

ThefirststageonourjourneytobeingaGlobalDigitalExemplarwillbeourfoundationstage:creatingasolidinformationanddigitalplatform.Ourstageoneactionsareoutlinedbelow:

Wewillintroduce:

• E-consultations,onlineorusingamobileapp,sothatpatientscanseetheirGPorhealthandcareprofessionalratherthanattendingthepractice.

• Self-careappstotransformthewaypeopleengageinandcontroltheirownhealthcare,empoweringthemtomanageitinawaythatisrightforthem.

We are committed to using technology to be “electronic glue” which helps

health and care organisations work better together, enables our frontline staff

to provide the best care possible and enables people to make the best lifestyle

and health choices


• AnewElectronicReferralSystem(E-RS)toelectronicallyreferpatientstohospitalsandotherhealthcaresettingsfortreatment,diagnosisorcare.

• AsystemthatsupportsGPandotherhealthcareprofessionalstomakeclinicaldecisions,bygivingelectronicaccesstoexpertsinhospitalandothersettings.

• AccesstoGPrecordsforurgentandemergencycareclinicians,aswellasgivingGPsaccesstohealthinformationfromhospitals,sothattheverybestjoined-upcarecanbeprovidedtopatients.


Our buildings and estate

TheestateisakeyenablerofthesouthwestLondonHealthandCarePartnershipandthefutureestatewillneedtosupporthealthandsocialcareservicedeliveryandsustainabilitythroughprovisionoffitforpurposeandvalueformoneyaccommodationthat:

• EnsurethatourestatesupportsourLocalTransformationBoardLocalHealthandCarePlans;inparticularthatthereissufficientcapacityincommunityandprimarycaresettingstorelievepressureonacutesitesandprovideserviceslikeantenatalsupport,mentalhealthandsocialcareservices,deliversevendayservices

• Addressessignificantbacklogmaintenanceissuesonourmainhospitalsitesandensuresallbuildingschosentodelivertheagreedclinicalconfigurationarefitforthe21stcentury

• Re-shapesthementalhealthestatetomeetfutureservicerequirements

Thecurrenthealtheconomyestateacrossacute,community,primarycareandmentalhealthsettings(butexcludingthelocalauthorityestate)hasatotalestimatedannualrunningcostof£190millionperannum(excludingdepreciationandinterest)andcomprisesapproximately700,000m2offloorspace.Thereareanumberofissuessuchas:

• PrimarycareandcommunityservicesoperateformalargenumberofestatesacrosssouthwestLondon.Inanumberofcasesthismaynotbewelldesignedforhowwewanttodeliverservicesoutsideofhospitalsandwill

thereforerequireeitherupgradingorreplacing.ThiswillneedtobeinlinewiththeemergingnewhealthandcaremodelsbeingdevelopedbyLocalTransformationBoardsandwewilldevelopalongtermpipelinetodeliverlocalfacilities.Thismaymeanthatsomeservicesmovefromtheirexistinglocationbutwillstillbeaccessibletothelocalpopulation.Itmayalsomeanthatsomeservicesaremovedawayfromahospitalsettingintomorelocalfacilities.Wehaverecentlybidfor£10milliontosupportthesetypeofserviceschangesacrossCroydon.

Ourmajoracutehospitalsallrequiresignificantinvestmenttobringthemfullyupto21stCenturystandards.

- BothStGeorge’sHospitalandKingstonHospitalhaveidentifiedtheneedforadditionalcapitalsincetheSTPwasoriginallypublishedin2016followingrecentbuildingsurveys.Thesewillmodernisesubstantialelementsoftheexistingbuildings

- Croydonhaverecentlysubmittedabidofcirca£120milliontoNHSEnglandforsiterationalisationandmodernisation

- EpsomandStHelierUniversityHospitalsNHSTrustaredevelopingoptionsfortheprovisionoftheirexistingservicesandhavebegunengagingtheirlocalpopulationonthese.Thisisalongtermprojectwhichwouldrequireinvestmentupto£600millionwhichwillstretchbeyondthelifeofthisSTP

We are committed to improving our buildings so that we can deliver high

quality care from all South West London sites


TheoriginalSTP(publishedinNovember2016)estimatedthatweneeded£1.3billiontodeliverourplanstoimproveourbuildingsandestate.Wethinkthismayincrease.

Localpeoplehavetoldusabouttheirviewsonourbuildings.Wehavelistenedtotheseviewsandhaveadaptedourplansandprioritiesgoingforwardtoreflectwhattheyhavesaid.Thefullsummaryofwhatpeoplehavesaidisinsection7.Insummary,thecommonthemesacrosssouthwestLondonareexplainedbelow:

• Localpeopletoldus…thathospitalsitesandsomewardsshouldbeupgradedastheyareveryoldandneedtobebroughtuptomodernstandards.Peoplefeltthatthepoorenvironmentinhospitalwardscouldimpactpeople’smoodsandgeneralwellbeing.Peoplefeltthatsomehospitalsneededtoinvestmoremoneytomakesurethatwardsarekeptwarm,cleananddonothavestructuralissuessuchasleakingceilings.Peoplewantedthehospitalgroundstobemaintainedandnicegardensandplacestosit,theyfeltthatthiswouldhaveapositiveimpactontheirmentalhealth.Peopleappreciatedthenewlyestablishedcommunityhealthsettingssuchas

TheNelsonandJubileeCentreandlikedthattheynolongerneededtovisitaHospitalbutsomefeltthatascommunityservicesbecomebigger,thestandardofcaremaydeteriorateasmorepeopleusethem.

• WearedevelopingapipelineofschemesforsouthwestLondonwhichwilldevelopinlinewithLocalTransformationBoardLocalHealthandCarePlans.Whilewewillreleasefundstosupportthisfromthesaleofunwantedbuildingsweknowthatthiswillnotbesufficienttomeetourcapitalfundingrequirements.Wewillthereforeneedtosecureadditionalcapitalfunding.WhiletherewillbesomeNHScapitalfundsavailable,inthecurrenteconomicclimatethesemaybelimitedandthereforealternativefundingsourceswillneedtobeexplored.

• SouthwestLondonisplayingafullpartinthedevelopmentoftheLondonEstatesBoardwhichhasbeencreatedaspartofLondondevolutionprocessandwillworkwiththeBoardtoidentifyandsecuretherequiredcapitalstreamstohelpusrealiseourwiderplans.


12. SUPPORTING OUR LOCAL COMMUNITIES

Thegreatestinfluencesonourhealthandwellbeingarefactorssuchaseducation,employment,housing,healthyhabitsinourcommunitiesandsocialconnections.AssomeofthelargestemployersandorganisationswithinsouthwestLondon,werecognisetheimportantroleweplayinourlocalcommunitiesandeconomies.

Tosupportourlocalcommunitieswewill:

• Helplocalpeopleintoemployment,andtostayinemployment,bycreatingapprenticeshipsandsupportingemploymentofvulnerableindividualsinourorganisations

• Considerhowwecanbecomemoresustainableand‘green’organisationsandinparticularhelpreduceairpollution.Facilitatingmorepersonandenvironmentallyfriendlytraveloptionssuchaswalking,cyclingandusingpublictransport

• Contributetotacklingobesityanddiabetesthroughprovidingahealthyfoodenvironmentinourbuildings,forourstaffandourserviceusers,includinghealthycateringandvendingmachines

• Focusonhelpingourstafftokeephealthythroughpromotingpositivementalhealth,physicalactivityandexercise,maintainingagoodwork-lifebalanceandprovidinganenvironmentthatsupportshealthyeating


13. APPENDIX

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ClinicalqualitystandardsforacuteservicesprovidedinSouthWestLondonoroperatedby

aSouthWestLondonTrust

September2017

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Contents

1 Introduction.............................................................................................................................32 Scopeofthisdocument............................................................................................................42.1 Inscopeofthisdocument.............................................................................................................42.2 Outofscopeofthisdocument......................................................................................................43 ClinicalStandardsandConsultantWorkforceImplications.......................................................63.1 EmergencyDepartment(“ED”).....................................................................................................63.2 Obstetrics......................................................................................................................................83.3 Emergencysurgery......................................................................................................................103.4 Paediatrics...................................................................................................................................123.5 Acutemedicine............................................................................................................................173.6 Intensivecare..............................................................................................................................194 Clinicalinterdependencies.....................................................................................................214.1 InterdependenciesforanadultED.............................................................................................224.2 Interdependenciesforachildren’sED........................................................................................234.3 Interdependenciesforanobstetricunit.....................................................................................244.4 Implicationsofinterdependenciesforacuteservices.................................................................245 Workforceandtraininginterdependencies............................................................................26

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1 Introduction

The work underpinning this document was led by a Task and Finish Group, comprising theMedicalDirectorsofthefourSWLondon-basedAcuteTrusts,andwasapprovedbytheSWLondonClinical Senate on 28 September. The document begins by setting out the recommended clinicalstandards forsixacuteclinical services provided inSWLondonoroperatedbyaSWLondonTrustelsewhere (section 3). It then covers the key interdependencies between acute and supportingservices (section 4). Finally, section 5 covers the workforce and training interdependencies thatneedtobeconsidered.

It is intended tohelpeachLocalHealthandCare system, ledbya Local TransformationBoard, toassessitscurrentandlikelyfuturepositionagainsttheclinicalstandardsthathavebeencollectivelyidentifiedas key for acute service delivery. These clinical standards will support further work toensure that acute services in each local system are robust, able to provide the services that thesystemhas agreed are essential for acute service delivery, and to provide the specific acutesub-specialty services, supporting services and elective services that meet the local population’sneed.

We recognise that the acute standards set out here represent just one part of a wider clinicalmodel for SW London. In particular, demographic change means increasing demand resultingfrom more complex health needs and this requires all health and care providers, including thevoluntarysectorandlocalcommunities,toworktogetherindifferentways.

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2 Scopeofthisdocument

2.1 InscopeofthisdocumentThisdocumentfocusesonthekeyclinicalstandardsthatcontributetowardsimprovedpatientcare,safetyandexperience.Wehaveprimarilyfocusedonstandardsrelatingtotheconsultantworkforce,butwehavereferencedstandardsrelatingtootherkeystaffgroupswhereapplicable.Thedocumentsetsouttheconsultantstaffinglevelsthatarerequiredtomeetthestandards.Theserepresenttheminimumrequirementforconsultants,givenasufficientnumberofmid-grades.Iftherearemid-gradeshortagesthatcannotberesolvedthroughrecruitmentormitigatedthroughotherroles,thiscouldresultinahigherrequirementforconsultantsthanstatedinthisdocument.

2.1.1 ServicesinscopeTheSWLClinicalBoardidentifiedsixservicesaskeytothesustainabilityofacuteservicesandnotedthatthereweremanyinterdependenciesbetweentheseservicesandothersupportingservicesthatrequirefurtherconsideration:

• EmergencyDepartment• Obstetrics• EmergencySurgery• Paediatrics• AcuteMedicine• IntensiveCare

2.1.2 GeographicscopeTheclinicalstandardssetoutinthisdocumentshouldapplytoacuteservicesinSWLondonand/oroperatedbySWLondonTrusts.Hencethere iscurrentlynoexpectationthatthestandardsagreedherewillapplytoanyoftheservicesprovidedatsitesinSurreyDownsotherthanthoseprovidedatEpsomHospital.

The acute services listed above are currently provided on all five acute siteswithin SW London /operatedbySWLondonTrusts,exceptforemergencysurgery,whichisprovidedonfoursites:

• StGeorge’s• Kingston• Croydon• Epsom(noprovisionofemergencysurgery)• StHelier

Havingagreedwhichclinicalstandardsshouldbeapplicabletoeachservice,wehavedevelopedandagreed a set of workforce requirements to meet the clinical standards at a non-tertiary hospital(Croydon, Epsom, Kingston and St Helier), and at a tertiary hospital / major trauma centre (StGeorge’s).

2.2 OutofscopeofthisdocumentWe recognise that there are other areas that impact on clinical quality aside from the consultantworkforce.PreviousworkhasidentifiednursingshortagesanddelayedpatientdischargesasparticularissuesthatacuteTrustsshouldseektoaddress.Theseissueswillbetargetedthroughlocalinitiatives,

5

whileimprovementsinoperationalperformance,suchasReferraltoTreatment(RTT)and4-hourA&Eperformance,willbetargetedthroughtheSWLSustainabilityandTransformationPartnership(STP).

Althoughmid-gradestaffingisclearlyimportant,itisbeyondthescopeofthiswork.Thisisbecauseitisdifficulttocapturethedataaccuratelybecauseitchangessofrequently.However,itisimportanttonotethechallengesinstaffingmid-graderotas,whichcouldbemitigatedinfuturethroughbetterrecruitmentandretentionprocessesand/oralternativemodelsofcare.

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3 ClinicalStandardsandConsultantWorkforceImplications

3.1 EmergencyDepartment(“ED”)

3.1.1 ClinicalstandardstomeetinED1. Each ED in SW London or operated by a SW London Trust should meet 7 Day Clinical

Standards1,includingdiagnosticstandards:a. Hospitalinpatientsmusthavescheduledseven-dayaccesstodiagnosticservicessuch

as x-ray, ultrasound, computerised tomography (CT),magnetic resonance imaging(MRI), echocardiography, endoscopy, bronchoscopy and pathology. Consultant-directeddiagnostictestsandcompletedreportingwillbeavailablesevendaysaweek.Acutetrustsshouldmakeajudgmentthroughtheirclinicalgovernanceprocessesandindiscussionwiththeircommissionersregardingwhichdiagnosticteststheirpatientsrequireaccessto7daysaweekandwhetherthesearedeliveredonsiteorviaaformalnetworkedarrangement.Anetworkedapproachmayinvolvepatienttransfer,imagetransferordiagnosticianin-reachindifferingcircumstances

2. EDsshouldalsomeetthefollowingLondonQualityStandards(“LQS”)2:a. Aconsultant inemergencymedicine tobe scheduled todeliver clinical care in the

emergencydepartmentforaminimumof16hoursaday(matchedtopeakactivity),seven days a week. Outside of these 16 hours, a consultant will be on-call andavailabletoattendthehospitalforthepurposesofseniorclinicaldecisionmakingandpatientsafetywithin30minutes(Note:thisisthekeyclinicalstandarddeterminingtheconsultantstaffingrequirement)

b. A trained and experienced doctor (ST4 and above or doctor of equivalentcompetencies) inemergencymedicinetobepresentintheemergencydepartment24hoursaday,sevendaysaweek

3. EDsshouldmeetmandatoryoperationalstandards,inparticular:a. TheNHSConstitutionsetsoutthataminimumof95percentofpatientsattendingan

EDdepartmentinEnglandmustbeseen,treatedandthenadmittedordischargedinunderfourhours

b. AllhandoversbetweenambulanceandEDmusttakeplacewithin15minuteswithnonewaitingmorethan30minutes

4. EachEDshouldbeabletoachieveaminimumratingof‘Good’ineachoftheCQC’s5domains(especiallyKLOES4):

a. Staffinglevelsandskillmixshouldbeplannedandreviewed,sothatpeoplereceivesafecareandtreatmentatalltimes,inlinewithrelevanttoolsandguidance,whereavailable

5. EachEDshouldmeettheRCPstandardthatpatientsreferredforemergencymentalhealthcaremustbeseenwithin60minutes(Jan2014)

1NHS.UK,2017.NHSSevenDayServicesClinicalStandards.LastrevisedSep2017.https://www.england.nhs.uk/wp-content/uploads/2017/09/seven-day-service-clinical-standards-september-2017.pdf2LondonHealthProgrammes,2015.Acute,EmergencyandMaternityServices,LondonQualityStandards.LastrevisedNov2015.http://www.londonhp.nhs.uk/wp-content/uploads/2016/01/All-London-Quality-Standards-Acute-Emergency-and-Maternity-Services-Nov-2015.pdf

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6. Each ED shouldmeet TARN trauma standards, with additional standards to bemet by StGeorge’sataMajorTraumaCentre3.Inparticular:

a. CTimagingmustbeperformedwithin1hourofarrivalforpatientsmeetingtheNICEheadinjurycriteria

b. If thepatient isadmitteddirectly to theMTCor transferredasanemergency, thepatientmust be received by a trauma team led by a consultant in theMTC. Theconsultantcanbefromanyspecialty,butmustbepresentwithinfiveminutes

7. EveryEDmusthavecomprehensivefront-doorclinicalstreamingbyOctober201748. EveryEDmustaspiretohaving24-hour“core24”mentalhealthteamsbyMarch201919

3.1.2 ImplicationsforEDconsultantstaffinglevelsMedicalDirectorsofthefourSWLacutetrustsagreedthatthefollowingconsultantstaffinglevelsarerequiredtomeettheaboveclinicalstandardsandprovidesustainablecare.AsEDconsultantsseldomwork in areas outside of emergency medicine, Medical Directors felt that WTE was the mostappropriatemeasureofconsultantavailability.

3TheTraumaAudit&ResearchNetwork,2015.TARNCoreStandards.https://www.tarn.ac.uk/content/images/53/Standards%20used%20in%20reports.pdf4Urgent&EmergencyCareDeliveryPlan&Governance–presentationforEDDeliveryBoardChairsmeeting20thApril20175Basedonanassumed10PAsperWTE.TherequirementforWTEscouldbereducedifjobplansincludeahigherfigurethan10PAs

Hoursofconsultantcover

ConsultantWTE5

Reasonforrequirement

Minimumrequirementtomeetthestandards

16hours,7daysaweek

12 16/7coverisrequiredtomeettheLQSstandard.Analysisofpatientarrivaltimesalsosuggeststhatactivityvolumesarehighforaround16hoursperdayandjustifies16/7consultantpresence.

12WTEwouldallowfortwoconsultantstobeon-sitemuchofthetimeandthreeconsultantstobeonsiteatsomepeaktimes.Itwouldrequireconsultantstoworkatleast1in6weekends,assumingthelightestweekendmodel,withoneconsultantresidentattheweekendandanotherconsultantoncall.

Duetohighvolumesofactivity,therewilloftenbetheneedfortwoconsultantstoberesidentattheweekend,resultinginworking1in4weekends.

8

WealsorecognisethattheRoyalCollegehasfoundtheretobeanationalshortageinthenumberofregistrarsinED.Insomecases,thishasresultedinconsultantsonmid-graderotas,whichcouldinturnresultinanincreasedrequirementforconsultants.

3.2 Obstetrics

3.2.1 ClinicalstandardstomeetinObstetrics61. EachobstetricunitwithinSWLondonoroperatedbyaSWLondonTrustshouldmeet7Day

ClinicalStandards72. The Obstetrics Task and Finish Group’s consensus (Feb 2016) was that all obstetric units

shouldhave14/7on-unitconsultantcover8.(Note:thisisthekeyclinicalstandarddeterminingtheconsultantstaffingrequirement)TheservicesmayalsobefurtherconsideredinlinewithrecommendationsintheCumberlegereport.

3. Eachobstetricunitshouldbeabletoachieveatleastaratingof‘Good’intheCQC’s5domains(especiallyKLOES4):


4. Obstetric units should consider perinatal and antenatal mental health standards that arerelevantforworkforceplanning;however,thesedonotaffectconfiguration:

6TheemergingconclusionfromtheTaskandFinishGroupwasthatsitesotherthatStGeorge’s(which,asalargetertiarycentre,hasdifferentrequirements)requireaminimumof12WTEconsultantanaesthetiststocovertheemergencygeneralsurgeryandtraumarotasandaminimumof12furtherWTEconsultantanaesthetiststocovertheemergencyobstetricsrota.Thisconclusionhasnotbeenworkedthroughfully.ThenumberofadditionalconsultantanaesthetiststhatwouldberequiredtocoverelectivecaseswouldbedependentupontheworkloadateachTrust.7NHS.UK,2017.NHSSevenDayServicesClinicalStandards.LastrevisedSep2017.https://www.england.nhs.uk/wp-content/uploads/2017/09/seven-day-service-clinical-standards-september-2017.pdf8NHSEngland,2016.BetterBirths,ImprovingoutcomesofmaternityservicesinEngland,AFiveYearForwardViewformaternitycare.https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf

Requirementtomeetthestandardsandprovidesustainableworkingpatternsifactivityishigh(>100,000attendancesp.a.)

16hours,7daysaweek

12-16 Theexactrequirementwithinthisrangedependsonseveralfactors,e.g.thenumberofdirectclinicalcontactPAsineachconsultant’sjobplanandtherobustnessofthemid-gradestaffing.

Highvolumesofactivitymeanthattherewilloftenbetwoconsultantsormorerequiredtobepresent.Poorpatientflowexacerbatesthisneedaspatientsremaininthedepartmentuntillateatnight.

Requirementforamajortraumacentre

24hours,7daysaweek

24 SGH,asamajortraumacentre,requires24WTE(toenableittomeetthestandardsassociatedwiththeNHSbestpracticetariffrequirementformajortrauma)

9

a. Trusts shouldmeetmidwife to birth-rate ratios as defined inBirth-ratePlusor anequivalentlocalstandard

5. Each obstetric unit should meet the Royal College of Obstetricians and Gynaecologists’(“RCOG”)standardsonmidwiferystaffingnumbers9:

a. Womeninestablishedlabourshouldreceiveone-to-onecarefromamidwifeb. Midwifery staffing levels should be calculated and implemented to provide the

midwife-to-womanstandardratioinlabourof(1.0-1.4WTEmidwivestowoman)6. Each obstetric unit in SW London or operated by a SW London Trust shouldmeet BAPM

guidanceonmedicalandnursingnumbers10:a. TheminimumresidentstaffinglevelforaneonatalICUisonejuniortrainee(ST1-3)or

AdvancedNeonatalNursePractitionerandoneseniortrainee(ST4-8),appropriatelytrainedspecialtydoctororANNP,withconsultantpresenceatleast12/7andmorestaffrequiredasunitsincreaseinsize

b. AllNICUsshouldhavesufficientnursingstafftodelivernursetopatientratiosof1:1foranNICU,1:2foranHDUand1:4foraSCBU

7. Eachobstetricunitshouldmeetsafestaffingguidance11

3.2.2 ImplicationsforobstetricsconsultantstaffinglevelsMedicalDirectorsofthefourSWLacuteTrustsagreedthatthefollowingconsultantstaffinglevelsarerequired to meet the above clinical standards and provide sustainable care. Note that MedicalDirectorsfeltthatthenumberofconsultantscontributingtorotaswasabetterindicatorofabilitytomeetthestandardsthanWholeTimeEquivalent.Thisisbecauseobstetriciansfrequentlycovernon-acuteactivity(suchasoutpatientclinicsandelectivetheatrelists).

9RoyalCollegeofObstetriciansandGynaecologists,2016.ProvidingQualityCareforWomen,Aframeworkformaternityservicestandards.https://www.rcog.org.uk/globalassets/documents/guidelines/working-party-reports/maternitystandards.pdf10BritishAssociationofPerinatalMedicine,2010.Servicestandardsforhospitalsprovidingneonatalcare(3rdedition).http://www.bapm.org/publications/documents/guidelines/BAPM_Standards_Final_Aug2010.pdf11NationalInstituteofHealthandCareExcellence,2015.Safemidwiferystaffingformaternitysettings.https://www.nice.org.uk/guidance/ng412RoyalCollegeofObstetriciansandGynaecologists,2007.RCOGSaferChildbirthReport;table8,page34


Consultantheadcount


RCOGcategoryA;<3000birthsp.a.12

14hours,sevendaysaweek

10 14/7coverisrequiredtomeettheTaskandFinishGroup’sagreedstandard.

Twoconsultantsshouldberesidentduringtheweektoenablecoverofbothanelectiveandemergencyprocedureandoneattheweekend.Thisresultsinarequirementof8WTE.However,atleast10consultantsarerequiredtocontributetoobstetricsrotas(whomayalsodogynaecologywork).Thiswouldrequireconsultantstoworkatleast1in5weekends,assumingthelightest

10

WealsorecognisethattheRoyalCollegehasfoundtheretobeanationalshortageinthenumberofregistrarsinobstetrics.Insomecases,thishasresultedinconsultantsonmid-graderotas,whichcouldinturnresultinanincreasedrequirementforconsultants.SWLMedicalDirectorshavenotfoundthistobe a current issue for SWLondon rotasbutwewill continue tomonitor this as theevaluationprocessprogresses.

3.3 Emergencysurgery

3.3.1 Clinicalstandardstomeetinemergencysurgery1. Notethatthesestandardsexcludeyoungchildren,whowouldcontinuetobetransferredto

StGeorge’sHospitalforemergencysurgeryaspertheagreedpathway.2. EachemergencysurgeryunitinSWLondonoroperatedbyaSWLondonTrustshouldmeet7

dayclinicalstandards13,including:a. Allemergencyadmissionsmustbeseenandhaveathoroughclinicalassessmentbya

suitableconsultantassoonaspossiblebutatthelatestwithin14hoursfromthetime

13NHS.UK,20176.NHSSevenDayServicesClinicalStandards.LastrevisedSep20176.https://www.england.nhs.uk/wp-content/uploads/2017/09/seven-day-service-clinical-standards-september-2017.pdf

weekendmodel,withoneconsultantresidentattheweekendandanotherconsultantoncall.

RCOGcategoryB;3000–4000birthsp.a.


12 Highervolumesofactivitymeanthatitislikelythat(atleastattimes)twoconsultantswillberequiredtoberesidentattheweekend,withanotherconsultantoncall.With12consultantscontributingtoobstetricsrotas,thiswouldallowforbetween1in4to1in6weekendsworked,dependinguponhowoftentwoconsultantswererequiredtoberesident.

RCOGcategoryC1;4000–5000birthsp.a.


14 Highervolumesofactivitymeanthatatpeaktimes,threeconsultantsarelikelytoberequired,resultinginarequirementof14consultantscontributingtoobstetricsrotas.Thiswouldrequireconsultantstowork1in6weekends.

RCOGcategoryC2;>5000birthsp.a.


16 If16consultantscontributetoobstetricsrotas,thiswouldsupportamodelwhereconsultantsworkamaximumof1in4weekends,allowingthreeconsultantstoberesidentformuchofthetimetomanagethehighestvolumesofactivity.

SpecialistCentre


21 SGH,asaspecialistcentre,requires21WTE,asagreedbytheTaskandFinishGroup.

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of admission to hospital (Note: this is the key clinical standard determining theconsultantstaffingrequirement)

b. All patients admittedduring theperiodof consultant presenceon the acuteward(normallyatleast08.00-20.00)shouldbeseenandassessedbyadoctor,oradvancednon-medicalpractitionerwithasimilarlevelofskillpromptly,andseenandassessedbyaconsultantwithinsixhours

c. Consultantinvolvementforpatientsconsidered‘highrisk’(definedaswheretheriskofmortalityisgreaterthan10%,orwhereapatientisunstableandnotrespondingtotreatmentasexpected),shouldbeseenandassessedwithinonehour

d. Hospitalinpatientsmusthavescheduledseven-dayaccesstodiagnosticservicessuchas x-ray, ultrasound, computerised tomography (CT),magnetic resonance imaging(MRI), echocardiography, endoscopy, bronchoscopy and pathology. Consultant-directeddiagnostictestsandcompletedreportingwillbeavailablesevendaysaweekwithin1hourforcriticalpatients,within12hoursforurgentpatientsandwithin24hoursfornon-urgentpatients.AcuteTrustsshouldmakea judgmentthroughtheirclinicalgovernanceprocessesand indiscussionwiththeircommissionersregardingwhichdiagnostic tests theirpatients requireaccess to7daysaweekandwhetherthese are delivered on site or via a formal networked arrangement. A networkedapproachmay involve patient transfer, image transfer or diagnostician in-reach indifferingcircumstances

e. Allpatientsontheacutesurgicalassessmentunitandotherhighdependencyareasseenandreviewedbyaconsultanttwicedaily

f. All patients admitted acutely to be continually assessed using the National EarlyWarningSystem (NEWS). TheNEWScompetencybasedescalation triggerprotocolshouldbeusedforallpatients

3. EmergencysurgeryunitsshouldalsomeetthefollowingLQSstandards14:a. Allpatientsadmittedasemergenciesarediscussedwiththeresponsibleconsultantif

immediatesurgeryisbeingconsidered.Foreachsurgicalpatient,aconsultanttakesanactivedecisionindelegatingresponsibilityforanemergencysurgicalproceduretoappropriately-trainedjuniororspecialtysurgeons

b. Allhospitalsadmittingemergencygeneralsurgerypatientstohaveaccesstoafullystaffedemergencytheatreimmediatelyavailableandaconsultantonsitewithin30minutesatanytimeofthedayornight

c. Whenon-take,aconsultantandtheirteamaretobecompletelyfreedfromanyotherclinicaldutiesorelectivecommitments

4. Each emergency surgery unit should achieve a minimum rating of ‘Good’ in the CQC’s 5domains(especiallyKLOES4):


5. Standards referenced by the National Emergency Laparotomy Audit (NELA) should beconsideredgoodpracticebutnotmandatory15:

14LondonHealthProgrammes,2015.Acute,EmergencyandMaternityServices,LondonQualityStandards.LastrevisedNov2015.http://www.londonhp.nhs.uk/wp-content/uploads/2016/01/All-London-Quality-Standards-Acute-Emergency-and-Maternity-Services-Nov-2015.pdf15NELA,2015.TheFirstPatientReportoftheNationalEmergencyLaparotomyAudit.http://nela.org.uk/All-Patient-Reports

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a. Each higher risk case (predicted mortality ≥5%) should have the active input ofconsultantsurgeonandconsultantanaesthetist

b. Clear protocols for the postoperative management of elderly patients (over 70)undergoing abdominal surgery should be developed which include, whereappropriate, routine review by an MCOP (Medicine for Care of Older People)consultantandnutritionalassessment

6. EmergencyteamsatStGeorge’sHospital,asaMajorTraumaCentre,shouldhavearoleinsupportingthetraumaservice.

7. EachemergencysurgeryunitneedstohavedefinedprotocolsfortransferringyoungchildrentoStGeorge’s

8. Eachemergencysurgeryunitshouldmeetsafestaffingguidance16

3.3.2 ImplicationsforemergencysurgeryconsultantstaffinglevelsMedicalDirectorsofthefourSWLacuteTrustsagreedthatthefollowingconsultantstaffinglevelsarerequired to meet the above clinical standards and provide sustainable care. Note that MedicalDirectorsfeltthatthenumberofconsultantscontributingtorotaswasabetterindicatorofabilitytomeetthestandardsthanWholeTimeEquivalent.Thisisbecausesurgeonsfrequentlycovernon-acuteactivity(suchasoutpatientclinicsandelectivetheatrelists).

3.4 Paediatrics

3.4.1 Clinicalstandardstomeetinpaediatrics1. Eachpaediatric unit in SW Londonor operatedby a SW London Trust shouldmeet 7 day

clinicalstandards,17including:a. Allemergencyadmissionsmustbeseenandhaveathoroughclinicalassessmentbya

suitableconsultantassoonaspossiblebutatthelatestwithin14hoursfromthetimeofadmissiontohospital

16NationalInstituteforHealthandCareExcellence,2014.Safestaffingfornursinginadultinpatientwardsinacutehospitals.https://www.nice.org.uk/guidance/sg117NHS.UK,2017.NHSSevenDayServicesClinicalStandards.LastrevisedSep2017.https://www.england.nhs.uk/wp-content/uploads/2017/09/seven-day-service-clinical-standards-september-2017.pdf


Consultantheadcount


Requirementtomeetthestandards


10 10consultantscontributingtoemergencysurgeryrotas(givenhighvolumesofelectivework)allowsforaseparateconsultanttobeoncallatnightandresidentinthedaytime.

Ifelectivevolumesarelower,andthesameconsultantcanbeoncallatnightandresidentinthedaytime,thenthiscouldaccommodateamodelwithfewerconsultants.

13

b. All patients admittedduring theperiodof consultant presenceon the acuteward(normallyatleast08.00-20.00)shouldbeseenandassessedpromptlybyadoctor,oradvancednon-medicalpractitionerwithasimilarlevelofskill,andseenandassessedbyaconsultantwithinsixhours(notethatthepaediatricTaskandFinishGroupagreedthatallsitesshouldhave14/7consultantcover)

c. Hospitalinpatientsmusthavescheduledseven-dayaccesstodiagnosticservicessuchas x-ray, ultrasound, computerised tomography (CT),magnetic resonance imaging(MRI), echocardiography, endoscopy, bronchoscopy and pathology. Consultant-directeddiagnostictestsandcompletedreportingwillbeavailablesevendaysaweekandcompletedwithin1hourforcriticalpatients,within12hoursforurgentpatientsandwithin24hoursfornon-urgentpatients.AcuteTrustsshouldmakeajudgmentthrough their clinical governance processes and in discussion with theircommissionersregardingwhichdiagnosticteststheirpatientsrequireaccessto7daysa week and whether these are delivered on site or via a formal networkedarrangement.Anetworkedapproachmayinvolvepatienttransfer,imagetransferordiagnosticianin-reachindifferingcircumstances

d. Allpatientsontheacutemedicalunit(AMU)ortheequivalentpaediatricadmissionsunitandotherhighdependencyareasareseenandreviewedbyaconsultanttwicedaily

e. Whereamentalhealthneedisidentifiedfollowinganacuteadmission,thepatientmustbeassessedbypsychiatric liaison/CAMHSwithin1hourforemergencycareneedsandwithin14hoursforurgentcareneeds

f. All patients admitted acutely to be continually assessed using the Paediatric EarlyWarning Score (PEWS). The PEWS competency based escalation trigger protocolshouldbeusedforallpatients.

2. AllpaediatricunitsshouldmeetthefollowingLQSstandards18:a. Whenon-take,aconsultantandtheirteamaretobecompletelyfreedfromanyother

clinicaldutiesorelectivecommitmentsb. Aconsultantpaediatriciantobepresentandreadilyavailableinthehospitalduring

timesofpeakemergencyattendanceandactivity.Consultantdecisionmakingandleadership available to cover extendeddayworking (upuntil 10pm), sevendays aweek.

c. Allshortstaypaediatricassessmentfacilitiestohaveaccesstoapaediatricconsultantthroughoutallthehourstheyareopen

3. PaediatricunitsshouldalsomeetthefollowingHealthyLondonPartnershipstandards19,20:a. The Paediatric Assessment Unit should be geographically co-located with an

EmergencyDepartmentorin-patientwardb. Equipmentmustbeavailabletosupportthedaytodayactivityontheunitaswellas

resuscitation,stabilisationandtransferofchildrenwhobecomecriticallyunwell

18LondonHealthProgrammes,2015.Acute,EmergencyandMaternityServices,LondonQualityStandards.LastrevisedNov2015.http://www.londonhp.nhs.uk/wp-content/uploads/2016/01/All-London-Quality-Standards-Acute-Emergency-and-Maternity-Services-Nov-2015.pdf19HealthyLondonPartnership–TransformingLondon’shealthandcaretogether,2017.London’spaediatricassessmentunitstandardsforchildrenandyoungpeople.https://www.healthylondon.org/sites/default/files/Paediatric%20Assessment%20Unit%20Standards.pdf20HealthyLondonPartnership’sChildrenandYoungPeople’sProgramme,2016.Londonacutecarestandardsforchildrenandyoungpeople.https://www.myhealth.london.nhs.uk/system/files/HLPCYP_Acute%20Standards%2025%20May%202016.pdf

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c. AllchildrenaccessingaPaediatricAssessmentandShortStayUnit(PASSU)musthaveastandardisedinitialassessmentincludingpainscorewithin15minsofarrival,ifthishasnottakenplaceintheED

d. ThePASSUshouldworkwithinan integrated systemwith community servicesandhence promote ambulatory and community-based care to support admissionprevention,careathomeandreducedlengthofstay

e. PaediatricnursestaffingshouldcomplywithRoyalCollegeofNursing(RCN)guidelinesandregularauditofpatientacuityusingappropriatetoolsshouldinformworkforceplanning

f. Everychildoryoungpersonwhoisadmittedtoapaediatricdepartmentwithanacutemedicalproblemisseenbyapaediatricianonthemiddlegrade(ST4+)orconsultantrotawithinfourhoursofadmission

g. A consultant paediatrician is to be present and readily available in the hospital tocoverextendeddayworking(upuntil10pm),sevendaysaweek

h. Wherechildrenareadmittedwithsurgicalproblemstheyshouldbejointlymanagedby teams with competencies in both surgical and paediatric care, which includeshavinganamedconsultantpaediatricianandanamedconsultantsurgeon

i. Allshortstaypaediatricassessmentfacilitiestohaveaccesstoapaediatricconsultantthroughoutallthehourstheyareopen,withon-siteconsultantpresenceduringtimesofpeakattendance

j. Atleastonemedicalhandoverinevery24hoursisledbyapaediatricconsultant(orequivalent)

k. Whenon-take,aconsultantandtheirteamaretobecompletelyfreedfromanyotherclinicaldutiesorelectivecommitments(duringresidenthoursbutnotoncall)

4. Eachpaediatricunit shouldbeable toachieveaminimumratingof ‘Good’ in theCQC’s5domains(especiallyKLOES4):


5. ForserviceswithaLocalNeonatalUnitandpaediatricinpatients:a. Theremustbeat leastonedaytimemedicalrotatocovertheneonatalunitandat

leastoneseparatedaytimemedicalrotatocoverpaediatricinpatientsb. Itmay be sufficient to have a single night-time medical rota to cover both the

neonatal unit and paediatric inpatients. The night-time cover must include, as aminimum,onedoctoronsitewhoisST4oraboveand,ifthedoctoronsiteisnotaconsultant, an additional consultant on call. The decision about whether a singlenight-timerotaissufficientshouldbebasedonalocalriskassessmentthatincludesconsiderationof the following factors:volumeandacuityofpaediatricadmissions,numberofinpatients,levelofpaediatricinputrequiredontheneonatalandmaternityunits,andthenumberandcompetencyofthemiddlegradepaediatricdoctors

6. IfaservicehasaSpecialCareUnitandpaediatricinpatients,itisusuallysufficienttohaveasingledaytimeornight-timeconsultantrotathatcoversbothareas

3.4.2 ImplicationsforpaediatricsconsultantstaffinglevelsMedicalDirectorsofthefourSWLacuteTrustsagreedthatthefollowingconsultantstaffinglevelsarerequired to meet the above clinical standards and provide sustainable care. Note that MedicalDirectorsfeltthatthenumberofconsultantscontributingtorotaswasabetterindicatorofabilityto

15

meetthestandardsthanWholeTimeEquivalent.Thisisbecausepaediatriciansfrequentlycovernon-acuteactivity(suchasoutpatientclinics).

16

21Specialtypaediatrics(includingNICU)arenotincluded,asthescopeofthisdocumentisthe6coreservices,includinggeneralpaediatrics22FacingtheFuture:StandardsforAcuteGeneralPaediatricServices(revised2015).http://www.rcpch.ac.uk/sites/default/files/page/Workforce%20Implication%20of%20FtF%202015%20FINAL.pdf23Assumes2.5SPAsinalargeservice.Therequirementforotherservicesizescanbefoundinthe“NumberofSPAs”table,section3


Consultantheadcount


Minimumrequirementtomeetthestandardsatanon-tertiarycentre

14/7hoursofconsultantcoverwithanon-callrotaatallothertimes

12consultantscontributingtopaediatricandNICUrotas

14/7consultantcoverisnecessarytomeettheTaskandFinishGroup’sagreedstandard.

Thisrequiresaminimumof8WTE.

Thesameconsultantcanberesidentattheweekendandoncallatnight.However,ifconsultantsarealsocontributingtoNICUrotas,thiswouldrequireaminimumof12consultantscontributingtorotasforconsultantstoworkanaverageof1in6weekends.

Requirementtomeetthestandardsandmanagelargevolumesatanon-tertiarycentre(>2.5kemergencyadmissionsp.a.)


16consultantscontributingtopaediatricandNICUrotasrequiredtomanagehighvolumesofactivity

Thesameconsultantcanberesidentattheweekendandoncallatnight.However,ifconsultantsarealsocontributingtoNICUrotas,thiswouldrequireaminimumof12consultantscontributingtorotasforconsultantstoworkanaverageof1in6weekends.

Inaddition,givenlargevolumesofactivity(>2.5kemergencyadmissionsp.a.),itmaybenecessaryfortwoconsultantstoberesidentatweekends,whichwillrequire16consultantstocontributetorotas.

Requirementforaspecialistcentre(tocoveracutegeneralpaedsonly)21


10.0WTEs22 Forlargehospitalswhererotasforgeneralpaediatricsareentirelyseparatefromspecialistpaediatrics(includingNICU),therequirementis10.0WTEs23

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3.5 Acutemedicine

3.5.1 Clinicalstandardstomeetinacutemedicine1. AllacutemedicalwardsinSWLondonoroperatedbyaSWLondonTrustshouldmeet7Day

ClinicalStandards24,including:a. All patients admittedduring theperiodof consultant presenceon the acuteward

(normallyatleast08.00-20.00)shouldbeseenandassessedpromptlybyadoctor,oradvancednon-medicalpractitionerwithasimilarlevelofskill,andseenandassessedbyaconsultantwithinsixhours(NotethattheacutemedicineTaskandFinishgroupagreedthat,although12/7coversatisfiestheminimumrequirement,allsitesshouldhave14/7consultantcovertoprovideasafeserviceforpatients)

b. Allemergencyadmissionsmustbeseenandhaveathoroughclinicalassessmentbyasuitableconsultantassoonaspossiblebutatthelatestwithin14hoursfromthetimeofadmissiontohospital

c. Consultantinvolvementforpatientsconsideredhighrisk(definedaswheretheriskofmortalityisgreaterthan10%,orwhereapatientisunstableandnotrespondingtotreatmentasexpected)shouldbewithin1hour

d. Hospitalinpatientsmusthavescheduledseven-dayaccesstodiagnosticservicessuchas x-ray, ultrasound, computerised tomography (CT),magnetic resonance imaging(MRI), echocardiography, endoscopy, bronchoscopy and pathology. Consultant-directeddiagnostictestsandcompletedreportingwillbeavailablesevendaysaweekwithin1hourforcriticalpatients,within12hoursforurgentpatientsandwithin24hoursfornon-urgentpatients.AcuteTrustsshouldmakea judgmentthroughtheirclinicalgovernanceprocessesand indiscussionwiththeircommissionersregardingwhichdiagnostic tests theirpatients requireaccess to7daysaweekandwhetherthese are delivered on site or via a formal networked arrangement. A networkedapproachmay involve patient transfer, image transfer or diagnostician in-reach indifferingcircumstances

e. Hospital inpatients must have timely 24-hour access, seven days a week, toconsultant-directedinterventionsthatmeettherelevantspecialtyguidelines,eitheron-site or through formally agreed networked arrangementswith clear protocols.These interventions would typically be: critical care, interventional radiology,interventionalendoscopy,emergencygeneralsurgery,emergencyrenalreplacementtherapy, urgent radiotherapy, stroke thrombolysis, percutaneous coronaryintervention,cardiacpacing(eithertemporaryviainternalwireorpermanent)

f. Allpatientswithhighdependencyneedsshouldbeseenandreviewedbyaconsultanttwice daily (including all acutely ill patients directly transferred and others whodeteriorate).Onceaclearpathwayofcarehasbeenestablished,patientsshouldbereviewedbyaconsultantatleastonceevery24hours,sevendaysaweek,unlessithasbeendeterminedthatthiswouldnotaffectthepatient’scarepathway25

g. All patients admitted acutely to be continually assessed using the National EarlyWarningSystem (NEWS). TheNEWScompetencybasedescalation triggerprotocolshouldbeusedforallpatients

24NHS.UK,2017.NHSSevenDayServicesClinicalStandards.LastrevisedSep2017.https://www.england.nhs.uk/wp-content/uploads/2017/09/seven-day-service-clinical-standards-september-2017.pdf25NHS.UK,2017.NHSSevenDayServicesClinicalStandards.LastrevisedSep2017.https://www.england.nhs.uk/wp-content/uploads/2017/09/seven-day-service-clinical-standards-september-2017.pdf

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2. EachacutemedicalwardshouldalsomeettherelevantsectionsfromLQS26:

a. Whenon-take,aconsultantandtheirteamaretobecompletelyfreedfromanyotherclinicaldutiesorelectivecommitments

3. EachAMUshouldachieveatleastaratingof‘Good’intheCQC’s5domains(especiallyKLOES4):


4. During daytime hoursMonday-Friday, teams from the key supporting specialtiesmust beavailable to review patients on AMU when required so that delays to patient care andunnecessarytransferstootherwardsareminimised.Thesesupportingspecialtiesinclude,butarenotlimitedto:cardiology,respiratory,gastroenterology,elderlymedicine,acuteoncologyand palliative care. For some specialties, such as palliative care and acute oncology, thesupportmaybeprovidedthroughablendedrotaofconsultantsandspecialistnurses

5. FormalnetworkarrangementsmustbeinplacesothatstafffromeachAAUhaveaccesstotertiary-levelspecialist telephoneadvice24/7.Specialist transferprotocolsmustalsobe inplace.

6. EachAMUmustbe supportedbya24/7gastrointestinalbleeding rota (which could covermorethanoneTrust)

7. EachAMUshouldensurethatnursingstafflevelsfollowsafestaffingguidelines27,althoughthiswillnotmateriallyaffecttheclinicalmodelasstaffinglevelsarepredominantlydrivenbyactivityratherthannumberofsites:

a. Forexample,whilethereisnosinglenursingstaff-to-patientratiothatcanbeappliedacross all acute adult inpatientwards, there is evidence of increased risk of harmassociatedwitharegisterednursecaringformorethan8patientsduringthedayshiftandconsequentlyseniormanagementandnursingmanagersormatronsshouldtakethisintoaccount

8. RoyalCollegeofNursingstaffingguidelinesshouldbeconsideredasbestpracticebutnotasmandatorystandardstobemet28:

a. The composition of nursing staffing on acute wards should include at least 65%registerednurses

3.5.2 ImplicationsforacutemedicineconsultantstaffinglevelsMedicalDirectorsofthefourSWLacuteTrustsagreedthatthefollowingconsultantstaffinglevelsarerequired to meet the above clinical standards and provide sustainable care. Note that MedicalDirectorsfeltthatthenumberofconsultantscontributingtorotaswasabetterindicatorofabilitytomeet the standards thanWholeTimeEquivalent.This isbecausephysicians frequently covernon-acuteactivity(suchasoutpatientclinics).

26LondonHealthProgrammes,2015.Acute,EmergencyandMaternityServices,LondonQualityStandards.LastrevisedNov2015.http://www.londonhp.nhs.uk/wp-content/uploads/2016/01/All-London-Quality-Standards-Acute-Emergency-and-Maternity-Services-Nov-2015.pdf27NICE,2014.Safestaffingfornursinginadultinpatientwardsinacutehospitals.https://www.nice.org.uk/guidance/sg1.28RoyalCollegeofNursing,2011.GuidanceonsafenursestaffinglevelsintheUK.https://www.rcn.org.uk/professional-development/publications/pub-003860

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3.6 Intensivecare

3.6.1 Clinicalstandardstomeetinintensivecare1. EachintensivecareunitinSWLondonoroperatedbyaSWLondonTrustshouldmeet7Day

ClinicalStandards29,including:a. Allemergencyadmissionsmustbeseenandhaveathoroughclinicalassessmentbya

suitableconsultantassoonaspossiblebutatthelatestwithin14hoursfromthetimeof admission to hospital (Note: this is the key clinical standard determining theconsultantstaffingrequirement)

b. AllpatientsontheIntensiveCareUnit(ICU)andotherhighdependencyareasareseenandreviewedbyaconsultantduringtwicedailywardrounds(includingallacutelyillpatientsdirectlytransferredandotherswhodeteriorate)

c. Tomaximisecontinuityofcareconsultantsshouldbeworkingmultipledayblocksd. All patients admitted acutely to be continually assessed using appropriate ICU

protocols.e. Consultantinvolvementwhereapatientisunstableandnotrespondingtotreatment

asexpectedshouldbewithin1hour.f. Hospitalinpatientsmusthavescheduledseven-dayaccesstodiagnosticservicessuch

as x-ray, ultrasound, computerised tomography (CT),magnetic resonance imaging

29NHS.UK,2017.NHSSevenDayServicesClinicalStandards.LastrevisedSep2017.https://www.england.nhs.uk/wp-content/uploads/2017/09/seven-day-service-clinical-standards-september-2017.pdf


Consultantheadcount



14/7hoursofconsultantcover,withanon-callrotaatothertimes

12consultantscontributingtoacutemedicinerotas

8consultantswillallowtwoconsultantstobepresent14/7.However, even given the lightestweekend model, with one consultantresidentattheweekend,andanotheroncall, this would require consultants towork1in4weekends.12consultantscontributingtoacutemedicinerotaswouldallowconsultantstowork1in6weekends(giventhelightestweekendmodel)and1in4weekendsiftwoconsultantswererequiredtoberesident;thisisthereforeamoresustainablemodel.

Note:thisrequirementdoesnotequatetothebodyofconsultantsrequiredtoreviewwardinpatientsonaoncedailybasis.

20

(MRI), echocardiography, endoscopy, bronchoscopy and pathology. Consultant-directeddiagnostictestsandcompletedreportingwillbeavailablesevendaysaweekwithin1hourforcriticalpatients,within12hoursforurgentpatientsandwithin24hoursfornon-urgentpatients.AcuteTrustsshouldmakea judgmentthroughtheirclinicalgovernanceprocessesand indiscussionwiththeircommissionersregardingwhichdiagnostic tests theirpatients requireaccess to7daysaweekandwhetherthese are delivered on site or via a formal networked arrangement. A networkedapproachmay involve patient transfer, image transfer or diagnostician in-reach indifferingcircumstances

g. Hospital inpatients must have timely 24-hour access, seven days a week, toconsultant-directedinterventionsthatmeettherelevantspecialtyguidelines,eitheron-siteorthroughformallyagreednetworkedarrangementswithclearprotocols

2. EachintensivecareunitshouldalsomeetthefollowingLQSstandards30:a. Consultants freed from all other clinical commitmentswhen covering critical care

servicesb. Critical care units to have out-of-hours consultant intensivist rotas dedicated to

criticalcarec. Allreferralsforadmissiontointensivecaretobeimmediatelyreviewedbythecritical

careteamanddiscussedwithaconsultantd. Medicalstaffcapableofprovidingimmediatelifesustainingadvancedairwaysupport

tobeavailabletothecriticalcareunit24hoursadaye. Onceapatientisdischargedfromthecriticalcareunittoanotherwardinthehospital,

criticalcareteamreviewtobeavailabletoreviewthepatient24hoursand48hoursafterdischarge

f. No non-clinical critical care transfers out of a hospital to take place with anoperationalstandardof≤5%

g. Alldischargesfromacriticalcareunit(includingastepdownincriticalcarelevel3tolevel 2 that involves a change in location) are to be to an appropriate namedconsultant

h. 100%ofdischargestobebetween08.00and20.00.80%ofdischargesfromcriticalcaretowardstobeduringthenormalworkingdayforthatward,normally08.00to17.00

3. Eachintensivecareunitshouldbeabletoachieveatleastaratingof‘Good’ontheCQC’s5domains(especiallyKLOES4):


4. ICUs should consider Intensive Care Society (ICS) (2015) guidelines31 (e.g., a guidelineconsultant/patientratioofbetween1:8–1:15)butnotasmandatorystandards.OtherICUguidelinestoconsiderincludeAHPandnursingstandards:

a. Criticalcareshouldbedeliveredasamultidisciplinaryteam.

30LondonHealthProgrammes,2015.Acute,EmergencyandMaternityServices,LondonQualityStandards.LastrevisedNov2015.http://www.londonhp.nhs.uk/wp-content/uploads/2016/01/All-London-Quality-Standards-Acute-Emergency-and-Maternity-Services-Nov-2015.pdf31IntensiveCareSociety,2015.GuidelinesfortheProvisionofIntensiveCareService,Edition1.https://www.ficm.ac.uk/sites/default/files/GPICS%20-%20Ed.1%20(2015)_0.pdf

21

b. The ICU lead dietitian will be involved in the assessment, implementation andmanagementofappropriatenutritionsupportroute,incollaborationwiththerestoftheMDTteam

c. Level3patients(e.g.,ICU)requirearegisterednurse/patientratioofaminimum1:1todeliverdirectcare

d. Level2patients(e.g.,HDU)requirearegisterednurse/patientratioofaminimumof1:2todeliverdirectcare

e. EachdesignatedCriticalCareUnitwillhaveanidentifiedleadnursewhoisformallyrecognisedwithoverallresponsibilityforthenursingelementsoftheservice

f. A minimum of 50% of registered nursing staff will be in possession of a postregistrationawardinCriticalCareNursing

5. EachICUunitinSWLondonoroperatedbyaSWLondonTrustmusthavetheabilitytoprovideintensive care outreach to other services (e.g., acute medicine). Consultants should beavailable to discuss and review patients forwhom there is a question aboutwhether thepatientshouldbeadmittedtoICUformanagement

3.6.2 ImplicationsforintensivecareconsultantstaffinglevelsMedicalDirectorsofthefourSWLacuteTrustsagreedthatthefollowingconsultantstaffinglevelsarerequiredtomeettheaboveclinicalstandardsandprovidesustainablecareintheSWLICUs.NotethatMedicalDirectorsfeltthatthenumberofconsultantscontributingtorotaswasabetterindicatorofabilitytomeetthestandardsthanWholeTimeEquivalent.Thisisbecauseintensivecareconsultantsfrequentlycovernon-acuteactivity(suchasanaestheticlists).

4 Clinicalinterdependencies

In addition to defining the clinical standards for acute services, the question of clinicalinterdependenciesisalsoanimportantissuetoconsider.OurexpectationisthattheTrustswillwork


Consultantheadcount




9consultantsperunitcontributingtotherota

9consultantscontributingtotherotaallowsforaseparateconsultanttobeoncallatnightandresidentinthedaytime(witharesponsibilitytocoverICUpatientsaswellasoutreachpatientsasrequired).

Itwouldbepossibletomeetthestandardof12/7hoursofconsultantcoverwithanon-callrotaatallothertimeswithfewerthan9consultants.However,theviewoftheTask&FinishGroupisthatthiswouldbecomeunsustainable(duetothedisproportionatenumberofnightsandweekendsthatconsultantswouldberequiredtowork).

22

togetherwhereverpossibletosupporteachotherandoptimisedeliveryofservices.Werecognise,however,thateachTrustmustprovidetheservicesrequiredtosupporttheir localpopulation,andthismayresultinsomevariationinthesub-specialtiesprovidedateachsiteandintheprovisionofservicesoutsideof thesecoreacuteservices.Theremayalsobeotherareasoutsideof thesecoreacuteserviceswhereTrustswillneedtoworktogethertodeliverservices(forexample,usingnetworkarrangements).

Theanalysisherelaysoutasuiteofservicesthatarecoretodeliveryofanacuteservicemodel.Theproposed interdependenciesarebasedondiscussionswithMedicalDirectors (Jan2017),previousworkundertakenbytheTaskandFinishGroups(Jan–June2016),SWLAcuteProviderCollaborativeclinical workshops (Dec 2015) and previouswork undertaken by the Better Services Better ValueprogrammeandClinicalworkinggroups(2012).

Theaimwastoidentify(primarilyfocusinguponclinicalviability):

• Whichservicesmustbedeliveredonsiteaspartofanacutemodel• Which services could be networked froma clinical perspective (accessible rather than co-

located)

Thisanalysispointstothreekeysetsofinterdependentservices,eachassociatedwithamainentrypoint intoa site;adultED,children’sEDandobstetrics. Inaddition,MedicalDirectorsagreed thatwhendeliveringacuteservicesinSWLondonoroperatedbyaSWLondonTrustallthreemainentrypointsmustbeprovided.

4.1 InterdependenciesforanadultED

• Acutemedicine,bydefinition,providesassessment,investigationandtreatmentforpatientsadmittedurgentlyorasanemergencythroughEDandhencemustbeco-locatedwithED

• Intensivecare,bydefinition,providestreatmentandmonitoringforpatientsinacriticallyillorunstableconditionandhencemustbeco-locatedwithED

o However,anHDUratherthananICUmightbeappropriateincertaincircumstances,forexample,ifvolumesofactivityareinsufficienttofillafullrota’sworthofbeds/ifthereisnoemergencysurgeryonsite

• Anaestheticsmustbeco-locatedwithcriticalcare• TheTaskandFinishGroupagreedthatemergencysurgerydoesnotneedtobecollocated

withallEDsalthoughthereshouldbeaccesstoappropriatesurgicalopiniono AmodelofsurgicaltransfersimilartoEpsomandStHelierwasproposedandagreed

asaclinicallyappropriatewayforward

23

• 7DayClinicalStandardsstatethathospitalinpatientsmusthavescheduledseven-dayaccesstokeydiagnosticservices(e.g.,x-ray,ultrasound,CT,MRI,pathology),includingaccesswithin1hourforcriticalpatients

o High volumes of activity mean that imaging and diagnostic services must be co-locatedwithED

o TheTaskandFinishGroupagreedthatpathologyandinterventionalradiologydonotneedtobeco-locatedbuttheremustbetimelyaccessfromeachsitewithanadultED

4.2 Interdependenciesforachildren’sED

• TheTaskandFinishGroupconcludedthatallEDsinSWLondonoroperatedbyaSWLondontrustneededat least tohavefacilities forchildrentobeobserved inabed,stabilised,andtransferredifnecessary

o Medical Directors differentiated between a ‘standard’ inpatient paediatric ward,whichisconsultant-led(14/7on-siteandoncallatallothertimes)andmanageslowtomediumacuity conditions, and a ‘high intensity’ inpatient paediatricward, alsoconsultant-led, which manages medium to high acuity conditions and providesadvancedcriticalcareinaLevel3PaediatricCriticalCareUnit

o Medical Directors agreed that all sites should, as a minimum, have a ‘standard’inpatientpaediatricwardonsite,butnotallsitesrequireco-located‘highintensity’inpatientpaediatrics;itwouldbefeasibleandsafe,forexample,tohavehighintensityinpatientpaediatricswithaccesstoadvancedcriticalcareatStGeorge’sHospital,and‘standard’inpatientpaediatricsontheothersites

• Anaestheticsmustbeco-locatedwithcriticalcare• TheTaskandFinishGroupagreedthatemergencysurgerydoesnotneedtobeco-located

withallEDsalthoughthereshouldbeaccesstoappropriatesurgicalopinion• 7DayClinicalStandardsstatethathospitalinpatientsmusthavescheduledseven-dayaccess

tokeydiagnosticservices(e.g.,x-ray,ultrasound,CT,MRI,pathology),includingaccesswithin1hourforcriticalpatients


o TheTaskandFinishGroupagreedthatpathologyandinterventionalradiologydonotneedtobeco-locatedbuttheremustbetimelyaccessfromeachsitewithachildren’sED

24

4.3 InterdependenciesforanobstetricunitNotethatthisclinicalmodelappliestoobstetricunitswithunselectedtakes,whichrequireaLocalNeonatalUnitandITUonsite.Ifanobstetricunithasaselectedtake,thenaSpecialCareUnitandHDUwouldbesufficient.

• Obstetrician-ledmaternityservicesarenotarequirementinanacutemodelbuttheviewofcliniciansisthattheyshouldbeprovidedonallacutesitesbecauseaveryhighproportionofthepopulationwillneedthematsomepointandtheyshouldthusbekeptasclosetothepatientaspossible

• Ifobstetricsservicesaretobeprovidedwithunselectedtakes,theymustbeco-locatedwithalevel3ICU,anaestheticsandaLocalNeonatalUnit

• TheTaskandFinishGroupagreedthatemergencysurgerydoesnotneedtobeco-locatedwithallEDsalthoughthereshouldbeon-siteaccesstoappropriatesurgicalopinion

o AmodelofsurgicaltransfersimilartoEpsomandStHelierwasproposedandagreedasaclinicallyappropriatewayforward

• 7DayClinicalStandardsstatethathospitalinpatientsmusthavescheduledseven-dayaccesstokeydiagnosticservices(e.g.,x-ray,ultrasound,CT,MRI,pathology),includingaccesswithin1hourforcriticalpatients


o TheTaskandFinishgroupagreedthatpathologyandinterventionalradiologydonotneedtobeco-locatedbuttheremustbetimelyaccessfromeachsitewithanadultED

4.4 ImplicationsofinterdependenciesforacuteservicesTheviewofMedicalDirectorsisthatwhereacuteservicesaredeliveredinSWLondonoroperatedbyaSWLondonTrust,theyshouldhaveanon-siteadultED,children’sEDandobstetricunit.MedicalDirectorshavethenagreedupontheinterdependenciesforeachofthesethreecoreservices.

TheimplicationsarethatallacuteservicemodelsinSWLondonoroperatedbyaSWLondonTrustmusthavethefollowingservicesonsiteiftheyhaveunselectedtakes:

• AdultED• Children’sED• Consultant-ledobstetricsunit• Acutemedicine

25

• ICU(Level3,asrequiredtobeco-locatedwithobstetrics)• Anaesthetics• Imaginganddiagnostics• ‘Standardintensity’inpatientpaediatrics• Neonatal(LocalNeonatalUnit,asrequiredtobeco-locatedwithobstetrics)

AllacuteservicemodelsinSWLondonoroperatedbyaSWLondonTrustmusthavetimelyaccesstothefollowingservices,whichdonotnecessarilyneedtobeoneachsite:

• Emergencysurgery• Interventionalradiology(accessiblewithin1hourifrequired)• Pathology• ‘Highintensity’inpatientpaediatrics• Mentalhealth

26

5 Workforceandtraininginterdependencies

Theabilitytomeettrainingandworkforcerequirementsisalsocriticaltothelong-termsustainabilityofservicesinSWL.Wehavethereforegatheredinformationaroundthetrainingandworkforcerequirementsforconsultants,mid-grades,nursesandalliedhealthprofessionals(AHPs)workinginthesixcoreacuteservices(Table1).

27

Table1:Workforceandtraininginterdependenciesbycoreacuteserviceandstaffgroup

Coreacuteservice

Consultants Middlegrades Nurses&AHPs

Elementsthatcutacrossall6services

• ManyoftheworkforceconstraintsareassociatedwiththeEWTD.WedonotyetknowhowtheseconstraintswillbeaffectedbyBrexit.

• Allstaffmusthaveprotectedtimeforcontinuousprofessionaldevelopment.

• TheConsultantcontractmustbeadheredto.

• Consultantsmustbeabletofulfiltherequirementsforrevalidation.

• ConsultantswithasubstantialacademiccomponenttotheirjobmusthaveprotectedPAsforresearchand/orteaching.

• ConsultantswithmanagerialresponsibilitiesmusthaveprotectedPAstocoverthis.

• ConsultantsresponsiblefortrainingjuniordoctorsmusthaveprotectedPAstocoverthis(e.g.atrainingendoscopylist).ThesePAsmustbeontopofthePAsforelectiveworkthatarenecessaryforthemtomaintaintheirowncompetencies.

• Thenewjuniordoctorcontractmustbeadheredto.

• SpecialtyregistrarsmustbeabletofulfiltherequirementsforAnnualReviewofCompetenceProgression.

• Specialtyregistrarsareentitledto:o “eitherdayreleasefortheequivalent

of1dayperweekduringuniversityterms;or

o uptoamaximumof30daysinayear;and

o studyleavetositanexaminationforahigherqualificationwhereitisnecessaryaspartofastructuredtrainingprogramme(upto2occasions).”32

• SASdoctorsmustbeabletofulfiltherequirementsforrevalidation.

• TheAFCT&Csmustbeadheredto.

• Safestaffingguidancemustbeadheredto.33

• NursesandAHPswithmanagerialresponsibilitiesmusthaveprotectedtimetocoverthis.

• Specialistnursesmusthavejobplansthatenablethemtomaintaintheircompetencies.

• TheRCNrecommendsa“commitmenttoprepareallwardsistersadequatelyinnon-clinicalskillsdevelopmentasapre-requisitetotakinguptheirrole.TheRCNconsidersthatthisinvestmentshouldfocusonleadershipandmanagementtraining...”34

32BMA.Juniordoctors’handbook–studyandprofessionalleave(2015)33https://www.nice.org.uk/guidance/service-delivery--organisation-and-staffing34RoyalCollegeofNursingsubmissiontothePrimeMinister’sCommissiononNursingandMidwifery

28

• Trustsshouldconsidertheirrelationshipswiththelocalnursing,midwiferyandAHPschoolssothatsufficientacutetrainingplacementsareavailable.

ED

• Tomaintaintheircompetencies,consultantsmusthavesufficienttimescheduledforadultandpaediatricED.

• EveryEDthattreatschildrenmusthaveatleastoneconsultantwithasub-specialtyinpaediatricEM.

• “AlltrainingrotationsmustallowexperienceinatleastoneteachingcentreandoneDGHED.Traineesshouldspendapproximately25%oftheirtotaltimeinyearsST4-6caringforchildren.”35

• AlltraineesmustachieveCT3/ST3competencesinPaediatricEM.TheRCEM’s“preferredmodelcomprisesatleast6mexperienceinEMwithapaediatricfocus,plussomefocusedadditionaltraininginacutegeneralpaediatrics/neonates.Atleast3mofthistrainingshouldideallybeinadepartmentrecognisedforpaediatricEMsub-specialtytraining.”

• Theremustbeadequatesupervisionofstaffworkinginstandaloneunits

• TheEDmustbeofsufficientscaletojustifyafullrotaofpaediatricnurses.

Obstetrics • Tomaintaintheircompetencies,obstetriciansmusthavesufficienttimescheduledforelectiveprocedures.

• “Themajorityofconsultantswillbeexpectedtocontributetodeliverysuitecareandthismustincludesubspecialistswhererelevant.However,…tofunction[as]agynaecologicalsubspecialist,with

• TraineesmustachievetheRCOGcurriculumcompetencies.

• “TrainingviatheAdvancedTrainingSkillsModule(ATSM)routemustdelivertheconsultanttheservicedemandsandmustfulfiltherequirementstocoveremergencygynaecologyanddeliverysuiteasaminimum.TheATSMsmustalsoprovidetherangeof

• Thesafemidwiferystaffingguidanceshouldbeadheredto.37

• “Midwiferystaffingratiostoachieveaminimumofonemidwifeto30births,acrossallbirthsettings.”38

35TheRoyalCollegeofEmergencyMedicine.Atrainee’sguidetoSpecialtyTraininginEmergencyMedicine(2015)37NICEguideline.Safemidwiferystaffingformaternitysettings(2015)38Londonqualitystandards.QualityandSafetyProgrammeMaternityservices(2015)

29

therestrictionsofEWTD,deliverysuiteout-of-hourscarewillleadtosuchlevelsofcompensatoryrestthattheprimaryclinicalfocuswillbediminishedconsiderably.”36

• Iftheconsultantoncalldoesnothavecompetenciesinacutegynaecology,asecondconsultantwiththesecompetenciesmustberosteredasasecondoncall.

• “Theon-callconsultantshouldattendinperson,whateverthelevelofthetrainee,inanumberofhigh-risksituations,including,forinstance,eclampsia,maternalcollapse,C-sectionformajorplacentapraevia,majorpostpartumhaemorrhageandreturntotheatreforlaparotomy.”

experiencenecessarytofunctionasaconsultantwitharelevantspecialistinterest.”

• “Itisanticipatedthattraineeswillundertakeatleast2ATSMsinST6&7butprobablymore.”

Emergencysurgery

• Tomaintaintheircompetencies,surgeonsmusthavesufficienttimescheduledforelectiveprocedures(thiscouldbeonanalternativesitethroughanetworkarrangement).

• “Itis[RCSpolicy]thatconsultantsurgeonsshouldbefreeofelectivecommitments(NHSandprivate)duringemergencyoncalls.”

• TraineesmustachievetheRCScurriculumcompetencies.39

• “SeparatingemergencyandelectiveservicescanhelptoachieveWTD2009compliance.”40

• Traineesmustnotworksomanyoncallshiftsthattheirelectivetrainingiscompromised.TheRCSrecommendsthat“traineesatST3–4should,whereverpossible,beprecludedfromworkingfullshiftsatnightinordertoconsolidatetheirlearningandmaximise

• Thesafestaffingguidancefornursinginadultinpatientwardsshouldbeadheredto41

36TheRoyalCollegeofObstetriciansandGynaecologists.TheFutureWorkforceinObstetricsandGynaecology(2009)39IntercollegiateSurgicalCurriculumProgramme.https://www.iscp.ac.uk/40TheRoyalCollegeofSurgeonsofEngland:Separatingemergencyandelectivesurgicalcare:recommendationsforpractice(2007)41NICEguideline.Safestaffingfornursinginadultinpatientwardsinacutehospitals(2014)

30

daytimetrainingopportunitiesonthemorecomplexelectivecases.”

Paediatrics • Tomaintaintheircompetencies,paediatricianswithacraftspecialtymusthavesufficienttimescheduledforelectiveprocedures.Thecurrentpaediatricmodelsupportsthis(theDGHsarestaffedwithgeneralpaediatricianswithaspecialistinterestandthespecialistpaediatriciansarebasedatSGH).

• TraineesmustachievetheRCPCHcurriculumcompetencies.42

• Formanyofthesub-specialties,thismeansthattheymusthavesufficienttimescheduledforelectiveprocedures.

• TheRCNsafestaffingguidanceforchildrenandyoungpeople’sservicesmustbeadheredto43

Acutemedicine

• Tomaintaintheircompetencies,physicianswithacraftspecialtymusthavesufficienttimescheduledforelectiveprocedures.

• TraineesmustachievetheRCPcurriculumcompetencies.

• Tomaintaintheircompetencies,traineesinacraftspecialtymusthavesufficienttimescheduledforelectiveprocedures.

• Thesafestaffingguidancefornursinginadultinpatientwardsshouldbeadheredto44

Intensivecare

• Tomaintaintheircompetencies,intensivistswhoarealsoanaesthetistsmusthavesufficienttimescheduledforelectiveanaesthesia.

• Tomaintaintheircompetencies,dual-accreditedintensivistsmusthavesufficienttimescheduledforelectiveactivityrelatingtoadualaccreditedspecialty.

• TraineesmustachievetheICMcurriculumcompetencies.45

• “DuringtheblocksofICMtraininginboth[coreandenhancedtraining],thetrainee’sduties[must]beexclusivelydedicatedtothepracticeofICMthroughoutthehospital.”

• ForJointCCTProgrammes,minimumdurationsoftheICMandotherspecialtycomponentshavebeenset

• TheBACCNguidancefornursestaffingincriticalcareshouldbeadheredto46

• “Therearetobeclearlydefinednurse:patientratiosforeachlevelofcriticalcare,whichasaminimumwillbe:

• Level3patientshave1:1nursingratios

• Level2patientshave1:2nursingratios”

42TheRoyalCollegePaediatricsandChildHealth.CurriculumforPaediatricTraining(2010)43RoyalCollegeofNursing.Definingstaffinglevelsforchildrenandyoungpeople’sservices(2013)44NICEguideline.Safestaffingfornursinginadultinpatientwardsinacutehospitals(2014)45TheIntercollegiateBoardforTraininginIntensiveCareMedicine.TheCurriculumforCCTinIntensiveCareMedicine46BritishAssociationofCriticalCareNurses.StandardsforNurseStaffinginCriticalCare(2009)

31

• “Aminimumof70%ofnursingstafftohavepost-graduatequalificationinintensivecareequivalenttoCC3N.”47

47Londonqualitystandards:QualityandSafetyProgrammeCriticalcare(2015)

1

ClinicalqualitystandardsforacuteservicesprovidedinSouthWestLondonoroperatedbyaSouthWestLondonTrust:currentposition

andgapanalysis

November2017

Assessmentagainstclinicalqualitystandardsforacuteservices 2

Contents

1 Introduction............................................................................................................................32 Methodology..........................................................................................................................43 Currentposition......................................................................................................................53.1 Currentactivitylevels..................................................................................................................53.2 Currentconsultantstaffinglevels...............................................................................................74 Theconsultantworkforce-abilitytomeettheclinicalstandardsnowandby2021................84.1 AbilitytomeetEDstandards.......................................................................................................84.2 Abilitytomeetobstetricsstandards...........................................................................................94.3 Abilitytomeetemergencygeneralsurgerystandards.............................................................104.4 Abilitytomeetpaediatricsstandards.......................................................................................114.5 Abilitytomeetacutemedicinestandards................................................................................124.6 Abilitytomeetintensivecarestandards...................................................................................134.7 Summarytable..........................................................................................................................155 Conclusion............................................................................................................................16Appendix1:Retirementratemodel............................................................................................17


1 Introduction

ThisdocumentsupportstheevaluationofclinicalsustainabilityofacuteTrustsinSouthWestLondonwithinasetofcoreacuteservices.Itreferstothestandardssetoutin‘Clinicalqualitystandardsforacute servicesprovided in SWLondonoroperatedbya SWLondonTrust’ (henceforth ‘the clinicalstandards’),andevaluates thecurrentand likely futurepositionofeachTrust’sconsultantstaffinglevels against these standards. Section 2 describes the methodology used to assess staffingsustainability.Section3coversthecurrentactivitylevelsandconsultantstaffinglevelswithineachofthe six services (emergency department, acutemedicine, paediatrics, emergency general surgery,obstetricsandintensivecare).Section4thenpresentsananalysisoftheextenttowhicheachTrustiscurrentlyabletomeettheconsultantstaffingrequirementssetoutinthestandards,thegap(ifany),alongwiththeprojectedavailabilityofnewconsultantsinSWLbetweennowand2021.

WerecognisethattheacutestandardssetouthererepresentjustonepartofawiderclinicalmodelforSWLondon.Moreover, consultant staffing isoneelementof staffing,alongsidemiddle-grades,nursing, and other key health professionals. In addition, demographic change means increasingdemandresultingfrommorecomplexhealthneedsandthisrequiresallhealthandcareproviders,includingthevoluntarysectorandlocalcommunities,toworktogetherindifferentways.

PleasenotethatthisdocumentwascompiledbasedupondiscussionsbetweenOct2016–October2017ledbytheMedicalDirectorsofthe4SWL-basedAcuteTrustsanddatasubmissionssourcedfromtheAcuteTrustsandotherNHSrecordkeepingsystemsduringthistimeframe.


2 Methodology

Wegatheredevidencearoundtheactivitylevelsandstaffinglevelsforthesixacuteservices,settingoutthefollowingquestionsforeachservice:

• Whatisthecurrentactivitylevelateachsite,andwhatRoyalCollegesizecategorywouldtheservicefitinto(wherethesesizecategorisationsareavailable)?

• Whatisthecurrentconsultantstaffinglevelateachsite?• AreacutesitesinSWLondon/servicesoperatedbySWLondonTrustsabletomeetrelevant

clinicalstandardsgiventheircurrentconsultantworkforce?• Towhatextentmightgrowth intheconsultantworkforceoverthenext fiveyearssupport

eachsite’sabilitytomeettherelevantclinicalstandards?

o EstimatedfromHealthEducationEngland(“HEE”)data(usingthenumberoftraineeconsultantsprojectedtogainCertificateofCompletionofTraining(“CCT”)inLondonbetween 2017-2021, adjusted for i) expected attrition during training, and ii)migration intoandoutofLondonfollowingCCTforconsultantpositions).Wehavealso factored in the projected number of retirements (assuming a consultantretirementrateof3.1%p.a.–seeAppendix1fordetails).

o TwomethodologieshavebeenusedtoestimatethelikelyproportionoftheLondonconsultantworkforcewhomightbeexpectedtoworkinSouthWestLondon:thefirstisaproportionbasedonthepopulationinSWLondon(16.4%),thesecondisbasedon the proportion of attendances/inpatient spells within the SW London trusts,relativetoLondonasawhole(variesbyspecialty).


3 Currentposition

3.1 CurrentactivitylevelsThefollowingtableshowstheactivitylevels,byTrust,foreachcoreacuteservice,andthecategorisationaccordingtoRoyalCollegesizecategorisations(wheretheseareavailable).Thisdataispresentedbecauseunitactivitydeterminestheminimumconsultantstaffingrequirement.TheviewoftheMedicalDirectorsisthatitcouldalsoimpacttheavailabilityofopportunitiesforconsultantstomaintaintheirskills,andonthenumberoftraineesthataunitcouldsupport.

Acuteservice

StGeorge’s

Kingston Croydon Epsom1 StHelier Source2/comments

ED 16/17attendances 169,825 105,045 119,967 58,557 87,853 NHSE-Unify2datacollection–MsitAE3(figuresincludeType1&3data;Type2dataisexcluded)

CEMcategory4 4 4 4 2 3 1:<50kp.a.2:50k-80kp.a.3:80k-100kp.a.4:>100kp.a.

Obstetrics 15/16births 5,153 5,670 3,833 1,927 2,891 NHSDigital–HES

RCOGcategory5 SpecialistCentre

C2 B A B A:<2.5kp.a.B:2.5k-4kp.a.C1:4k-5kp.a.C2:5k-6kp.a.C3:>6kp.a.

1ForED,obstetrics,acutemedicineandpaediatrics,theEpsomandStHelierfiguresareapproximate–itisassumedthat40%oftheESUHactivitytakesplaceatEpsomand60%takesplaceatStHelier.2Forobstetricsandintensivecare,HESdatawasthoughttobemoreaccuratethanSUSdata.15/16dataisquotedsince16/17HESdatahasnotyetbeenpublished.3https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2015/08/Quarterly-time-series-2004-05-onwards-with-Annual-updated-06-05-2016-Q4-2016.xls.Type1Departments–MajorA&E;Type2Departments–SingleSpecialty(e.g.Opthalmology);Type3Departments–OtherA&E/MinorInjuryUnit4CEM,2011.EmergencyMedicineOperationalHandbook:TheWayAhead.https://www.rcem.ac.uk/docs/Policy/The%20Way%20Ahead_Final%20Dec%202011.pdf5RCOG,RCM,RCA,RCPCH,2007.SaferChildbirth:MinimumStandardsfortheOrganisationandDeliveryofCareinLabour.https://www.rcog.org.uk/globalassets/documents/guidelines/wprsaferchildbirthreport2007.pdf


Acuteservice

StGeorge’s

Kingston Croydon Epsom StHelier Source/comments

Acutemedicine

16/17non-electiveadmissions

16,244

14,909 20,334 13,505 17,165 Non-electiveadmissionsundermedicalspecialtiesforpatientsaged18+

RCPcategory6 3 2 3 2 3 RCPcategoriesbasedonestimatednumberofspells/24h

1:<252:25-443:45-604:>60


16/17non-electiveadmissions

3,922 2,489 3,655 98 2,211 Non-electiveadmissionsunderselectedsurgicalspecialtiesforpatientsaged18+(includes:general,colorectal,breast,uppergastrointestinalandvascularsurgery)

Paediatrics 16/17non-electiveadmissions,excludingPAU

5,425 3,727 6,176 2,126 2,435 Non-electiveadmissionsforpatientsaged0-17,excludingPaediatricAssessmentUnitadmissions

16/17non-electiveadmissions,includingPAU

9,315 6,841 6,176 2,126 2,684 Non-electiveadmissionsforpatientsaged0-17,includingPaediatricAssessmentUnitadmissions

RCPCHcategory7 L L L S S S:<2.5kp.a.L:>=2.5k-p.a.

Intensivecare

16/17criticalcaredaysLevel3

16,513 1,742 2,816 908 2,530

Levels1-2 6,627 1,561 2,454 4,053 1,682

6RCP,2012.Deliveringa12-hour,7-dayconsultantpresenceontheAMU.https://www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit-4-delivering-12-hour-7-day-consultant-presence-acute-medical-unit7RCPCH,2013.BacktoFacingtheFuture.http://www.rcpch.ac.uk/sites/default/files/page/Back%20to%20Facing%20the%20Future%20FINAL.pdf8EpsomICUactivityincludesSWLEOC(SouthWestLondonElectiveOrthopaedicCentre)forbothLevels2and3


3.2 CurrentconsultantstaffinglevelsThefollowingdatawasobtaineddirectlyfromeachTrust.

Acuteservice StGeorge’s Kingston Croydon EpsomandStHelier

ED CurrentconsultantWTE 26.8 10.25 10 14


19 16 12 26



9 9 10.1 10

Paediatrics Currentconsultantheadcount(consultantswiththecompetenciestocoveracutepaediatricsoncalls;forSGH,acutegeneralpaediatriciansonly)

9 14 12 2610

Acutemedicine

Currentconsultantheadcount–dedicatedacutecarephysicians 9 9 8 11


17 21 25 30

Intensivecare Currentconsultantheadcount(consultantswhocontributetothecriticalcarerota(s))

24 8 8 7

9Notethatgynaecologyworkmayalsobeasignificantpartofsomeoftheseconsultants’jobplans.10Thisincludes8WTEacutepaediatricconsultantswhomanagethepaediatricEDserviceonbothsites11Giventhecomplexityoftheacutemedicalrota,wehaveincludedthefiguresfordedicatedacutecarephysiciansandforthetotalnumberofconsultantswhocontributetotheacutemedicalrota(includesacutecarephysiciansandnon-acutecarephysicians).Therequirementismetbyacombinationofdedicatedacutecarephysiciansandnon-acutecarephysicians.


4 The consultant workforce - ability to meet the clinical

standardsnowandby2021

The following analyses are not adjusted for changes to activity between now and 2021. LocalTransformationBoards(LTBs)arecurrentlymodellingfutureactivityprojections.Followingthiswork,eachLTBwillneedtore-confirmtheirexpectationsandplanstomeettheagreedqualitystandards.Thiswilldependuponlocalvariationsinthedifficultyofrecruiting,andlocalrecruitmentplans,aswellasthenationalshortageofconsultantsincertainspecialties.

4.1 AbilitytomeetEDstandards

Therangepresentedintheclinicalstandards(12-16)reflectsthefactthatconsultantstaffinginbusyemergencydepartments13isdependentupontherobustnessofmiddle-gradestaffinglevels(i.e.lowerlevelsofconsultantstaffingwouldrequireastrongmiddle-gradepresence).

12CalculatedfromHEEdataonthenumberoftraineesprojectedtogainCCTinLondonbetween2017-2021,adjustedfori)expectedattritionduringtraining,andii)migrationintoandoutofLondonfollowingCCTforconsultantpositions.ThebandingreflectstwomethodologiestocalculatetheproportionofLondonconsultantslikelytoworkwithintheSWLondonTrusts(oneaccordingtotheSWLondonpatientpopulation;theotherbasedontheproportionalattendancesbyspecialtywithinSWLondon,relativetoLondonasawhole)13Definedintheclinicalstandardsashavingactivitylevelsexceeding100,000attendancesperannum

StGeorge’s Kingston Croydon Epsomand

StHelier

Sum

RequiredconsultantWTE 24 12-16 12-16 24(12foreachsite)

72-80

CurrentconsultantWTE 26.8 10.25 10 14 61.25

CurrentWTEgap Nogap 1.75–5.75 2-6 10 13.75-21.75

Expectedretirementsin

SWLbetweennowand

2021(assumesa

consultantretirementrate

of3.1%p.a.–see

appendix1)

7.3

ProjectedWTEgapinSWL

in2021assumingnonew

consultantsarehired

21.05–29.05

Totalprojectedavailability

ofnewconsultantsinSWL

betweennowand2021(to

coverallnewEDpostsin

SWL)12

18-21


TheWTE calculation abovewas extrapolated using the number of PAs in the job plan of the EDconsultantsateachTrust.TheanalysissuggeststhatbothCroydonandKingstonarefacinggaps intheirEDstaffing,whichtheTrustsarecurrentlymanaging;howeverthischallengeisexacerbatedbydifficultieswithmiddle-grade staffing.AlthoughStGeorge’shasno consultant-level gap, theED iscurrentlyshortof7middle-grades,asubstantialchallengefortheTrust.Epsom&StHelierhasagapof10consultantswhichisbeingmanagedthroughacontinued,dedicatedrecruitmentandretentionprogramme,supportedbyaCESRtrainingprogramme.

Whenconsideringthecombinationofretirementsandanticipatedfutureavailabilityofconsultantswithinsouth-westLondon,themaximumlikelyavailabilityofnewconsultantsmatchestheminimumanticipated requirement for consultants, suggesting that ED consultant availability will present achallengefortheregionintothefuture.ThechallengewillbeparticularlyfeltbyEpsom&StHelier,giventhesizeofitsgap.Fortheregion,thissuggeststhatfocusedeffortsonmanagingmiddle-graderecruitmentwillbekeytoasustainableEDposition.

4.2 Abilitytomeetobstetricsstandards

14Notethatgynaecologyworkmayalsobeasignificantpartofsomeoftheseconsultants’jobplans.

StGeorge’s Kingston Croydon EpsomandSt

Helier

Sum

Requiredconsultant

headcount

21(specialistcentre)

16(categoryC2)

12(categoryB)

22(Epsom–categoryA,StHelier–categoryB)

71

Currentconsultant

headcount(consultants

withthecompetenciesto

coveracuteobstetricson

calls14)

19 16 12 26 73

Currentheadcountgap 2 Nogap Nogap Nogap 2

Expectedretirementsin

SWLbetweennowand

2021(assumesa

consultantretirementrate

of3.1%p.a.–see

appendix1)

9.0

Projectedheadcountgap

inSWLin2021assuming

nonewconsultantsare

hired

11.0


Obstetrics inSouthWestLondonappearstobesustainable,currentlyaswellas inthefuture. It isimportanttonotethattheapparentsurplusofobstetricians,relativetoclinicalstandards,doesnotmeantheserviceisover-staffed,sinceobstetriciansalsocovergynaecologyaswellassomeelectiveandoutpatientservices.Thereisalsoashortageofmiddlegradedoctors,particularlyatEpsom&StHelier,andhencearequirementforadditionalconsultantstocoverthisshortage. Importantly,theavailabilityofnewconsultantscoversbothobstetricsandgynaecology.

4.3 Abilitytomeetemergencygeneralsurgerystandards

Thegapinemergencygeneralsurgeryisminimalacrossallsites,anditappearstobeasustainableservicecurrentlyandgoingintothefuture.StGeorge’sfacesagapof1consultant.Kingston,although

15CalculatedfromHEEdataonthenumberoftraineesprojectedtogainCCTinLondonbetween2017-2021,adjustedfori)expectedattritionduringtraining,andii)migrationintoandoutofLondonfollowingCCTforconsultantpositions16CalculatedfromHEEdataonthenumberoftraineesprojectedtogainCCTinLondonbetween2017-2021,adjustedfori)expectedattritionduringtraining,andii)migrationintoandoutofLondonfollowingCCTforconsultantpositions

Totalexpectedavailability

ofnewconsultantsinSWL


coverallnewobstetrics

andgynaecologypostsinSWL)

15

41-44

St

George’s

Kingston Croydon Epsom

andSt

Helier

Sum

Requiredconsultantheadcount 10 10 10 10 39

Currentconsultantheadcount

(consultantswhocontributetothe

emergencysurgeryrota)

9 9 10.1 10 38.1

Currentheadcountgap 1 1 Nogap Nogap 2

ExpectedretirementsinSWL

betweennowand2021(assumesa

consultantretirementrateof3.1%

p.a.–seeappendix1)

4.5

ProjectedheadcountgapinSWLin

2021assumingnonewconsultants

arehired

6.5

Totalexpectedavailabilityofnew

consultantsinSWLbetweennowand

2021(tocoverallnewgeneral

surgerypostsinSWL)16

15-16


appearingtohaveagapof1,employsastaffingmodelwhichcompletelysplitselectiveandemergencycare.Asaresult,theserviceoperateseffectivelywith9consultants.

4.4 Abilitytomeetpaediatricsstandards

Thesustainabilityofconsultantstaffinginpaediatricsiscomplicatedatthenon-tertiarycentresbythefactthattheseconsultantsalsosupporttheneonatalrota.BothStGeorge’sandKingstonfacesmallbutmanageablegapsinpaediatrics.Croydon’shighactivityfiguresfornon-electiveadmissionsreflectlocalhealthneedsandthefactthattheydonotcurrentlyhaveaPAU.Itslevelofneonatal

17Therequiredheadcountisbasedonnon-electiveinpatientpaediatricactivityexcludingPaediatricAssessmentUnit(PAU)activity,whichwasagreedbyMedicalDirectorstobemoredirectlyrelatedtostaffingrequirements18Forlargehospitalswhererotasforgeneralpaediatricsareentirelyseparatefromspecialistpaediatrics(includingNICU),therequirementis10.0WTEs19Thisincludes8WTEacutepaediatricconsultantswhomanagethepaediatricEDserviceonbothsites20CalculatedfromHEEdataonthenumberoftraineesprojectedtogainCCTinLondonbetween2017-2021,adjustedfori)expectedattritionduringtraining,andii)migrationintoandoutofLondonfollowingCCTforconsultantpositions21Basedonanexpected70%ofthetotalnumberofpaediatricconsultants

St

George’s


andSt

Helier

Sum

Requiredconsultantheadcount17 1018 16 12-16 24(12at

eachsite,asactivitylevelsarelower)

66


(consultantswiththe

competenciestocoveracute

paediatricsoncalls)

9 14 12 2619 53

Currentheadcountgap 1 2 0-4 Nogap 3-7


betweennowand2021(assumes

aconsultantretirementrateof

3.1%p.a.–seeappendix1)

9.2

ProjectedheadcountgapinSWLin

2021assumingnonew

consultantsarehired

12.2-16.2


consultantsinSWLbetweennow

and2021(tocoverallnew

paediatricspostsinSWL,including

specialistpaediatricsposts)20

45-46


generalpaediatricconsultantsin

SWLbetweennowand202121

30-31


activityisalsolowerthantheequivalentfigureatKingston.CurrentstaffinglevelsareinterpretedinthecontextofthedevelopmentofaPAUandoptimisedoutofhospitalprogrammes.Longertermreviewofstaffingwithrespecttoactivitylevelswillbemaintained.

4.5 Abilitytomeetacutemedicinestandards

AcutemedicineisasignificantchallengeacrossSouthWestLondon.Staffingtheacutemedicalrotaisnotaproblem,giventhattheacutecarephysiciansaresupportedbylargenumbersofnon-acutecarephysicians(the“ologists”).Amuchbiggerchallenge,however,istheprovisionofhighqualitycaretotheacutemedicalwards,wherethesmallnumbersofacutecarephysiciansisexacerbatedbytheshortageofmiddlegradedoctors.Thiswillbecomemorechallengingastheservicemovesto22Giventhecomplexityoftheacutemedicalrota,wehaveincludedthefiguresfordedicatedacutecarephysiciansandforthetotalnumberofconsultantswhocontributetotheacutemedicalrota(includesacutecarephysiciansandnon-acutecarephysicians).Therequirementismetbyacombinationofdedicatedacutecarephysiciansandnon-acutecarephysicians.23Anestimatednetgrowthrateof2%p.a.wasagreedbytheMedicalDirectors.ItwasnotpracticabletouseHEEdataforacutemedicineduetotherangeofspecialtytrainingprogrammesthatequipdoctorswiththecompetenciestocovertheacutemedicalrota.

St

George’s


andSt

Helier

Sum

Requiredconsultantheadcount 12 12 12 24(ontwosites)

60

Totalnumberofconsultantswho

contributetotheacutemedical

rota(includesacutecare

physiciansandnon-acutecare

physicians)22

17 21 25 30 93

Currentconsultantheadcount–

dedicatedacutecarephysicians

9 9 8 11 37

Currentheadcountgapifonly

acutecarephysiciansaretaken

intoaccount

3 3 4 13 23


betweennowand2021

(assumesaconsultant

retirementrateof3.1%p.a.–

seeappendix1)

6

ProjectedheadcountgapinSWL

in2021assumingnonew

consultantsarehired

29

Totalanticipatedavailabilityof

newconsultantsinSWLbetween

nowand2021(acutecare

physiciansonly)23

9


fullydelivera7daymodelofcare.TheproblemismostpressingatEpsom&StHelier,whichhasthefewestnumberofdedicatedacutecarephysiciansperacuteinpatientsite.

4.6 Abilitytomeetintensivecarestandards

ForSt.George’s,KingstonandCroydon,thegapinICUdoesnotposeasubstantialchallengeandisbeingmanagedbythespecialties.EpsomandSt.HeliercurrentlyoperatesaservicewherebyLevel1/2criticalcare isprovidedwithinEpsom’sHDU,andLevel3patientsarestabilisedovernightandtransferred to St. Helier, which has a Level 3 ICU. As such, the staffing requirement at Epsom ismanagedbystafffromStHelierandvisitingstafffromtheotherthreeacuteTrustswhocontributetothe staffing for SWELEOC. The gap, therefore, is manageable within the context of the lesserrequirementofthesiteandplanstoappointafurthertwoconsultantsatStHelier.

24EpsomHospitalhasanadultcriticalcarefacilitythathastheabilitytotreatandstabiliselevel3patientsovernight.ThereisanexpectationthatsuchpatientswilleitherstepdownorbetransferredtotheintensivecareunitatStHelieriftheyrequireongoinglevel3care.Inaddition,thereisaPACU,staffed24/7byconsultantintensivists,ontheEpsomsite(withinSWELEOC).25CalculatedfromHEEdataonthenumberoftraineesprojectedtogainCCTinLondonbetween2017-2021,adjustedfori)expectedattritionduringtraining,andii)migrationintoandoutofLondonfollowingCCTforconsultantpositions

StGeorge’s Kingston Croydon Epsom

andSt

Helier

Sum

Requiredconsultantheadcount 27(forthreeunits–general,neuro&cardiothoracic)

9 9 9(forHDUatEpsomandICUatStHelier)24

63


(consultantswhocontributeto

thecriticalcarerota(s))

24 8 8 7 45

Currentheadcountgap 3 1 1 2 7


betweennowand2021

(assumesaconsultant

retirementrateof3.1%p.a.–

seeappendix1)

5.6

Projectedheadcountgapin

SWLin2021assumingnonew

consultantsarehired

12.6

Totalexpectedavailabilityof

newconsultantsinSWL


coverallnewICUpostsin

SWL)25

9


ThesmallnumberofconsultantsprojectedtocomethroughthetrainingprogrammeshouldalsobenotedandmaymeanthatTrustswillneedtolookfurtherafieldtorecruitadditionalconsultants.


4.7 Summarytable

26EDfiguresareWTE(asEDdoctorsseldomworkinareasoutsideofemergencymedicine,MedicalDirectorsfeltthatWTEwasthemostappropriatemeasureofavailability).Thefiguresforalltheother

acuteservicesareheadcount27Assumesaconsultantretirementrateof3.1%p.a.–seeappendix1fordetails.Note:wehavemodelledvariousconsultantretirementratescenarios,rangingfrom2%p.a.to6%p.a.Inthebest-case

scenario(rateof2%),theprojectedWTE/headcountgapinSWLin2021,assumingnonewconsultantsarehired,isstillgreaterthantheprojectedavailabilityofnewconsultantsinSWLbetweennow

and202128CalculatedfromHEEdataonthenumberoftraineesprojectedtogainCCTinLondonbetween2017-2021,adjustedfori)expectedattritionduringtraining,andii)migrationintoandoutofLondon

followingCCTforconsultantpositions29Seefootnote29onpage14

Acuteservice CurrentconsultantWTE/headcountgap26 ProjectedWTE/headcountgapin

SWLin2021assumingnonewconsultantsare

hired27

Projectedavailabilityof

newconsultantsinSWLbetweennowand202128

StGeorge’s Kingston Croydon EpsomandStHelier

Sum

ED Nogap 1.75–5.75 2-6 10 13.75-21.75 21.05–29.05 18-21

Obstetrics 2 Nogap Nogap Nogap 2 11.0 41-44

Emergencysurgery 1 1 Nogap Nogap 2 6.5 15-16

Paediatrics 1 2 0-4 Nogap 3-7 12.2-16.2 30-31

Acutemedicine(ifonlyacutecarephysiciansaretakenintoaccount)

3 3 4 13 23 29 9

Acutemedicine(allconsultantswhocontributetoacutemedicinerota)

Nogap Nogap Nogap Nogap 0 N/A N/A

Intensivecare 3 1 1 229 7 12.6 9

16

5 Conclusion

Thisdocumenthasprovidedanassessmentofcurrentconsultantstaffingagainsttheclinicalstandardsfortheagreedsixcoreacuteservicesdescribedin‘ClinicalqualitystandardsforacuteservicesprovidedinSWLondonoroperatedbyaSWLondonTrust’.Itshouldbenotedthatthisassessmentispartofawiderevaluationofoverallclinicalsustainability.Consultantstaffingisonecomponentofoverallstaffingfortheseservices,whichincludesmiddle-grades,nursesandotherhealthprofessionals.Thesesixcoreservicesarealsoasubsetofservicesprovidedoneachsiteandfurtherworkwillneedtobeundertakentoassessthesustainabilityofthiswidersetofservices.

Theassessmentsuggeststhat,withtheexceptionofEpsom&StHelier,acuteTrustsinSWLondonarebroadlyclinicallysustainableinthesixcoreserviceswithrespecttoconsultantstaffing.Itisalsounlikelythatfutureactivityprojectionswillchangethatbroadconclusion.Thereareexistinggapsinanumberofthesixcoreservices,buttheyarerelativelysmallandarebeingmanagedbytheTruststhroughadedicatedcommitmenttoongoingrecruitmentandretentionefforts,andsupportedthroughtheuseoflocumstaffing.MedicalDirectorsoftheseTrustshaveconfirmed,withtheirBoards,thattheybelievetheycanrecruitthenecessaryadditionalconsultantsandarethereforeclinicallysustainableinthesixcoreacuteservices.

Themostchallengingserviceisprobablyacutemedicine,wherethemovetofullydelivera7daymodelofcarewillbeparticularlychallenginginrespectofmedicalcoverfortheacutemedicalwards.Thereisanationalshortageofdedicatedacutecarephysiciansandthisisexacerbatedbyashortageofmiddlegradedoctors.Equally,additionalconsultantsarerequiredtoensurethatbothemergencydepartmentservicesandintensivecareservicesareabletocomplywiththeagreedstandards.

AsfarasEpsom&StHelierisconcerned,ithasalreadycentralisedallofemergencygeneralsurgeryandLevel3intensivecareononesite.Inaddition,thefigurespresentedinthisdocumentdemonstratethat,ascurrentlyconfigured,itmeetsthestandardsforobstetricsandpaediatrics.However,thefiguresalsodemonstratethatitdoesnotmeetthestandardsforitsEDservicesandfacesparticularpressuresinacutemedicine.

ForED,Epsom&StHeliercurrentlyhasagapof10consultantsbetweenitscurrentstaffingandtheagreedqualitystandards,whichrepresentsbetween46%and73%ofthetotalgapforSWLondon.Foracutemedicine,Epsom&StHelierhasagapof13consultantsbetweenitscurrentstaffingandtheagreedqualitystandards(ifonlyacutecarephysiciansaretakenintoaccount),whichrepresents57%ofthetotalgapforSWLondon.

ThesizeofthesetwogapsforEpsom&StHelierisconsiderableandthechallengesforEpsom&StHelierwillincreaseasthemovetofullydelivera7dayservicemodelintensifies.TheprojectedshortageintheavailabilityofnewconsultantsforSWLondonasawholeforthesetwoservicesisalsoanimportantfactor.Therefore,inthelongerterm,itisunlikelythatEpsomandStHelierwillbeabletodeliveralloftheseacuteinpatientserviceswithoutalevelofchangetotheirclinicalmodel.

17

Appendix1:Retirementratemodel

Table1.Inputdata–consultantageprofiledatafromNHSEmployers

Age %ofconsultantpopulation(raw) %ofconsultantpopulation(cleaned)

<34 2% 2.0%

35-44 37% 36.6%

45-54 40% 39.6%

55-64 19% 18.8%

65+ 3% 3.0%

Total 101% 100%

Table2.Assumptions

Assumptions

Proportionofaged55-64whoare55-59 66.67%

Annualretirementrate:age<34 0%

Annualretirementrate:age35-44 0%




Annualretirementrate:age65+ 20%

Table3.Minimodel

Age %ofconsultantpopulation

Annualretirementrate

Annual%oftotalconsultantbodyretiring

<34 2.0% 0% 0.0%35-44 36.6% 0% 0.0%45-54 39.6% 0% 0.0%55-59 12.5% 10% 1.3%60-64 6.3% 20% 1.3%65+ 3.0% 20% 0.6%Total 100.0% N/A 3.1%

PublicengagementontheSouthWestLondonSustainabilityandTransformationPlanByworkstreamtheme

05 September 2017

Public engagement on the South West London Sustainability and Transformation Plan – By work stream theme

Restricted External Draft – Version: 2.0

OPM Group

Classification RestrictedExternal

Contents

1. Executive Summary ........................................................................................ 3

2. Introduction ..................................................................................................... 8

3. Overarching themes ..................................................................................... 12

4. Seven day acute services and urgent & emergency care ......................... 15

5. More care closer to home ............................................................................ 27

6. Prevention and early intervention ............................................................... 35

7. Mental health services ................................................................................. 39

8. Learning Disabilities ..................................................................................... 51

9. Children’s services ....................................................................................... 55

10. Maternity services ........................................................................................ 62

11. Cancer ............................................................................................................ 68

12 Planned Care ................................................................................................. 72

13. Next steps ...................................................................................................... 75


3

1. ExecutiveSummaryTheNHSinsouthwestLondon,workingwithlocalcouncils,isintheprocessofdevelopingalong-termplanforlocalhealthservices,calledtheFiveYearForwardPlan,oraSustainabilityandTransformationPlan(STP).ThisworkisbeingcarriedoutbysixlocalClinicalCommissioningGroups(CCGs),localauthorities,fourhospitalstrusts,clinicians,communityhealthservicesandmentalhealthtrustsandpatientsandmembersofthepublic.ThesixsouthwestLondonboroughsareCroydon,Kingston,Merton,Richmond,SuttonandWandsworth.

SinceMarch2016,theNHShasbeenundertakingagrassrootsoutreachengagementprogramme,fundedbyNHSEngland,toreachouttoseldomheardcommunities.TheNHSprovidedfundingtolocalgrassrootsorganisationstoruneventsthatwereenjoyabletotheirpopulations,andthenattendedtolistentoviewsonlocalhealthissues.Thefundingwasallocatedvialocalhealthwatchorganisationsthatpromotedtheopportunity,evaluatedthebidsandadministeredthefunding.Inaddition,OPMGroupwascommissionedtodesign,facilitateandreportonsixopenaccesshealthandcareforums,oneineachofthesixsouthwestLondonBoroughs.

Thisreportprovidesasummaryofthefeedbackfromtheallthisengagementactivity,organisedbyworkstreamtheme.IthasbeenindependentlycompiledbyOPMGroup.

1.1. Overarchingthemes

Overall,peopleweresupportiveoftheproposalsandthedirectionoftravelindicatedinthedraftplan.Thismeanttheywantedtoknowthepracticaldetailsoftheproposalswhichwouldhelpthemunderstandhowthesechangeswouldbeachievedandwhatitwouldmeanfromapatientperspective.Theysharedideas,concernsandquestionswhichtheNHSinsouthwestLondoncanusetoshapeimplementationplans.

Severalcommonissuesemergedinthediscussionsaboutthedifferentworkstreams:

• Concernsaboutaperceivedlackoffundingandresourcestoinvestinservicechanges,particularlyinthelightoflocalservicesalreadybeingchangedorcut.

• CapacityconcernsforlocalNHSservices,aspeoplebelievedcommunityservices,localNHShospitalsandGPswouldnotbeabletocopewithpotentialchangesindemandcausedbysomeoftheproposals.PeoplealsonotedthecurrentdifficultyinaccessingGPappointments.

• Improvingandincreasingsignpostingtoservicestomakethepublicawareofservicesinthearea,aswellaseducatingpeopleabouthealthcarechoices.

• Concernsoverqualityofservicesandofequalityinaccessingtheseservices.

• Difficultyinchangingbehaviourofthepublicandstaffwhichwouldberequiredtosuccessfullydelivertheproposals.

• Theneedtoimprovestaffcommunicationskillssothatpatientsandcarersaretreatedwithempathyandrespect,especiallythosewithcomplexoradditionalneeds.


4

• TheneedformorejoinedupITsystemstoaidcommunicationbetweenservicesandavoidpatientshavingtorepeatthemselves.

1.2. Sevendayacuteservicesandurgent&emergencycare

Overall,thereweremixedviewsabouttheabilitytoimplementanddeliverthequalityofhealthcareservicedesired,andtherewasconcernfrompeopleregardingthecapacityoftheservicesundertheproposedsevendayacuteservicesplan.WhilepeopleagreedwiththeaimtoreducethenumberofpatientsusingA&E,therewereconcernsaboutwhatalternativeswouldbeavailable,particularlyassomepotentialalternativesarealsoclosing.TherewaslowawarenessofNHS111,andthosewhowerefamiliarwithitwerenotconfidentitwouldreducedemandonA&E.Indiscussingalternativeservices,severaleventsdiscussedhowlimitedaccesstoGPsputsstrainonacuteservices.

TransportationneedsandgeographicalimplicationsofnewserviceproposalswereraisedasconsiderationsfortheimplementationoftheSTP.

Somefeltexistingurgentandemergencycareandacuteservicesneedtobeimprovedtoensuretheyareinclusiveandmeettheneedsofdiverseusersandprovideperson-centredcare,andwaitingtimesarereduced.Therewereconcernsaboutmentalhealthcrisiscare,andlackofmentalhealthawarenessinA&E.

AcriticalsuccessfactoridentifiedincarryingoutthechangesidentifiedwastheabilityoftheNHStocommunicateandsignposttotheservicesavailabletopatients

1.3. Morecareclosertohome

Overall,whiletheideaofhavingmorecareclosertohomewassupported,therewereconcernsthatthelocalNHSdidnothavethecapacityandresourcestomanagethechangetowardsamorelocalcaremodel.Inorderfortheplanstobeeffective,peoplebelievedsignificanttraininganddevelopmentwouldbeneededforpharmaciststobeabletodeliverappropriatehealthcare,especiallyforvulnerablepeople,andthatinvestmentwouldbeneededtoimprovepharmacistfacilities.

Thereweremixedresponsesregardingtheimpactofthisplanonquality,aspeoplefeltitmayreducewaitingtimes,buttherewereconcernsaboutinformationsharingandworkloadmanagementwhich,ifnotaddressed,coulddiminishquality.

Detailedfeedbackwasprovidedonprimarycareservices,relatingtoconcernsaboutappointmentavailability,accessibility,referrals,andholisticandperson-centredcare.Inaddition,severalspecificareasoffeedbackrelatingtovariableoutofhospitalcarewereprovidedforconsiderationandimprovement.

Theintroductionofnewrolessuchascarenavigatorswerepositivelyreceivedbutmanywantedmoredetailabouthowtheseteamswouldsupportlocalpatientcareinpractice.Finally,awarenessofappropriateservicesislowandpeoplesuggestedadditionalcommunicationfromtheNHSto


5

bothprofessionalsanddirectlytothepublicwouldhelpensurepatientsusedtheavailablelocaloptions.

1.4. Preventionandearlyintervention

Overall,peoplesupportedtheinclusionofpreventionapproachesintheSTP,andadesireformorepersonalisedandholisticcare.However,therewereconcernsaboutwhethertheSTPwouldbeabletochangepeople’sbehaviours.Therewerealsoconcernsovertheintroductionofpreventionservicesthatmayleadtoprivatisationorservicecutsinotherareasthatwouldcompromisecare.

Somepeoplehadquestionsregardingtheroleofdifferentcommunitygroupsandhowtheresourceswouldbemanagedtoensurehighqualitycare.Inaddition,moredetailedinformationwasrequestedregardinglocalityteams,theirroleinhealthcareandhowthesewouldoperateinpractice.

Peopleemphasisedthatcommunicationiskeytoensuringchangeinbehaviourforprevention,andpeopleagreedtheNHSmustimproveitsoutreachforthistobesuccessful.

Finally,whilesomepeoplesupportedtheuseoftechnologytomonitorhealth,theydidnotseeitasauniversaltoolandwantedmoreinformationaboutwhichcontextsitwouldbeusedin.

1.5. Mentalhealthservices

Overall,therewaslowconfidenceincurrentmentalhealthservicesduetoperceptionsofpoorquality,closures,longwaitingtimes,underfundingandinabilitytocope.Therefore,therewereconcernsthattheSTPwillnotbesuccessfulinthisarea.

Peoplesupportedaholisticapproach,incorporatingphysicalconditionsandcoordinatingwithmultipleorganisations,butquestionedhowthiswouldworkinpractice.ItwasfeltthatsignificantinvestmentintrainingandadditionalskillswouldbeneededforGPsandotherstodeliverhigherqualitymentalhealthservicesandreducestigma.Peoplealsowantedmoreinformationaboutwhereproposedmentalhealthtreatmentwouldtakeplace.Theyemphasisedtheneedforhighqualityoutofhospitalmentalhealthcare,andmoresupportintransitionsintothecommunity.

Aninclusiveapproachtomentalhealthwasdesiredwiththeneedsofmarginalisedandvulnerablegroups,suchaschildren,LGBTandethnicminoritieshighlightedasanimportantconsiderationfortheSTP.

Peoplewantmorementalhealthawarenessandeducationinschools,aswellmoreintegrationwithmentalhealthservicesandschoolstosupportchildrenandfamilies.Finally,itwasfeltthattheNHSshouldimproveitscommunicationaboutavailableservicesformentalhealth,aswellassignpostingpeopletocareinmoreinformalsettingssuchasdrop-incafes.

1.6. Learningdisabilities

PeoplewereconcernedaboutlongwaitingtimestoseeaGPandrequestedthatGPappointmentsforpeoplewithlearningdisabilitiesshouldbelongertoallowmoretimetoexplaininformation


6

clearly.Itwasstronglyfeltthatstaffneedtocommunicatemoreclearlywiththosewithlearningdisabilities,andinvolvethemintheircare(notjusttheircarers).Peoplealsoemphasisedthatmoresupportforcarersisneeded.

Peoplealsohighlightedaneedforimprovedaccessibilityforthosewithdisabilities(physicalaccessandaccessiblecommunications).Finally,itwasnotedthatthereshouldbemoreawarenessofannualhealthchecksforchildrenwithlearningdisabilities,includingremindersfromtheGPsurgery.

1.7. Children’sservices

Overall,whilepeopleagreedwiththeprincipleofreducingunnecessaryA&Evisitsfromchildrenandparents,theyfeltitwouldbechallenginginpractice.Peoplebelievedthattoreducetheburdenonacuteservices,moreflexibleGPservicesareneeded.

ItwasstronglyfeltthattheSTPshouldaddresschildren’sdiversehealthneeds,includinggivingsupportformentalhealthservicesandfamilieswithdifferentculturalbackgrounds.Inparticular,peopleemphasisedtheneedforimprovedstandardsofcareforchildrenandyoungpeoplewithalearningdisability,along-termcondition,orautism.Itwassuggestedthatdoctorsshouldinvolvechildrenmoreactivelyindiscussingtheirsymptoms,conditionsandtreatments.

Peoplebelieveincreasedawarenessisneededaboutwhatservicesareavailableforchildren’shealthaswellaswhenitasappropriatetouseeachservice.Therewasalsoadesireformoreeducationandinformationtosupporthealthylifestylesforchildrenandfamilies.

1.8. Maternityservices

Overall,whendiscussingmaternityservices,peoplediscussedthelackofaccesstoqualitycareduetomidwiferystaffshortageswhichneededtobeaddressed.Continuityandconsistencyofmaternitycarewerebelievedtobeareasforimprovementwithspecificissuesduetotheshortageofmidwives.Manypeoplewouldliketoseeincreasedpersonalisationandpatient-ledapproachestocare,howeveremphasisetheimportanceofprioritisingpatientsafety.

Post-natalcarewashighlightedasaservicethatrequiredimprovementandpeoplewouldliketoseethisaddressedintheSTP.

Communicationandattitudesofstaffinvolvedinmaternitycarewasseenasvariableandinneedofimprovementinordertoadequatelysupportwomengivingbirthandtheirfamilies.Finally,peoplesuggestedcommunicationsandoutreachshouldbecarriedouttoraiseawarenessofservicesandcatertodifferinganddiverseneedsinthecommunity.

1.9. Cancer

Peoplediscussedcancercareatallstages,fromscreeningandprevention,throughtosupportingpatientstolivewithandaftercancer.

Peoplefeltmoreworkcouldbedonetoincreaseuptakeofscreening,andtoincreasepreventativecareandguidancetothoseathigherriskofcancer.Peopleemphasisedtheneedforearlydiagnosis


7

andsuggestedGPscouldreceiveadditionaltrainingfromhospitalspecialists.Furthermore,itwasnotedthatdeliveringnewsofadiagnosisshouldbedeliveredwithempathyandsensitivity.

Peoplesuggestedadditionalfollowupsupportcouldbeprovidedafterdiagnosisandaftertreatment,bothbyNHSstaffandthroughsignpostingtosupportinthecommunity.Additionalsupportcouldalsobeprovidedtohelppatientsdealwithsideeffectsandlongtermdamagecausedbycancertreatments.

Finally,therewasadesireforNHSSWLtosetthe‘goldstandard’forcancerdiagnosis,treatmentandcare,includingbeingproactivelyinvolvedintrialsandnewtreatments.

1.10. Plannedcare

Inrelationtoplannedcare,peoplefeltspecialisthospitalsorelectivecentrescouldproducebetteroutcomesbuttherewereconcernsaboutthefeasibilityofplansandwhethertheywouldleadtonecessarycostsavings.Concernswereraisedaboutwhethertherearesufficientstafftodeliverplannedcareeffectivelyandefficiently,andsomethoughtcurrentstaffareoverworkedandoverstretchedwhichimpactsonpatients.Peoplenotedthattheyweremorepreparedtotravelfornon-urgentelectivecare,buthighlightedthatensuringappropriatetransportationwillbeimportant.

Itwasfeltthatthereisscopeforcurrentpracticesarounddischargeandaftercaretobeimproved,whileaproposalthatreducesthewastedtimeasaresultofcancellationsofoperationsandoutpatientappointmentswouldalsobewelcomed.Finally,peoplefeltthereshouldbeimprovedinternalandexternalcommunicationbetweenservices,includingGPs,hospitalsandsocialcareproviders.


8

2. Introduction

2.1 BackgroundWhyisaforwardplanbeingdeveloped?

TheNHSinsouthwestLondon,workingwithlocalcouncils,isintheprocessofdevelopingalong-termplanforlocalhealthservices,calledtheFiveYearForwardPlan,oraSustainabilityandTransformationPlan(STP)1.Thedraftplanisavailablehere.

ThisworkisbeingcarriedoutbysixlocalClinicalCommissioningGroups(CCGs),localauthorities,fourhospitalstrusts,clinicians,communityhealthservicesandmentalhealthtrustsandpatientsandmembersofthepublic.Itcoversallaspectsoflocalhealthservicesincludinghospitals,primarycare,mentalhealthandcommunityservices.

ThelocalNHShasidentifiedfourkeychallenges–money,workforce,estatesandconsistentqualityofcare–whichtheFiveYearForwardPlanwillaimtoaddressbysettingoutplansto:

• usemoneyandstaffdifferentlytobuildservicesaroundtheneedsofpatients

• investinmoreservicesinlocalcommunitiestoimproveoutcomesforpatients,includingpreventativecare

• investinestates(buildings)tomakethemfitforpurpose

• trytobringallservicesuptothestandardofthebest.

Whathasbeendonesofar?

AnoutlinestrategywaspublishedinJune2014,settingoutaplanforthelocalNHSanddetailingthestandardsofcarethatpeopleinsouthwestLondonshouldexpect.

AnissuespaperwaspublishedinJune2015settingoutthechallengesforlocalservicesandinitialideasabouthowtotacklethem.InSeptember2015,TheNHScommissionedaseriesofdeliberativeeventstogaintheviewsofmembersofthepublicandlocalstakeholdersontheIssuesPaper(theeventsweredeliveredbyOPMGroup;seethereporthere).

SinceMarch2016,theNHShasbeenundertakingagrassrootsoutreachengagementprogramme,fundedbyNHSEngland,toreachouttoseldomheardcommunities.TheNHSprovidedfundingtolocalgrassrootsorganisationstorunenjoyableeventsfortheirpopulations,tolistentoviewsonlocalhealthissues.Thefundingwasallocatedvialocalhealthwatchorganisationsthatpromotedtheopportunity,evaluatedthebidsandadministeredthefunding.In

1AllNHSregionsarerequiredtodevelopaSustainabilityandTransformationPlan(STP).


9

addition,OPMGroupwascommissionedtodesign,facilitateandreportonsixopenaccesshealthandcareforums,oneineachofthesixsouthwestLondonBoroughs.

2.2 Methodology

2.2.1 Healthandcareforums

PeopleforthehealthandcareforumswererecruitedbyNHSSouthWestLondon.Theywereinvitedtoattendeventsvia:

• emailstothosewhohadattendedpreviousevents

• engagementwithlocalcommunityandvoluntarygroupsandlocalHealthwatchgroups

• advertisingvialocalpress,radioandsocialmedia.

Eacheventhadcapacityforupto100participants.

Thesixeventswereheldintheeveningsandlasted3hours(6-9pm).Theformatoftheeventsencouragedanin-depthdialoguewithpeopleaboutthekeyissuesandquestionsraisedinthedraftFiveYearForwardPlan.Peoplehadtheopportunitytojointworoundsoftablediscussions,witheachroundincludingatleast6tables,eachtablefocusingononeof6topics.Mosteventshad6tablesforeachroundofdiscussion,butforsomeroundstherewerefewertables(ifnopeoplechoseaparticulartopic),andforothersthereweretwotablesforthemorepopulartopics(sothatpeoplecouldfocusonthetopicoftheirchoice).

EacheventwasindependentlyrunbyOPMGroup’sfacilitationteam,madeupofoneleadfacilitatorandtablefacilitatorstomanagethetablediscussions.

NHSrepresentatives(includingCCGChiefOfficersandChairs,hospitalmedicaldirectorsandchiefexecutivesandotherNHSstaff)attendedtheevents,tosetthescene,presentthedraftFiveYearForwardPlanandanswerquestionsfromparticipants.Ateachevent,thelocalNHSrepresentatives:

• ProvidedbackgroundinformationontheFiveYearForwardPlan,explainingwhatitis

• OutlinedthechallengesfacinghealthcareinsouthwestLondon

• DescribedhowtheFiveYearForwardPlanisproposingtoaddressthesechallenges

Thisinformationformedthebasisforthetablediscussionsamongstparticipants,toelicittheirresponsestoandconcernsaroundthePlan.

2.2.2 Grassrootsengagementactivities

Theaimofthegrassrootsengagementactivitieswastodevelopmeaningfulconversationswithseldomheardcommunities.NHSSouthWestLondonrecognisedthatthesecommunitieswoulddifferacrossboroughs,however,ingeneraltheyfocusedonthosepeoplefromgroupswithprotectedcharacteristics,asdefinedbytheEqualityAct(2010).TheyalsoenabledlocalHealthwatchorganisationstosuggestotherlocalcommunitiesthatwerehardertoreachineachborough.


10

Tosuccessfullydeliverthisprogramme,NHSSouthWestLondonworkedcollaborativelywithlocalHealthwatchorganisationsandgrassrootsgroups.EachHealthwatchorganisationwasinvitedtomanageapotoffundingthatlocalgrassrootsgroupscouldapplyfortorunevents/activitiesenjoyabletotheirpopulation.EachHealthwatchwasabletosettheirownapplicationguidelineswitharequestthatgroupsapplyingforthefundingshouldbefromseldomheardgroupsandtherewouldbeanopportunityateacheventforNHSstafftoattendandspeakwithindividuals.

Healthwatchorganisationsusedtheirconnectionsandcommunicationchannelstopromotethisopportunitytolocalgroups,particularlythosegroupswithprotectedcharacteristics/seldomheardvoices.Theyadvertisedtheopportunitythroughtheirwebsitesandviasocialmedia.SomeHealthwatchesusedamoretargetedapproachbymakingdirectcontactwiththoseorganisationsthattheythoughtwouldbenefitfromthefunding.EachorganisationwasabletoapplyforthefundingandHealthwatchwouldchecktheapplicationandthenlettheorganisationknowiftheyweresuccessfulinreceivingthefunding.

Oncethisprocesswascompleted,theinformationwaspassedontotheprogrammeteamforcontacttobemadewiththelocalorganisation;congratulatingthemonbeingsuccessfulintheapplicationprocess.Arrangementswerethenmadeforattendanceattheevent,includingdiscussionsaroundwhatthemostappropriatewaytospeaktopeopleontheday.

Ateachsession,theprogrammeteam,localCCGandHealthwatchwereinvitedtoattend.Wheresessionshadaspecificfocustowardsaworkstream,theassistantdirectors,orotherworkstreampeople,werealsoinvitedtoattendorsendquestionsthatwouldberelevantfortheengagementteamtoask–thishelpedtoensurethattheconversationswererelevanttolocalprioritieswithineachareaoftheSTP.

TheprogrammeandlocalCCGattendedeachsessionandspoketoattendeesabouttheirexperienceoflocalservices.Duringtheevents,theengagementteamhadadedicatedslot/opportunitytodiscusslocalhealthissuesandtolistentotheviewsofthoseparticipating.Thiswasthroughavarietyofmechanismssuchasone-to-oneconversations,focusgroupsorgroupdiscussions.Thequestionsaskedateachsessionweretailoredtotheaudience.

2.3 Participants

ThetablebelowsummarisesthenumberofpeoplewhoattendedeachoftheeventsandengagementactivitiesacrossthesixLondonBoroughs.

Borough Date Numberofparticipants

Croydonhealthandcareforum

7thFebruary,2017 33

Croydongrassrootsengagementevents

May–November2016 11eventsspeakingtoover222people

Mertonhealthandcareforum 29thJune,2017 33


11

Wandsworthhealthandcareforum

14thMarch,2017 44

Mertongrassrootsengagementactivities

May–December2016 10eventsspeakingtoover250people

Wandsworthgrassrootsengagementactivities

June2016–Feb2017 10eventsspeakingtoover200people

Kingstonhealthandcareforum

8thFebruary2017 35

Richmondhealthandcareforum

2ndMarch2017 55

Kingstongrassrootsengagementactivities

March2016–March2017 15eventsspeakingtoover302people

Richmondgrassrootsengagementactivities

June2016–March2017 18eventsspeakingtoover378people

Suttonhealthandcareforum 1stFebruary,2017 30

Suttongrassrootsengagementactivities

July–December2016 13eventsspeakingtoover284people

2.4 AboutthereportThisreportprovidesasummaryofthefeedbackfromthesixhealthandcareforumsandthegrassrootsengagementactivities,capturingthekeythemesdiscussedbythepeopleinthefollowingsections:

• Keyoverarchingthemesemergingacrosstheeventsandactivities

• Asummaryofthediscussionsaroundeachofninetopics

Aseparatereporthasbeenproducedorganisingtheinformationbyeachofthefourmaingeographicalareas(eachoverseenbyaLocalTransformationBoard).Thesefourareasare:Croydon,Kingston&Richmond;Merton&Wandsworth;andSutton.

ThelocalNHSwillusethefeedbackfromtheseeventstofurtherinformthedevelopmentandimplementationoftheFiveYearForwardPlan,workingwiththeirlocalauthoritiesandlocalpeople.


12

3. OverarchingthemesOverall,peoplewerebroadlysupportiveoftheideaspresentedtothem.Theybroadlyendorsedthedirectionoftravelifitwasachievable.However,anumberofcommonissuesemergedinthediscussionsaboutthedifferentworkstreamswhichlargelyrelatedtothefeasibilityofimplementingtheplans.Thefollowingisasummaryoftheseoverarchingthemes.

3.1 Fundingandfinance

Manyoftheconversationsatthesixhealthandcareforumswereunderpinnedbyconcernsaboutthescarcityoffundingandwhethertheplanswouldbeaffordable.Whilemanyoftheambitionsintheforwardplanresonated,mostbelievedthatinrealitythesewouldnotbeachievedwithoutasignificantincreaseinspending,whichtheydidnotbelievewouldbepossible.Somewereworriedthatfundingpressuresmayleadtoprivatisationofservices.

Atthegrassrootsengagementactivities,thistopicfeaturedlessprominently,howevertherewereseveralquestionsabouthowchangesandimprovementswouldbefundedandworriesthatmoneywouldbewastedonunnecessarychanges.

3.2 Capacityofservices

Manypeopleatthesixhealthandcareforums,andthegrassrootsengagementactivities,raisedconcernsthatthecurrentstrainonserviceswouldmeanthattheNHSwouldbeunabletodelivertheproposedchangesintheplan.Itwasobservedthatthecurrentlocalservicesdidnothavethecapacitytotakeonadditionalworkinordertoreducetheburdenonacuteservices.Whiletheintegrationofcommunityandvoluntarysectorwasgenerallywelcome,therewerequestionsastohowthiswouldbemanagedtoensurequalitycare.Theperceptionsofcurrentpoorqualityof,andlimitedaccessto,mentalhealthservicesgavelowconfidenceintheSTPproposalformanagingmentalhealth.Perceivedseverestaffshortagesalsogivecauseforconcern,especiallyforGPaccess,midwifeservices,andin-hospitalcare.Inaddition,peoplethoughtthattrainingandnewskillswouldbeneededforthedeliveryoflocalcareservicesincludingpharmacisttrainingandmentalhealthtrainingforGPs.

3.3 AccesstoGPs

Asnotedinconcernsovercapacity,limitedaccesstoGPswasacommonthemeacrossthesixhealthandcareforums,andthegrassrootsengagementactivities.ManypeoplebelievethattheywillnotbeabletoreducethenumberofA&EvisitsoracuteservicesstrainwithoutadequateaccesstoGPs.Currently,peoplediscussedhowtheystruggletogetanappointmentwiththeirGPandthelackofflexibleaccess.TheybelievedenhancedGPaccesscouldreduceA&Evisitswithchildrenastheythoughtparentsrequireflexibleaccesstohealthservices.

3.4 Educationandawarenessofservices


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Improvedandmoresignpostingtoserviceswasoftensuggestedtoensurepatientscanaccessthemostappropriatecare.ManypeoplesuggestedthatcurrentcommunicationfromtheNHSwaslacking,anddidnotadequatelyinformthepublicoflocalservicesavailabletothem.TherewereseveralsuggestionsthatGPsandotherprofessionalsshouldbemoreawareoflocalservicesthattheycandirectpatientsto.Raisingawarenessthroughmoreinformalsettingsandschoolsweresuggestedasimportanttoolsforchildren’sservicesandmentalhealth.

3.5 Quality

Theimpactonqualityofservicesandcarewasakeyconcernformanyparticipants.Overall,thereweremixedfeelingsaboutwhattheimpactonqualitymightbe,assomechangeswouldimproveaccessandqualityoftreatments.However,severalraisedconcernsabouthowreductionsinacutecare,movingcaremorelocallyandincreasingpreventionservicescouldnegativelyimpactqualityasresourceswerespreadmorethinly.

3.6 Changingbehaviour

ChangingbehaviourwasnecessaryforseveralaspectsoftheSTPtobesuccessful,andthiswasraisedasaconcernatseveralofthehealthandcareforums.ManybelievedtheSTPunderestimatedhowchallengingitcouldbetochangepeople’sbehaviour,inbothwheretheyreceivecareandintheirlifestyles.Inadditiontopatientbehaviourchange,somesuggestedthathealthcarepractitionersmayneedtochangebehaviourtodeliverdifferentservices.Forexample,peoplesuggestedthereshouldbeamorepatientledandpersonalisedapproachtoservicedelivery.

3.7 Practicaldeliveryofproposals

Thereweremultiplediscussionsatthesixhealthandcareforumsofhowtheoperationalchangeswouldbeimplementedandmanagedpractically.Manywouldlikemoredetailregardinghowandwherehealthserviceswouldbeprovided,forexamplewherealternativementalhealthserviceswouldbelocated.Thetransportationandtravelimplicationsofchanginghealthcarelocationswereraisedasaconcerninmultipleevents.Forsomeideas,suchastheholisticapproachtomentalhealthandtheuseoflocalityteams,manypeoplerequestedmoreinformationaboutwhatthiswouldmeaninpracticeforpatients.Tointroducenewwaysofreceivingcare,suchasusingtechnologyorpharmacists,peoplewouldlikeadditionalinformationabouthowthiswouldimpactdifferentpatientsandwhentheseservicesaremostappropriatetouse.

3.8 Equalityofaccesstohealthservices

Peoplesupportedequalaccesstoservicesforallindividualsintheircommunity,andhighlightedwaysinwhichtheSTPcouldmakethismoreinclusive.Formentalhealthandchildren’sservices,theneedsofthosewithlimitedEnglishorlackinginlocalsupportnetworkswereraised.Givingmedicalinformationinmultiplelanguagesandanawarenessofculturaldifferencesweresuggestedasimportantconsiderations.Therewasconsiderablefeedbackaboutmakingservicesmoreaccessible


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andinclusiveforpeoplewithlearningdisabilitiesandforthosewithAutismSpectrumDisorders.Peoplefeltthatmentalhealthservicesshouldcarryoutmoreoutreachofservicesformanymarginalisedorminoritygroupsincludinglesbian,gay,bisexual,andtransgender(LGBT)individuals,homeless,andblackandminorityethnicity(BME)individuals.Therewasbroadsupportforensuringthatservicesarefittoprovideforthediverseneedswithineachoftheircommunities.

3.9 Staffcommunicationskills

Duringthegrassrootsengagementactivitiesinparticular,peopleprovidedmixedfeedbackabouttheirexperienceofstaffattitudesinbothclinicalandadministrativeroles.Theyfeltadditionaltrainingshouldbeprovidedtostaffonhowtocommunicatewithandsupportthosewithparticularneeds,includinglearningdisabilities,mentalhealthissues,autismspectrumdisorders,physicaldisabilities,andchildrenandyoungpeople.

3.10 Informationmanagementandtechnology

Therewereseveralcommentsatthesixhealthandcareforumsandatthegrassrootsengagementactivities,regardinginformationmanagementandtechnology.ThemostcommonthemewasaroundjoiningupITsystemssothattherecouldbemoreefficientcommunicationbetweenservices,avoidingpatientshavingtorepeatthemselves.

Atthegrassrootsengagementactivities,thereweresomeconcernsaboutanincreasedrelianceontechnology,suchasonlinerepeatprescriptionsandonlineGPconsultations,becauseofworriesthatthosewithoutinternetaccessmightmissout.Otherswelcomedanincreaseduseoftechnology,particularlyworkingparentsandcarers.


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4. Sevendayacuteservicesandurgent&emergencycare

Thissectionsummarisesthediscussionsacrossthesixhealthandcareforumsandthegrassrootsengagementactivitiesaboutsevendayacuteservices.Ithighlightstheemergingthemesandkeymessagesaboutthecaseforchangeandtheideasdevelopedsofar.

ThesuggestionsoutlinedintheSTPrelatingtosevendayacuteservicesinclude:

• Makingsurethatpeopleareadmittedintohospitalonlywhenitisthebestplaceforthem,andstayfortherightlengthoftime.

• Improvingquality,withtherightstaffinplace7daysaweek

4.1 Keymessages

• Overall,therewasconcernfrompeopleregardingthecapacityoftheservicesundertheproposedsevendayacuteservicesplan

• WhilepeopleagreedwiththeaimtoreducethenumberofpatientsusingA&E,therewereconcernsaboutwhatalternativeswouldbeavailable,particularlyassomepotentialalternativesarealsoclosing

• TherewaslowawarenessofNHS111,andthosewhowerefamiliarwithitwerenotconfidentitwouldreducedemandonA&E

• Indiscussingalternativeservices,severaleventsdiscussedhowlimitedaccesstoGPsputsstrainonacuteservices

• Somefeltexistingurgentandemergencycareandacuteservicesneedtobeimprovedtoensuretheyareinclusiveandmeettheneedsofdiverseusersandprovideperson-centredcare,andwaitingtimesarereduced

• Therewereconcernsaboutmentalhealthcrisiscare,andlackofMHawarenessinA&E

• TransportationneedsandgeographicalimplicationsofnewserviceproposalswereraisedasconsiderationsfortheimplementationoftheSTP

• Thereweremixedviewsabouttheabilitytoimplementanddeliverthequalityofhealthcareservicedesired

• AcriticalsuccessfactoridentifiedincarryingoutthechangesidentifiedwastheabilityoftheNHStocommunicatetheservicesavailabletopatients

4.2 Feasibility


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4.2.1 Capacityofavailableservices

ConcernswereraisedacrossseveralofthehealthandcareforumsregardingthecapacityofexistingNHSservicesandhowtheywouldcopewiththisproposedchange.

Whilemanypeopleagreedwiththeprinciplesandaimtomanageresourcesmoreefficientlyanddelivereffectivecare,peoplewerescepticalabouthowthiswouldbedelivered.PeopleinSuttonbelievedthatallfiveA&Eserviceswerealreadyoperatingabovecapacity,suggestingthattheywouldnotbeabletoconsolidatethesewithoutimpactingpatients.Similarly,peopleinKingstonhadconcernsthattheproposalsforsevendayserviceswouldspreadresourcesmorethinlyandthereforewouldnotimprovehealthcareintheirborough.TheysuggestedthattheSTPhadcontradictoryaimstobothprovidemorelocallevelcareandconcentrateresourcesintofewerhospitals,whichtheybelievewillputincreasedpressureonthewaitinglists,specialistsandA&Eservicescurrentlyoffered.OtherpeoplefromWandsworthandMertonwerenotconfidentintheNHS’sabilitytomanagethischangeandbelievedthattherewouldnotbesufficientfundingtodelivertheproposal.Somepeoplebelievedthatthemotivationforthischangewaspoliticalratherthanevidence-based.

Regardingspecificservices,althoughoneparticipantinWandsworthsharedanegativeexperienceaboutSt.George’sHospitalA&E,twootherpeoplesaidthatthehospital’stieredapproachtoA&Ecare(i.e.differentareasdependingontheseverityofneed)wasefficient.InCroydon,whileitwasnotedthatCroydonUniversityHospitalhadimprovedandisnowamuchbetterservice,theywereconcernedthatbedcapacityatacuteservicescouldbeanissuethatwouldcausechallengesifacuteserviceswererationalised.InKingston,theyalsoquestionedhowtheSTPconsiderstheuseofservicesinneighbouringareassuchasTootingorSurrey.

Additionally,somepeoplebelievedthesechangeswerebeingproposedtoolate,asconditionshadalreadysignificantlydeterioratedattheirservices,andbelievedthetimescaleofchangesmaybeoverlyoptimisticandwouldtakelongerthan5yearstoimplement.

4.2.2 Directingpatientstoalternativeservices

Acrossallsixhealthandcareforums,therewasadiscussionofalternativeservicesbeingutilisedratherthanrelyingonacuteservicessuchasA&E.Overall,therewassupportforideathatthereshouldbeareductionintheuseofA&Eandagreementaboutre-directingpatientstoappropriatealternativeservices.

InCroydonandMerton,peoplebelievedthereiscurrentlymisuseofA&Eservicesduetoaninaccurateunderstandingofwhereisthemostappropriateplacetoaccessdifferentcare(e.g.usingA&Efortreatingcoughsandcolds).PeoplealsoquestionedwhypatientswhodonotneedtobeinA&Earenotsenttootherlocationsuponarrival.PeopleinWandsworthalsobelievedtherewasmisuseofA&Eservicesthatcouldbereduced,andsuggestedchargingpatientstohelpreducethenumberofunnecessaryvisits.Theyalsohighlightedthatchangingbehaviouraboutwheretogowouldonlyworkifservicelevelswerethesameinnon-A&EsettingsastheyareinA&E(i.e.beingseenwithin4hours).


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WhiletheotherhealthandcareforumsalsohighlightedtheneedtoreduceunnecessaryuseofA&E,theyalsoquestionedthepotentialclosureofA&EfacilitiessuggestedintheSTP.InRichmond,peopleaskedwhatcriteriawouldbeusedtodecidewhichfacilitytoclose,andwherepeoplewouldbedirectedtoinstead.Similarly,inKingstonandMerton,whiletherewasagreementthatitwouldbebesttoreducethenumberofindividualsinA&Einappropriately,therewasconcernaboutwhatalternativeservicesareavailabletopatients.Forexample,analternativesuggestedwastoutilisepharmacists,however,fundingtotheseserviceshadalsobeencut.Thepeoplethereforerequestedmoredetailsofhowthemodelforlocalserviceswouldrelievethestressonacuteservices.InSutton,itwassuggestedthatthealternativestoA&Ewerealsobeingclosed,leavingpeoplewithverylimitedoptionsregardingtheirhealthcare.Somebelievedthelackofsocialcarefundingmadeitdifficulttoeffectivelysupportpatientsoutsideofthehospital.

ManypeopleatthegrassrootsengagementactivitiesdiscussedwheretheymightgoforurgentcareiftheywerenotabletogetaGPappointment,asanalternativetoattendingA&E.Manysaidthattheywoulduseanurgentcarecentre;walk-incentre;orcall111inthesecases.AsmallnumberofpeoplefeltthatA&EwastheironlyoptioniftheywereunabletogetaGPappointment.

Therewasafeelingthaturgentcarecentresandwalk-incentreshavemadeapositivedifferencetoA&Edepartments,bydeliveringurgentcaretopatientssothattheydonothavetoattendA&E.SeveralpeoplesaidtheywouldusetheirlocalwalkincentreorurgentcarecentreratherthanA&E,asthewaitingtimeswereoftenshorteranditisalessstressfulplacetowait.However,somepeoplehighlightedthatthereisalackofawarenessofwhatUrgentCareCentresshouldbeusedfor,andagenerallackofawarenessaboutwhatservicesareavailableinthecommunityforurgentandemergencycare.

SeveralspecificcommentsweremadeaboutTeddingtonMemorialHospital(walk-incentre),withmanysayingtheyhadpositiveexperiencesthere,andsomeexpressingconcernsthatitcouldbeunderthreatofclosure.Somementionedlongwaitingtimesbuttheyfeltthiswasoffsetbyitbeinglocalandfamiliar.Ontheotherhand,somepeoplefeltdisappointedthatinsomecasestheyhadbeenreferredbacktotheirGPforanemergencyappointmentaftervisitingthiswalk-incentre.

NotallpeoplehadheardoftheNHS111service.Amongthosewhoknewoftheservice,peoplesharedmixedfeedback.Severalpeoplehadpositiveexperiencesofusingthe111service,includingfriendlyandhelpfulcalloperators;arranginganambulanceinanemergency;beingabletoaccessasame-dayappointment;andbeingabletoaccessrepeatprescriptions.Incontrast,somepeoplewerenotconfidentinthequalityofthe111service,expressingconcernsthatthecalloperatorswerenotnecessarilymedicallytrainedandthereforethattheymaynotbetriagedappropriately.Somefelttheywouldnotuse111becausetheyhadheardithasabadreputation.Itwasfeltthatthereshouldbemoreawarenessofthe111service,toensurepeopleknowitexistsandtohelppeopleunderstandwhentousetheservice.Therewasasuggestionthatthe111servicewouldbeimprovedifitcameundertheLondonAmbulanceService,duetohavinggreaterconnection,eliminatingunnecessarycalls,andhavingaunifiedapproachtotrainingandstandards.

TherewasageneralopennesstousingNHSwebsitesorapps(suchasHealthHelpNow)forhelpandadvice,althoughthereweresomereservationsforcertainsymptoms,orinthecaseofachild’shealth.


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4.2.3 AccesstoGPs

PeopleinmostofthesixhealthandcareforumsraisedquestionsandconcernsregardinglimitedordelayedaccesstolocalGPs,whichtheyfeltwasincreasingrelianceonA&Eservices.Kingstonpeopletalkedaboutthedifficultyingettinganappointmentlocally.InCroydon,peoplediscussedthedifficultandofteninconsistentaccesstoaGPintheirborough.ItwasrecognisedthatthiswasbeingdrivenbydifficultiesinrecruitingandretainingGPs.WandsworthpeoplealsoraisedtheshortageofGPsasaconcernfortheSTP,andpeopleinMertonsaidwhileonlineappointmentbookingwasuseful,theystillstruggledtogetshortnoticeappointments.SeveralpeoplewereconcernedthatwhiletheSTPproposedanincreaseintheuseofcommunityservicestorelievethepressureonacuteservices,therewasnoadditionalfundingforsuchservicesandGPsarealreadystrugglingwithcapacity(seeChapter5onCareClosertoHomeformoredetails).

4.3 Desirability

4.3.1 Impactonquality

SomepeopleinthehealthandcareforumsdidnothaveconfidenceintheNHS’sabilitytocarryoutchangestoacuteservicesanddidnotbelievethatthisplanwouldhaveadequatefundingneededtoachieveitsgoals.WhilesomepeopleinWandsworthweresupportiveoftheneedforchanges,theyvoicedtheirconcernoverhowthiswouldworkinpractice.TheclosureofanA&EintheareawasbelievedtohaveanegativeimpactontheNHS’sabilitytodeliverhealthcare.InRichmond,somepeoplewereconcernedthiscouldmeanareductionincurrenthealthstandards,forexampleduetoincreasedtraveltimeandhavingfewersitestochoosefrom.

Therewasdisagreementabouttheconsolidationofservicesassomefeltitwasnotnecessarytohaveallspecialistservicesavailableallsevendaysaweekwhileothersbelievedqualityservicemeantthesamemixandlevelofstaffatalltimes.PeopleinWandsworthhadpositiveexperienceswithlocalservices,andbelievedthattheproposedchangeswouldhavelittleimpactonthem(eitherpositivenornegative).InCroydon,somealsobelievedthattheremaybebettercareofferedinfewersites,forexampleiftherewerehubstotriagenon-urgentcare.Additionally,peoplelikedtheprospectofquickeraccesstoelectiveandrehabilitationservicesoutsideoftheacuteservicelocation.

SomepeoplefeltthatintermediatecareisnotaddressedintheSTPandtheyrequestedinformationaboutwhattheplanswouldbeforthosewhoarewellenoughtoleavehospital,butnotyetwellenoughtobeathome.

4.3.2 Transport

Peopleatthesixhealthandcareforumsraisedquestionsregardingthetransportationandaccessibilityofproposedfutureacuteservices.

Traveltimewasimportanttomanypeopleandmostbelievedthattravellingshortdistancestocareispreferred.InSutton,peoplequestionedwhethertheremovalofoneA&Eservicewouldmean


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havingtotravelfurtherforemergencycare,andemphasisedthehighqualityofcareavailabletothemfromStHelier.Whenpressed,someexplainedthatqualitywasagreaterpriorityforthem–forexample,althoughservicesatCroydonUniversityHospitalwerecloser,somepeopletravelledtothefurtherawayStGeorge’sHospitalduetoperceivedlowerstandardsofcareattheformerhospital.Similarly,peopleatMertonandatothereventsacceptedthattravelingfurtherforspecialistcaremightbenecessarytoimprovethequalityofcareoverall.However,fewcouldseehowreducingthenumberofA&Eswouldleadtoanimprovementincarequalityforpatientsneedinga‘generalist’.Peopleatthegrassrootsengagementactivitiesalsoraisedtravelandtransportasissuestoconsiderinrelationtobothurgentandemergencycare,andacuteservices.ItwashighlightedthatinanyreorganisationofacuteservicesinLondon,traveltimetoreachahospital(andtrafficcongestion)shouldbecarefullyconsidered.

PeopleatbothCroydonandKingstoneventsdiscussedhowtravellingattheweekendsandoutofworkinghoursismoredifficult,especiallyfortheelderlyorvulnerablegroups,duetotheirrelianceonpublictransport.InRichmond,peoplediscussedtheimplicationsofthesevendayacuteserviceandSTPproposalsgiventheirgeographicalplacement.Becausetheydonothaveahospitalinthisborough,theyquestionedhowthedifferentareasoftheboroughwouldbeimpacted.

Somealsoraisedpracticalconsiderations,suchas

• whetheracutecasesneedingadmissionwouldremaininthesamehospitalorwouldbetransferred.

• wherefollow-upappointments,andphysiotherapyifrequired,wouldbedelivered.

Severalpeopleinthegrassrootsengagementactivitiescommentedontheprovisionofpatienttransportwherebyvulnerablepatientsaretransportedtoandfromtheirhomeswhentheyneedtovisithospital.Itwasnotedthatpatienttransportisnotalwayssuitableforthosewithphysicaldisabilitiesandshouldbemademoreaccessible.Itwasalsonotedthatvisitstohospitalusingpatienttransportcantakeawholeday,whichcanbeverytiringforsomepatients.Itwassuggestedthatdriversshouldtakepatientstotheirfrontdoor,assomearedischargedverylateinthedayandcanbeconfusedordisorientated.

Parkingfacilitiesathospitalswerealsoraisedduringthegrassrootsengagementactivities.TherewasageneralfeelingthatparkingatEpsomandStHelierandatStGeorge’sisextremelyexpensiveandshouldbereviewedsothatitdoesnotstopfriendsandfamilyfromvisitingrelativesorneedingtocuttheirvisitshort.Somefeltthathospitalparkingshouldbefreeorthatanyincomegeneratedshouldbereinvestedinpatientcare.Itwasalsonotedthatparkingcanbedifficultforpeoplewithdisabilities,particularlyiftherearecomplexpaymentsystems.

4.3.3 UrgentandEmergencyCare

Peoplealsohadspecificfeedbackrelatingtothecurrenturgentandemergencycareservicesintheregion.


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Inclusiveaccesstourgentandemergencycare

Atthegrassrootsengagementactivities,severalpeoplediscussedhowtoensureinclusiveaccesstourgentandemergencycare,fordifferentgroupsofpeople.

Inrelationtothosewhoaredeaf,somepeoplesharednegativeexperiencesatA&EatStHelierHospital.Anumberofindividualshadinformedthereceptionistthattheyweredeaf,howeverduetoabreakdownincommunicationorachangeinreceptionstaffduringthewaitingperiod,thisinformationwasnotpassedon.Asaresult,patientsdonotheartheirnamebeingcalledandmissedtheirappointedtimeslot.Theyfeltitwouldbebeneficialifascreenwithnamewasavailableinthewaitingarea,sothatpeoplewhoaredeafknowwhentheyarebeingcalled.

Inrelationtopeoplewithlearningdisabilities,peoplesharedseveralnegativeexperiencesandmadesomesuggestionsforhowtheA&Eexperiencecouldbeimproved.Somepeoplehighlightedthatlongwaitingtimeswithachildwithalearningdisabilityareparticularlydifficult.Therewasasuggestionthatpatientswithalearningdisabilityshouldbeseenfirst,andthatthereshouldbeclearerinformationforbothcarersandpatientsaboutwhattoexpectatA&Ewhenyouhavealearningdisability.PeoplealsonotedthattherewasnolearningdisabilityspecialistonsitewhentheyhadattendedA&E.Whentheyaskedtoseethelearningdisabilitynurse,A&Estaffdidnotknowiftherewassucharole(atCroydonUniversityHospitalandatKingstonHospital).NotallpatientswithalearningdisabilityhadHospitalPassports.

AccesstotranslationservicesforthosewhospeaklanguagesotherthanEnglishwasseenaspatchyandunpredictable.Somepatientshadtorelyonfamilyandfriendstotranslate,whichmaynotalwaysbeappropriate.

Anumberofcaseswerenotedwhere,atStHelierHospital,transgenderpeoplehadbeenputonthesamewardastheirbirthgender,ratherthanthegenderinwhichtheywerelivingtheirlives,whichmadethemfeelveryuncomfortable.

Inrelationtocarers,severalpeoplehighlightedthatnavigatingtheA&Esystemasacarerisverydifficult,withalackofinformationaboutwhattoexpect.Itwassuggestedthat,becausecarersoftenhavetoattendA&Eonaregularbasis,thereshouldbeimprovedsignpostingtootherserviceswhereapplicable,andmoresupportforcarerstostaywell.

Finally,itwashighlightedthatdoctorsandnursesdonotalwaysrelatetoyoungpeopleverywell.Itwassuggestedtherecouldbepeersupportavailableforyoungpeople.Formoreinformation,pleaseseeChapter9onChildren’sServices.

MentalhealthsupportinA&Edepartments

ThefollowingsectionsummarisesfeedbackrelatingtoA&Eservicesforpeoplewithmentalhealthconditions,fromthegrassrootsengagementactivities.Fordetailedfeedbackonmentalhealthservicesmorebroadly,andcrisiscareforpeoplewithmentalhealthissues,seeChapter7onMentalhealth.

PeoplefeltthatbasicmentalhealthawarenesstrainingshouldbeprovidedforreceptionstaffinA&Edepartments,andperhapsalsoforsecuritystaff.Theyalsofeltthatthereshouldbebetter


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signpostingfromstaffinA&Etofurthersupportformentalhealthissues.SomesharednegativeexperienceswheretheyfeltA&Estaffshowedalackofunderstandingofmentalhealth.SeveralpeoplenotedthatiftheyarriveinA&Einneedofmentalhealthsupport,buttheyaredressedwell,thatitisassumedtheyarenotincrisisandarenottakenseriously.

PeoplewantedtoseethefollowingchangestoMHservicesalongsideanyotherplanswithintheSTP:

• theNHSshouldalsoconsiderinvestingmoreinpeersupportalongsideclinicallytrainedstaff.

• seeingA&Econsultantswithoutabackgroundinmentalhealthwasveryunhelpful.MentalhealthnursespresentinallA&Eswouldhelpensurepeopleincrisisaretreatedappropriately.

• ifyougotoaccidentandemergencyinaMHcrisis,youshouldbegivenaprivateroomawayfromotherpeopletohelpkeepyoucalm.

• wheninA&Eyoushouldbegivenanumberedticketthatshowsyourplaceinthequeueonascreen.Theyfeltthatthiswouldhelpwithpeople’sanxietiestoknowhowlongtheywouldneedtowait.

• peopleincrisisorwithamentalhealthconditioncouldbegivenaseparateentranceandareatoA&E.Thiswouldstopanyanxietiesaroundotherpatientslookingattheindividualandjudgingthem.

WaitingtimesinA&Edepartments

TherewasconsistentfeedbackthatwaitingtimesatA&Earetoolong.Peoplealsofeltthattherewasalackofcommunicationfromstaffwhenwaitingtimesarelong,whichaddstopeoplefeelingfrustratedandunsureofwhentheywillbeseen.

ThewaitingtimesatKingstonHospitalandStGeorge’swerebothspecificallyreferredtoasbeingtoolong,byseveralparticipants.AtStGeorge’s,peoplealsocommentedthatthewaitingareaisverypoorandinadequateforthenumberofpatientswhoattend.Itwasalsonotedthat,forparentsofchildrenwithadditionallearningneeds,StGeorge’sisinappropriatefortheirneedsduetothelongwaitingtimesandthelackofasensoryroom.Incontrast,bothKingstonandStGeorge’sA&Edepartmentswerepraisedbyasmallnumberofparticipants,includingthatwaitingtimesandstaffcommunicationweregood.

PeoplenotedthatwhentheyarenotseenforseveralhoursafterarrivalatA&Etheygetveryworriedbecausetheydonotknowwhatiswrongwiththem.Somenotedthatthetriagesystemshouldbeimprovedtoensurethatmoreurgentcasesareseenmorequickly.

SomealsonotedthattheyareseenfasteratA&EwhentheyweretakentherebyambulanceorreferredtherebytheirGP,comparedwithiftheyattendedbythemselves.


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LondonAmbulanceService

Concernswereraisedthatparamedicscouldrefusetotransportapatienttohospital.Peoplefeltthatiftheyhadcalled999,anambulanceshouldrespondappropriately.Therewerealsoconcernsraisedaroundthetriagingbythe999callhandlers.Itfeltthatifsomeonewasunabletofullydescribetheirconditionduetopain,theywouldbedealtwithinappropriately.

4.3.4 AcuteServices

Inadditiontofeedbackonurgentandemergencyservices,somepeoplealsomadecommentsaboutthecurrentacuteinpatientservicesprovidedinSWL.

Inclusiveandperson-centredcare

Atthegrassrootsengagementactivities,therewereseveralcommentsregardingcareprovidedtopeoplewithspecificneeds,andhowthiscouldbeimproved.

Inrelationtoelderlypatientsorthosewithdementia,itwashighlightedthatpatientsonMaryMooreWardatStHelierHospitalwerenotlookedafterwell,andthatnurseswerediscouragedfromkeepingthepatientsmobile.ItwasalsosuggestedthatthestandardsofcarefortheelderlyatKingstonHospitalareverypoor,andthatthereisalackofmanagementaroundelderlypatients’longtermhealthcare.Itwassuggestedthat

• physiotherapyshouldbeprovidedduringthehospitalstaytoelderlypatientswhohavehadfalls,inordertomaintaintheirconfidenceandmobilityoncetheyaredischarged.

• olderpeoplearenotalwayshelpedtofeedthemselveswheninhospital,leadinginsomecasestothepatientnotbeingabletoeat.Similarly,severalpeoplenotedthatwaterisnotalwaysprovidedatpatients’bedsides.

• the“blueband”schemeforthosewithdementiawashighlypraised.Itwasnotedtobeanexcellenttooltohelpstaffbemoreawareofpatients’mentalhealthandtakemoretimewhenexplainingaprocedure.Therewasalsoasuggestionthatthe“dementiafriend”modelshouldberolledoutacrossallhospitalstosupportbettercarefortheelderly.

• therewereseveralexamplesofpeoplefeelingthattheyneededacataractoperationbutthatsurgeonstookthechoiceawayfromthemsayingthattheydidnotthinkthepatientshouldtaketherisk.Thesepeoplewouldhavepreferredtobeabletomaketheirowninformedchoice,weighinguptherisksandbenefits.

Itwasalsofeltthatthereneedstobemoreactivitiesforpatientstoparticipateinduringthedaywhiletheyareinacutecare.Theyfeltthiswouldhelpwithisolation,mentalhealthandgeneralwellbeing.

Inrelationtothosewithlearningdisabilities,itwasfeltthathospitalstaffarenotalwaysaware,andthereforedidnottakeadditionaltimetohelpthemunderstandwhatwashappening.Itwasfeltthateveryonewithalearningdisabilityorautismshouldbeprovidedwithahealthpassporttohelpstaffknowandunderstandeachperson’sindividualneeds,likesanddislikes.


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ItwashighlightedthatStHelierHospitalisverygoodatprovidingaccesstointerpretingservices,includingbeingabletobookinterpreterswithlittletonodelay.

InrelationtoGypsy,RomaandTraveller(GRT)communities,itwasnotedthatsincetheyliveinaverytightcommunity,theydonotlikefamilymemberstobeinhospitalalone.Asaresult,familymembersoftensleepincommunalareas(suchascanteens)inordertobeclosetotheirlovedones,soprovidingalternativewaitingareaswouldbehelpful.

Inorderforfamiliesandfriendstosupportpatientswhiletheyareinhospital,itwassuggestedthatvisitingtimesonwardsshouldbemoreflexibleandallowrelativestocomeinearlier.Forexample,theyfeltvisitinghoursof12-8pmwouldbeidealassomevisitorscouldhelpwithfeedingthepatientstheirlunchwhichwouldreducetheburdenonthenursingandcarestaff.

Somepatientssharedexperiencesofbeingregularlymovedtodifferentwardswithoutbeinginformedofthereason.Itwasalsonotedthatsomepatientsareplacedoninappropriatewards,suchasayoungerpersonbeingplacedonadementiaward,causingdistress.

Waitingtimes

ThequeuesandwaitingtimesatthepharmaciesatStGeorge’sandStHelierHospitalswerecommentedonspecificallyasbeingverylong.Forexample,somepeoplehadwaitedtwohoursbeforereceivingtheirprescription.

Buildingsandsignage

Peoplefeltthatoftenthedirectionsaroundhospitalsarenotveryclear,particularlyatKingstonandCroydonUniversityHospital.Itmadepeopleconfusedandanxiouswhendirectionsstoppedorwhenwordingfordepartmentswereverylong.Therewasasuggestionthatamapshouldbeprovidedinaneasytoreadformattohelpwithnavigatinghospitals.

ItwasalsohighlightedthatthestandardofthebuildingatStHelierisverypoor,includingplasterfallingoffthewalls,wetfloorsinthetoilets,andnolocksontoiletdoors.

4.3.5 Discharge

Therewereseveralcommentsaboutdischargeatthegrassrootsengagementactivities.

Acommonthemewasthatpatientsweredischargedfromhospitallateatnightbutwerenotprovidedwithanytransporttogethome,nordidtheyhaveanycareavailableathome.Incontrast,onepatientsaidtheyweretakenhomeinanambulanceeventhoughtheycouldhavetakenataxi,whichwaythoughtwasawasteofmoney.Itwasnotedthatbeingdischargedwithnocareathomeoftenleadstobeingreadmittedwithinashortspaceoftime,especiallyiftheyhadexperiencedafallinthefirstplace.Beingdischargedlateatnightwasalsoraisedaspecificissueforhomelesspeople,sincesheltersandotherservicesareclosedandtheythereforehavenowhereelsetogo.

Somefelttheyweredischargedtooquicklyortooslowly.Severalpeoplenotedthattheirdischargehadbeendelayedfromacutecare,sometimeswaitingseveralhoursformedicationand/ortransport


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tobearranged.Othersnotedthattheyweredischargedtooquickly,beforetheyweremedicallyfittoleave,whichtheyfeltwasdrivenbyalackofbedspaces.

ItwasfeltthatthereshouldbecloserworkingbetweenNHSandsocialcareservicesinrelationtodischargefromacutecare.Peoplehighlightedthatifhospitalstaffknowwhatservicesareavailableinthecommunity,theycouldreferpatientsthereforsupportandthereforebeabletodischargethemsoonerbutmoresafely.Theyfeltthatacareplanshouldbeputinplacebeforesomeoneisdischargedfromhospital.

Itwassuggestedthathospitalsshouldwritemoredetailednotesaboutapatient’shealthandwellbeingbeforetheyaredischargedintotheirhomesorcarehomes,sothatappropriatesupportcanbeputinplace.

AnothersuggestionwasthatwhenpatientsattendA&Eforsomethinglikeafall,theyshouldbecheckedoveratoutpatientsupondischargetocheckifthereareanyotherissues-itwasfeltthiscouldsavetimeandmoneybyreducingtheriskofreadmittancetoA&E.

4.4 Adviceondelivery

4.4.1 Communication

Todeliverthechangesproposed,somepeopleatthesixhealthandcareforumsbelievedcommunicationaboutNHSserviceswouldbeacriticalsuccessfactor.

Overall,manysuggestionsweremadeabouthowtoreachouttothepublicabouttheuseofacuteservices.Somepeoplebelievedtherewasalackofinformationandknowledgeaboutwherepatientscanaccesscareoutsideofhospitals.InCroydonandMerton,peoplediscussedhowtoreducethemisuseofA&Eacuteservicesandsuggestedbettercommunicationofalternativeservicesisneededtoaddressthis.Forexample,informinggroupsofdifferentculturalbackgroundsofwhichservicesotherthanA&Eofferhighqualitymedicaladvice.

PeopleinSuttonsuggestedcurrentrelianceontheNHS111linetosignpostpatientstotheappropriatecarewouldbeineffectiveduetothefrequencyofcallersbeingdirectedtoA&E.Itwasrecognisedthatachangeincommunicationapproachisneededforsignpostingpatientstothebestcareoptions.

Somesuggestedthatitwouldbedifficulttochangebehaviour,andthatitwouldbemorestraightforwardtochangetheservice.Specifically,havingGPservicesalongsideA&E,withthesameservicecommitmentsasA&E(i.e.seenwithoutandappointment,withinfourhours)couldbeacost-effectivewaytoensureonlythosewhoneededA&Eusedit.

4.4.2 Staffattitudesandcommunicationskills

Sensitivity,empathyandresponsiveness

Acommonthemeatthegrassrootsengagementeventswasthathospitalstaffsometimeslackedsensitivityandempathyintheircommunicationwithpatientsandtheirrelatives.Hospitals


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mentionedinthiscontextincludeKingston,StHelier,StGeorge’s,Moorfields,andCroydonUniversityHospital.Peoplefeltthatstaffshouldbetrainedinhowtocommunicatemoresensitivelywiththeirpatients,aswellasinculturalawareness,respectandcompassion.Insomecases,staffwereobservedtobeunresponsivewhenpatientsrangtheirbuzzerforhelp.Somepeoplenotedthatalackofempathyalsomeansthatcareisnotpersonalisedbecausestaffdonotalwaystrytogettoknowtheirpatients.

ItwassuggestedthatHealthCareAssistantsshouldstayonthesamewardandwiththesamepatient,soastoprovideemotionalcareandsupportforthepatientaswellasensuretheyareeatinganddrinkingenough.

Communicatingwithpatientswithspecificconditions

Peoplehighlightedthatstaffinurgentandemergencycare,andinacuteservices,shouldbetrainedtobeabletocommunicatemoreeffectivelywithpatientswhohavespecificconditions,specifically:

• Adultswithmentalhealthconditions

• Childrenwithmentalhealthconditions

• Peopleinametalhealthcrisis

• Childrenwithlearningdisabilities

• ChildrenwithAutismSpectrumDisorders

• Peoplewithphysicaldisabilities

Communicationwithpatientsandfamilymembers

Severalpeoplenotedthatlinesofcommunicationbetweenhospitalstaffandpatientsandtheirrelativescouldbeimproved.Severalexamplesweregivenofwhenpatientnoteswerenotthoroughlyreadbymedicalstaff,insomecasesleadingtoinappropriatetreatment.Exampleswerealsogivenofwhenrelativeswerenotlistenedto,causingdelaysindiagnosis.Severalpeoplealsonotedthatrelativeswerenotinformedofwhatwashappeningwithapatient’streatment,includingnotinformingthemofthepatientbeingtransferredtoanotherhospitalfortreatment,norwhenapatientwasreadytobedischarged.

Incontrast,afewpeoplenotedthattheyfeltlistenedto,welllookedafter,andthateverystepintheirtreatmentwasexplainedclearlytothem.

Finally,peoplewantedtoseebettercommunicationbetweenhospitalconsultantsandGPsandfeltthattheyshouldbeabletotalktoeachotheraboutapatient’sdiagnosis/resultsratherthanthepatientbeingthe“go-between”.

4.4.3 Staffing

PeopleatthegrassrootsengagementactivitiesfeltthatinorderfortheplansintheSTPtobedelivered,thereneededtobemoreexpertstaffavailable,includingspecialistnurses,and


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psychiatristsinadditiontoseniordoctors.Somefelttherewasanover-relianceonbankstaffandthatmorestaffshouldbefullyemployedinordertoreducethepressureonover-stretchedstaff.


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5. MorecareclosertohomeThissectionsummarisesthediscussionsacrossthesixhealthandcareforumsandgrassrootsengagementactivitiesaboutmorecareoptionsclosertohome.Ithighlightstheemergingthemesandkeymessagesaboutthecaseforchangeandtheideasdevelopedsofar.

ThesuggestionsoutlinedintheSTPrelatingtomorecareclosertohomeinclude:

• Settingupareabased‘localityteams’tosupportpatientsinareasincludingpreventionandearlyintervention

• Greateravailabilityoftreatmentinlocalhealthcentres

• Joinedupservicesinthecommunitytoprovidemoreintensivesupporttopeopleathome

• Additionaladviceandsupportviaanimproved111telephonehelpline,‘carenavigators’signpostingpeopletotherightservices,greateruseofsmartphoneappsandSkypeetc.forthosepeoplethatwanttousethem

• ClinicalpharmacistsinGPpracticestohelppeoplewithlongtermconditionsmanagetheirmedication

• Encouragingpeopletovisittheirlocalpharmacistforadviceandsupportforminorconditions

5.1 Keymessages

• Whiletheideawassupported,therewereconcernsthatthelocalNHSdidnothavethecapacityandresourcestomanagethechangetowardsamorelocalcaremodel

• Peoplebelievedsignificanttraininganddevelopmentwouldbeneededforpharmaciststobeabletodeliverappropriatehealthcare,especiallyforvulnerablepeople,andthatinvestmentwouldbeneededtoimprovepharmacistfacilities

• Mixedresponsesregardingtheimpactofthisplanonquality,asitmayreducewaitingtimes,buttherewereconcernsaboutinformationsharingandworkloadmanagementwhich,ifnotaddressed,coulddiminishquality.Somewantedreassuranceonthesecurityofonlinepatientrecords

• Detailedfeedbackwasprovidedonprimarycareservices,relatingtoconcernsaboutappointmentavailability,accessibility,referrals,andholisticandperson-centredcare

• Severalspecificareasoffeedbackrelatingtovariableoutofhospitalcarewereprovidedforconsiderationandimprovement

• Newroleswerepositivelyreceivedbutmanywantedmoredetailabouthowtheseteamswouldsupportlocalpatientcareinpractice

• AwarenessofappropriateservicesislowandpeoplesuggestedadditionalcommunicationfromtheNHStobothprofessionalsanddirectlytothepublicwouldhelpensurepatientsusedtheavailablelocaloptions


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5.2 Feasibility

5.2.1 Resourcestoimplementplan

Overall,atthesixhealthandcareforums,manypeoplewerepositiveabouthavingmorecareservicesclosertohome.However,theyhadseveralconcernsabouttheexecutionofthisproposal.Somefeltthatthereweremajorchallengestoovercomeandquestionedwhetheradequateresourceswereavailable.

Peopleraisedconcernsregardinghowsustainabletheproposedchangeswouldbe,andquestionedhowthiswouldfitintothecontextofcurrentfundingcuts.Further,peoplewonderedhowlongerGPsurgeryhourswouldbepossiblewiththeGPshortagesandworriedthatthisbudgetshiftwouldnegativelyimpactonacutecare.TheimpactonhospitalcarewasdiscussedinRichmond,wheretheywereconcernedthatshiftingfundingbackandforthbetweenthehealthandsocialcarebudgetswasnegativelyaffectingbothservices.ThereweremoregeneralconcernsinRichmondandWandsworththattherewouldbedifficultyintegratinghealthandsocialcare(e.g.supportingcarersafterearlydischargeofpatients),coordinatingthehealthadministration,andimprovingITsystemsinorderfacilitateoutreachsuchasbeingabletoSkypewithpatients.PeopleinMertonhighlightedtheneedforintegrationwithvoluntarysectorsuchashospicesaswellasthelocalauthority.

Somepeoplewithpositiveexperiencesofpharmacistslikedtheideaandweresupportiveofusingthemwhereappropriate.However,theythoughtfacilitieswouldneedtobeimprovedtoensurehighqualitycare-forexamplebyprovidingaprivateroomtodiscusshealthconcerns.Thereweremanyconcernsthatpharmacistsdidnothavethefundingnecessarytocopewithadditionalpatientsandthesenewdemands.

5.2.2 Skillsandtraining

Atthesixhealthandcareforums,peoplediscussedtheuseofnursesandpharmacistsasanalternativetoGPs.Peopleexpressedconcernsoverthetrainingneededforpharmaciststodeliverqualityhealthcareadvice.

Manybelievedthattheplandoesnotaccountforthetrainingrequiredtoservicepatientswithadifferentrangeofneeds.Somepeopleraisedthattheywouldliketoknowthatthepharmacistisknowledgeableenoughtotreattheirmedicalneeds.Peoplesuggestedtrainingwasnecessarytoensuretheycancommunicatewellwithpatientsaspharmacistsdon’thaveexperiencegivingthisadvice.Aminorityofpeoplewereconcernedthatthepersonalviewsorbeliefsofpharmacistsmightinfluencethetreatmentandadvicetheyprovide.Theywouldthereforeneedtobeassuredtheywouldreceiveequaltreatment,beforetheywouldconsiderapproachingapharmacistinsteadofadoctor.Therewereseveralsuggestionsthatpharmacistsmayneedextrasupportortrainingtogiveservicestovulnerablegroupsandpeoplewithprotectedcharacteristics.

Atthegrassrootsengagementactivities,peopleemphasisedthatGPsshouldtalktopatientsinplainEnglish,includingclearexplanationsofwhatmedicationisbeingprescribed,why,andanyknownsideeffects;andprovidemoreclarityaboutreferralprocesses.


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PeoplesuggestedthatfurthertrainingwasneededforbothGPsandreceptionstaff,relatingtocommunicatingwiththosewithlearningdisabilities;andcommunicatingwithsensitivity.TherewerealsosuggestionsforfurthertrainingforGPs,aroundspecificconditionssuchasME(ChronicFatigueSyndrome),ADHD/Autism,mentalhealth,andsupportforcarers.

Therewasasuggestionthatreceptionistscouldplayadifferentroleandhelpsignpostpeopletoservices.Thiswouldhelpreduceisolationandimprovehealthandwellbeing.

5.3 Desirability

5.3.1 QualityofcarefromhealthprofessionalsotherthanGPs

Atthesixhealthandcareforums,thereweremixedviewsonhowthequalityofcarewouldbeimpactedbytheproposedchange.Whileitmayresultinfastertreatmenttoseekoutpharmacists,visitingGPswouldremaindifficultandwithoutthisoptionpeoplewereconcernedaboutthequalityofmedicaladvicetheywouldreceive.

Severalpeoplesuggestedthattheproposedchangescouldhelptoreducewaitingtimestoseeatrainedprofessionalandreceivenecessarymedication.ThiswashighlightedinKingstonasbeingusefulforlong-termconditionsmanagement,aswellasatMertonwherepeopleraisedthesuccessoftheLiveWellgroupinmanagingchronicillnesslocally.Manypeoplefeltcomfortableusingtheirpharmacistandrequestedadditionalsignpostingtowhenthiswasappropriate(e.g.whenyouhaveahightemperature).SomepeopleinWandsworthsaidtheyfeltcomfortableoncethequestionofprivacyhadbeenaddressed.Somepeoplepraisedtheirlocalnursesassourceoflocalcare,forexampleaspecialistdiabeticnurseandParkinson’snurseinRichmond.

However,therewereconcernsoverhowinformationwouldbesharedwiththeGPwherenecessaryandhowtheinformationwouldbestored.Inaddition,CroydonandWandsworthpeoplequestionedhowpharmacieswouldcopewithanincreaseinworkloadwithoutadditionalfundingtoensurethepharmacistswouldbeabletocopewiththesechanges.

Atthegrassrootsengagementactivities,peoplealsodiscussedthepotentialforpharmaciststoplayagreaterroleincareclosertohome.Therewasmixedfeedback,duetovariationinpeople’sexperiencesofpharmacists.Somewereverysupportiveoftheideaofusingpharmacistsmorefrequently,sincetheyhavefoundthemtobehelpfulandaccessible.However,otherswereconcernedduetoexperiencesofpoorcommunicationfromtheirpharmacists,insufficientinstructionastohowtotakeamedication,orbeinggiventhewrongmedication.

Peoplesuggestedthatinorderfortheproposaltobesuccessful,moreeducationwasneededforthegeneralpublicaroundusinglocalpharmaciesandgoingtoseethemforadvice.Othersuggestionsincludedpharmacieshavinglongeropeninghours,andshorterwaitingtimestocollectmedication.


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5.3.2 Newrolesforsupportingcare

Atthesixhealthandcareforums,somepeoplewerepositiveaboutcarenavigatorsandlocalityteams’newrolesindeliveryserviceclosertohome.However,questionswereraisedabouthowthisservicewouldbecarriedout.

PeopleinKingstonwerepositiveabouttheidea,howeversuggestedthattheSTPshouldoutlinemorehowthiswouldworkinpractice.Forexample,itwasnotclearwhattheremitfortheseroleswas,howtheywouldbeaccessedandhowtheywouldinteractwithotherservices.Therewaspositivityaboutthepossiblecollaborativeandjoinedupapproachtheserolescouldfacilitate,howevertheneedforadequatetrainingwasemphasisedinRichmond.SomeinWandsworthfeltthattheteamscouldbeusedmorestrategicallytosupportfamiliesandcarersaswellaspatients.

Atthegrassrootsengagementevents,somepeoplenotedthattheyfounditdifficulttonavigatethecaresystemforcertainconditionsorissues.Carers,inparticular,founditdifficulttonavigatethroughthecaresystemandfeltthattheyhadnotreceivedhelpfuladviceorguidancefromGPs.Inlightoftheseexperiences,peoplewelcomedtheideaofcarenavigators,particularlyiftheirjobincludespatientliaisonandsupportforbothpatientsandcarers.Therewasasuggestionthatiflocalpracticenetworksweresetup,ineachareaoneortwoGPscouldtaketheleadonlearningdisability,andsharetheirknowledgemorewidelyamongstotherpractitioners.Theyalsowelcomedtheideaofmorecoordinatedcare,butemphasisedthatthisrequireseveryoneknowingwhatservicesareavailable.

5.3.3 PrimaryCare

Atthegrassrootsengagementactivities,thereweremanydiscussionsaboutprimarycare,whicharesummarisedbelow.

Appointments

Atthegrassrootsengagementactivities,manypeoplehadexperiencedproblemswithgettingGPappointmentsatsuitabletimes.Severalpeopleemphasisedtheimportanceofappointmentsbeingavailableafter6pmandatweekendstoaccommodatethosewhofinditdifficulttovisitduringtheday.Forsomeindividuals,notbeingabletoobtainaGPappointmenthadledtothemattendingA&Einordertobeseen.Otherswouldattendawalk-inclinic,asnotallhadheardofthe111service.Incontrast,severalpeoplesaidtheyhadpositiveexperiencesofgoingtotheGPandfounditquiteeasytogetaGPappointment,althoughitwasnotalwayswiththeirnamedGP.

Whenmakingappointments,somepeoplesaidtheywerehappyforreceptioniststoaskthereasonfortheircall,howevertheydidnotlikereceptionstaffactingas‘gatekeepers’intermsofhowquicklyyoucanseeaGP.Somearguedthatreceptionstaffareunqualifiedtoaskmedicalquestionsandtheyshouldrespectpeople’sconfidentialitybynotaskingpersonalquestionsinanopenplanwaitingroom.Itwassuggestedthatreceptionistsshouldbetrainedinconfidentialityandmademoreawareoftheirsurroundings.


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SeveralpeoplefeltthatGPappointmentsweretooshort.Theyfeltthat10minuteswasnotlongenoughtolearnaboutanindividual’shealthproblemandfindasolution.Thisisparticularlythecasewhendiscussingcomplexcasesincludingmentalhealthconcerns.Peopleweregenerallyunawarethatyoucanbooktwoappointmentsifyouneedtodiscussmultipleorcomplexissues.

SomepeoplementionedthatthePatientOnlinesystemhasmadeiteasiertobookanappointmentthenightbefore,andthatithasmadeitaloteasiertocollectprescriptionsfromtheirpharmacyofchoiceatatimeconvenienttothem.

ThereweremixedviewsabouttheideaofonlineappointmentswithaGPviaSkypeoremail,andsomewouldprefertoseetheGPinperson,althoughmanyarecomfortablewithtelephoneconsultations.

Referrals

Severalpeoplediscussedthattherewereverylongwaitingtimesforreferralsfromprimarycareintosecondarycareorspecialistservicessuchasphysiotherapistsormentalhealthprofessionals.Manyhadwaitedseveralmonthsforanappointmenttocomethrough,atwhichpointtheirconditionsmayhaveescalated(seeChapter6onearlyinterventionformoredetails).

OthersfeltthatGPswerereluctanttomakereferralsatall,perhapsduetobeingunderpressuretoreducetheburdenonotherNHSservices.

TherewasasuggestionthatGPsshouldallowself-referraltocertainservices,ortorepeatservices,inordertosaveGPappointmentsforconcurrentreferrals.

Access

Therewereseveralconversationsrelatingtoimprovingaccesstoprimarycarefordifferentgroupsofpeople.

InrelationtothosewhospeaklanguagesotherthanEnglish,severalpeoplehaddifficultiesbookinganappointment,aswellasproblemsduringconsultationswithGPsbecauseofnothavinginterpretersavailable.TherewereseveralexperiencesofGPsbeingreluctanttouseLanguageLineinordertoaccessinterpreters.Incontrast,someGPsofferexcellentinterpretationserviceseitherbyarranginganinterpreterinadvance,orbyhavingGPswhocanspeakspecificlanguagesavailabletothosepatientswhoneedthem.

Similarly,forthosewhoaredeaf,peopleraisedconcernsaboutGPsnotbookinginterpretersforroutineappointments.TheyhadtheimpressionthatGPsurgeriesfeltthatitwastheresponsibilityofthepatientandwerenotawareoftheprocessforbookinganinterpreterforadeafpatient’sappointment.Severalindividualsnotedthattheyhadbeenaskedtobringfamilymembersintoappointmentstointerpretforthem,howevermostfeltthatthiswasnotappropriateastheymaywishtodiscussconfidentialmatters.Althoughonlineappointmentbookingshavemademakinganappointmenteasierfordeafpatients,itisonlypossibletoarrangeaninterpreterbycallingthesurgery.Severalindividualsstatedthattheywouldliketobookappointmentsviaemailortext.

Whileonlinebookingsandappointmentshaveimprovedaccessforsomepeople(e.g.peoplewhoaredeaf;orworkingcarers),therewereconcernsthatthosewhoareelderlyorwhodonothave


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accesstotheinternetmightmissoutonappointments.Peoplesuggestedthattelephoneappointmentsshouldcontinueforthosewhodonothaveinternetaccess.

Therewereafewcommentsaboutwaitingareasnotbeingsuitableforthosewithdisabilities.Forexample,ifyouarevisuallyimpaireditcanbedifficulttoregisterusingautomatedsystemsandtherecanbedifficultieswiththeboardsthatscrollthroughandtellpeoplewhenthedoctorisreadyfortheirappointment.PeopleemphasisedthatallGPsurgeriesshouldbewheelchairaccessible.

Accessforcarerswasraisedasanissue.WorkingcarerscanfinditespeciallydifficulttogetaGPappointment,andpeoplefeltthatbothGPsandpharmacistsshouldplayabiggerroleinidentifying/supportingthehealthandwellbeingofcarers.

SomepeoplefeltthatGPsurgeriesneedtobemoreLGBTinclusiveandthiswouldincludehavingmorepublicationsandvisiblepostersavailableinthereceptionarea,andmoreproactivepromotionofHIVtestingamongthiscommunity.

ItwasnotedthatitcanbeparticularlydifficultforpeoplefromtravellingcommunitiesandforhomelesspeopletoregisterwithaGP,althoughwalk-inserviceshelpwiththis.

Holistictreatmentandperson-centredcare

Therewereseveraldiscussionsatthegrassrootsengagementactivitiesaboutprimarycareservicesthatweremoreholisticandperson-centred.PeoplefeltthatGPsshouldrecognisethatpeopleareexpertsintheirowncareandshouldpaymoreattentiontowhattheythinkiswrongwiththem.TheyalsofeltthatcarersshouldreceivemoresupportfromGPs,includingprescribedrespitecare.

Continuityofcarewasseenasbeinglinkedtoapersonalisedapproach.SomepeoplewereconcernedthattheywerenotalwaysabletoseethesameGP,orthattheyoftenhavetoseelocums,sothereisnorelationshipdevelopmentbetweenpatientandGP.Thiswasparticularlyimportantforthosewithlong-termconditions,seriousillness,orchildrenwithadditionalneeds.Incontrast,otherssaidtheydidnotmindiftheydidnotseethesameGP,aslongastheygotanappointmentwhenneeded.

5.3.4 Outofhospitalcare

Atthegrassrootsengagementactivities,peoplediscussedoutofhospitalservices,withvaryingfeedbackbasedontheirexperiencetodate.Forexample:

• Inrelationtolong-termconditions,somepeopleweredisappointedinthesupporttheyhadreceived,slowdiagnosis,orlackofhelptoenableself-management.Peoplewantedmoresupporttakingcontroloftheirownhealth.Forexample,onepatientnotedthattheyhaddiabetesandhadtohaveinjectionstwiceaday.Theywouldliketobetaughthowtogivethemselvesinjectionssothattheycouldgoawayforthenight,buthaven’tbeentaughthowtodoit.

• Therewasasuggestionthatcommunitynursescouldattendshelteredaccommodationtopickupissuesearlyon–thiswouldpreventconditionsfromescalatingandreducetherelianceonGPs.


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• Finally,therewasalotofpraiseforthenewlybuiltNelsonHealthCentreandmanypeopleappreciatedthattheycangetlotsofthingsdoneinoneplaceratherthantravellingtodifferenthospitals.

Akeythemeaboutoutofhospitalcarewastheinconsistencypeopleexperienced.Forexample,thosewhohadreceivedhomehelpappreciatedtheserviceandfoundithelpedthemtostayhealthyandoutofhospital.However,othersdidnotknowwhotocontactforthiskindofsupport.

Somepeoplefounditverydifficulttogetanappointmentwithacommunitychiropodist,andwereonlyentitledtooneappointmenteverysixmonths,whichwasnotenoughforolderpeopleorthosewithlearningdisabilities.Thismeantpeoplehadtoeitherhadtoliveindiscomfortorpayforsupportprivately.


5.4.1 Communicationandsignposting

Atthesixhealthandcareforums,thecurrentlackofknowledgeaboutlocalserviceswashighlightedasabarrierforrollingouttheplan.Manypeoplethoughtthatpeopledonotfeelconfidentaboutwheretogotoseekappropriatecare,andthatthereisanopportunityfortheNHStocommunicatethismoreclearly.Severalpeoplesuggestedthatraisingawarenessofthedifferentservicesandwhatprofessionalscanofferthroughimprovedcommunicationswouldbeimportant.Inparticular,somefeltthatpeopledon’tknowwheretogoasanalternativetoA&E.InKingstonandRichmond,peoplesuggestedthatmorecouldbedonebyGPreceptioniststosignposttoappropriatecare,aswellasimprovingservicessuchasthe111phoneline.

Tosupportpeopleusingcareclosertohome,manyagreedthatthe111serviceneedstobeimproved.InCroydon,somesuggestedthe111serviceisnotabletoprovidenecessaryadviceandsignpostingtoservices.Peoplebelievedthereislowtrustintheserviceandsuggesteditshouldbeimprovedandre-launched.PeopleinWandsworthbelievedthatthecurrentstateof111ispotentiallyincreasinguseofacuteservicesratherthanreducingit,astheyoftendirectcallerstoA&E.Inaddition,theyfeltthe111operatorsdonotcommunicatewell–specificallytheyfelttheoperatorsasktoomanyquestions,ratherthanlisteningtothecallersmorefully.

Atthegrassrootsengagementactivities,peopleraisedseveralissuesrelatingtocommunicationfromprimarycareservices.

Itwasfeltthereshouldbebettersignpostingandadvertisingofavailableservices,suchascommunitygroupsandthenewGPHubs,aswellashowtonavigatethehealthandsocialcaresystem.

AfewpeoplefeltveryconcernedarounddataprotectionwiththePatientOnlinesystem.Peoplefeltunsettledthattheirpersonalmedicalnotescouldpotentiallybelookedatorhackedinto.Improvedinformationaboutthiswouldbehelpful.

SeveralpeoplewantedclearerinformationabouthowtocomplainabouttheservicetheyhadreceivedfromGPsurgeries.


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5.4.2 Joined-upservices

Manypeopleatthegrassrootsengagementactivitiesemphasisedtheneedformorejoined-upservices.ThisincludesGPsurgeriesandhospitalscommunicatingbetterwitheachothertoensurethebestoutcomesforpatients,andNHSservicesworkingmorecloselywithsocialservices.

TherewassomediscussionaboutthenewGPHubs.Peoplewerebroadlysupportiveoftheideaofhavingseveralhealthprofessionalsinthesameplace,andnotedthatthewaitingtimeforappointmentsisshorter.However,theyhighlightedthattheservicecanbemoreimpersonalduetoseeingdifferentGPs,andthehubscaninvolvetravellingfurtherdistanceswhichcanbedifficultforthosewithmobilityproblems.ThereweresomepositiveexperiencesoftheLeatherheadHub,whereitispossibletogeteveningappointments,howevertheyfeltthatthehubsystemwouldbenefitfrommoreawarenessraising.

Onepersonhadapositiveexperienceof‘GPPooling’services,wherebyiftheirGPsurgeryisclosedortheycannotgetanappointmenttheyarethenreferredtoanothernearby.


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6. PreventionandearlyinterventionThissectionsummarisesthediscussionsacrossthesixhealthandcareforumsandgrassrootsengagementactivitiesaboutpreventionandearlyinterventionservices.Ithighlightstheemergingthemesandkeymessagesaboutthecaseforchangeandtheideasdevelopedsofar.

ThesuggestionsoutlinedintheSTPrelatingtomentalhealthservicesinclude:

• Betterpreventionandearlyinterventionsupportedby‘locality’teamsofhealthprofessionalsdedicatedtosupportingatleast50,000strongcommunities.LocalityteamswouldbringtogetherhealthprofessionalsfromacrosstheNHSwhowouldworkalongsideGPsurgeriesandotherpartners

• Localityteamswill:

- Helppeopletostaywellbyplacingagreateremphasisonpreventionandearlyintervention

- Takeactionearlybyworkingtoidentifypeopleathighriskofhospitaladmissionandsupportthembeforetheirconditiondeterioratesandtheyneedtogointohospital

• Itwillbeeasiertoreceivetreatmentinyourlocalhealthcentre,atalocalclinicorathome,aswewillbeputtingmoreresourcesintoyourlocalcommunities.

• Wewillworkwithpublichealthtoencouragepeopletolivehealthierlives.Forexample

- Rollingoutthe“LondonHealthyWorkplace”and“makingeverycontactcount”schemes

- Developingbettertoolstohelppeoplemakepositivechanges–suchassmokingcessationandweightlossreferralservices

- Usingmoderntechnology(suchassmartphoneappsforpeoplewhowantit)toencouragemoreself-care.

6.1 Keymessages

• Peoplesupportedtheinclusionofpreventionapproaches.However,therewereconcernsaboutwhethertheSTPwouldbeabletochangepeople’sbehaviours

• Somepeoplehadquestionsregardingtheroleofdifferentcommunitygroupsandhowtheresourceswouldbemanagedtoensurehighqualitycare

• Therewasadesireformorepersonalisedandholisticcare,whichpeoplefelttobelinkedtoimprovedpreventionandearlyintervention.

• Therewereconcernsovertheintroductionofpreventionservicesthatmayleadtoprivatisationorservicecutsinotherareasthatwouldcompromisecare

• Moredetailedinformationwasrequestedregardinglocalityteams,theirroleinhealthcareandhowthesewouldoperateinpractice


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• Communicationiskeytoensuringchangeinbehaviourforprevention,andpeopleagreedtheNHSmustimproveitsoutreachforthistobesuccessful

• Somepeoplesupportedtheuseoftechnologytomonitorhealth,howevernotasauniversaltoolandwantedmoreinformationaboutwhichcontextsitwouldbeusedin

6.2 Feasibility

6.2.1 Changingpatientbehaviour

Whiletherewassupportforpreventionapproachestohealthcare,manyhadconcernsoverthefeasibilityofchangingpeople’sbehaviourinpractice.

ManypeopleacrosseventsbelievedchangingbehaviourischallengingandthattheeffortrequiredmaybeunderestimatedintheSTP.InRichmond,thepeoplelikedthefocusonpromotinghealthierlivingandreducingobesity,whichtheyfeltcouldimproveoutcomesandalleviatedemandforresources.However,theyobservedthiswouldbealong-termeffectwhiletheplannedchangesrequiredshorttermbenefitstosupportthehealthcaresystem.Inaddition,theyhadconcernsthatpreventionistypicallythefirstprogrammetobeaffectedbybudgettightening.

Somepeoplemadesuggestionsofhowchangecouldbebettersupportedintheplan.InSutton,peoplesuggestedtheNHS111servicecouldfocusonprevention,orthattargetingspecificgroupssuchaselderlypeopleincarehomeswouldbemoreefficientthantargetingthewholepopulation.Thiswasechoedbypeoplewhosupportedmoreeducationforthepubliconpreventionaswellensuringthathealthcareprofessionalsseethevalueofearlyintervention.Somepeopledidwarnthatbeingtoofocusedonpreventioncouldberiskyassomeonemightunderestimateahealthissueandnotseektreatment.

6.2.2 Supportfromcommunity

Thereweresomequestionsabouttheroleofdifferentcommunityorganisationsinthegoalsforpreventionandearlyintervention.SomefeltthattheSTPwasoverlyoptimisticabouttheresourcesthatwereavailableasmorewouldbeneededtosupportthis.Inaddition,therewasconcernthatvoluntarysourcescouldbereplacingmedicalprofessionalswhichpeopledidnotwant.InMerton,peoplesuggestedlackoffundingandcommunicationbetweenserviceswouldbeachallengeforpartnerships.Further,ifresourceswerenotavailablepeopleatsomehealthandcareforumsworriedthatthiscouldleadtoprivatisationoftheservices.

Overall,peoplebelievedthatsupportfromfamilies,friendsandcommunitieswouldbeneededtosupportbehaviourchange.Peoplesuggestedaculturalchangewasneeded,shiftingtowardspersonalresponsibilityandcollaborationbetweenhealthcareprofessionalswithfamilies.

6.3 Desirability


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6.3.1 Holistictreatmentandperson-centredcare

Therewereseveraldiscussionsatthegrassrootsengagementactivitiesaboutmakingprimarycareservicesmoreholisticandperson-centred.Inrelationtolifestyleandprevention,severalpeoplesaidthatGPsdonotroutinelyprovideinformationondiet,wellbeingandmentalhealth.Whenthisinformationoradviceisprovided,theyfeltitwaslackingindetailorsignpostingtofurthersupport.Theyfeltmoreshouldbedonetosupporthealthylifestylesandpreventill-health.

PeoplealsofeltthattheNHSshouldinvestmoreinsocialprescribingandlocalinitiatives,astheseapproachessupportbothmentalandphysicalwellbeingbyhelpingpeopleremainactiveandreducingsocialisolation.

Inrelationtoperson-centredcare,manypeoplefeltthattheirconditionswerelookedatonebyoneratherthanbeingconsideredasawholeperson.Theyfeltthattheprimarycaresystemstilloperatesaverymedicalisedmodelofcareratherthanaholisticone.However,theyalsoacknowledgedthatatthemomentGPsdonothavetimetosupportpeopletolivehealthierlives,orsupportcarersintheirrole.

6.3.2 Qualityofservices

Somepeopleraisedconcernsthatamovetowardspreventionandearlyinterventionwouldleadtofurtherlossofservices,whiledoinglittletorelievetheNHSburden.ThereweresomewhobelieveditwasrealistictomovetowardspreventiontoreducedemandsontheNHS,howeverotherswereconcernedthattheplanwasnottransparentastheybelievedthatthelevelofservicewouldnotcontinue.InSutton,peopleworriedthechangeswouldcompromisecareanddidnotbelievetherewasenoughevidencethatpreventionwasreducingNHSdemand.InCroydon,peoplewereconcernedthatfurtherscutswouldfollowthischangeandwerefrustratedthatpreviouspreventionserviceshadbeenlostsuchastheCroydonPOPbus.

6.3.3 Localityteams

Whilesomepeopleatthesixhealthandcareforumsexpressedtheirinterestinthelocalityhealthteams,therewerewidespreadquestionsabouthowthesewouldoperateinpractice.Forexample,inRichmond,peoplefeltlocalityteamsmightbeagoodideatoenablepractitionerstoaddresslocalproblems.However,theydidnothavesufficientinformationtoknowifthiswouldbepossible.

Manypeoplewantedmoreinformationabouthowthesewouldoperate,suchashowtheteamswouldberunorcoordinated,whowouldtheyworkwith,wheretheywouldbeaccommodatedandwhichprofessionalswouldbeincluded.InKingston,somewereconcernedthatthiswouldaddanotherlayertoanalreadycomplexhealthadministrationsystem.



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6.4.1 Communication

Todeliverthispreventionandearlyinterventionprogramme,manypeoplebelievedtheNHSwouldneedtoimproveitscommunicationwiththepublicandensurethatpractitionerswereawareofalltherelevantservices.

PeopleatthehealthandcareforumsKingston,RichmondandCroydonbelievedthattheabilitytocommunicateinformationabouthealthwouldneedtobeimprovedtoeffectchangeinbehaviour.Itwassuggestedthatposters,advertisementsandinformationonscreensinGPsofficescouldbeusedtocommunicateanddetailtheservicesavailable.Additionally,onlineinformationandGPknowledgeaboutlocalserviceswasthoughttobeimportant.SomepeoplesuggestedthatGPsneedtoknowmoreaboutcommunity-basedearlyinterventionservicesthattheycansignpostpatientstoasappropriate.Somepeoplebelievedthattheinabilityofpractitionerstocommunicatewitheachotherispreventingsomeearlyintervention.InMerton,peoplesuggestedmorerealistichealthylivingadvocatesandrolemodelstopromotechangingbehaviour.

6.4.2 Useoftechnology

Thereweremixedresponsestotheideaofusingtechnologytomanagehealthandencouragepreventativeactivities.SomeinKingstonwerepositiveabouttheideaofhealth-relatedappssuchasabloodpressuremonitor.However,othersdidhaveconcernsabouthowthehealthinformationwouldbeused,forexampleiftherewascauseforconcernwouldthisbesenttotheGP.Manypeoplepointedouttheissuesofaccessibilityasnotallwillbeabletousetechnologyinthiswayforexampletheelderly,homelessorvulnerablegroups.Forthesegroups,itwassuggestedthatmorecommunity-basedhealthorsocialprescribingoptionscouldbemoreuseful.Atthegrassrootsengagementactivities,peoplewereworriedaboutconfidentialityofinformationheldinonlinesystems.


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7. MentalhealthservicesThissectionsummarisesthediscussionsacrossthesixhealthandcareforumsandgrassrootsengagementactivitiesaboutmentalhealthservices.Ithighlightstheemergingthemesandkeymessagesaboutthecaseforchangeandtheideasdevelopedsofar.

ThesuggestionsoutlinedintheSTPrelatingtomentalhealthservicesinclude:

• Earlypreventionandinterventionforpeoplewithmentalhealthissuestoavoidtheirconditionworseningandreachingcrisispoint.Bydoingthiswewillhelptoavoidpatientsneedingtobeadmittedurgentlyintohospital.

• Developingperinatalmentalhealthservicesinthecommunity.

• Supportingcommunitybasedrecovery-thisincludesembeddingmentalhealthintoprimarycare.

• Mentalandphysicalhealthservicesworkingbetterwithoneanother-recognisingthatpoormentalandphysicalhealthareoftenrelated.

• Apsychiatricdecisionunitwillassessanddeveloptreatmentplansforpeoplewithserious/enduringlongtermmentalhealthconditionsincrisis.

7.1 Keymessages

• Therewaslowconfidenceincurrentservicesduetoperceptionsofpoorquality,closures,longwaitingtimes,underfundingandinabilitytocope;therefore,thereareconcernsthattheSTPwillnotbesuccessful

• PeoplefeltthatsignificantinvestmentintrainingandadditionalskillsmaybeneededforGPsandotherstodeliverhigherqualitymentalhealthservicesandreducestigma

• Peoplewantedmoreinformationaboutwhereproposedmentalhealthtreatmentwouldtakeplaceandpromotedtheneedforoutofhospitalmentalhealthcare,andmoresupportintransitionsintothecommunity

• Peoplesupportedaholisticapproach,incorporatingphysicalconditionsandcoordinatingwithmultipleorganisations,butquestionedhowthiswouldworkinpractice

• Aninclusiveapproachtomentalhealthwasdesiredwiththeneedsofmarginalisedandvulnerablegroups,suchaschildren,LGBTandethnicminoritieshighlightedasanimportantconsiderationfortheSTP

• Peoplewantmorementalhealthawarenessandeducationinschools,aswellmoreintegrationwithmentalhealthservicesandschoolstosupportchildrenandfamilies

• TheNHSshouldimproveitscommunicationaboutavailableservicesformentalhealth,aswellassignpostingpeopletocareinmoreinformalsettingssuchasdropincafes

7.2 Feasibility


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7.2.1 Funding

Acrossthesixhealthandcareforums,therewereconcernsthatthecurrentlackofNHSfundingresourcesavailabletosupportmentalhealthserviceswouldleadtodifficultiesimplementingtheplan.Somepeoplehighlightedthemisalignmentbetweenthedemandformentalhealthservices(forexample,that1in4peoplewillexperiencementalhealthcondition)andtheleveloffundingallocated.AfewpeopleinKingstonsuggestedbudgetscouldbepooledfromNHS,localauthoritiesandthepolice.

Atthegrassrootsengagementactivities,oneparticipantnotedthatSpringfieldHospitalusedtouseanin-houseteamfortalkingtherapies,butthishasnowbeencontractedoutwhichseemsamuchmoreexpensivewaytodelivertheservice.

7.2.2 Capacityofservices

Manypeopleatthesixhealthandcareforumsexpressedconcernsaboutthecurrentprovisionofmentalhealthservicesintheircommunityandwerethereforepessimisticaboutthesuccessoftheplannedchanges.InMerton,peoplefeltcurrentserviceswerenotadequatewithtoofewsessionsoftreatmentliketalktherapy.

Localservicesclosing

IntheSuttonevent,therewereconcernsthatwhileaneedformoreholistictreatmentofmentalhealthhadbeenidentified,severallocalserviceshadbeenclosed(e.g.‘MemoryLane’mentalhealthdrop-incentre)andtheycurrentlydonothaveamentalhealthcrisiscentre.Manyvoicedconcernsthatwhenfundingisreduced,patientswillneedtotravelfurtherorreceivehelpinnon-specialistfacilitiessuchasA&E.OneparticipantquestionedifthereareenoughNHSstafftoimplementapreventativeapproachtomentalhealth,particularlyforchildren.InRichmondhowever,peoplefeltthatmentalhealthprovisionwasverygoodduetostronglocalvolunteersupportformentalhealthcarewhichreducespressureonNHSservices.

Peopleatthegrassrootsengagementactivitieswerealsoconcernedaboutthecapacityofexistingandfutureservices,notingthatmanymentalhealthservicesseemtobeclosingdowndespitethehighlevelsofneed.

Longwaitingtimes

Peopleoftennotedthattherearecurrentlyextensivewaitingtimestoreceivetreatment,whichisleavingpatientswithoutadequatesupport.InSutton,peoplewereconcernedthatlongwaitingtimestoaccessmentalhealthservices,combinedwithlimitedsupportforpatientsandcarersafterinitialtreatment,wouldcontinueunderthenewproposals.PeopleinCroydonfeltthattherewasalongwaittogetonIAPTservices,andthatdifficultiesinaccessingGPsareleadingtoevenlongerwaitingperiods.

Manypeopleinthegrassrootsengagementactivitiessharedtheirexperiencesoflongwaitingtimestoaccessmentalhealthservices,including6-12monthwaitsfortalkingtherapy;an18-monthwaittoseeapsychiatrist(forsomeonewhowassuicidal);afiveyearwaittoseeatherapistforPost-


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TraumaticStressDisorder;an11-monthwaitforanADHDassessmentatSpringfieldHospital;upto12weeksforIAPTservicesorCognitiveBehaviouralTherapy(CBT);andafour-weekwaittohaveatelephoneconversationfortheSuttonUpliftService.Peoplehighlightedthatlongwaitingtimescanputpeopleoffseekingtreatment,andcanleadtoconditionsescalating,endingupincrisiswhichcouldhavebeenaverted.

Lackoflocalbedsandstaff

Alackofbedspaceswasalsohighlightedbyparticipants,particularlyatEpsom,Springfield,andQueenMary’s.Somenotedthatevenifabedisallocateditisoftenonlytemporaryandpatientsareregularlymovedbetweenwards.Duetoalackofbedspaces,somealsohighlightedthattheyhavetotravelfurthertobeadmittedtohospital,whichcanbechallenging.

Othersechoedthisconcernaboutbeingtreatedsomewherefurtherfromhome.Supportoutsideborough.Somehadonlybeenabletoreceivethetreatmenttheyneededoutsidetheirownborough,makingitverydifficultforfamilymemberstotraveltovisitthemandprovidethemwithsupport,leavingthemfeelingvulnerableandisolated.

Peopleatthegrassrootsengagementactivitiesalsosharedconcernsaboutalackofresourcestodelivertheplansformentalhealthservices.Somequestionedwhethertherewouldbeenoughqualifiedstaff,especiallytoprovideearlyinterventions.Othershighlightedacurrentlackofbedsformentalhealthpatients,particularlywithinRichmond,whilesomewereconcernedthatmentalhealthwardsinEpsomandLeatherheadwereclosing.Thesepeoplefeltthatthisleadstopeoplebeingtransferredoutoftheirlocalareaforemergencymentalhealthcare,andhavingfeweroptionsavailableforpeopleincrisis.Similarly,peoplefeltthatdrop-inservicesforMentalHealtharelackingandasaresultpeople’smentalandphysicalhealthisdeclining.

7.2.3 Trainingandskills

PeopleatthesixhealthandcareforumswereconcernedthatthementalhealthplansrelyonGPstocarryoutmoreservicesorseemorepatients.Inadditiontothecapacityissuesraisedabove,peoplefeltGPsmaynothavetheappropriateknowledgeandtrainingtorecogniseandtreatarangeofmentalhealthconditions.

OthersfelttherewasatendencyforGPstoprescribemedicationsratherthantalkingtherapiesorsocialprescribing.PeoplesuggestedtheplanshouldaddressthisbymakingGPsmoreawareoftheIAPTprogrammeandotherservicesgivingaccesstotalktherapy.

Similarly,atthegrassrootsengagementactivities,severalexampleswereprovidedofGPsprescribingantidepressantswithoutlookingatalternativetreatmentoptions.PeoplefeltGPsweretooquicktohandoutpills–andmoreshouldbedonetotreatthecausenotjustthesymptoms.Inmanycasestheantidepressantshadanegativeimpactonpeople’squalityoflife.InmostcasesGPsdidn’treferpeopleonforspecialistsupportortreatmentbeforeprescribingpills,butpeoplefeltthatyoushouldbeseenbyamentalhealthspecialistbeforebeingprescribedanything.SomealsonotedthatGPssometimessimplygivelifestyleadvicetopatientsexhibitingsymptomsofmentalhealthissues,ratherthanreferringthemforfurthersupport.


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SeveralpeoplefeltthatitwouldhelpifeachGPpracticehadamentalhealthcarespecialisttoprovidemoretailoredsupport.

Peoplealsoagreedthatnursesanddoctorsshouldhaveregulartrainingonhowtodealwithchallengingpeople,howtocommunicatewithsomeonewithamentalhealthcondition,andhowtonottakethingspersonally.Somealsofeltthatpsychiatristsshouldbetrainedtospendmoretimetalkingtothepersonratherthanjustfocusingonmedicationandchangingprescriptions.

7.3 Desirability

7.3.1 Crisiscare

Atthegrassrootsengagementactivities,therewasaconsistentviewthatthereneedstobe24/7crisissupportforpeoplewithmentalhealthconditionsandtheirfamilies.Peoplefeltthatverylittlesupportwasprovidedattheweekends,whichcanbethemostdifficulttimesforpeoplewithmentalhealthissues.Theyfeltthereneedstobeanincreaseinwalk-inservicesandoutofhoursservicestosupportindividualswhentheyneeditmost.Somepeoplefeltitwouldbehelpfuliftherewasasafehousetogotointimesofcrisis.

AvoidingA&Eifpossible

Oftenbothindividualswithmentalhealthissuesandtheircarers,resorttogoingtoA&Einacrisis,althoughpeoplerecognisedthatthisisnotthebestplacetotreatthemortheirlovedones.TherewasastrongfeelingthatspecialistmentalhealthnursesshouldbepresentinHospitals,especiallyinA&E.IfsomeonepresentedatA&Eandwasexperiencingamentalhealthcrisis,itwasfeltthatadedicatedsafespacewouldworkwell.ItwasalsonotedthatthereneedstobefasterassessmentsatA&E.

Manypeopleatthesixhealthandcareforumsfelttherewasnotenoughdetailabouthowthementalhealthproposalswouldoperateinpractice,andparticularlyaboutwherepatientswouldbedirectedfortreatment.PeopleagreedthatA&Eshouldnotbethefirstportofcallforsomeonewithamentalhealthcrisisasthiscanbeanoverwhelmingenvironment,butfelttherewerefewalternativeoptions.AttheCroydonevent,therewerequestionsabouthowtokeeppatientsoutofhospital,becausetherecentclosureofthelocalFoxleyHillwomen’smentalhealthservicemeanspatientsarenowsentdirectlytothehospitalinstead.

Experiencesofcurrentservices

Somepeopleatthegrassrootsengagementactivitiesreportedspecificconcernsaboutcurrentcrisisservices.Forexample

• Thereweresignificantlevelsoffeedbackthatthecrisissupportlineisoftenoutofactionorunavailable.Peoplesharedtheirexperiencesofbeingtoldtoleaveamessagebutthennotgettingacallback.


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• ItwasfeltthatmentalhealthcrisiswasnotdealtwithverywellatEpsomhospitalandafewindividualsfeltletdownbytheNHS.Theynotedthatthereisalackofbedsavailabletotreatindividualswhentheyexperienceamentalhealthcrisis.

Othershadbetterexperiences.Forexample,peoplewelcomedtheintroductionofstreettriageinMerton,wherebyaqualifiednursewouldbebasedinpolicestationstosupportpolicewhentheyattendtomembersofthepublicexhibitingbehavioursthatindicatetheyhaveamentalhealthcondition.Peoplefeltthiswouldimprovetheskillsofthepoliceforceandtherelationshipbetweenthemandserviceusers.

ItwasalsonotedthattheNHSaredevelopingthe‘LotusSuite’inthepsychiatricdecisionunit,andpeoplehopedthatthiswouldprovideabetterexperienceforpeople.

SomepeoplehadpositiveexperiencesofcrisissupportoutsideSWLondon.Forexample,onepersonrecentlyusedtheSafeHavenServiceprovidedbyNHSSurrey&BordersPartnership.ShefeltthatthisservicewasverygoodwhenshewasincrisisandfeltthatmoreoftheseservicesshouldbeacrosssouthwestLondon.ReferencewasalsomadetothesinglepointofaccessserviceprovidedbySLAManditwasnotedtobeapositiveserviceforindividualsexperiencingamentalhealthcrisis.ItwassuggestedthatSWLondonshouldoperateasimilarservice,astheyprovideanexperiencethatislessmedicalandperceivedtobemorecosteffective.

7.3.2 Diagnosisandearlyintervention

Atthegrassrootsengagementactivities,therewereseveralcommentsrelatingtothedifficultyingettingadiagnosisforamentalhealthproblem.Therewasconsistentfeedbackthatpeoplearemorelikelytogettreatmentiftheyhaveasupportivefamilywhocampaignforbettercare.

Peoplenotedthatlatediagnosiscanhaveasignificantimpactonlaterlife,increasingtheriskofearlydeath.Severalpeopleemphasisedthatwhenpeopleseekhelp,supportshouldbeimmediate.Theynotedthatittakesalottomakethedecisiontoseekhelpformentalhealth,sonotreceivingitimmediatelymayputpeopleoffandtheirconditioncouldescalate.Therewereseveralexamplesoflatediagnosisofconditions,andtheimpactthishasonpeople:

• SomepeoplefeltthatitwasverydifficultforadultstoreceiveadiagnosisofAutism.TheyfeltthatGPsblockthesediagnoses,forexampleiftheindividualhasastablejobandfamily,eventhoughadiagnosiscanoftenhelppeopletodevelopself-awarenesssothattheycanmaintainpositiverelationshipswithcolleaguesandfamilymembers.TheyfeltthatthereneedstobemuchgreaterawarenessandunderstandingofAsperger'sandHighFunctioningAutisminadults.

• SeveraladultswithADHD(agedbetween35–52)hadonlyrecentlybeendiagnosed.Theynotedthattheyhadgonethroughthemajorityoftheiradultlivesbeingtoldtheyhadarangeofmentalhealthconditionssuchaspersonalitydisorders,depressionandanxiety.

Itwasnotedthatdiagnosisformentalhealthconditionssitsbetweendifferentorganisations,whichleadstoadisjointedsystem.Forexample,Tolworthwilldiagnosesomementalhealth


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conditions,butYourHealthcareareresponsiblefordiagnosingADHD.Itwasfeltcommunicationbetweenthesetwoprovidersispoor.

Therewasaviewthatsomegroupsofpeopleneededenhancedsupport.Forexample.inrelationtoearlyintervention,peoplefeltthatthereshouldbeearlierandmorevisiblesupportformentalhealth,particularlyformenwhomightnotseekhelpduetothestigmaaroundmentalhealth.Itwasalsofeltthatthereshouldbemoresupportforpeoplewithhighlevelneedse.g.personalitydisorders.

7.3.3 Inpatientmentalhealthservices

Atthegrassrootsengagementactivities,severalpeoplesharedtheirexperiencesofinpatientmentalhealthservices,whichtheyfeltneededtobeimproved.

AtbothRoehamptonandEpsommentalhealthunits,individualswereplacedonmixedwardswhichtheydidnotfeelcomfortablewith.

TherewereseveralcommentsaboutnegativestaffattitudestowardspatientsatRoehampton,Epsom,Springfield,QueenMary’s,RichmondRoyalandBethleminpatientservices,includingstaffnottakingpatientsseriously,notbeingavailable,over-medicatingandusingcontrollingbehaviour,poororganisation,andalackofpersonalisedcare.

PeoplenotedthattheenvironmentwithinNHSmentalhealthservicesneedstobemoreinformalandpersonalisedsothatitpromotesrecovery.

7.3.4 Outofhospitalmentalhealthcare

Peopleatthesixhealthandcareforumshadquestionsabouttheuseofspecialistmentalhealthunits.InKingston,thereweresomeconcernsthatthepsychiatricdecisionmakingunitcouldmeanthatpatientswouldnotgetspecialistcareuntiltheywereclassifiedas‘severe’or‘enduring’.InRichmondandMerton,peopleaskedwhetherthePsychiatricUnitatSpringfieldHospitalwouldbechanged.Somepeoplewerefrustratedthattherewasnotinformationabouthowthisunithadperformed(forexample,haditreducedtheuseofA&E?Didithavesuccessfulpatientoutcomes?).Theypointedoutthatresidentialcareisveryexpensiveandoftenlackstherapeutictreatments,insteadonlyofferingpsychiatricdrugs.Inlinewithconcernsaboutinpatientcareoutlinedabove,furtherconcernswereraisedbypeopleaboutthequalityofexistingoutpatientserviceswhichwouldbeusedintheplan.InKingston,oneparticipantdescribedTolworthHospital(amentalhealthservice)asbeingstressfulforpeopleexperiencingmentalhealthissues,especiallyduetolongwaitswhileattheservicetoseeaspecialist.

Transitionalsupport

Atthegrassrootsengagementactivities,manypeoplecitedexamplesofpeoplebeingdischargedfrommentalhealthcaretooearlywithouthavingaddressedtheunderlyingproblem,andwithoutsupportinplaceathomeorinthecommunity.Thisledtoconditionsescalatingandcausingrelapse


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andmeantthatpeopleenduphavingtogobacktotheirGPforareferraltoget‘backintothesystem’.

Itwasfeltthatpatientsneededmoretransitionalsupportafterbeingdischargedfromhospitalcaretohelppreventrelapseandsupportthetransitiontolivingindependently.Theyexpressedconcernthatthiskindofsupportisbeingcloseddown,suchasFoxyLaneHalfwayHouse.Severalpeopleagreedthatthereshouldbelongtermsupportprovidedforpeopleoncethey’vebeendischargedfromcare(whetherthisisasaninpatientorcommunitypatient).Theyemphasisedthatpeoplewilloftenfallintoacrisisagainifnofurthersupportisgiventohelpthemmaintaintheirhealthandwellbeing.Peoplealsosaidthatchangesincarecoordinatorshappenfrequently,andthatpeopleneedtohaveconsistentcare.

Experienceofservices

Therewasasuggestionthattheexisting9-5pmmentalhealthhelplineshouldberolledouttoa24hourlocallineratherthanbeingreferredtoCrisisLineafter5pm.

Atthegrassrootsengagementactivities,severalpeoplealsocommentedonoutpatientmentalhealthservices.

Somehadexperienceofreceivingoutpatientcarethatwaslackinginempathyorcompassionfortheindividual.Forexample,oneparticipantdescribedthatstaffwereawarethatasideeffectofhismedicationismemoryloss,yetdidnotprovideanysupportforhimtofindhiswayhomeaftergoingintotakethemedication.

Therewasvariedfeedbackaboutpsychiatriccare.SomepeoplefeltthatCommunityPsychiatricNurses(CPN)aregenerallygood,buttheappointmentsthattheyofferaretooshortandtimeismainlyspentfillinginformsforassessmentsandnottalkingthroughthecurrentissues.Somenotedthatpsychiatriccarecontinuouslychangeswithlittleornonotificationorconsultation.

7.3.5 Holisticapproachandpersonalisedcare

Peopleatthesixhealthandcareforumsagreedwiththeproposalforaholisticapproachtomentalhealththatintegratedmentalandphysicalhealth,andwouldgenerallyliketoseeamorewell-roundedapproachtopatientcare.

InCroydon,peoplebelievedthataholisticapproachwasneededthataccountedforhowmentalhealthissuesinteractedwithvariousconditionsandillnesses.PeopleinRichmondquestionediftreatmentandcarewouldbejoinedupinpracticeandwhatthiswouldmeanforpatients.InSutton,peoplesuggestedlinkingmentalhealthserviceswithotherphysicalhealthservicessuchhavingmentalhealthprovisionwithinavisionrehabilitationclinictoimprovecare.InMerton,peoplesupportedthisintegrationasseeninalocalhospitalgivingcancerpatientspsychologicalsupport.InRichmond,therewassupportfortheideaofworkingmorecoherentlywitharangeofvoluntaryorganisationstogiveamoreintegratedpatientexperience-forexamplebetweenGPsandIAPT.

Aholisticapproachtomentalhealthcarewasalsodiscussedatthegrassrootsengagementactivities.Manypeoplefeltthatcurrentlythereisalackofparitybetweenthetreatmentofphysicalillness


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andmentalhealthillnessbytheNHS,withphysicalhealthconditionstreatedbeforementalhealth,orwiththeconditionsbeingtreatedcompletelyseparately.Theyagreedthatthereshouldbeamoreholisticapproach,citingseveralexamplesofhowmentalandphysicalhealthconditionsimpacteachother.Forexample,theynotedthatlong-termconditions(e.g.diabetes)areoftenlinkedtoalowmoodifpatientsdonotfeelabletomanagetheirconditionwell.Somealsonotedthatfibromyalgiaisalifechangingconditionandthatpeoplecantakesometimetocometotermswiththeirbodychangingsomuch.Theyfeltthattheycouldfallintodepressionastheyhavenofurthersupporttohelpthemwiththeirmentalwellbeingfollowingthisdiagnosis.

Peoplefeltthatstaffshouldprovideindividualcarespecifictotheirneedsratherthanagenericpackage,takingintoaccountthateveryoneisdifferent.

7.3.6 Inclusiveoutreachandissuesaffectingspecificcommunities

Peopleatthesixhealthandcareforumsbelievedadditionalsupportisneededwithinthementalhealthservicesofferedforindividualswithadiverserangeofneeds.Theyalsothoughtitwasimportanttoensurethatallservicesareinclusivetoallpatients.

Peoplehighlightedtheimportanceofservicesforaminorityofvulnerablepatients,includingBMEpatientsandthosewithculturalbarrierstounderstandingoridentifyingmentalhealthissues.OtherssuggestedtheplanshouldrecogniseandaccommodatetheneedsofspecificgroupsincludingLesbian,Gay,BisexualandTranssexual(LGBT)people,adolescentsandperinatalpatients.InWandsworth,peoplewereconcernedthatcareforvulnerablepopulationswascurrentlyinconsistentandshouldbeimprovedaspartoftheseproposals.

Atthegrassrootsengagementactivities,therewereseveraldiscussionsabouttheneedtoaddressissuesthataffectspecificcommunities.

Withrelationtothehomelesscommunity,peopleexpressedalotoffrustrationatthelackofservicesforhomelesspeopleuntiltheyareinacrisis.Theyfeltthattherewasstigmaattachedmentalhealthissueswithinthiscommunityandtheyfeltpeopleneededtobemadeawarethatmentalhealthissuesareverycommon.Manysaidthattheystrugglewithdaytodaylivingbecausetheycannotmanagetheverylittlemoneytheyhave.Theymayendupspendingtheirmoneyonalcoholtodealwithhowtheyarefeelingemotionally,andoftenhavetorelyonfoodbankservices.Peoplesharedsomesuggestionstohelpaddresstheseissues,includingpracticalsupporttoshowthemhowtobudget;andmoretrainingforfrontlinestaffinprimaryandsecondarycare(includingreceptionists)tohelpremovethestigma.Itwasalsonotedthat‘dualdiagnosis’wasanissueexperiencedbymanyhomelesspeople(havingbothaphysicalissue,mentalhealthandalcoholandsubstancemisuse).Furthermore,homelesspeopleoftenstruggletoaccessprescriptionmedicationbecauseofnotbeingabletoregisterwithaGP,yettheycannotaffordtobuymedicationthemselves.

WithrelationtotheLGBTcommunity,peoplehighlightedthatpoormentalhealthandself-loathingcanbequiteprevalent,andsomepeoplecopebyturningtodrugsandalcohol.SomenotedthatthereisanexcellentMertonDrugandAlcoholteamattheWilson,howevertheyfeltthisneedstobebetterpromoted.


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ItwasnotedthatmanyTamilwomenstayathomewhiletheirhusbandsareatwork.Thiscanleadtolonelinessanddepression.PeoplewerenotawareofwheretheycouldgoiftheyneededtreatmentandtheyfeltthebestideawastofindoutaboutservicesthroughGPs.

ItwasalsonotedthatpeoplefromtheGypsy,Romany,andTraveller(GRT)communitysometimesdon’tseektreatmentformentalhealthconditionsastheyarefearfulthatiftheydo,theirchildrenwillbetakenawayfromthem.Moreneedstobedonetoreassurepeoplesothattheyfeelmorecomfortableseekingsupport.PeoplehighlightedthatthereisquiteahighrateofanxietyanddepressionwithintheGRTcommunityandtoomuchrelianceonprescribingmedicationtotreattheseconditions.

Peoplealsonotedthatlonelinesscanhaveahugeimpactonaperson’smentalwellbeing,especiallyfollowingthedeathofalovedone.Theyfeltthatmoreneedstobedonetosupportthementalhealthofpeoplewhoarelonelyorrecentlybereaved.

Therewereconcernsthattherewasnotmuchsupportforfamilieswhoaresupportingrelativeswithmentalhealthproblems.Anindividualstatedthattheyfeltthat,duetotheshortfallintheNHSfunding,familieswereoftenlefttopickupthejobwithoutanysupport.Severalpeopleechoedthisneedtoprovidebettersupporttocarers.

Finally,somepeoplenotedthatSuttonCCGhasbeenunabletoprovideBritishSignLanguage(BSL)Counsellingfordeafpeopleandemphasisedthatthisneedstochange.

7.3.7 Mentalhealthcareforchildrenandadolescents

Atthegrassrootsengagementactivities,therewereseveraldiscussionsaboutmentalhealthservicesforchildrenandadolescents.

Diagnosis

Manyparentshadexperiencedastruggletogetadiagnosisfortheirchild,includingfeelingthattheirconcernsweredismissedbyhealthprofessionals.Oftenithadtakenseveralyearsbeforeadiagnosiswasprovided,whichaffectedthechildren’seducationalandpersonaldevelopment.Theyalsofoundthatonceadiagnosiswasgiven,therewasalackoffurthersupportandalsonopathwayinplacetocheckforotherhealthconditions.Inrelationtothis,theynotedthat,forexample,childrenwhohaveautismspectrumdisorders(ASD)willoftenhavevitamindeficiencies,epilepticepisodes,andG.Iandheartproblems,whichshouldbecheckedfor.Parentsemphasisedthattheywouldliketoseeaspecialistfollowingadiagnosis,tounderstandmoreabouttheconditionandwhattreatmentorsupportoptionsareavailable.

Navigatingthesystem

Aconsistentthemewasthatparentswereunsureofhowtonavigatethesystemandwheretogotogetmoreinformationontheirchild’shealthandmentalhealthneeds.

Manyoftheyoungpeoplesaidtheyhadexperiencedanxietyanddepression,buttheydidnotfeelthattheygotthehelpthattheyneededwhentheyneededit.NoneofthemwereroutinelyinformedabouttheIAPTservicesandwhattreatmentoptionsareopentothemfortheirmentalhealthneeds.


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ChildrenandAdolescentMentalHealthServicesandtransitions

TherewasvariedfeedbackaboutChildrenandAdolescentMentalHealthServices(CAMHS).SeveralpeoplenotedthattheywereonlyabletoaccessCAMHSwhenthingsgotreallybad,andthattherewaslimitedsupportforthemattier1.OncetheyhadaccessedCAMHS,manypeoplefoundthesupporttobegood,withexcellenttherapists.However,othersfelttheyhadnotreceivedenoughsupport,(forexampletohelpparentsmanagetheirchild’sbehaviour,andtohelpthemmaintaintheirownwellbeing)andthatcommunicationwasverypoor.SomenotedthatstaffwithinCAMHSseemover-stretchedandtheyfeltthisisleadingtochildrennotbeinggivenfullassessments.Inrelationtoamoreholisticapproachtomentalandphysicalhealth,somenotedthatthereshouldbemoreawarenesswithintheNHSofthelinkbetweenhearinglossandbehaviouralissuesandprovideaccesstoappropriateCAMHSservicesforthis.

Peoplenotedthatthereneedstobeclearerlinksbetweendifferentservices,forexampleacutetrustslinkingupproperlywithcommunityserviceswhenthechildisinthecareofbothofthem.SomeparentsnotedthatonceachildtransitionsfromCAMHStoadultservices,thepathwayisverydifficulttonavigateandpeoplegetlostinthesystem.Theyfeltthatthetransitionbetweenchildandadultmentalhealthservicesneedtobemorestreamlinedandsupportive.

Crisissupport

Itwashighlightedthatthereisnocrisissupportavailableforchildrenwhomareexperiencingmentalhealthdifficulties.

Itwasalsofeltthatthereisalackofspecificsupportforchildrenwhoaretransgender.Despitetherebeingresearchtosuggestthatautisticchildrenhaveahigherrateofbecomingtransgenderthanotherindividuals,therearenospecificservicesinplacetosupportthem.


7.4.1 Workingwithschools

Peopleatseveralofthesixhealthandcareforumsdiscussedtheimportanceofeducationaboutmentalhealthandtheroleofschoolscouldplayinpromotingservicesandraisingawareness.

Therewasagreementamongpeopleabouttheimportanceofmentalhealthsupportwithintheeducationsystem,toholisticallytacklementalillness.InKingstonandSutton,peoplebelievedthereshouldbeamorecompleteapproachtosupportingmentalhealthinchildrenbyworkingtojoinresourcesinschools,familiesandlocalhealthservices.Somepeoplebelievedthatmoresustainedandconsistentsupportisneededfromanearlystage,ratherthanleavingcaregiversalonetomanageacondition.

Therewerealsosuggestionsthatschoolsandeducationservicesshouldknowmoreaboutmentalhealthconditionsandwhatsupportisavailable.Additionally,inSuttonpeoplebelievedthatthereshouldbemoreinformationaboutearlymentalhealthinterventionsintheschoolcurriculum.


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Peopleatothereventssimilarlysuggestedthatmentalhealtheducationshouldbedeveloped,andthatworkwasneededtoalleviatestigmaandencouragemorepeopletoseeksupport.

Similarly,atthegrassrootsengagementactivities,therewereseveralcommentsaboutmentalhealthsupportinschools,andimprovedlinksbetweenschoolsandCAMHS.Somefeltthatmentalhealth,physicalhealthandeducationshouldallbejoinedupandtreatedtogetherratherthanseparately.Forexample,oneyoungpersonreceivedgoodsupportfromCAMHSbutwhenthatendedandshestartedreceivingtheHealthEducationalSupportPlan,thesupportbecamelesseffectivebecauseitonlyconcentratedonschoollifeanddidnotaddressthementalhealthissues.

Parentsandyoungpeoplealikeemphasisedthatschoolsneedtoprovidemorementalhealthsupport.Youngpeoplewhohadacounsellorintheirschoolhadmixedfeedback,withsomefeelinganxietyaboutbeingseengoingforanappointment.Itwassuggestedthatamoreinformalapproach,ratherthananappointment-basedsystemcouldhelpaddressthisissue.Youngpeoplealsofoundthattheschoolnursewasofteneitherunavailable,orunapproachable,whichputthemoffgoingforsupport.Someyoungpeoplehadconfidedintheirschooltutor,howevertheyfelttheyreceivedmixedmessagesaboutwhetherconversationswouldbeconfidentialornot,andalackoftransparencyaboutthis.Someyoungpeoplesaidtheywouldratherseeksupportoutsideschoolsothattheirpeersdidnotfindoutthattheyneededhelp.However,theyfeltthatthereisalackofawarenessofyouthcentresthatcouldprovidesupportoutsideofschool,andthatschoolsshouldhelpraiseawarenessofwheretheycouldgethelp.

7.4.2 Raisingawarenessofmentalhealthservicesandsupport

PeopleacrossthesixhealthandcareforumsbelievedthatcommunicationfromtheNHSneedstobeimprovedtoincreasetheuseofmentalhealthservicesandsuggestionswereofferedabouthowtocommunicatewiththecommunitybetter.

InSutton,peoplebelievedthattheNHScouldbetterinformthepublicandlocalmedicalprofessionalsaboutwhatservicesareavailablefromacrossthemedical,communityandvoluntarysectors.Inaddition,someinWandsworthsuggestedthatincreasedsignpostinginGPsurgeries,awarenesscampaignsandadditionaltrainingfor111phonelineoperatorscouldhelpsupportthosewithmentalhealthissues.Peoplesuggestedraisingawarenessandtrainingnon-medicalstaff(e.g.GPreceptionist)tosupportpeoplewithmentalhealthconditionsandtosignposttotreatmentoptionsearlier.InWandsworth,peoplediscussedTheCrisisCaféinMertonasanexampleofaprovidingsupportinacommunitysetting,wheresignpostingtocarewasavailableinamoreinformalspace.InKingston,peoplesuggestedcarenavigatorscouldhelpwithcommunicationthroughoutthedeliveryofmentalhealthservices,asitreducestheneedforpatientstorepeatthemselveswhichcanbedistressing.

Atthegrassrootsengagementactivities,asuggestionmadewastoensurepostersinhospitalsandGPsurgerieswereuptodatetomakesurepeopleareawareofwhatotherservicesformentalhealthareavailable.


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7.4.3 Mentalhealthawarenessandstigma

Peopleatthegrassrootsengagementactivitiesfeltthatthestigmatowardsmentalhealthissuesisslowlychangingandmorepeoplearespeakingoutabouthowtheyfeel.However,theyfeltthisisnotthecaseforeveryone,andmanypeoplestilldonotaccessthesupporttheyneedbecauseofstigma.Itwasmentionedthatpeersupportandcommunitygroupsarevitaltopeoplewhohaveamentalhealthcondition,howeversomepeoplearestilltooscaredtospeakoutabouthowtheyarefeelingandatargetedapproachshouldbetakentoreachthosepeople.Itwasalsosuggestedthatmoretrainingisavailableforfrontlinestaffinprimaryandsecondarycare(includingreceptionistsetc.)toremovethestigma.

Peoplefeltstronglythatthereshouldbesomeoneinthecommunitytotalktoaboutpreventingcrisis.Theysuggestedthatprivatedropincafesshouldbeavailableineachboroughtoprovideindependentadvicearoundwaysinwhichapersoncouldkeepthemselveswellmentally,tohelpreducethestigmaaroundusingmentalhealthservices.

7.4.4 Improvementstocrisiscare

Peopleatthegrassrootsengagementactivitiesalsohadsomesuggestionsforserviceimprovements.Peopleweresupportiveofthe‘crisiscafe’conceptbutfeltthatthismodelassumesthatpeopleunderstandtheirowntriggersandknowwhentoseeksupport.Theyemphasisedthatpeopleneedmoretrainingandsupporttoenablethemtounderstandtheirconditionandwhenitmightescalate.Theyalsoemphasisedthattheseservicesshouldbewelladvertisedtoraiseawarenessthattheyareavailable.

SeveralpeoplenotedthattheywouldhavelikedamedicalreviewoncetheirMHcrisiswasover.Theywouldliketobegiventheopportunitytoreducetheamountofmedicationtheywereprescribedduringcrisis.

CommunityCentrestaffaskediftheywouldbeabletoaccessthelocaldirectoryofservicessothattheycouldsignpostindividualstothemostappropriateservicesbeforetheygointocrisis.CentrestaffallalsoaskediftheycouldhaveaccesstotheCrisisResponseService,astheyoftenrecognisewhentheirmorefrequentvisitorsaremovingintocrisis.

7.4.5 Joined-upworking

Atthegrassrootsengagementactivities,peopleemphasisedthatallaspectsofthehealthserviceneedtoworktogethermore,andthatatthemomentitfeelsverydisjointed.

TherewerealsosomesuggestionsabouthowtheNHScouldworkmorecloselywithotheragencieswithaviewtoenablingamoreholisticapproachthatincludesbothmentalandphysicalhealth.Forexample,oneparticipantsuggestedthereshouldbeahealthadvisoratthejobcentre,particularlyforwhenpeoplearesanctionedbythejobcentre,asthiscanhaveadetrimentaleffectonmentalhealth.


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Peoplefeltthatthereneedstobemorejoiningupwiththevoluntarysectorandcommunitygroupswhocanofferexcellentsupportandactivitiesforpeoplesufferingfrommentalhealthissues.Oneparticipantnotedthatco-productionandasset-basedcommunitydevelopmentareimportantapproaches,andthattheNHSshouldtakethisapproachwhencommissioningmentalhealthservicesanddevelopingmentalhealthstrategies.

Itwasfeltthatcurrently,signpostingtothevoluntarysectorisaproblem,andmanypeoplehadtodotheirownresearchorbeluckyenoughtoreceiverecommendationsfrompeopletheymet.Itwasfeltthatpeopleneedasafeenvironmentwherepeopleknowthemandcantelliftheyareontheedgeofacrisis,andthatthevoluntarysectorplaysavitalroleinthis.However,peoplefeltthatthereneedstobemoreinvestmentincommunitygroupsandthevoluntarysectortoenablethissupport.

8. LearningDisabilitiesThetopicoflearningdisabilitieswasnotdiscussedatthesixhealthandcareforumshowevertherewassomediscussionduringthegrassrootsengagementactivities.Thediscussionsfocusedpredominantlyonadvicefordeliveryofservicesthataresuitableforpeoplewithlearningdisabilities.Thesediscussionsaresummarisedbelow.

8.1 Keymessages

• PeoplewereconcernedaboutlongwaitingtimestoseeaGPandrequestedthatGPappointmentsforpeoplewithlearningdisabilitiesshouldbelongertoallowmoretimetoexplaininformationclearly.

• Staffneedtocommunicatemoreclearlywiththosewithlearningdisabilities,andinvolvethemintheircare(notjusttheircarers).

• Thereisaneedforimprovedaccessibilityforthosewithdisabilities(physicalaccessandaccessiblecommunications).

• Thereshouldbemoreawarenessofannualhealthchecksforchildrenwithlearningdisabilities,includingremindersfromtheGPsurgery.

• Moresupportforcarersisneeded.

8.2 Desirability

8.2.1 Primarycare

Peoplefounditdifficultwhentheycouldn’tgetanappointmentwiththeirdoctorandnotedthatsometimestheyhadtobook6-8weeksinadvancebeforetheycouldgetanappointmentwiththeirGP.ItwasalsostronglyfeltthatpeoplewhoattendedtheirGPsurgeryshouldbeinformedofanydelaystotheirappointmentsinadvanceasitcancauseanxietyandstress.


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ItwasfeltthatGPsshouldallowalongerappointmentslotforpatientswhomhavealearningdisabilitysothatthepatientcanaskquestionsifneededandtheGPhasenoughtimetoexplainthingsproperly.Manyfeltthatitisimportantforthecarertobeinvitedtotheappointmenttohelpsupportthepatient.

Peoplehighlightedthatproblemsforpeoplewithlearningdisabilitieswhenaccessingprimarycarearewelldocumented,includingdiagnosisanddelaysintreatment.

8.2.2 Communicationfromhealthcareprofessionals

TherewereseveralreferencestoGPreceptionistsandmanyindividualshadnegativeexperiences;particularlyinrelationtohowtheydealwithpeoplewithlearningdisabilities,andparticularlychildrenwithlearningdisabilities.

Somepeoplefeltthatthedoctorwouldeithertalktotheirsupportworkerorjustlookatthecomputerandtype.ThismadethemfeelignoredandsadandfeltitwasimportantthatGPstalkdirectlytothepatientaswell.

Peoplenotedthatwhenlettersaresentouttopatients,theyarenotwrittenin‘easyread’formatsandsometimescontaincomplicatedlanguage.Thismeanspatientshavetoreplyonothersinordertounderstandthecontents.ItwassuggestedthatGPscouldphonepatientswithlearningdisabilitiesafterlettersaresenttoexplainandansweranyquestions.

However,somepeoplefeltthateveninperson,GPssometimesspeakinjargonandthatthiscanbedifficultforsomeonewithalearningdisabilitytounderstand.

Peoplehadsimilarfeedbackinrelationtocommunicationwithpharmacists.Theysuggestedthatwhenpeoplearegiventheirmedication,thepharmacistshouldtakethepatientintoaroomandexplainhowtotakeit.Sometimespeoplearegivenmanydifferentpillsandonlywritteninstructionswhichcanbedifficulttounderstandforthosewithlearningdisabilities.

Inordertofacilitateappropriatecommunication,peoplefeltthatindividualswithalearningdisabilityshouldhavethisnotedontheirfilessothatstaff(bothreceptionistsandclinicalstaff)areawareandadditionalprovisionscanbemade.

8.2.3 Accessibility

SomepeoplefeltthattheirGPsurgerieswerenotveryaccessibleandnotedthatallGPpracticesmustbewheelchairaccessible,includinghavingwideenoughlifts.SpecificmentionwasmadeofSurbitonHealthCentrewhichpeoplenotedneedsmoreaccessrampstobeinstalled.

PeoplenotedthatPatientOnlinehasmadeiteasierforpeopletopickupprescriptions.However,somewerefrustratedthattheywerestillunabletobookonlineappointmentsorseetheirmedicalrecordsonline.


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8.2.4 AnnualHealthChecks

Therewereseveralcommentsrelatingtoannualhealthchecksforpeoplewithalearningdisability.

ItwasnotedthatnotallGPsurgeriesinvitepeoplewithalearningdisabilityfortheirannualhealthcheck.ItwasstronglyfeltthattheGPsshouldwritetothepatientinadvancetoorganiseandremindthemtobookanannualhealthcheck.ManyfeltthattheannualhealthcheckisanextremelyimportantappointmentandGPsshouldtakethetimetodiscussandexplainwhattheyaredoing.Themajorityofpeoplespokentohadneverheardorbeenofferedayearlyhealthcheckforthemselvesortheirchildren,indicatingalackofawarenessofthisserviceforchildrenwithadisability.Peoplealsonotedthatwhentheyareofferedanannualhealthcheck,theywereseenfor20minutesratherthananhour,whichtheyfeltwasnotlongenough.OnepersonmentionedthathisparticularGPsurgerydidn’tknowaboutannualhealthcheckswhentheyaskedatreception.

8.2.5 Specialistservices

Severalcommentsandsuggestionsweremadeinrelationtospecialistservicesforpeoplewithalearningdisability.

Somesaidthatthespecialistcareforchildrenwithdisabilitiesispoorandthatitisnotoftentailoredtoanindividual’sneeds.Peoplefeltthereshouldbespecialistclinicsespeciallyforpatientswithcomplexneedstohelpaddressthis.

Somepeoplealsonotedthatnosupportorinformationisofferedtoparentsonhowtoobtainclinicalsamplessuchurine,whenachildwearsanappy.

Finally,inrelationtodentalcareforpeoplewithlearningdisabilities,somepeoplewereconcernedthatthespecialneedsdentistryserviceatStJohn’sHealthCentre,Twickenhamhas“vanished”withnoinformationprovidedtothosethatregularlyaccessedtheservice.

8.2.6 Diagnosis

Therewereseveralreferencestothedelayindiagnosisforchildwithlearningdisabilities.

Parentsdescribedthatitcouldtakeseveralyearsbeforeadiagnosisismade,withsomedescribingatwo-yearwaittoseeCAMHSinCroydon.

Thisisdiscussedfurtherinthe‘Careforchildrenandadolescents’sectionwithinthe‘MentalHealth’chapter.

8.2.7 Communicationbetweenservices

Peoplefeltthereisalackofcommunicationbetweenservicesandthishasanimpactofcarethatisbeingdelivered.Whenseeinganewprofessional,theydescribedhavingtoexplaineverythingagainandtheyhighlightedthatthisisdifficultwhenyouhaveachildwithadisability.

8.3 Feasibility&Advicefordelivery


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Nospecificplanswerepresentedatthehealthandcareforumsandthereforefeasibilitywasnotdiscussed.Equally,feasibilitywasnotspecificallydiscussedatthegrassrootsengagementactivities.


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9. Children’sservicesThissectionsummarisesthediscussionsacrossthesixhealthandcareforumsandgrassrootsengagementactivitieseventsaboutchildren’sservices.Ithighlightstheemergingthemesandkeymessagesaboutthecaseforchangeandtheideasdevelopedsofar.Acrossthehealthandcareforums,therewerefewerattendeesatthistopicgroupthanatothersandinsomecases,therewerenopeopletodiscusstheproposedchangestochildren’sservices.

ThesuggestionsoutlinedintheSTPrelatingtochildren’sservicesinclude:

• ParentswithyoungchildrenwillhaveimprovedaccesstoGPsoranothercommunitybasedservice

• ChildrenrequiringshorttermhospitaltreatmentwillbetreatedinspecialistunitslinkedtoA&E

• Childrenneedingextendedhospitalsstayswillseespecialistsmorequickly.

9.1 Keymessages

• SomepeopleexpressedconcernsthattherewerecurrentlynotenoughNHSresourcestocarryouttheproposalsforchildren’sservices.

• WhilepeopleagreedwiththeprincipleofreducingunnecessaryA&Evisitsfromchildrenandparents,theyfeltitwouldbechallengingduetoaperceivedabsenceofalternatives

• Peoplebelievedthattoreducetheburdenonacuteservices,moreflexibleGPservicesareneeded

• Therewereconcernsaboutlongwaitinglistsforreferralstospecialistclinics,andlongwaitsatclinics,sometimeswithinappropriatewaitingareas

• TheSTPshouldaddresschildren’sdiversehealthneeds,includingimprovingmentalhealthservices,servicesforlearningdisabilitiesandprovisionforfamilieswithdifferentculturalbackgrounds

• Peoplebelieveincreasedawarenessisneededaboutwhatservicesareavailableforchildren’shealthaswellaswhenitasappropriatetouseeachservice

• Itwassuggestedthatchildrenshouldbemoreinvolvedinactivelydiscussingtheirsymptomsandconditionswithdoctorsdirectly

• Therewasadesireformoreeducationandinformationtosupporthealthylifestylesforchildrenandfamilies


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9.2 Feasibility

9.2.1 Resourcestodeliverservices

SomepeopleexpressedconcernsthattherewerecurrentlynotenoughNHSresourcestocarryouttheproposalsforchildren’sservices.AttheRichmondhealthandcareforum,peoplewereconcernedthatthelackofstaffacrossthehealthcareservice(fromGPstomidwives),combinedwithinsufficientfundingofservices,wouldleadtoaninabilitytodelivertheSTP.Oneparticipantsuggestedtheconsolidationofhealthandsocialcarebudgetstoachievebetterhealthoutcomeswithgreaterresources.

InRichmond,peoplelikedtheuseofacommunitypaediatricnurseandwouldliketoseethisservicemoreoften.

Atoneofthegrassrootsengagementactivities,itwasraisedthatthewayfundingisorganisedisperceivedtocauseproblemsfordeliveringchildren’sservices.Inparticular,itwasnotedthatfundingforhearingscreeningfornewbornbabiesisincludedinthe“postnatalmaternitypayment”.However,becauseofthisallocation,thematernityleadsineachoftheacutetrustsdonothavemoneyforallbabies,andthereforetimeandresourcesarespentchasingpayment.Itwashopedthatamorecollaborativeapproachtocommissioningandmorejoined-upworkingwouldhelpalleviatethiskindofissue.Itwassuggestedthatnewbornhearingscreeningshouldbeincludedinthefive-yearstrategyforlocalhealthservicestofacilitatecontinuityanduniformityacrossthesector.

Itwasfeltthatgenerallychildrenandyoungpeopleareoftenseenbytraineeswhoregularlyrotate,thereforethereislittlecontinuationincareandalackofexperiencedspecialiststaff.

9.2.2 AlternativestoA&E

MostpeopleatsupportedtheideaofreducingthenumberofunnecessaryvisitstoA&Ebyparentswithchildren.However,theybelievedthatitwouldbechallengingtodothis.Atboththehealthandcareforumsandthegrassrootsengagementactivities,manyagreedthatA&Ecanbeanunsuitableenvironmentfortreatingchildren,butbelievedthatanxiousparentsoftendonotthinkthereisanalternative.PeopleinKingstonhighlightedthatexistingservicessuchastheNHS111phonelinearenotalwayseffectiveforparents,asiftheyareworriedabouttheirchildtheyarelikelytopreferin-persondiagnosisandtreatment.Also,otherservicescanbeslowertoaccessastheydonothaveatargettoseeallpatientswithinfourhours,orhaveserviceswhichareperceivedtobeofvariablequality.InCroydon,peoplebelievedthatparentswouldtaketheirchildrentoA&EifGPswerenotaccessibleastheydidnottrustpharmacyorcommunityservices.

ImprovingaccesstoGPswasthereforeconsideredtobefundamentaltoreducingthenumberofchildrenunnecessarilyinA&E.Accesstoappointmentsandadvicewasraisedasanissueatmostevents.Peoplesuggestedthat,ifparentshaveconfidencethatthecaretheirchildrenarereceivingoutofhospitalisappropriate,thentheywillstoprelyingonA&Eastheirfirstchoice.Itwas


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emphasised,however,thatGPsarecurrentlyundergreatpressure,thereforeactionsshouldbetakentoincreasetheircapacity.

Whenyoungpeoplewereaskedwheretheywouldgoiftheyneededurgentcare,mostsaidtheywouldcall999orgotoA&EbecausetheyknewwhereA&Ewasandbecausetheyknewthatdoctorswouldbethere.Afewsaidtheywouldgototheirlocalwalk-incentrebecausetheythoughtitwouldnotbesuchalongwaitasA&E.AfewalsosaidtheywouldasktheirparentstomakeaGPappointment.

Someyoungpeopleinthegrassrootsengagementactivitieswerealsoawareofseveralotherservicestheycouldaccessforsupport,includingChildLine;Talkbus;thelocalsubstancemisuseteam;andpolice.Iftheyneededsupportfordrugoralcoholproblems,youngpeoplefeltitwasimportanttohavesomewheretogowheretheywouldnotbejudged,somewherethatwassafeandsecure,andthatsupportgroupsandcounsellingwouldbevaluable.

9.3 Desirability

9.3.1 Flexibleservicesforparents

Toachievetheproposedaimsforchildren’shealthcare,peopleatthehealthandcareforumsraisedtheissueofflexibleaccesstoservicesforparentsaswhiletheyagreedA&Ewasnottheoptimalsolution,itwasviewedasflexible.Therewerecommonconcernsthata‘onesizefitsall’approachwouldnotbesuitableforparents.Inacoupleofevents,peoplediscussedthatparentsmayneedaccesstoGPsafternormalworkinghoursandthattheyshouldbeaccessiblesevendaysaweek.

9.3.2 Appointmentsandreferrals

Atthegrassrootsengagementactivities,peoplenotedthatthereareoftenlongwaittimesforreferralsintospecialistclinicsorsupportservicesforchildrenandyoungpeople.Itwassuggestedthatimprovedsystemsshouldbeintroducedtohelpmanagethis.

Peoplealsosaidthatappointmenttimesatspecialistclinicsrarelyrunontimeandthiscanbedifficulttomanage,especiallywhenyouhaveanautisticchild.Assuch,itwasfeltthatwaitingroomsneedtobemoreautism-friendlyandhaveasensoryareaforchildren.

9.3.3 Inclusivesupportfordiverseneeds

Toaddressthediverserangeofneedsineachcommunity,peopleacrossthehealthandcareforumssuggestedsomespecificareasofimprovementtobeaddressedintheplan.

AttheCroydonhealthandcareforum,theadditionalneedsofimmigrantfamilieswerediscussedanditwassuggestedextrasupportmaybeneededasextendedfamilymembersmaynotbeavailable.AsimilarconcernforparentswithlimitedsocialnetworkswasraisedinKingston,astheymaybelessconfidentinmanagingtheirchild’scare.BotheventsbelievedthosewithEnglishasasecondlanguagewouldneedtailoredsupport,suchasinformationavailableinmultiplelanguages.


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Morenervousparentswerebelievedtobemorelikelytotaketheirchildtothehospitalasthefirstportofcall,thereforethereshouldbeadditionaleffortstosupportthesegroups.

Inaddition,peopleinKingstondiscussedprovisionofcareforchildrenwithmentalhealthconditionsandadditionalneeds.TheybelievedmoreneedstobedonetoaddressthiswithintheSTPproposals,includingclarityofwhatqualifiesasamentalhealthissueinachild,andinformationaboutwhatservicesspecialisinginpaediatricmentalhealthareavailableforchildrenandtheirparents.Forparentswithchildrenwithspecialeducationalneedsanddisabilities,peoplesuggestedthatdirectroutestoservicescouldreducetheburdenonGPs.

Atthegrassrootsengagementactivities,peopleemphasisedtheneedforimprovedstandardsofcareforchildrenandyoungpeoplewithalearningdisability,along-termcondition,orautism.Thisincludesfurthertrainingforstaffonhowtocareforthesechildreneffectivelyandcommunicatesensitively.Itwassuggestedthatstaffworkingwithinthehealthcaresystem,needtobefriendlierandhaveanimprovedabilitytorelatetoyoungpeople,especiallythosewithcomplexneeds,learningdisabilitiesorautism.Itwasalsofeltthatthereshouldbequickeraccesstospecialistadviceandsupportforpeoplewithlearningdisabilities,inordertoavoidanydetrimentalimpactsonchildrenfromdelayeddiagnosisorsupport.

Therewasasuggestionthatmorespecialistcarecouldbeprovidedwithinschoolssothatchildrendidnothavetoattendhospitalregularlyfortheirappointmentsandhavetomissschoolasaresult.

Thetransitionstageaschildrenwithlong-termconditionsbecomeadultswasfelttobeverychallenging,andtherewerecallsforcommissionerstoaddressthisissueandensurelong-termorlifetimecareisplannedfromthepointatwhichaconditionisdiagnosed.PeoplefeltthatmorejoinedupworkingbetweenGPs,specialistclinics,schools,hospitalsandotherformsofcarewouldbeneededaschildrenwithlong-termconditionsbecomeadults.

9.3.4 Outofhospitalcare

Therewerespecificconcernsfromparentsofchildrenwithunilateralhearingloss,thattheirchildrenarenotgiventhesametreatmentorconsiderationasthosewithbilateralhearingloss.Theyweredisappointedbythelackofsupporttheyreceived.

Accesstospeechandlanguagetherapyserviceisseentobepatchyandinconsistent.Itwasfeltthatspeechandlanguagetherapistsneedspecialisttraininginhowtoworkwithandsupportchildrenwhohavehearinglossastheydonotappeartobeexperiencedinthisarea.

Peoplealsovoicedconcernsthattherewasinsufficientsupportprovidedthroughoutofhospitalcare,bothbytheNHSandtheLocalAuthority.Forexample,peoplehighlightedalackofcontinuityofcareintermsofspeechandlanguagetherapyforchildren.Therewasasuggestionthathavingspeechandlanguagetherapyand/oroccupationaltherapyfundedaspartoftheEducationandHealthandCarePlan(EHCP)fromthelocalauthoritydoesnotworkwell,asthereareeithernotenoughsessions,nosessions,orinconsistentanddifferenttherapists.


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9.3.5 Communication

Peopleatthegrassrootsengagementactivitiesemphasisedthatcommunicationbothwithinandbetweenchildren’sservicesshouldbeimproved.Forexample,itwasfeltthatcareisnotwellcoordinatedbetweentheNHSandlocalauthorityforchildrenwhohaveaneducationhealthplan.

Itwasalsofeltthatthereshouldbeimprovedcommunicationwithparentsaboutwhattoexpectintermsofwaitingtimesforappointments.Itwassuggestedthatwhenalong-termconditionisdiagnosedinachild,theirparentsshouldbeprovidedwithadesignatedsupportworkerwhocanprovideadvice,supportandguidanceasparentsgettogripswiththeirchild’scondition.TheyfeltthatthiskindofsupportwouldleadtolessstressamongparentsandpotentiallyfewertripstotheGPortoA&E.

9.3.6 MentalHealth

Detailedfeedbackaboutmentalhealthcareforchildrenandyoungpeople,canbefoundinsection7.4.7.

PeopleatthegrassrootsengagementactivitiesquestionedhowChildandAdolescentMentalHealthServices(CAMHS)areinvolvedintheplansforchildren’sservices.Therewasafeelingthatmentalhealthforchildrenandyoungpeopleneededparticularconsiderationandimprovement.ItwasfeltthatthewaitingtimestoreceivesupportthroughCAMHSwastoolong,theprocessisconfusing,andthethresholdsforsupportaretoohigh,leavingyoungpeoplewithnosupportandatriskofself-harming.


9.4.1 Raiseawarenessofservices

Peopleatthehealthandcareforumsbelievedthatmoreshouldbedonetopromoteservicesforchildren’shealthavailableinthecommunity,aswellaswhenyouuseeachone.ManypeoplethoughttheNHScoulddomoretocommunicatewiththepublicaboutchildren’shealthservices.Theygaveseveralsuggestionsforhowtoimprovethiscommunication,including

• providingbettersignpostingtootherserviceswhenparentsandcaregiversarriveatA&E;

• GPsexplainingtoparentsaboutwhentousedifferentservicesduringappointments(e.g.discussingwhentogotothepharmacistratherthanGP)

• GPsurgeriessignpostingtoappropriateserviceswhenbookingappointments;

• developingpartnershipswithschoolsandcommunitybasedservicestoadvertisewhereparentsshouldseekmedicaladvice;

• havinganurseavailablewithinschoolswhocandiscusschildren’shealthwithparents.

Inadditiontoraisingawarenessofservices,somebelievedtherewasaneedtoclarifywhatservicesshouldbeusedwhen.Forexample,whentospeaktoaGPonthephone,whentoseethemin


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personandwhentogotoA&E.InWandsworth,peoplesuggestedthatthesestandardsshouldbeadheredtoinGPsurgeriestoensureconsistentandappropriatetreatmentisgiven.InMerton,peopleemphasisedtheimportanceofgivingparentsconfidenceinwhichservicetheyshoulduse,andsuggestedreachingouttolocalparentgroups.

Atthegrassrootsengagementactivities,itwasnotedthattheHounslow&RichmondAsthmaservicebroughtgreatimprovementsbytakingtheprogrammeintoschools,andthatthismodelcouldbeusedforotherconditionstoo.

9.4.2 Useoftechnology

Atthehealthandcareforums,somepeoplelikedtheideaofusingtechnologytohavemoreflexibleservicesforparentsandchildren.InadditiontotraditionalGPappointments,somepeopleinKingstonandMertonsuggestedusingtechnologysuchasSkypetoprovideremoteappointmentsandinWandsworththeysuggestedtelephoneconsultations.However,theysuggestedthatremoteappointmentsmaynotbereliableforadviceanddiagnosisinallcases,asparentswouldneedtobeabletoaccuratelydescribeorassesssymptoms.Othersuggestedapproachesweretohavewalk-inclinicsforfirststagediagnosisfromwhichappropriatefollowupcouldbesignposted,orhavingaGPavailableinahospitalsetting.

Youngpeopleatthegrassrootsengagementactivitiessuggestedthatanappcouldbehelpfulforpeopletofindtheirnearestsurgeryandgivehealthinformationsuchasshowingwhathealthyandunhealthyfoodsare.

9.4.3 Children’sroleintreatment

AttheWandsworthhealthandcareforum,itwashighlightedthatinadministeringchildren’shealthservices,thereshouldbeaculturalchangeinhowyoungpatientsarecommunicatedwith.Thiswouldincludeaskingchildrenabouttheirsymptomsdirectlyratherthanthroughtheparentsasintermediaries.Theyfeltthiswouldencourageacultureofconfidenceamongyoungpeopleaccessinghealthcare.InMerton,peoplealsosuggestedthatbetterunderstandingtheneedsofchildrenandparentsthroughlocalparentgroupswouldhelpgivebettercare.

Similarly,atthegrassrootsengagementactivities,peoplefeltthatchildrencouldbecommunicatedwithmoreeffectivelytohelpthemmanagetheirownconditions,suchasexplainingwhytheyareprescribedmedication,howitwillhelpthem,andwhenorhowtotakeit.

9.4.4 Prevention(promotinghealthylifestyles)

Atthegrassrootsengagementactivities,educationandpromotionaroundhealthylifestyleswasdiscussedwithchildrenandyoungpeople.

Peopleshowedagoodawarenessofthedistinctionbetweenhealthyfoodandlesshealthyoptions,aswellasmoredetailedunderstandingofwhatmakesfoodhealthorunhealthy.Therewasalsoawarenessofthe“fiveaday”and“eatarainbow”campaignsandwhattheymean,andtherewas


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positivefeedbackaboutthe“EatWellPlate”.Mostchildrensaidtheyexerciseregularly,howeversomewantedmoreadviceaboutwhatisconsideredtobegoodexercise.

Indiscussingmentalhealth,somechildrentalkedaboutstressassociatedwithschoolanddailylife,withsomecitingexamsandhomeworkascausesofanxiety.

Itwasnotedthatinformationonpersonaltopicssuchassex,relationships,andeatingwellusuallyonlycomesthroughoutsideorganisationsratherthanbeingdiscussedatschools.Themajorityofthechildrenwhotookpartwantedmoresupportfromschoolaboutheathylifestyles,includingclassessuchasfoodtechnology,lessonsonwhatishealthyandunhealthy,andlessonsonhealthybodyimageandeatingdisorders.Somechildrenalsowantedhealthierchoicesforschoollunches.Incontrast,someyoungpeoplefeltthatwhentheyaregiventoomuchinformation,itcouldhavetheoppositeeffectandcouldputpeopleofffromlistening.

Amongparents,somenotedthattheyhavereceivedsupportthroughtheirchild’sschooltohelpwithbudgetingandhealthyeating.Incontrast,otherssaidtheyhadnotreceivedanysupportonhealthyeatinghabitsinrelationtotheirchildrenorthemselves.

Parentsmadeseveralsuggestionsabouthowtosupportfamiliestobehealthier,includinghavingmorefreefitnessactivitiesforchildren;moreeducationaroundhealthandexercise;vouchersforhealthierfoodforsingleparents;gymsandswimmingpoolsatreasonablepricesforfamilies;andquickerandbettertreatmentofailmentsthatpreventpeoplefromexercising.


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10. MaternityservicesThissectionsummarisesthediscussionsacrossthesixhealthandcareforumsandgrassrootsengagementactivitiesaboutmaternityservices.Ithighlightstheemergingthemesandkeymessagesaboutthecaseforchangeandtheideasdevelopedsofar.

Acrossthesixhealthandcareforums,thematernityservicestableswereattendedbylowernumbersofpeoplethanforothertopics,andduetothehighrepresentationofolderparticipants,mostpeoplehadnotusedmaternityservicesinrecentyears.

ThesuggestionsoutlinedintheSTPrelatingtomaternityservicesinclude:

• Morepersonalisedcarebefore,duringandafterbirthwithwomenseeingthesamemidwife/teamofmidwivesthroughouttheirpregnancy

• Bettermentalhealthsupportformothersstrugglingtocope.

• Greaterprovisionofconsistentandunbiasedinformationaroundtheoptionsavailabletoensurewomengivebirthintheplaceoftheirpreference(i.e.midwife-ledunit,homebirth).

• Ensuringwomenreceivehighqualitycarewhichsupportsthemtohaveanormal,healthexperiencewhilstalsocaringforhigherrisk,morecomplexbirths(suchasmotherswithdiabetesorobesity).

10.1 Keymessages

• Whendiscussingmaternityservices,peoplediscussedthelackofaccesstoqualitycareduetomidwiferystaffshortageswhichneededtobeaddressed

• Post-natalcarewashighlightedasaservicethatrequiredimprovementandpeoplewouldliketoseethisaddressedintheSTP

• Continuityandconsistencyofmaternitycarewerebelievedtobeareasforimprovementwithspecificissuesinmidwiferycareduetotheshortageofmidwives

• Manypeoplewouldliketoseeincreasedpersonalisationandpatient-ledapproachestocare,howeveremphasisetheimportanceofprioritisingpatientsafety

• Communicationandattitudefromstaffinvolvedinmaternitycarewasseenasvariableandinneedofimprovementinordertoadequatelysupportwomengivingbirth

• Peoplesuggestedcommunicationsandoutreachshouldbecarriedouttoraiseawarenessofservicesandcatertodifferinganddiverseneedsinthecommunity


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10.2 Feasibility

10.2.1 Accesstoqualitymidwiferycare

Peopleatthesixhealthandcareforumsbelievedthereisinsufficientaccesstomidwivescurrently,andhadquestionsaboutwhereadditionalstaffproposedwouldbesourcedfromgiventhecurrentshortages.InKingston,somepeoplebelievedtherewasacurrentlackoftrainedmidwivestodeliverthenecessarymaternityservices.ThiswasechoedbysomepeopleinRichmond,whomalsobelievedthatrecruitmentwasachallengewhichwouldincreaseduetotheimpactofBrexit.

Therewasfurtherdiscussionofhowthedifficultiesinrecruitingmidwiveswouldimpactcareprovision.InRichmond,peoplesuggestedthatthechallengesinrecruitingandretainingmidwivescouldreducequality,ashighstaffturnoverandpressuretofillpositionswithlessqualifiedstaffwasbelievedtoimpactpatienttrust.Oneparticipantalsosuggestedthatmidwiveshaveahighworkloadandthiscouldberelievedwiththesupportofalabourassistanttocoachpatientsthroughbirth.Similarly,concernsaboutthemidwives’workloadwerediscussedinWandsworthwhereseveralpeoplebelievedoverworkwasleadingtopooreroutcomesforpatients.Theybelievedthattheemphasisonproductivitywasleadingtomidwivesnotbeingabletoeffectivelyofferemotionalsupporttothewomentheyworkwith.Peoplesuggestedtrainingformidwivesshouldincludehelpingthemtotakecareofthemselvessotheyareabletodeliverthebestqualitycare.

Discussionsatthegrassrootsengagementactivitiesalsoreflectedtheseconcernsaboutthequalityofmidwiferycare.StGeorge’smaternityservicesweredescribedas“appalling”.Forexample,oneindividualdescribedthatwhendeliveringherthirdchild,shewasleftforlongperiodsoftimewithnomidwifeavailableandbelievesshedidnotreceivepropercarefromstaff.Incontrast,severalotherpeopleweremorepositiveabouttheirexperiencesofStGeorge’sandfeltcarewasattentiveandappropriate,suggestingthereisalackofconsistencyaroundthequalityofcare.OthersfeltthattherearetoomanylocummidwivesatKingstonHospitalandthattheydonotseemtocareaboutmothersandtheirchildren.Incontrast,thematernityservicesatEpsomwerepraisedduetogoodstandardsofcarefromthestaff.

Itwasalsohighlightedthatbothhoursandpayformidwivesneedtobereviewedinordertohelpwithstaffretention.

10.3 Desirability

10.3.1 Post-natalcare

PeopleatthesixhealthandcareforumswerebroadlysupportiveoftheSTPproposalsforpre-andpost-natalcare.However,therewerealsosomeconcernsandquestionsregardingthepost-natalcareproposalsandhowthesewouldworkinpractice.

Manypeoplediscussedthekindofsupporttheyfeltwasneededpost-partumandacrossthepregnancy.InRichmond,whilepre-natalandbirthingcarewereagreedtobehighquality,post-natalcaredidnotmatchthisandwasconsideredsurprisinglypoor.Aparticipantbelievedthat


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personalisedcarewasmostimportantafterthebirth,offeringmoreflexibleservicespost-partum.Othersbelievedthattherewasaneedforpost-natalclassesforwomenaftertheyhavegivenbirth.Additionally,atleastoneparticipantfeltmoreshouldbedonetoencouragenewfatherstolearntohelpcareforinfantsandmothers.Theybelievedthiswasparticularlyimportantforvulnerablemotherssuchasthosesufferingfrompost-partumdepression.

SupportformentalhealthacrosspregnancywasalsoanimportantneedpeoplefeltneededtobeaddressedintheSTP.Similarly,inWandsworthpeoplediscussedhowtosupportwomenwhoarestrugglingtocopeparticularlyafterthepregnancy.WhiletheSTPaimsweresupported,theyquestionedhowprofessionalswouldbeabletoidentifythosewhoarenotcopinginpractice,particularlywhenthereisastigmaaboutdisclosinginformation.Peoplebelievedhavingstrongtrustandcommunicationbetweenwomenandtheircareprofessionalswasvitalbefore,duringandafterbirth.

Peopleatthegrassrootsengagementactivitiesalsofeltthatpost-natalsupportwaslacking.Severalmothersfeltthatnotenoughsupportwasgivenaftertheirbabieswereborn.Ofnote,peopledidn’tfeeltheyreceivedenoughsupportaroundfeedingandwereputundertoomuchpressuretobreastfeed.Theemphasisonbreastfeeding(ratherthanfeeding)meantthattheirbabiesendedupbeingdehydrated.SomenotedthattheyweregivenonlyverygenericinformationafterthebirthoftheirchildthroughStGeorge’sHospital,ratherthanadvicethatwasspecifictotheirsituation.

Othersnotedthatthequickturnaroundafterbirthcausessomeconcerntonewmothers.TheyhighlightedaneedinMaternityunitstoaccommodatealongerhospitalstayafterbirth,andthatthisshouldbeconsideredwhennewpremisesandrebuildsareplanned.

Therewasasuggestiontohaveahelplinenumbertocallafterhavingahome-birth.Peopledescribedthatafterahome-birth,theirnotesweretakenawayandtheywerenotgivenanycontactnumbers.

10.3.2 Continuityandconsistencyincare

ManypeopleatthesixhealthandcareforumsagreedwiththeSTPthatmaternityservicesshouldbedelivereddifferently.Specifically,therewereseveralcommentsregardingtheneedforincreasedconsistencyinthecarereceivedaswellasmorecontinuitybeforeandafterbirth.

Afewpeoplediscussedstandardisationofmidwiferytogivegreaterconsistencyinthetreatmentandapproachofmidwifes.InRichmond,peoplesupportedhavingmoreconsistency,includingport-natalvisitstoprovideadditionalsupporttomothers.PeopleinWandsworthbelievedmidwifesshouldhaveasharedmindsetabouthowtheyworkwithwomenintheircareandasimilarpatientledapproachtoofferingchoice.

InKingston,somepeoplehadexperiencedalackofcontinuityincaredeliveredacrossthepregnancyfromcheck-upstopost-natalcare.InWandsworth,aparticipantrecommendedmanagingexpectationsaboutwhattheNHScandeliver,includinglettingwomenknowtheymaynotseethesamemidwifethroughouttheirpregnancyorbirth,tobemoretransparentaboutwhatispossible.


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Theneedforimprovedcontinuityandconsistencyofmaternitycarewasalsodiscussedatthegrassrootsengagementactivities.Peoplefeltverystronglythattheircarewouldbeimprovediftheyhadthesamemidwifethroughouttheirmaternityjourney.Theyfeltthiswouldenablethemtobuildabondbetweenthemotherandmidwife,andwouldhelpthemidwifetopickuponsoftersignsofconcern.

Somepeoplewouldalsoprefertohavemore‘checkpoints’,especiallyforoldermothersorthoselikelytoexperiencecomplicationswiththeirpregnancy.

Severalpeopledescribedhavingveryinconsistentcarefromonepregnancytothenext,orfromdifferentmidwivesordifferenthospitals,orthatthestandardofcarehaddroppedsignificantlyfromfirstpregnanciestomorerecentpregnancieswithinthesamehospital.

10.3.3 Personalisedandsafecare

Acrossseveralofthehealthandcareforums,peoplediscussedtheprovisionofpersonalisationinmaternitycare,howevertherewereconcernsaboutwhatpersonalisationwouldmeaninpractice.Peoplebelieveditwouldbeimportanttobalancethepatientledapproachwithpatientsafety.

Manypeopleweresupportiveofamoreholisticapproachtomaternitycare,allowingwomentohavechoiceinpregnancyandlabourassuggestedintheSTP.AparticipantinKingstonhighlightedtheneedforwomentofeellistenedtoratherthanabureaucratic,‘box-ticking’service.InWandsworth,peoplesupportedtheideaofempoweringwomentohavemorechoiceintheirmaternitycare.However,somequestionedwhattherealchoicesofferedtomothersare,andhowchoicewouldextendbeyondwhichhospitaltogivebirthin.

Manypeopleatthesixhealthandcareforumsagreedthatprovidingaccuratemedicaladvicewasmoreimportantthanpersonalchoiceinsupportingwomen’smaternitycare.InSutton,somepeoplebelievedthatwithoutthenecessaryinformation,allowingpatientstomakematernitycarechoicescouldharmtheirhealthratherthanempowerthem.ThisconcernwassharedinRichmondwherepeoplewereconcernedwomenwouldnotmakesafeorhealthychoiceswithoutadvicefromapractitioner.Inbringingtogethertheseconcerns,peopleinWandsworthbelievedthatwhilechoiceforwomenmustalwaysbebalancedbymedicaldecisionsaboutwhatissafe,wherethereisscopeforchoicethereshouldbeashifttowardswomanledapproaches.

Discussionsaboutpersonalisedmaternitycare,holisticcare,andincreasedchoicealsotookplaceatthegrassrootsengagementactivities.Severalpeopleweresupportiveofhome-birthswhereappropriate,howevertheyemphasisedthatsufficientstaffareneededinordertobothpromoteanddeliverthis.ThededicatedhomebirthteamatKingstonHospitalwaspraisedinparticularasagoodmodelofcare.Incontrast,otherpeoplefeltthatahospitalisbestplacetogivebirth,particularlyforthebirthofafirstchild,andtheyfeltthehospitalneededtobelocal.SomepeopledescribedmaternityservicesatStGeorge’sasreallygood.Onecouplenotedthattheteamwereopen-mindedtotheuseofacupunctureandcomplementarytherapies,whichtheyvalued.

Itwashighlightedthatsometimesmothersdonotgetabirthplanuntilverylate,andthattherewasalackofsupportforwomentodevelopaplanthatwastailoredtowhattheywanted.


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Therewerealsosomeconcernsrelatingtohigh-riskpregnanciesnotbeingidentified,forexamplenotbeingidentifiedashigh-riskfollowingthebirthofaprematurebaby,withverynegativeconsequencesfortwosubsequentpregnancies.

10.3.4 Staffcommunicationandattitudes

Atthegrassrootsengagementactivities,severaladditionalcommentsweremaderegardingtocommunicationfromstaff.Severalpeopledescribedpoorexperiencesofcommunicationwheninhospital,andalackofempathyfromstaffduringananxioustimeformothersandtheirpartners.ThiswasparticularlythecaseatKingstonandCroydonUniversityHospital.Othersdescribedthatalackofclarityincommunicationledtothembeingkeptinhospitallongerthannecessary.

Severalexamplesweregivenofinsensitiveattitudesandtreatment,includingpregnantwomennotbeingtakenseriouslywhentheyhaveconcernsaboutthehealthoftheirbaby,andespeciallyduringandafterstillbirths.Forexample,onepersonnotedthattheyhadtogivebirthinthesamewardasotherwomenhavinglivebirthsandfoundthisverytraumatic(atEpsomHospital).Itwasalsonotedthatnotonlywasthebirthtraumatic,buttherewasnosupportoraftercare.


10.4.1 Inclusiveoutreach

PeopleatthesixhealthandcareforumsmadeseveralsuggestionsregardinghowtheSTPwouldbedeliveredtothecommunity.OnecommontopicwashowoutreachandcommunicationsforserviceswouldbeaddressedintheSTP.

Peoplebelievedthatitwasimportanttopromotethematernityservicesavailableaswellasmakingtheseaccessibletoindividualswithadiverserangeofneeds.SomesawitasimportanttohavematernitycareclosertothehomeandmorepersonalratherthaninalargeGPsurgerywhichisbusywithhighnumbersofpatients.PeopleinSuttonbelievedthatitwasimportanttotailorinformationbasedonaperson’sneeds,suchasGPsandmidwivesgivingmoreinformationtopatients,andgivinginformationsourcesinmultiplelanguages.Severalalsospokeabouttheneedforconsiderationofculturaldifferencesinhowwomenandtheirsupportnetworksprefertoreceivecare.

PeopleinSuttonandKingstonbothhighlightedtheneedtosupportat-riskpatients.Somefeltthattheneedforpersonalisationwaslinkedtooutreachandsafeguarding,asforexample,ifdonewellthiscouldhelptoidentifywomenwhoareexperiencingoratriskofdomesticviolence.Theybelievedthatthemedicalisationofmaternitycareisabarriertosafeguardingoutreachandconversations.

10.4.2 Improvedwaitingareas

PeopleatthegrassrootsengagementactivitiesfeltthatthewaitingareawithintheEmergencyGynaecologyUnit(EGU)needstobeimprovedtoappropriatelyaccommodatethoseattending


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(manyofwhichareexperiencingalossofachild).Somenotedthattherewasalsoalongwaitingtimeandnowhereforchildrentokeepthemselvesoccupied.Itwasfeltthattheareawasnotchildfriendlyandtheroomthatyouhavetowaitinwasverysmallandnotappropriate.


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11. CancerThetopicofcancercarewasnotdiscussedspecificallyatthesixhealthandcareforums,howevertherewasdetaileddiscussionduringthegrassrootsengagementactivities.Thesediscussionsaresummarisedbelow.

11.1 Keymessages

• Peoplefeltmoreworkcouldbedonetoincreaseuptakeofscreening,andtoincreasepreventativecareandguidancetothoseathigherriskofcancer.

• PeopleemphasisedtheneedforearlydiagnosisandsuggestedGPscouldreceiveadditionaltrainingfromhospitalspecialists.

• Deliveringnewsofadiagnosisshouldbedeliveredwithempathyandsensitivity.

• Peoplesuggestedadditionalfollowupsupportcouldbeprovidedafterdiagnosisandaftertreatment,bothbyNHSstaffandthroughsignpostingtosupportinthecommunity.

• Additionalsupportcouldbeprovidedtohelppatientsdealwithsideeffectsandlongtermdamagecausedbycancertreatments.

• TherewasadesireforNHSSWLtosetthe‘goldstandard’forcancerdiagnosis,treatmentandcare,includingbeingproactivelyinvolvedintrialsandnewtreatments.

11.2 Desirability

11.2.1 Screeningandprevention

Therewereafewcommentsaboutscreeningforcancer.Peoplehadpositivefeedbackaboutscreeningprogrammeswhichhadsuccessfullypickeduponearlysignsofcancer.Theyvaluedtheserviceandfeltthatitledtoearlydiagnosisandsuccessfultreatment.

However,itwasnotedthatthereisverypooruptakeofcancerscreeningamongtheGypsyRomaandTravellercommunity.Feedbacksuggestedpeoplefromthiscommunitydonotfeelcomfortablediscussingpersonalissueswithstrangers.Somesuggestedsolutionsincludedtakingpublichealthmessagesthroughchurches(wheremanyofthiscommunityattend),orhavingamobilescreeningunitthatgoestotheirsitestoscreenwomenduringtheday.

Itwasfeltthatthereshouldbemoreemphasisonpreventativecaretothosethatatriskofcertaincancers.Peoplethoughtthisshouldincludeincreasedactivityandweightmanagementandencouragingpatientstomanagetheirhealththroughlifestylechoices.

11.2.2 Diagnosis

Peopleatthegrassrootsengagementactivitiesemphasisedtheimportanceofearlydiagnosis,inordertoavoidtheneedformoreaggressiveformsoftreatmentandtoimproveclinicaloutcomes.


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Overallitwasnotedthatoncediagnosed,theNHSprovidesexcellentcare.However,thereweresomeexperienceswherereceivingthewrongdiagnosishadseriousrepercussions.Forexample,onepersonhadbeendiagnosedwithcancerofthewomb,andhadsurgerywhichinvolvedahysterectomy.Afterthisprocedure,abiopsywastakenanditwasidentifiedthattherewasnocancerpresent.

ThereweresomeconcernsthatGPsmightneedmoresupportandguidanceaboutspottingsymptomsofcancerthatarelessobvious,andtonotdismisssymptomsbecauseapatientisyounger.TherewerealsoconcernsthatGPsmaynotalwaysidentifysymptomsofrecurrence.TherewasasuggestionthatincreasedcommunicationbetweenGPsandspecialistsatthehospitalmighthelp.OneparticipantnotedthatthiswasstartingtohappenatCroydonUniversityHospital.

Peopleemphasisedtheimportanceofthediagnosesbeingdeliveredwithsensitivityandsupport.Severalpeoplesharedexperienceswheretherewasalackofempathy,includingwheretherewasaterminaldiagnosis.Somehadalsoreceivednosignpostingtosourcesofsupport,whileothershadtochasefollow-upreferralsthemselves.

Peoplealsonotedtheimportanceofhavingsomeonewiththemwhenreceivingadiagnosisofcanceraspatientsareunlikelytobeabletotakeineverythingthathasbeensaid.ItwasnotedthatMacmillanplayanimportantroleinthis,accompanyingpeopletotheirappointments.

Itwassuggestedthatmorecouldbedonetoidentifypeopleatriskofrecurringcancerorsecondarycancers.Forindividualsdiagnosedwithmetastaticcancer,peopleemphasisedtheneedforjoininguphealthandsocialcareservicestoprovidebettercare,andworkingtowardsmoreeffectivetreatmentandsymptommanagement.

TherewasaquestionaboutwhattheNHSinSouthWestLondonisdoingtoimplementtherecentMetastaticBreastCancerSpecificationfromTheLondonCancerAlliance.

11.2.3 Supportfollowingdiagnosis

Itwassuggestedthatitwouldbehelpfulifpatientscouldhaveafollowupappointment,possiblywithanurse,shortlyaftertheappointmentwithaconsultantwherethediagnosisisconfirmed,sothattheyhavetimetoabsorbthenewsandthenbeabletoaskfurtherquestions.

Peoplealsofeltthatthereshouldbemorecounsellingservicesforpeopleaffectedbycancer(bothpatientsandcarers),tohelpreducestrainonGPservicesduetopatientsexperiencingstressandanxietyfollowingadiagnosisofcancer.

Itwassuggestedthatmoresupportshouldbegiventopeoplewhoarediagnosedwithterminalcancer,tohelpthemacceptthediagnosisandcopewiththeirlife.Concernswereraisedparticularlyforpeoplewholiveontheirown,whocanfeelveryisolatedfollowingadiagnosis.

Peoplealsofeltthatmoresupportgroupswereneeded,includinginvestmentinsurvivorshipschemes.


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11.2.4 Treatment

Peopleemphasisedtheimportanceofprompttreatmentinimprovingoutcomesforcancer.

Inrelationtowherepatientsreceivetreatment,therewassomesupportfortheideaofusingcommunitysettingsaslongasthiscouldbedonesafely.Therewasasuggestionthatthefirstfewsessionsofchemotherapycouldbedoneinhospitaltowatchforanyadversereactions,followedbysubsequentsessionsinthecommunity.Whilstpeoplevaluedthespecialisttreatmenttheyreceived(forexampleattheRoyalMarsden)manyfeltthattheywouldpreferhavingalloftheirtreatmentinoneplace–ratherthangoingbetweensites(localandspecialist).

Intermsoffollow-upsoonaftertreatment,peoplenotedthattherewasalackofclarityaboutwhowouldprovidefollow-upcare,especiallywhentreatmenttakesplaceatseveraldifferenthospitals.Itwassuggestedthataguidecouldbeproducedsothatpatientswereclearonthefollow-uptheyshouldreceive.Similarly,peoplefeltthattherecouldbemoresignpostingaftertreatmenttoothersourcesofsupportavailabletotheminthecommunity,suchastheMulberryCentreandPaulsCancerSupport.ItwassuggestedthatGPscouldplayaroleininformingpatientsaboutthesesourcesofsupport.

Therewereseveralcommentsabouttheneedtoprovidemoresupporttopatientstohelpthemdealwiththesideeffectsofcancertreatment,andthelonger-termdamageitcancause.Therewasasuggestionthattherecouldbeaphysicalcheck-uponceayearforcancersurvivors,orheartchecksataminimum.SeveralpeoplefeltthatGPsshouldbecallingpeopleinforcancerreviews,andthatitshouldn’tbeuptothepatienttoinitiatethese.PeoplefeltstronglythatthatGPscouldhaveagreaterrolepostdiagnosis,includingfollowingupaftersurgeryregularlyandcheckinginontheirpatient’swellbeing.

Inordertoreducedelaysintreatment,itwassuggestedthattherecouldbeasystemwhereifonetrustorareahasthecapacity,theycouldtakeontreatmentfromanotherhospitalthatwasovercapacity.

ItwasnotedthatWestMiddlesexoperatefreeparkingspacesforthoseattendingappointmentsrelatingtotheircanceranditwassuggestedthatotherhospitalsshoulddothesame,duetothenumberofappointmentscancerpatientshavetoattend.

11.2.5 Supportfollowingtreatment

Itwassuggestedthatmorecouldbedonetosupportpatientsinthetransitionfromreceivingaggressivecancertreatmentstofollow-uptreatmentsaspartoftheirrecovery.PeoplenotedthatthisneednotinvolveadditionalNHSresources,butthatitcouldbeachievedbyjoiningupprimaryandsecondarycarewithsourcesofsupportinthecommunity.

Therewasalsoasuggestionthatphysicaltherapy,lymphedemaservicesandmentaloremotionalsupportcouldallbeprovidedlocallyratherthaninahospital,forexamplethrough–localhealthcentres,GPservicesandwalkincentres.Itwasfeltthatthiswouldhelpwiththetransitionandcouldalsobecombinedwithsupportforpatientstostartself-managingtheirhealthandwellbeingfollowingcancertreatment.


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11.2.6 Qualityofcare/treatment

TherewereseveralcommentsaboutthehighstandardsofcarereceivedattheRoyalMarsdenHospital.However,itwasnotedthatqualityofcarecanvarydependingonthetimeofyearapatientisdiagnosed.Forexample,hospitalschangetheirstaffattheendofJuly,whichcaninterrupttreatment,includingalossofknowledgeaboutthepatientandtheircondition.

TherewasacallfortheNHSinSouthWestLondontoseta“goldstandard”forLondonregardingcancerdiagnosis,treatmentandcare.Itwassuggestedthatthisshouldincludebetterdatacollectiononpatientssothattheycanbefollowedfromearlydiagnosistoendoftreatmentandbeyond,tohelpidentifyandmanageanycasesofmetastaticcancerthatarisefollowinginitialtreatment.

Itwassuggestedthatadditionaltrainingshouldbeprovidedtodistrictnursestosupportpatients’cancercare,tohelpeasetheburdenonGPs.

TherewerealsoconcernsthattheNHSinSouthWestLondonweretryingtopersuadepeopletosupporttheideaofspecialisthospitals,inordertojustifyclosinglocalhospitals.

11.2.7 Newtreatmentsandtrials

Therewereseveralcommentsaboutnewcancertreatmentsandofferingtheopportunityforpatientstotakepartintrials.

Therewasasuggestionthatprimarycancerandmetastaticcancerpatientsshouldbeofferedappropriatetrialsatthepointofdiagnosis.

Itwasnotedthatemergingresearchisshowingtheeffectivenessofa“onceanddone”doseofradiotherapy,andthatshorteremergingtreatmentssuchasthiswouldhelptheNHSmakefurthersavings.

ItwasalsosuggestedthattheOncotypeDXTest(whichcanidentifywhetherapersondiagnosedwithearlybreastcancerwouldbenefitfromchemotherapy)couldbeusedinapilottodeterminewhethercostsofadministeringthistestwouldbeoffsetbycostssavedthroughunnecessarychemotherapytreatmentsthatwouldbeavoided.ItwassuggestedthatinitiatingpilotssuchasthesewouldhelptheNHSinSouthWestLondonraisethebarintermsofpioneeringandhighqualitytreatments.


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12 PlannedCareThetopicofplannedcarewasnotdiscussedatthesixhealthandcareforums,howevertherewassomediscussionduringthegrassrootsengagementactivities.Thesediscussionsaresummarisedbelow.

12.1 Keymessages

• Peoplefeltspecialisthospitalsorelectivecentrescouldproducebetteroutcomesbuttherewereconcernsaboutthefeasibilityofplansandwhethertheywouldleadtonecessarycostsavings.

• Concernswereraisedaboutwhethertherearesufficientstafftodeliverplannedcareeffectivelyandefficiently,andsomethoughtcurrentstaffareoverworkedandoverstretchedwhichimpactsonpatients.

• Peoplearemorepreparedtotravelfornon-urgentelectivecare,butensuringthereisappropriatetransportationwillbeimportant.

• Thereisscopeforcurrentpracticesarounddischargeandaftercaretobeimproved.

• Aproposalthatreducesthewastedtimeasaresultofcancellationsofoperationsandoutpatientappointmentswouldbewelcomed.

• Thereisscopeforimprovinginternalandexternalcommunicationbetweenservices,includingGPs,hospitalsandsocialcareproviders.

12.2 Feasibility

12.2.1 Funding

Peoplebroadlyfeltthatprovidingspecialisthospitalsorelectivecentrescouldproducebetteroutcomesduetohavingspecialistsavailable24hoursaday.However,therewereconcernsaboutthefeasibilityofthisplan,intermsofhowitwouldbefunded,andhowitwouldcontributetocostsavingsacrosstheNHS.Forexample,theEpsomOrthopaedicunitprovedagreatsuccessuntilfinancialissuesthreatenedclosure,andasaresultmanyspecialistsleftandessentialexperiencedsurgeonsarenolongeravailabletotrainanddevelopfutureconsultants.ThepainclinicatKingstonwaspraised,however,staffwereunabletoprovidehomeappointmentsforpatientsduetohowtheyarefundedwhichwasseentobealimitation.

12.2.2 Staffingandresources

Severalconcernswereraisedaboutwhethertherewassufficientstafftodeliverplannedcareeffectivelyandefficiently,andhowthiswouldbeaddressed.Inordertoreducewaitinglistsandincreasepatientturnover,peoplenotedthatmorestaffwouldbeneeded,andacombinationof


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differentspecialismsisnecessarytotreatpatientseffectively.Itwasalsonotedthatadministrationservicesneedtobeimprovedtosupportmoreefficientdeliveryandlinkhospitalstogether.

Peoplesharedconcernsthathospitalstaffarecurrentlyoverworkedandoverstretched,leadingtonegativeexperiencesforpatientsincludingsomefeelingthattheywerebeingtreatedbyjuniorstafflackinginthenecessaryexperience.

Therewasasuggestionthatnewspecialiststaffmembersshouldbeemployedratherthanrelyingonlocums,sincelocumsareoftenmoreexpensive.

Therewasgeneralconsensusaroundtheneedtopaynursingstaffmore,inordertoimprovepatientcare.

Therewasaconcernthatequipmentisnotalwaysmanagedinthemostefficientway,forexampleorderingoperatingequipmentasneededratherthanhavingasupplyavailablemeansoperationsaredelayedduetolackofequipment.Somefeltthathavingspecialistelectivehospitalswouldhelpwithmanagingresourcesasexpensivespecialistequipmentcouldbeconcentratedononehospital.

12.3 Desirability

12.3.1 Accessibilityandtransport

Peoplefeltthatwhenelectivesurgeryisessentialbutnoturgent,theywouldbewillingtotravelfurtherdistancestoreceivespecialistcare.However,theyfeltthathavingadedicatedambulanceservicetohelpwithtransportationwouldhelpprovideabetterexperienceforpatientsbutalsohelptomakebedsavailablemorequicklybyenablingthemtotravelhomestraightafterbeingdischarged.

Somehighlightedthatthereisaneedtoensurethatthecorrecttransportationisallocatedwhenbookedforindividualstoattendplannedappointmentsathospital.Asageneralrule,seatedambulancesarebookedhoweverMEsuffersattimesstruggletositforlongperiodsoftime.

AlthoughKingstonHospitalisveryaccessibleintermsofpublictransport,someindividualsneedtodriveandtheythoughtthecarparkingchargesshouldbefreeoratareducecost,toaccommodatethis.

12.3.2 Aftercareanddischarge

Somepeoplewereconcernedaboutthequalityofaftercarefollowinganelectiveoperationandfeltthisneedstobeimproved.Forexample,thereweresomeconcernsaboutinfectioncontrolprotocols,andalsoexperienceswherepainpost-operationwasnotmanagedwellenough.

Peoplewerealsoconcernedabouttheirexperiencesofsupportfollowingdischarge.Somesaidtherewasnotenoughinformationprovidedonenablementcareandsupportthatwasavailabletothem.Somefoundthatphysiotherapistswerenotavailablesoonenoughafteranoperationforthetherapytobeeffective,andothersfoundthatthephysiotherapytheyreceivedwasveryminimal.


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Theyfeltthatmorephysiotherapywouldbeneededformorevulnerablepatientssuchasthosewhoareelderly.

Othershadexperiencesofbeingdischargedtooquickly,whiletheywerestillfeelingtheeffectsofageneralanaesthetic.

Forthoseinpainfollowinganoperation,somefeltclinicsshouldbemadeavailableintheircommunitytohelpwithpainmanagementiftheyareunabletogetaGPappointment.

Therewasasuggestionthatmoreshouldbedonetosupportpeopletoremainindependentwhentheyarereceivinginpatientrehabilitation,forexamplebeingabletowashanddressthemselveswheneverpossibleratherthansomeoneelsedoingsoforthem.

12.3.3 Appointmentsandwaitinglists

Severalpeoplesharedexperiencesofoperationsandfollow-upappointmentsbeingcancelled,orhavinglongwaitinglists.

Inrelationtocancelledoperations,thissometimeshappenedatveryshortnotice,suchasthedaybefore,causingsignificantdisruptiontopeople’sliveswhentheyhavemadearrangementsbasedontheappointment.

Outpatientappointmentswerealsocancelledatshortnotice,whileothershadlongwaitinglists,forexamplewaitingfivetosixmonthsforanoutpatientappointment.Whenanoutpatientappointmentwasmade,somepeoplefoundtheyhadtowaitforseveralhourspastthedesignatedappointmenttimebeforetheywereactuallyseen.

Similarly,somewereconcernedthatwaitingtimesfortestresultsweretoolong,causinganxietyforsomepatients.

Severalpeopleatthegrassrootsengagementactivitiessharedexperiencesoflongwaitingtimesoncetheyarrivedathospitalforascheduledappointmentandexpressedfrustrationatalackofcommunicationaboutanydelaysontheirarrival.Somealsohadexperiencesofappointmentsbeingchangedatshortnoticewithoutexplanation,orcancelledwithoutanewappointmentbeingissued.Therewasasuggestionthattheintroductionofnew“missedappointmentfees”wasunfairconsideringthecommonexperienceoflongwaitingtimesorcancelledappointments.


12.4.1 Communicationbetweenandwithinservices

Somepeopleemphasisedthatthereneedstobebettercommunicationbetweenservicesthatareinvolvedinanindividual’scare,forexample,patientshadexperiencedreferrallettersbeinglostbetweenservices.Inoneexample,apatienthadtostayinhospitalmuchlongerbecauseofalackofcommunicationwithsocialcarethatmeanttherewasnosupportavailabletochangetheirpressuresocksinthecommunity.


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Internalcommunicationwithinservicescouldalsobeimproved,forexamplepatientshadexperienceddifferentnursescomingtotakebloodpressurereadingsinquicksuccession,whileonedeafpatientdidnothavethesupportofaninterpreterbecausestaffkeptforgettingtoarrangeone.

TherewasalotofpraiseforSWLEOChoweversomepeoplefeltconcernedthatthepre-operationassessmentquestionnairewasinsensitiveandveryimpersonal.

Interpretationservicesarefoundtobebetterinhospitalsettingsthaninprimarycare.However,thereweresuggestionsthatwifishouldbeprovidedinallsettingssodeafpatientscanuseonlineinterpretingserviceswhenthereisnointerpreteravailableforappointments;andthatmorehealthsettingsshouldsignuptothe‘InterpreterNow’systemasabackupincaseinterpretersareunavailable.

13. NextstepsTheSustainabilityandTransformationPlaninsouthwestLondoniscurrentlyundergoingarefreshinordertoensurethattheworkmovestowardslocalplanninganddeliverytokeeppeopleoutofhospitalandensurethatdeliveryiscentredaroundtheLocalTransformationBoards(LTB).ItisexpectedthatarefreshedplanwillbepublishedinNovember2017.Alloftheoutputsfromtheengagementactivities(healthandcareforumsandgrassrootsengagementactivities)willfeedintothisrefresh.Inaddition,theareafeedbackwillbetakentoeachLocalTransformationBoardfortheirconsideration.Itwillbesavedasarepositoryofinformationwhichcanbedrawnuponwhencommunityintelligenceisneededaboutalocalservice.Thegrassrootsengagementprogrammehascontinuedinto2017/18–andthefeedbackwillbeconsideredataLTBlevel.


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Client NHSSWL

Company OPMGroup

Title PublicengagementontheSouthWestLondonSustainabilityandTransformationPlan

Subtitle Byworkstreamtheme

Dates lastpublished05/09/2017lastrevised30/11/2017

Status Draft

Classification RestrictedExternal

ProjectCode 10799

Author(s) BethanPeachPerlaRembiszewskiAnnaBeckett

QualityAssuranceby AnnaBeckett

Mainpointofcontact AnnaBeckett

Telephone 02072397800

Email [email protected]

PublicengagementontheSustainabilityandTransformationPlanByLocalTransformationBoard(LTB)area

05 September 2017

Public engagement on the Sustainability and Transformation Plan – By Local Transformation Board (LTB) area

2

TableofContentsTable of Contents ..................................................................................................... 2

1. Executive Summary ........................................................................................ 3

2. Introduction ..................................................................................................... 7

2.1 Background ................................................................................................. 7

2.2 Methodology ................................................................................................ 8

3. Findings by borough .................................................................................... 11

3.1 Croydon ..................................................................................................... 11

3.2 Kingston and Richmond ............................................................................ 20

3.3 Merton and Wandsworth ........................................................................... 37

3.4 Sutton ........................................................................................................ 54

4. Next steps ...................................................................................................... 61


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1. ExecutiveSummaryTheNHSinsouthwestLondon,workingwithlocalcouncils,isintheprocessofdevelopingalong-termplanforlocalhealthservices,calledtheFiveYearForwardPlan,oraSustainabilityandTransformationPlan(STP).ThisworkisbeingcarriedoutbysixlocalClinicalCommissioningGroups(CCGs),localauthorities,fourhospitalstrusts,clinicians,communityhealthservicesandmentalhealthtrustsandpatientsandmembersofthepublic.ThesixsouthwestLondonboroughsareCroydon,Kingston,Merton,Richmond,SuttonandWandsworth.

SinceMarch2016,theNHShasbeenundertakingagrassrootsoutreachengagementprogramme,fundedbyNHSEngland,toreachouttoseldomheardcommunities.TheNHSprovidedfundingtolocalgrassrootsorganisationstoruneventsfortheirpopulations,tolistentoviewsonlocalhealthissues.Thefundingwasallocatedvialocalhealthwatchorganisationsthatpromotedtheopportunity,evaluatedthebidsandadministeredthefunding.Inaddition,OPMGroupwascommissionedtodesign,facilitateandreportonsixopenaccesshealthandcareforums,oneineachofthesixsouthwestLondonBoroughs.

Thisreportprovidesasummaryofthefeedbackfromtheallthisengagementactivity,organisedbyLocalTransformationBoardArea.IthasbeenindependentlycompiledbyOPMGroup.

Duetothewide-reachingnatureoftheengagement,noteveryissuewascoveredineveryevent/activity.Therefore,comparisonsbetweenareasshouldbetreatedwithcaution.Tounderstandifthedifferenceshighlightedbeloware‘real’oraresultofwhoparticipated,amorefocussedandstructuredexercisewouldbenecessary.

1.1.1. Sevendayacuteservices

PeopleinallLocalTransformationBoardAreashadmixedviewsabouttheabilitytoimplementanddeliverthequalityofhealthcareservicesanticipatedintheplan.TheybelievedthatlimitedGPaccesswaslikelytobeasignificantbarriertodeliveringtheproposalsforsevendayacuteservicesandthatmanypeopleattendA&Eastheyareunabletoaccessanalternative.

InSutton,peoplerecommendedinsteadofaimingforbehaviourchange,theserviceofferingshouldbechangedsothatthatGPsandsocialcareserviceswereprovidedalongsideA&Esothatpeoplecanbedirectedeasilytotheappropriateservice.

PeopleinKingstonandRichmondrequestedfurtherinformationonthecriteriaforchoosingwhichA&Esitewouldclose,andpeopleinallareasexpressedconcernthatanyclosurewouldincreasepressureontheremainingservices.

Peopleinallareasalsocommentedonthecreationofmorespecialistcentres,withsomesupportingthisproposal,butothersexpressingconcernabouttraveltimesandtheimpactthiscouldhaveonpatientoutcomes.InKingstonandRichmond,somethoughtthatcentralisingservicescontradictedplanstotakecareclosertohome.TheyalsoraisedquestionsabouthowdecisionsmadeinSWLondonwouldbecoordinatedwithotherSTPs.


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PeopleinSuttonemphasisedthestrengthsofStHelier’shospital,whilepeopleinCroydonnotedtheimprovementstheyhadseeninCroydonUniversityHospital.

PeopleinallareasalsofeltthatitwasunclearthatNHS111couldreduceA&Euse,aspeoplecommentedthattheywereoftendirectedtoA&EbytheNHS111service.AllareasagreedmoreneedstobedonetoeducatepeopleaboutalternativestoA&E.InWandsworthandMerton,itwassuggestedthatpatientsshouldbechargedforservicemisuse.

1.1.2. Morecareclosertohome

PeopleinallLocalTransformationBoardAreassupportedtheideasaboutmorecareclosertohome,butexpresseduncertaintyastohowitcouldbedeliveredinpractice.InKingstonandRichmondpeoplewereparticularlyconcernedabouthowtohireandtrainstafftodeliverthisleveloflocalcare.

Peopleinallareascommentedontheproposalsforanincreasedroleofpharmacists.PeopleinCroydonandSuttonfeltthattheyneededtobebettertrainedandgavespecificexamplesofmistakespharmacistshavemade,underminingconfidenceforpharmaciststodeliverlocalcare.InKingstonandRichmondandMertonandWandsworth,peopleweremoreconfidentinpharmacists.However,peopleinallareascommentedthatpharmacistswouldneedtoadapttheirservices,suggestingspecialroomstoensureconfidentiality,andidentifiedaneedtosupportpharmaciststoimprovetheircommunicationskills.

PeopleinallareascommentedontheissuesaccessingGPappointments,andmanycommentedonthedifficultytomadesame-dayappointments.Itwasalsomentionedinallareasthatreceptionstaffactingas‘gate-keepers’toappointmentsmadepatientsfeeluncomfortable.PeoplecommentedthatGPs,hospitalstaffandnursesneededmoretrainingtocommunicatewithpatientswithadditionalneeds,suchaslearningdisabilities,autismandmentalhealthissues.

PeopleinallareasalsocommentedthatGPsoftenlackinformationtosignposttoalternativeservicesandallcommentedthatGPsweretooquicktoprescribemedicationinthecaseofmentalhealthissues,ratherthanconsideringalternativetreatments.

1.1.3. Preventionandearlyintervention

PeopleacrossallLocalTransformationBoardareasweresupportiveofplansforprevention,butfeltthattheywouldbechallengingtodeliver.Peopleexpressedconcernsaboutwhethertherewouldbethebudgettodeliverbothtreatmentservicesandprevention.PeopleinCroydonandSuttonexpressedconcernsthattheproposalsmaynotdelivertheanticipatedbenefitsandothersfelttheywouldtakealongtimetorealise.

InKingstonandRichmondpeopleexpressedsupportfortheuseoftechnologysuchassmartphones,solongasservicesremainforthosewhoareuncomfortableusingthesetechnologies.Otherareasmentionedtheuseoftechnologybuthadmixedviews.

Peopleinallareaswantedmoreinformationabouthowlocalityteamswillworkinpractice.InKingstonandRichmondpeoplecommentedontheneedtoworkwithfriends,familyandcommunities,aswellasthevoluntarysectortodelivertheproposalsaroundprevention.InMerton


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andWandsworthpeopleexpressedconcernsthatthisproposalcouldleadtoanoverrelianceonthevoluntarysector.

1.1.4. Mentalhealth

Peopleallsupportedmoreintegratedmentalhealthservices,suggestingthatphysicalandmentalhealthshouldbebetterlinked.PeopleagreedthatA&Eshouldnotbethefirstportofcallforapatientsufferingfromamentalhealthcrisis,butexpressedconcernsaboutwhetherGPsaresufficientlyknowledgeabletosupportmentalhealthpatients.InMertonsomehighlightedtheimportanceofearlyinterventionsothattheneedforcrisiscarewasreduced.

InCroydonandSutton,peoplefeltthattheyarenotgettingenoughfundingformentalhealthservicesandinSuttontheywereparticularlyconcernedgivenrecentclosuresandthelackofalocalcrisiscentre.

Overalltherewasconcernaboutcurrentmentalhealthservices,andwhilepeopleinRichmondfelttheirservicesweregood,allotherareasfeltsignificantimprovementswereneeded.Peopleraisedspecificconcernsaboutthelongwaitingtimesforreferrals,theneedstoeducatestaffandpatientstoovercomethestigmaattachedtomentalhealthandthedeliveryofChildrenandAdolescentMentalHealthServices.InMertonandWandsworth,peoplecommentedonthedifficultyintransferringfromCAMHStoadultmentalhealthservices.

1.1.5. LearningDisabilities

Therewaslittlevariationacrosstheareasonviewssurroundinglearningdisabilityservices.Inallareaspeoplefeltthatservicesproviders,includingnursesandreceptionstaff,neededmoretraininginhowtodelivercaretopatientswithlearningdisabilitiesandautism.Therewasemphasisontailoringservicestoindividualneeds,withapatient-centredapproachasopposedtotreatingeachconditionseparately.Peoplefeltthatmoreshouldbedonetopromotetheannualhealthcheckforchildrenwithlearningdisabilitiesasmanywereunawareofit.

1.1.6. Children’sservices

Peopleagreedwiththeproposalstoreduceparent’srelianceonA&E,butallthoughtthattherewasaneedtoprovidemoredetailaboutviablealternativesandagreedthatmoreflexibleaccesstoGPswasrequired.InKingstonandRichmond,peopleemphasisedtheimportanceofsupportingparentswhomightfeelisolatedastheyfeltthesewouldbemostlikelytobenervousandthereforeover-useservices.

InCroydon,peoplenotedthathighstaffturnover(forexampleinoccupationaltherapy)couldbedetrimentaltochildrenusingtheseservices.ThiswasechoedacrosstheotherLocalTransformationBoardAreaswherepeoplefeltthatcontinuityincarewasparticularlyimportantforchildrenwithlearningdisabilities.

InCroydonpeoplecommentedthattherewasmorescopetoencouragehealthierlifestylesforchildrenbothinandoutofschool.


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1.1.7. Maternityservices

InKingstonandRichmond,peoplewerepositiveaboutthepre-natalservices.Despitethis,allLocalTransformationBoardAreasagreedthatchangestomaternityserviceswererequired.

InMertonandWandsworth,peoplesaidthattheyagreewiththeproposedinclusionofperinatalandmentalhealthservicesintheplan,andcommentedthatthereshouldbemoresupportforpatientswhohaveexperiencemiscarriage.

Mostareascommentedonthenationalshortageofmidwivesandthatthereshouldbebettertrainingtoensureconsistencyincare.

Peopleinallareassupportedtheideaforamorepersonalisedmaternityservice,butwantedtoensurethatsafetywasmaintainedasapriority.KingstonandRichmondandMertonandWandsworthwereparticularlypositiveaboutofferingchoicewhereitcouldbedelivered(althoughpeopleinMertonfelttheplanswerenotambitious).Incontrast,inSuttontherewassomeconcernthatpeoplemightnotbeequippedtomakegoodchoices.

1.1.8. Cancerservices

InCroydonpeoplecommentedthatGPsneededmoresupporttospotcancerearlier.PeopleinCroydonalsospecifiedthatthereshouldbemoreaccesstodrugtrialsandtheyfeltthatdatacollectioncouldbeimproved.

InKingstonandRichmond,peoplecommentedthatthereshouldbeincreasedsupportforcancerpatientsfollowingdiagnosisandtreatmentandthatGPsshouldbemoreinvolvedwithtreatment,followingupwithpatientswhiletreatmentisunderway.

Peopleacrossallareascommentedthatthecommunicationofacancerdiagnosisshouldbedeliveredwithmoresensitivity.

1.1.9. PlannedCare

InKingstonandRichmondpeoplediscussedadequatetransportoptionsforplannedcare.InMertonandWandsworthfewpeoplementionedplannedcareothertocommentonthelengthofwaitinglists.InSutton,peoplecommentedonfollow-upcaresuchasphysiotherapywhichtheythoughtcouldbeimproved.


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2. Introduction

2.1 BackgroundWhyisaforwardplanbeingdeveloped?

TheNHSinsouthwestLondon,workingwithlocalcouncils,isintheprocessofdevelopingalong-termplanforlocalhealthservices,calledtheFiveYearForwardPlan,oraSustainabilityandTransformationPlan(STP)1.Thedraftplanisavailablehere.

ThisworkisbeingcarriedoutbysixlocalClinicalCommissioningGroups(CCGs),localauthorities,fourhospitalstrusts,clinicians,communityhealthservicesandmentalhealthtrustsandpatientsandmembersofthepublic.Itcoversallaspectsoflocalhealthservicesincludinghospitals,primarycare,mentalhealthandcommunityservices.

ThelocalNHShasidentifiedfourkeychallenges–money,workforce,estatesandconsistentqualityofcare–whichtheFiveYearForwardPlanwillaimtoaddressbysettingoutplansto:

• usemoneyandstaffdifferentlytobuildservicesaroundtheneedsofpatients

• investinmoreservicesinlocalcommunitiestoimproveoutcomesforpatients,includingpreventativecare

• investinestates(buildings)tomakethemfitforpurpose

• trytobringallservicesuptothestandardofthebest.

Whathasbeendonesofar?

AnoutlinestrategywaspublishedinJune2014,settingoutaplanforthelocalNHSanddetailingthestandardsofcarethatpeopleinsouthwestLondonshouldexpect.

AnissuespaperwaspublishedinJune2015settingoutthechallengesforlocalservicesandinitialideasabouthowtotacklethem.InSeptember2015,TheNHScommissionedaseriesofdeliberativeeventstogaintheviewsofmembersofthepublicandlocalstakeholdersontheIssuesPaper(theeventsweredeliveredbyOPMGroup;seethereporthere).

SinceMarch2016,theNHShasbeenundertakingagrassrootsoutreachengagementprogramme,fundedbyNHSEngland,toreachouttoseldomheardcommunities.TheNHSprovidedfundingtolocalgrassrootsorganisationstoruneventsfortheirpopulations,tolistentoviewsonlocalhealthissues.Thefundingwasallocatedvialocalhealthwatchorganisationsthatpromotedtheopportunity,evaluatedthebidsandadministeredthefunding.Inaddition,OPMGroupwas

1AllNHSregionsarerequiredtodevelopaSustainabilityandTransformationPlan(STP).


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commissionedtodesign,facilitateandreportonsixopenaccesshealthandcareforums,oneineachofthesixsouthwestLondonBoroughs.

2.2 Methodology

2.2.1 Healthandcareforums

PeopleforthehealthandcareforumswererecruitedbyNHSSouthWestLondon.Theywereinvitedtoattendeventsvia:

• emailstothosewhohadattendedpreviousevents

• engagementwithlocalcommunityandvoluntarygroupsandlocalHealthwatchgroups

• advertisingvialocalpress,radioandsocialmedia.

Eacheventhadcapacityforupto100people.

Thesixeventswereheldintheeveningsandlasted3hours(6-9pm).Theformatoftheeventsencouragedanin-depthdialoguewithpeopleaboutthekeyissuesandquestionsraisedinthedraftFiveYearForwardPlan.Peoplehadtheopportunitytojointworoundsoftablediscussions,witheachroundincludingatleast6tables,eachtablefocusingononeof6topics.Mosteventshad6tablesforeachroundofdiscussion,butforsomeroundstherewerefewertables(ifnopeoplechoseaparticulartopic),andforothersthereweretwotablesforthemorepopulartopics(sothatpeoplecouldfocusonthetopicoftheirchoice).

EacheventwasindependentlyrunbyOPMGroup’sfacilitationteam,madeupofoneleadfacilitatorandtablefacilitatorstomanagethetablediscussions.

NHSrepresentatives(includingCCGChiefOfficersandChairs,hospitalmedicaldirectorsandchiefexecutivesandotherNHSstaff)attendedtheevents,tosetthescene,presentthedraftFiveYearForwardPlanandanswerquestionsfrompeople.Ateachevent,thelocalNHSrepresentatives:

• ProvidedbackgroundinformationontheFiveYearForwardPlan,explainingwhatitis

• OutlinedthechallengesfacinghealthcareinsouthwestLondon

• DescribedhowtheFiveYearForwardPlanisproposingtoaddressthesechallenges

Thisinformationformedthebasisforthetablediscussionsamongstpeople,toelicittheirresponsestoandconcernsaroundthePlan.

2.2.2 Grassrootsengagementactivities

Theaimofthegrassrootsengagementactivitieswastodevelopmeaningfulconversationswithseldomheardcommunities.NHSSouthWestLondonrecognisedthatthesecommunitieswoulddifferacrossboroughs,however,ingeneraltheyfocusedonthosepeoplefromgroupswithprotectedcharacteristics,asdefinedbytheEqualityAct(2010).TheyalsoenabledlocalHealthwatchorganisationstosuggestotherlocalcommunitiesthatwerehardertoreachineachborough.


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Tosuccessfullydeliverthisprogramme,NHSSouthWestLondonworkedcollaborativelywithlocalHealthwatchorganisationsandgrassrootsgroups.EachHealthwatchorganisationwasinvitedtomanageapotoffundingthatlocalgrassrootsgroupscouldapplyfortorunevents/activitiesenjoyabletotheirpopulation.EachHealthwatchwasabletosettheirownapplicationguidelineswitharequestthatgroupsapplyingforthefundingshouldbefromseldomheardgroupsandtherewouldbeanopportunityateacheventforNHSstafftoattendandspeakwithindividuals.

Healthwatchorganisationsusedtheirconnectionsandcommunicationchannelstopromotethisopportunitytolocalgroups,particularlythosegroupswithprotectedcharacteristics/seldomheardvoices.Theyadvertisedtheopportunitythroughtheirwebsitesandviasocialmedia.SomeHealthwatchesusedamoretargetedapproachbymakingdirectcontactwiththoseorganisationsthattheythoughtwouldbenefitfromthefunding.EachorganisationwasabletoapplyforthefundingandHealthwatchwouldchecktheapplicationandthenlettheorganisationknowiftheyweresuccessfulinreceivingthefunding.

Oncethisprocesswascompleted,theinformationwaspassedontotheprogrammeteamforcontacttobemadewiththelocalorganisation;congratulatingthemonbeingsuccessfulintheapplicationprocess.Arrangementswerethenmadeforattendanceattheevent,includingdiscussionsaroundwhatthemostappropriatewaytospeaktopeopleontheday.

Ateachsession,theprogrammeteam,localCCGandHealthwatchwereinvitedtoattend.Wheresessionshadaspecificfocustowardsaworkstream,theassistantdirectors,orotherworkstreampeople,werealsoinvitedtoattendorsendquestionsthatwouldberelevantfortheengagementteamtoask–thishelpedtoensurethattheconversationswererelevanttolocalprioritieswithineachareaoftheSTP.

TheprogrammeandlocalCCGattendedeachsessionandspoketoattendeesabouttheirexperienceoflocalservices.Duringtheevents,theengagementteamhadadedicatedslot/opportunitytodiscusslocalhealthissuesandtolistentotheviewsofthoseparticipating.Thiswasthroughavarietyofmechanismssuchasone-to-oneconversations,focusgroupsorgroupdiscussions.Thequestionsaskedateachsessionweretailoredtotheaudience.

2.2.3 People

ThetablebelowsummarisesthenumberofpeoplewhoattendedeachoftheeventsandengagementactivitiesacrossthesixLondonBoroughs.

Borough Date Numberofpeople


7thFebruary,2017 33

Croydongrassrootsengagementevents




10


14thMarch,2017 44






8thFebruary2017 35


2ndMarch2017 55






Suttongrassrootsengagementactivities


2.2.4 Aboutthereport

Thisreportprovidesasummaryofthefeedbackfromthesixhealthandcareforumsandthegrassrootsengagementactivities,capturingthefeedbackbyLocalTransformationBoardarea.Itincludesanexecutivesummarywhichpullsoutsimilaritiesanddifferencesfromacrosstheareas;asummarytableperLTBwhichpullsoutkeythemesandthenamoredetailedanalysisofthefeedbackperworkstream.

Aseparatereporthasbeenproducedorganisingtheinformationbyeachworkstream(acrossboroughs).


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3. Findingsbyborough

3.1 Croydon



7thFebruary,2017 33

GrassrootsEngagementEvents


3.1.1 Overarchingthemes

ManypeopleagreedthatthereisaneedforchangeintheNHSnationally.Severalpeoplefeltlocalcircumstancesexacerbateaneedforchangestothehealthservice(e.g.Croydonhasalargeanddiversepopulation;theHomeOfficenearCroydonmeansmanyasylumseekersmovetotheborough).

SomepeoplefelttheplanslaidoutintheSTPhadbeendiscussedbeforeandhospitalclosureswereoffthetable.SomefeltthattheSTPwasnotrealisticinthecontextoftheresourcesavailableandthattherewasnotenoughdetailintheplan.

Sevendayacuteservices

GPaccesswasasignificantissue,impactingontheperceivedfeasibilityofchanges,andpotentiallydrivingperceivedmisuseofA&E.

Therewerealsoconcernsaboutwhethertheexistingcapacityofacuteserviceswassufficient.

Althoughsomecouldseeacaseforfewer,morespecialistcentres,othershadconcernsabouttheimplicationsfortraveltimes.

Morecareclosertohome

Peopleweregenerallysupportiveoftheplantohavemorecareclosertohome,butthereweredifferentopinionsabouthowitcouldworkinpractice.

SomeconcernsaboutwhetherNHS111wouldmeetexpectationsandwhethernurses/pharmacistswouldbesuitablealternativestoGPs.

Somespecificconcernsaboutprivacyofapharmacistconsultation,andspecificexamplesofmistakesmadewhichwouldunderminetheirconfidenceinpharmacists.

Somequestionsaboutthefeasibilityofextendingoutofhospitalservices,whentherearealreadyinsufficientstafftocoverthecurrentprovision(especiallyGPs).

ExamplesofdifficultiesgettingappointmentsandwiththeaccessibilityofGPservices.Also,frustrationwithreceptionistsactingasgate-keepers.


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Identifiedroomforimprovementascurrentlyfeelpost-diagnosissupportandsignpostingcanbelacking.

Preventionandearlyintervention

Mostpeoplethoughttherewerechallengestoachievingtheplansforpreventionandearlyintervention.

Specifically,theyfeltitwouldbeunder-resourcedandchangeswouldnotleadtotheanticipatedbenefitsandsomefelttherewasariskthiscouldleadtoprivatisationofhealthservices.Althoughsomefeltthat‘fun’activitiescouldleadtobehaviourchange,othersthoughtthiswouldbedifficult.

Peoplewereunclearabouthowlocalityteamswouldwork,andwereconcernedthatusingbudgetstosupportat-riskpatientscouldcompromisecareforothers.

Someidentifiedpreventativeorearlyinterventionopportunitiesmissedduetolongwaitinglistscurrently.

Mentalhealth

Peoplewanttoknowwhichservicescouldbediscontinuedandhow,ifatall,physicalandmentalhealthwillbelinked.

PerceptionthatthereisnotsufficientcapacityinIAPTcurrentlywhichleadstolongwaitingtimes.

Thereisaneedforservicestobebettertailoredtotheneedsofminorityorvulnerablepatients.

Peoplewanttobetreatedwithmorecompassionasinpatients,andwereconcernedthatreductionsincommunityserviceswouldleadtomorecasesendingupinhospital.

Experiencesofcommunityhubsafterdischargearemixed–somepreferthem,buttraveltimescanmakeregularvisitsdifficult.

SomefeltthatCroydonisnotgettinga‘fairshare’offundingforMHservices.

TherewereparticularconcernsaboutCAMHS,andmentalhealtheducationinschools.

LearningDisabilities

PeopleraisedparticularissuesincludingtheneedforGPstoensureallstaffareawarewhichpatientshavelearningdisabilities.Additionally,theywantedGPstohavemoreknowledgeofLDandrelatedissues.

Children’sservices

TheNHSneedstopromoteawarenessandsignpostingtoavailableservices.

However,ifnoGPisavailable,mostbelievedparentswouldcontinuetouseA&Easanalternative,ratherthanacommunitybasedservice.

Highstaffturnover(forexampleinoccupationaltherapy)wasseentohaveadetrimentalimpactonchildrenusingtheseservices.


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Morescopetoencouragechildrentohavehealthierlifestylesbothinandoutofschool.

Maternityservices

Peoplevaluedhavingalocalhospitaltogivebirthin.

Cancerservices

GPsneedmoresupporttospotcancerearlier,andwaitinglistsneedtobereduced.

Peoplewouldlikemoreaccesstodrugtrials,andfeltdatacollectioncouldbeimproved.

Mostwereopentoideaoftreatmentincommunitysettings,aslongasitwassafe.

3.1.2 Sevendayacuteservices

Overall,peoplefeltthereweremanychallengestoachievingtheproposedplansforsevendayacuteservicesintheSTP.Forexample,GPaccesswasasignificantissueformanypeople.PeoplewereconcernedthataccesstoaGPcanbepatchydependingonthepracticeyouattendandfeltthatinconsistentaccesstoGPscanincreasedemandforA&E.Atthegrassrootsengagementevents,peoplecommentedthatatCroydonHospitalthey‘neverservepeopleontime.’MostunderstoodthataccesstoGPsisstrainedbecauseofdifficultiesinrecruitingsufficientnumbersofclinicians,andthoughtthisshouldbeaddressed.

Somepeoplefromthehealthandcareforumwereconcernedaboutacurrentlackofcapacityinacuteservices,andthoughtthiscouldbeexacerbatedbyhavingfeweracuteservices.ThiswasechoedbypeopleatthegrassrootsengagementeventswhocommentedonthelongwaitingtimesinA&E,whichputsomepeopleoffgoingtoA&Eespeciallyatpeaktimes.Somepeoplealsofeltthatshorttraveltimeswereimportant,andwereworriedabouttravellingfurtheriftherewerefeweracuteservices.However,othersthoughttheremightbebettercareiftherewerefewersites,forexampleiftherewerehubstotriagenon-urgentcareandensurepeoplegototherightplace.Atgrassrootsengagementevents,peopleraisedconcernsaboutwalk-incentresbeingtoodrivenbyefficiencyandseeingpatientsinfiveminuteslots,ratherthanbypatientneeds.Somehealthandcareforumpeoplelikedtheideathatpatientsmightreceiveelectivesurgeryandrehabilitationquickerifittookplaceoutsideofanacuteservice.

TherewasabeliefthatCroydonUniversityHospitalhasimprovedandisnowsomewheretheywouldbehappytogo(ithadnotbeen,historically),althoughathehealthandcareforumtheydidnotexplainwhy.However,atthegrassrootsengagementevents,somepeoplecommentedonareasforimprovement,suchasthecurrentlackofsignageandcommunicationissuesatA&E,wherepeoplehavebeenleftfeelinganxiousandfrustratedwhentheyarenotgivenregularupdates.Afewpeopleatthegrassrootsengagementeventsalsomentionedcommunicationissueswithinthehospital,forexampleduetoalackoflearningdisabilityspecialistnursesorpeersupportavailableforyoungpeople,whicharebothneededtocaterservicesandcommunicationaccordingly.


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SeveralpeopleatthehealthandcareforumthoughtcommunicationfromtheNHSiscriticaltoensuringpeoplegototheappropriateplaceforcare.AtthegrassrootsengagementeventsonlyaminorityofpeoplehadheardofNHS111(butsomewhohadusedthisservicehadpositivereviews).Afewpeoplecommentedthattheywouldnotknowwheretogoinamentalhealthcrisis,withafewgivingexamplesofbeingrejectedatA&Eandhavingnowhereelsetoturnto.TheysuggestedthattherebementalhealthnursespresentatA&E.FormoreinformationaboutmentalhealthservicesinCroydonpleaseseesection3.1.5.

Peoplethoughtchangingbehaviouraboutwheretogowouldonlyworkifservicelevelswerethesameinnon-A&EsettingsastheyareinA&E(i.e.beingseenwithin4hours).TherewasaconcernaboutperceivedmisuseofA&Ecurrently,andconfusioninthegrassrootseventsaboutthedifferencebetweenA&EandUrgentCare.AcrosstheeventsinCroydon,somepeoplethoughtculturaldifferencesmeantmigrantspreferhospitalsovernon-A&Ecare,andsomethoughtpeoplewronglyrelyonA&Eforminorillnessessuchascoughsandcolds.SomepeoplefeltcommunicationfromtheNHStoencouragepeopletouseservicesappropriatelywasnecessarytoensurepatientsaccessedappropriatecare.

3.1.3 Morecareclosertohome

Althoughpeopleweregenerallysupportiveoftheplantohavemorecareclosertohome,thereweredifferentopinionsabouthowitcouldworkinpractice.

Somepeoplebroadlylikedtheideathatserviceswouldbemorejoinedup.ManypeoplesaidthattheplancouldworkifpreventionwasprioritisedandifserviceslikeNHS111wereimproved.However,somewerescepticalofthequalityofserviceNHS111providesandthoughtthatthiscouldhamperqualitycareasproposedintheSTP.

PeoplehaddividedviewsaboutwhetherseeinganurseorpharmacistinsteadofaGPwouldworkinpractice.Somesaiditcouldbeapositivechange(e.g.couldbequickerwaytoreceivecare/advice).However,eveniftheyweresupportiveoftheconcept,somepeoplefelttherewouldbebarrierstouptake(e.g.peoplenotknowingthatpharmacistsareskilled,andacurrentlackofpromotionofpharmacistservices).

Atthegrassrootsengagementevents,severalpeoplecommentedaboutcommunicationbreakdownswithpharmacists,leadingtounknownchangesmadetomedication,lackofadviceabouthowtotakemedication,orwrongmedicationbeinggiven.SeveralhealthandcareforumpeoplewerescepticalofusingapharmacistornurseinsteadofaGPorotherspecialist.Concernsaboutpharmacistsincludedalackofprivacyinlocationsthatpharmacistsoperate,aperceptionthatpharmacistsaretoooverworkedalready,aperceptionthatpharmacistscannotprescribe,andabeliefthatpharmacistsarenotskilledenough.Atthegrassrootsengagementevents,somepeoplecommentedthat‘PatientOnline’hasmadeiteasiertopickupprescriptions.

Atthegrassrootsengagementevents,somepeoplealsohighlightedcommunicationissuessurroundingGPprescriptions,suchasGPsaschangingmedicationwithoutnotifyingtheindividual,notdiscussingsideeffectswithpatients,andnotwritingprescriptionsforover-the-countermedicinefortheirchildren.


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SeveralpeopleatthehealthandcareforumhadconcernsabouttheplansformorecareclosertohomeincludinghowlongeropeninghourscouldbesustainediftheNHSwasalreadyshortofGPsandhowtheNHScouldshiftbudgetswithoutnegativelyaffectingacutecare.Somepeoplealsohighlightcurrentchallengesthatcouldaffectthesuccessoftheproposedchanges.Forexample,theythoughtthattherewasacurrentlackofpatientknowledgeaboutwhatservicesareavailableintheareaandahighnumberofpatientswhodonotshowupforappointmentswiththeirGP.Thesepeoplefelttheseproblemsshouldbeaddressedinorderfortheplanstowork.

Atthegrassrootsengagementevents,peoplediscussedthedifficultysurroundingbookingGPappointments,somesaidthattheyhadissuesgettingasamedayappointmentandotherscommentedthattheyhadtowaitseveralweekstobeseen.Otherpeoplecommentedthattheywerehappythattheycouldbookatelephoneappointmentifaface-to-faceonewasnotpossible.Peopleexpressedconcernsaboutissueswithreferralstohospitals,wherehospitalappointmentswerecancelledduetoincorrectinformationbeingprovidedbytheGPsurgeryandsomecommentedonlongwaitingtimesforreferralsfromGPs.Afewmentionedweekendappointmentswereavailable,whichtheyreallyvalued.

ThesepeoplealsoexpressedtheneedformoreinterpretersinGPsandhospitals.TheycommentedthatGPshaveagenerallackofunderstandingaboutautismandthatitcanbeveryhardtogetadiagnosis,particularlyforthosewhodonotspeakEnglish.FormoreinformationaboutlearningdisabilityservicesinCroydonseesection3.1.6.AfewspokemoregenerallyaboutaccessibilityissueswithGPs,commentingthatletterswereoftenwritteninawaythatwasdifficulttounderstand,andthatsomebuildinglayoutswereconfusingorinaccessiblewithdangerousstairs.

SomepeopleatgrassrootsengagementeventscommentedonissuesregardingreceptionstaffatGPsurgeries.Afewcommentedthatreceptionistsweretooloudwhendiscussingconfidentialpatientmatterswhichmeantthatotherpeoplecouldhearpersonalinformation.Peoplealsoexpressedfrustrationsthatreceptionstaffareactingaspractice‘gatekeepers’triagingpatientsforappointmentsandmakingdecisionsonwhethertheircasesareemergencies.SomepeopleinthegrassrootseventswhodidnotspeakmuchEnglishhighlightedthattheycanfindreceptionistsparticularlyintimidatingduetothelanguagebarrier.

Peopleatthegrassrootsengagementeventsemphasisedissueswithpost-diagnosissupport,wheretheycommentedthattheydidnotknowwheretoturntoforfollow-upsupport,withmanyrelyingonvoluntaryorganisations.Theysaidthattheywouldlikemoresupport,adviceandsignpostingtounderstandtreatmentandsupportoptionsforthemandtheirchildren.Theyalsonotedthatwhentheywerereferredforspecialistfollowupcaretherecouldoftenbealongwait.

3.1.4 Preventionandearlyintervention

MostpeoplethoughttherewerechallengestoachievingtheplansforpreventionandearlyinterventionintheSTP.Forexample,peoplefeltthattheSTPwasoverlyoptimisticabouttheresourcesavailabletodelivertheproposedchanges.Othersfeltthatthechangeswouldmeancurrentlevelsofcarewillnotbemetinthefuture.Additionally,manypeoplewereworriedthatthelackofresourcescouldleadtoprivatisationofhealthservices.


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Severalquestionswereraised,mainlyaroundthequalityofserviceandhowchangestopreventionandearlyinterventionwouldbecoordinated.PeoplewantedtoknowiffurthercutswouldfollowthechangesproposedintheSTPandwhatserviceswouldbelost.Whenaskedaboutlocalityteams,peoplehadquestionsonhowalocalityteamwouldberun,andwhowouldfindwho(e.g.wouldspecialistsreachouttopatientsorviceversa).Therewasalsoaconcernthatlocalityteamswouldonlyworkwithat-riskorvulnerablepatients,compromisingcareofothers.

ManypeoplefeltthatthequalityofcommunicationbetweentheNHSandthepublicislowbutthatthesuccessofpreventionandearlyinterventionwouldrelyongoodcommunicationfrompractitionerstopatients.Specifically,theyfeltthereisacurrentlackofcommunicationabouttheservicesavailableinthearea,andalackofconfidencethatCCGsandGPsknowenoughaboutservicestoshareusefulinformation.Peoplesaidthatposters,advertisementsinmainstreammediaandinformationonscreensinGPofficeswouldbeusefulwaystodisseminateknowledgeaboutlocalservices.

Peoplehadmixedviewsaboutwhetherchangingpeople’sbehaviourwouldbeasuccessfulapproachtoimprovingpreventionandearlyintervention.Somepeoplefeltthatbehaviourchangescouldbeintroducedandencouragedinschoolsorincommunitygroups(e.g.CroydonWeightWatchers,CroydonNordicWalkingorgroupsattheAsianResourceCentre)wherethefocusisonhavingfunratherthantellingpeoplewhattodo,andwherepeoplealreadytrustthepeopletheyinteractwithinthosesettings.Otherpeoplethoughtitwouldbechallengingtochangepeoples’behaviouriftheydidnotwanttochange.

AdiscussiontookplaceontheCroydonPOP(PartnershipforOldPeople)bus.Broadly,peoplesaidthatthisintervention(e.g.parkinginpedestrianisedareaandprovidingadviceonvarietyoftopics)wasuseful.Somepeoplewerefrustratedthatfundingfortheservicehadstopped.

Therewaslimiteddiscussionofthistopicinthegrassrootsevents.However,afewpeoplementionedexamplesofpreventativeopportunitiesmissed,leadingtoproblemsescalating.Forexample,onepersonfoundthecostofdentistsprohibitivesowouldwaituntiltheydefinitelyneededattention.Othersmentionedwaitinglistsforpsychologicalsupport(seesection3.1.5below).

3.1.5 Mentalhealth

DiscussionsaboutmentalhealthatthehealthandcareforumcentredonchallengesandquestionsaboutproposedchangestomentalhealthservicesintheSTP.Broadly,manypeoplewantedtoknowwhichserviceswouldbediscontinuedandhow,ifatall,physicalandmentalhealthmightbelinked.OneparticipantsaidtheywerenotsurewhattheNHSisproposingbecausetheyfelttheplansoundslikewhatshouldcurrentlybeoffered.

SomepeoplesaidadditionalIAPT(ImprovingAccesstoPsychologicalTherapies)servicesareneededtoreducewaitingtimesforpsychologicaltreatment.AtleastoneparticipantsaidthatalackofGPsinthenorthoftheboroughmeantlongwaitingtimesforcare.

SomepeoplesaidtherewasaneedforservicestobebettertailoredtotheneedsofminorityorvulnerablepatientsincludingBMEpatients,thosewhomightexperienceculturalbarriersto


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understandingmentalhealth,andthosestrugglingwithalcoholdependency.Thiswasechoedatthegrassrootsengagementevents,wherepeoplecommentedonculturalbarrierstoseekinghelp,notknowingwheretoturnformentalhealthissues,andanxietycausedbytheircommunicationwithTheHomeOffice.

PeopleatthegrassrootsengagementeventsexpressedconcernthatstaffthatworkinMentalHealthTrustssometimeswerenotabletoshowcompassiontotheindividualwhentheywereaninpatient.Manyofthesepeoplesaidthattheywantedpsychiatriststospendmoretimetalkingtopatientsratherthanmakingassumptionsthattheyneedmedicationorachangeofprescription.

Somepeopleatthegrassrootsengagementeventshadbeendischargedfromhospital(Bethlam/Springfield)andreferredtocommunityhubssuchasTamworthResourceCentretoreceivetheirmedication.Thereweremixedviewsaboutcommunityhubs,withsomefeelingpositivenottohavetomakeappointmentswiththeirGPsandothersexpressingfrustrationabouthavingtomakeregularvisitstoTamworthResourceCentretocollectmedication.Someexpressedconcernaboutthechangeofcarecoordinatorsandcommentedthatcareneededtobekeptconsistent.

Peopleinthehealthandcareforumfelttheyhaveseenthefundingtocommunityservicesbeingreducedandquestionedhowitwouldbepossibletokeepnon-urgentcareneedsoutofhospitalinthiscontext.Forexample,oneparticipantsaidthatbecausementalhealthserviceswerecutatFoxleyHill,patientsnowgotothehospitalforcare.AtleastoneparticipantfeltthatCroydonisnotgettinga“fairshare”offundingformentalhealthservices.

Peoplealsoaskedspecificquestionsonavarietyofmentalhealthtopicsduringthediscussion.Thesequestionsincludedhowmentalhealtheducationforschoolswouldbedeveloped,whattypeofsupporthomecarerswouldget,andwhatwouldbedifferentaboutcoordinatinghospitalandcommunitymentalhealthresources.

Overall,peopleagreedwiththeneedforaholisticapproachtomentalhealthissues,thataccountsforhowtheyinteractwithotherillnessesandphysicalconditions.

Atthegrassrootsengagementevents,somepeoplediscussedconcernsregardingmentalhealthsupportforchildren.Theyraisedissueswithconfidentialitywhenseeingaschoolcouncillororatutor,andmanysaidthattheywouldprefertoseekhelpoutsideofschool,butthattheydidnotknowwheretogotoreceivehelp.Toreadmoreaboutchildren’sservicesinCroydon,seesection3.1.7.

3.1.6 Learningdisabilities

Manypeopleatthegrassrootsengagementeventscommentedonthetreatmentofpatientswithlearningdisabilities,suggestingthatpeoplewithalearningdisabilityshouldbenotedontheGPsystemsothatallstaffareaware.Parentsalsocommentedthattheywantedmoresupportsurroundingdietandnutritionforchildrenwithautism,whocanoftenfixateoncertainfoodstothedetrimentofavarieddiet.SomealsonotedthelackofEasyReadoraccessiblematerials.

Severalpeoplecommentedthattheystruggledtogetadiagnosisfortheirchildandfeltthatthiscouldtakeseveralyears,commentingthatCAMHSinCroydonareoverrun.


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3.1.7 Children’sservices

Mostpeopleatthehealthandcareforumwhodiscussedchildren’sservicesattendedbecausetherewasalackofinterestamongotherpeopleandtheyfeltitwasimportantthatthetopicwasdiscussed.Generally,peoplehadsuggestionsandconcernsabouttheproposedapproachtochildren’sservicesintheSTP.

ConcernsandsuggestionscentredaroundhowtheNHSneededtopromotebetterawarenessandsignpostingofavailableservices.Peoplerecommendeddevelopingpartnershipswithschoolsandcommunity-basedservicestoadvertiseservicesortohavenursesavailableinschoolsforparentstospeaktoiftheyhaveconcernsabouttheirchild’shealth.

However,severalpeopleagreedthatchangingbehaviourinordertoreducethenumberofvisitstoA&Efornon-urgentcaremaybedifficult.Sincemanyparentscanbeanxiouswhentheirchildisill,peoplefeltitwaslikelyparentswouldstilltaketheirchildtoA&Einanon-emergencyifaGPwasnotavailable(ratherthanapharmacyorcommunity-basedservice).

Therewasarecognitionthatimmigrantfamiliesmightneedextrasupportbecausetheirextendedfamilymembersmightnotbearoundtoprovideadviceorcare.Additionally,manypeopleagreedthatinformationandservicesshouldbeprovidedindifferentlanguages.

Atthegrassrootsengagementevents,somepeoplecommentedontheturnoverofstaffforoccupationaltherapistswhichhasabigimpactonchildrenandtheirtreatmentandsuggestthatmoreoccupationaltherapistsareneeded.

Therewassomeemphasisofsupportinghealthierlifestylesforchildrenatthegrassrootsengagementevents,wherechildrenandyoungpeoplewereaskedabouttheirrelationshiptohealthcareandtheirunderstandingofdietandnutrition.Mostsaidthattheywouldcall999toseekmedicalhelp,orusethewalk-inclinicandsomewereunsurewheretogoforalcoholordrugproblems.Whendiscussinghealthyeatingandexercise,thechildrenparticipatingweregenerallyawareofwhichfoodswerehealthyandwhichwerenot,andsomewantedmorenutritioneducationandhealthierchoicesatschool.Otherscommentedthatmorelifestylehelpwasavailableoutsideofschoolandwantedtheretobemoreinformationinschoolabouttheseservices.FormoreinformationonpreventioninCroydon,seesection3.1.4.

3.1.8 Maternityservices

NopeopleattendedthematernitysessionsattheCroydonhealthandcareforumorcommentedontheserviceinthegrassrootsengagementevents.

3.1.9 Cancerservices

Cancerserviceswerenotdiscussedseparatelyatthehealthandcareforum,butwerediscussedatthegrassrootsengagementevents.PeoplementionedthatGPsneedtherightsupportandguidancefromhospitalstospotearlystagesofcancerwithlessobvioussymptoms.Theyalsodiscussedtheneedtobettermanagethehealthrequirementsofthemetastaticcancerpopulation,suggestingthat


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GPslearnhowtospotthepossiblesymptomsofrecurrence(beitalocaloneoradvancedstage)andgetthesepatientsseenasquicklyasthosewhomighthaveaprimarycancer.

Therewassomeconcernaboutwaitinglists,andoneparticipantmadethesuggestionthatpatientscouldbedirectedtohospitalswithshorterwaitinglistsifthelocalservicehadalongwait.Equally,peoplewereopentosometreatmentbeingprovidedincommunitysettings,aslongastheywereassuredthatitwouldbesafelymanaged.Equally,theyweresupportiveoftheservicehelpingpeoplewithcancertoself-managewhereappropriate–forexample,byencouragingthemtomanagetheirweight.

SomepeoplecommentedoncancertreatmentreceivedattheRoyalMarsden,askingformoretreatmenttrialsandnewtestingmethodstobeoffered.Peoplealsorequestedthatthedatacollectionofcancerpatientsbeimproved.SeveralmentionedthatthesuggestedproactiveapproachisparticularlyrelevantastheRoyalMarsdenispartofacancervanguard.

Somepeoplecommentedontheimportanceofpost-treatmentcare,suchasphysicaltherapyandemotionalsupport.Theysuggestedthatthiscouldbedonelocallyusingcommunitycentresandlocalservices.


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3.2 KingstonandRichmond



8thFebruary2017 35


2ndMarch2017 55






InbothKingstonandRichmondoneofthemostfrequentcommentsatthehealthandcareforumswasthatmoredetailisneededintheSTP.PeoplefeltthattheSTPasitstandsistooaspirationalandhigh-level,andtheywouldliketoseemoredetailedplans,figures,modellingandtimelinesabouthowtheproposalswillworkinpractice.TherewasalsoasuggestioninKingstonthattheSTPmirroredwhatwasinthe2008“HighQualityCareforAll”report,i.e.thattherewasnotanythingnewintheSTP.

PeopleinbothKingstonandRichmondquestionedhowtheproposedimprovementswouldbepossibletomakegiventhelackoffundingavailabletosupportthesechanges.SomepeoplefeltthattheSTPlacksrealismandpeoplewereconcernedabouthowtheNHSwouldbalancefundsbetweenhealthandsocialcareandsuggestedthatmorefundingneededtobedirectedtosocialcare,especiallyiftheNHSwantedpatientstoleavehospitalsooner,butalsotobettersupportpatientsoverthelongterm.

InRichmond,somepeoplefeltthatoneindividualorsmallgroupshouldchampionandleadthechangesoutlinedintheSTP,sotherewouldbeaccountabilityforcoordinationanddeliveryandtoavoidinconsistencyorduplicationofservices.Theydidnotbelievethatacollaborativeapproachtoleadingtheimplementationwouldbeeffective.

PeopleatthehealthandcareforumsinKingstonemphasisedtheimportanceofpublichealth,andofeducatingandinformingthepublicaspartofthepreventionandearlyinterventionagenda,aswellasmorebroadlysothatpatientsunderstandthechangesandwhotheyshouldseeforsupportindifferentsituations.

ManypeopleinbothareasraisedconcernsabouttheNHSandhealthcaregenerally,including:

• theirexperienceofpoorcommunicationwithinNHSandwithpatients;

• aperceivedlackofresourcesandstaff;


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• concernsaboutfundingcuts;

• questionsaboutthecostofadministration;

• concernsaboutprivatisationofNHSservices;and

• concernsabouttheprovisionofqualitycareforolderpeople.


Supportforplantodirectpeopletoalternativesservices,butlackofclarityonwhatthesemightbe.

WantedmoreinformationoncriteriaforchoosingwhichA&Etoclose,andhadconcernsabouttheadditionalpressureonremainingA&Eservices.

Mixedviewsonimpactofproposalsonquality,andconcernsthatcentralisingtheservicewascontrarytoplanstotakecareclosertohome.Anddiverseviewsonwhethersevendayservicewasdesirable.

Questionsabouthowgoodaccesswouldbeensured,especiallyforpeoplelivingonthebordersoftheSTP,andthelevelofco-ordinationwithotherSTPs.

Concernsaboutexistingacuteserviceincludingcommunicationandproblemswithdischarge.


Someconcernsandquestionsabouttheseplans,particularlyrelatingtothestaffingandtrainingrequired.

Supportiveofideaoflocalityteamsandpotentialforbetterjoined-upworkingifitcanbeachieved.

CurrentlackofconfidenceinalternativeserviceprovisionincludingNHS111andpotentiallypharmacists.

Needformoreinformationaboutwhendifferentservicesareappropriatetouse,encouragedbystaffworkingindifferentcaresettings.

Supportfortheideaofworkingmorecloselywithvoluntarysector,butconcernsabouthowitwouldworkinpractice.

SignificantconcernsaboutcurrentGPservicesincludingaccesstoappointments,accessibilityofservices,problemswithreferralsandGPsnotbeingpatientcentred.


Broadlysupportiveofplansbutconcernedthatitwillbechallengingtodeliver.

ThinklocalityteamsareagoodideabuthavequestionsabouthowtheywillfunctionandwanttoseeenhancedcommunicationwithinandbetweenNHSservices.

Supportforuseoftechnology,suchassmartphones,aslongasservicesremaininplaceforthosewhoarenotcomfortablewiththeseservices.


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Encouragementtoworkwithfriends/families/communitiesaswellasthevoluntarysectortodelivertheambitiousaroundprevention.

Mentalhealth

Someconcernsaboutexistingmentalhealthservices,althoughRichmondpeoplefeltthatserviceswerecurrentlygood.

Particularconcernsrelatedtoparityofesteem,knowledgeoffrontlinestaff,andgapsincludingformentalhealthcrisis.Additionally,regularchangesandtherangeoforganisationsinvolvedcouldmakenavigationdifficult.

SupportforplantoensureA&Eisnotthefirstportofcall,andfortheideaofcarenavigators,butsomequestionsabouttheoverallambitionandlikelyimpactonexistingservices.

Needformoreeducationforfrontlineandpublictounderstandmentalhealthconditions,andtoaddressstigma.

Additionalsupportrequiredforpeoplewithdiverseneeds.

LeadingDisabilities

SomeparticularchallengesfacedbyparentsofchildrenwithLD–theyaskedformoresupportandalsohelpinbookingsuitableappointments.

Lowawarenessofannualhealthcheck,andexpectationGPshoulddomoretopromotethisservice.


ConcernsthatlackoffundingwouldmakeitdifficulttoprovideservicesenvisagedintheSTP.

AgreedinprincipalwithreducingrelianceonA&Ebutwerenotclearparentsknow,ortrust,thealternatives.

Also,feltthatincreasedaccesstoGPswouldbeparticularlyimportant.

WantmoreinformationaboutCAMHSintheSTP.

Importanttoensurecareisflexibleandtailoredtoindividualneedsoftheyoungpersonandtheirparents.

Maternityservices

Agreementwiththecaseforchange,althoughpre-natalcareinbothboroughsreceivedpositivefeedback.

Supportforamorepersonalisedservice,butnotattheexpenseofsafety.Viewthatwhilethereareinsufficientmidwives,choiceshouldbealowerpriority,althoughimportantthatdiverseneedsaremet.

Viewthatmaternityservicesshouldnotbetoomedicalised,sothattheyalsosupportsafeguardingandpost-partumcare.

Supportfortheideaofgreaterconsistencyincareformidwives.


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Cancerservices

Someservicesreceivepositivefeedbackbutneedforincreasedsupportforpatientsfollowingdiagnosisandtreatment.

RequestthatGPsaremoreinvolvedintreatment,andfollowuponbothmentalandphysicalwellbeingwhiletreatmentisunderway,andfollowingtreatment.

PlannedCare Discussionrelatedtotheneedforadequatetransportoptionsandtheimportanceofavoidinglastminutecancellationsandlongdelays.


Therewassomeconfusionabouttheterm‘acute’.AttheKingstonhealthandcareforumpeoplequeriedwhetherthismeantemergencyservicesorspecialistfacilitiesandinRichmond,peoplegenerallytook“acutecare”tomeanA&E.Oncethiswasclarified,somepeoplesupportedtheideaofdirectingpeopletoplacesotherthanA&E,inprinciple.However,inpractice,theyquestionedwhereelsepeoplecango.

Responsetoplanstoconsolidateacuteservices

Thisraisedseveralissuesandqueries.InRichmondpeoplewonderedwhatcriteriawouldbeusedtodecidewhichA&Esiteswouldclose.SeveralpeoplealsocommentedthatitisalreadydifficulttogetaGPappointmentand,althoughtheSTPsuggestspeoplecouldvisitpharmacistsmoreoften,peoplethoughtthatfundingforpharmacistshadalsobeencut.Somepeoplecommentedthattherewereculturalreasonsforsomegroups,(forexamplerefugeegroups)forgoingtoA&Ewithminorneeds,andthatthiswouldbedifficulttochange.

InKingston,peoplerequesteddetailsandmodellingtoshowhowlocalservicescanrelievetheburdenonacuteservices.SomepeoplethoughtprovidingimprovedsupporttopatientsinhospitalsotheycanleavesoonermightalleviatetheperceivedpressureclosingA&Esitesmightcause.

WhilemanypeoplethoughtthatRichmondwasgenerallywell-servedforhealthcare,someworriedthechangescouldmeanareductioninhealthcarestandardssuchasincreasedtraveltime,andfeweracutesitestochoosefrom.Otherpeoplethoughttheprincipleofsevendayacuteserviceswasagoodidea(i.e.tohavefewersitesbutprovideimprovedcare;andtobecomebettermanagingstaffandservices),butfeltscepticalaboutwhethertheSTPcoulddeliverasproposed.

DuringonediscussionattheRichmondhealthandcareforum,somepeoplethoughtitwasnotnecessaryforacuteservicestohaveafullrangeofspecialistssevendaysaweek(e.g.physiotherapists),whileothersthoughtaqualityacuteservicedoesrequirethesamelevelandmixofstaffingoneverydayoftheweek.

InKingston,peopleidentifiedwhattheybelievetobetwoincompatibleaimswithintheSTP:toprovidecareatamorelocallevel,andtoconcentrateresourcesintoasmallernumberofacutehospitals.

Therewereconcernsthatconcentratingresourcesintoasmallernumberofacutehospitalscould:


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• exacerbatewaitinglists;

• makeaccessingtherightspecialistmoredifficult;

• increasepressureonA&E;

• meanhospitalsonlytreatthemostsevereemergenciesorconditions;and

• meanthattherighthospitalismuchfurtheraway.

Therewasaviewthatprovidingsevendayacuteservicesislikelytomeanresourcesarespreadmorethinly,ratherthananimprovementtoservices.Somepeoplesuggestedthemotivationtohavesevendayacuteservicesispoliticalratherthanbasedonevidence.Incontrast,somepeopleattheRichmondgrassrootsengagementactivitiessaidthattherewasfearamongtheolderpopulationaroundgettingillonFriday,astheywereconcernedabouttheleveloftreatmentthattheywouldgetovertheweekend.

MostpeoplesaidthatiftheywereillovertheweekendortheycouldnotgetanappointmentwiththeirGP,theywouldeithergotoTeddingtonMemorial,orcallNHS111.Yet,somepeoplewereworriedthattheywouldnotbeadequatelytriagedbytheNHS111service.OtherssaidthatiftheywerenotabletogetaGPappointmenttheywouldgotoA&E.PeoplecommentedonthelongwaitingtimesatA&E(particularlyatKingstonHospital)wheresomesaidthattheywouldavoidgoing.

Accesstoservices

Therewerealsoseveralquestionsrelatingtotheaccesstoacuteservices.PeopleattheRichmondhealthandcareforumdiscussedhowtheplanforsevendayacuteservicescouldworkgeographically.OneparticipantnotedpatientsdonotfitneatlywithinboroughsandbecausethereisnohospitalinRichmond,itwasn’tclearhowthechangeswouldapplyintheborough.Anotherparticipantwonderedwhatcoordinationbetweenregionsandboroughswasbeingplanned.

AttheKingstonhealthandcareforum,peoplefeltthattransportforelderlypeopleorthosewithdisabilitiescouldbemoredifficultatweekends(theysaidthereisnohospitaltransportatweekendsatthemoment),andthatthisshouldbetakenintoaccountinchangingtosevendayservices.TheyalsoquestionedhowtheSTPconsiderstheuseofservicesinneighbouringareassuchasTootingorSurrey.

SomepeoplecommentedontransportissuesatKingstonhospital,forexamplethatparkingcanbedifficultforpeoplewithdisabilitiesandshouldbefree.OtherscommentedthatpatienttransportwasnotalwaysadequateforpeoplewithphysicaldisabilitiesandafewsaidthatKingstonHospitalwasveryconfusingtonavigatearoundasthesignpostingisnotclear.

Tailoringacuteservicestodifferentneeds

AfewpeopleattheKingstonandRichmondgrassrootsengagementactivitiessharednegativeexperiencesaboutcommunicationissuesinhospital.Peoplementionedalackoftranslationservices,havingtorelyonfriendsorfamily.OtherscommentedthatA&Estaffdonotknowhowtoeffectivelycommunicatewithchildrenoradultswithmentalhealthconditionsorlearning


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disabilities.SeveralpeoplesaidthatstaffatKingstonHospitalwererude.Afewpeoplepraisedthe‘bluebandscheme’whichletstaffknowifapatientwassufferingfromdementia.

SomepeoplecommentedontheprovisionsforthosewhoarriveatA&Einamentalhealthcrisis,andsuggestedthatthesepatientsbegivenaroomawayfromotherstohelpthemkeepcalm,wheretheyshouldthenbeattendedtobysomeonewithexperienceworkinginmentalhealth.FormoredetailsaboutmentalhealthservicesinKingstonandRichmond,seesection3.2.5.

AttheKingstongrassrootsengagementactivitiespeoplecommentedthatdischargefromA&Ewasalwaysdelayed.Othersmentionedthatsomehomelesspeopleweredischargedintheearlyhoursofthemorningwhensheltersandotherservicesareclosed.

PeoplemadeseveralnegativeobservationsabouthowolderpatientswerebeingtreatedatKingstonHospital.Forexample,onecommentedthatolderpeoplewereseenasnotbeinghelpedtofeedthemselveswheninhospitalandanothercommentedthatthestaffweremorefocussedonfreeingupbedspace,thanprovidingcare.

PeopleatthehealthandcareforumsfeltthatintermediatecareisnotaddressedintheSTPandtheyrequestedinformationaboutwhattheplanswouldbeforthosewhoarewellenoughtoleavehospital,butnotyetwellenoughtobeathome.


PeopleattheKingstonandRichmondhealthandcareforumshadconcernsabouttheplansforhealthcareclosertohome.Theseconcernswerebroadlyabout:

• Alackofstafforadequatetrainingforstafftoservepatientscurrentlyandinthefuture;

• TheroleofcarenavigatorsintheSTP;

• ChallengeswithcommunicationandinformationsharingbytheNHSinternallyandexternally;and

• TherolethevoluntarysectorwouldplayintheSTP.

PeopleinthehealthandcareforumslikedtheideaoflocalityteamsprovidingservicesthatareusuallyaccessedviaaGPorOutpatients.However,theywantedtoknowmoreaboutwhatalocalityteamwouldlooklikeinpractice,andwhatroletheywouldplaybeyondinformationsharing.Similarly,theywantedtoknowwhattheremitofalocalhealthcentrewouldbe,howpatientswouldaccesssuchaservice,andwhatthewaitingtimeswouldbe.

InbothKingstonandRichmond,peoplewerepositiveaboutthefocusonlocalcare,joined-upworkingbetweenhealthandsocialcare,andincreasedcollaborationincommunitiestoimprovehealthcare.Forexample,somepeoplefelttheapproachwouldfacilitatethepreventionofhealthproblems.

Afewpeoplehadquestions,includingwhethercareandhealthserviceswouldbejoinedupacrosstheboroughs.AttheRichmondhealthandcareforumtheyaskedhowQueenMary’sHospitalwouldfunctionandbefundedundertheSTP.


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Staffingandtraining

Somepeopleinthehealthandcareforumsexpressedconcernsaboutstaffingandtraining.TheyquestionedwhethertheplanwouldbeviablesincetheyfeltGPsarealreadytoobusytomanagetheircurrentcaseload.Further,somepeoplefeltthattheplandidnotaccountforhowmuchtrainingwouldbeneededtopreparepractitionerstodelivercaretopatientswithadifferentrangeofneeds.

Closelyrelatedtostaffingandtrainingwerequestionsabouttheroleandtrainingofcarenavigators.Forexample,somepeoplewantedtoknowhowpatientswouldbeinformedoftheremitofthecarenavigatorroleandhowtheywouldbetrained.

Viewsofalternativeservices

PeopleattheKingstonhealthandcareforumfeltthattheNHS111serviceneedsre-launchingifittobeakeypartofthenewwayofworking;theyfeltthatpeopledonottrusttheserviceasitisnowandwantedtoknowmoreabouthowitwouldbeimproved.ThiswasechoedbypeopleatthegrassrootsengagementactivitieswheresomecommentedthattheyhadneverheardoftheNHS111serviceandothersthoughtithadapoorreputation.

AtthehealthandcareforumsinKingstonandRichmond,therewassupportfortheideaoflong-termconditionsbeingmanagedbypharmacists,andusingpharmacistsasafirstportofcallinsteadofGPsbecausetheyfelttherewouldbelesswaitingtimetoreceiveadvice.However,peoplewantedtobereassuredthatpharmacistswouldbeabletoprovideconsistent,reliable,andaccurateadvice.Somepeopleatthegrassrootsengagementactivitiescommentedthatpharmacistsneededtoimprovetheircommunicationskills,assomesaidthattheyweregivenmedicationwithoutbeinggivenadviceonhowtotake,andotherscommentedthattheirmedicationhadbeenchangedwithoutbeinginformed.

PeoplefeltcomfortableinprinciplewithseeingotherhealthprofessionalsinsteadofgoingtoA&Einanon-emergency.However,theyfeltthatcommunicationneedstobeimprovedtosupportthisshift,includingprovidinginformationaboutwhatdifferenthealthprofessionalscando,andraisingawarenessaboutdifferentservices,includingtheNHS111service,pharmacistsandotheroutofhouseservicesandwhentoseetheseratherthanaGP.

SomepeopleinKingstonsuggestedthatreceptionistsatGPsurgeriesshouldplayabiggerroleinsignpostingtoclinicalnursesorpharmacistswhenappropriate.Othersnotedthatlocalservicesneedtoofferamoreconvenientalternativetovisitingthehospital.Somealsothoughtthereneededtobeincreasedcollaborationandcommunicationbetweendifferenthealthandsocialcarepractitioners.Forexample,atleastoneparticipantfelthealthandsocialcarepractitionersworkinsilos,whichcanlimittheexchangeofinformationacrossservicesanddifferentareasofcare.

Peoplealsodiscussedtheuseofthevoluntarysector.Somepeoplelikedthattheplansforcareclosertohomeincludedworkingwithvoluntaryorganisations.Theyfeltthiscouldimproveaccesstoandthequalityofcare,sincevoluntaryorganisationshaveexpertlocalknowledge.Othersthoughttherewerechallengestoworkingwiththevoluntarysectorthatmighthindertheproposedchanges.Thesechallengesincludedhowtoensureconsistencyandqualityofcare,


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organisationalandlogisticalchallenges,andaperceptionthatthevoluntarysectorisbecoming“toocommercial.”

SomepeopleatthegrassrootsengagementactivitiescommentedthatthereshouldbebettersharingofpatientrecordsandinformationandthatthiswasparticularlyimportantforpeoplewithdisabilitiesandlongtermcomplexconditionswhousemultiplebranchesoftheNHS,andmultipleservices.Theyalsocommentedthatpatientsshouldbeabletogetaccesstotheirmedicalrecordsfreeofcharge.

GPpractices

ManypeopleatthegrassrootsengagementactivitiescommentedonGPpractices–specificallythedifficultiestheywerecurrentlyexperiencing,whichcouldimpactontheSTP’sabilitytodelivermorecareclosertohome.

Accesstoappointments

AfewsaidthattheyhadnoissuesgettingappointmentswithGPsandinparticular,somepraisedparticularpractices,forexamplefortheiruseof‘PatientOnline’tobookappointmentsinadvance.AnothersaidtheylikedthattheycouldhaveattelephoneGPconsultationwhentheywereunabletogetaface-to-faceappointment.Despitethis,mostpeopleatthegrassrootsengagementactivitieshaddifficultygettingaGPappointmentwhentheyneededone.TheysuggestedthatthiswasduetoashortageofGPs,andthoughtmoreemphasisshouldbeplacedonrecruitmentandregulatingregistrationtopractices.

Inmostcases,togetasame-dayappointment,peoplewererequiredtocallat8am.Inmanyinstances,theyhadtowaitonthelineforuptoanhour,andeventhenitcouldbeseveraldaysuntiltheygotanappointment.Somecommentedthattheyfelttheyhadto‘jumpthroughhoops’,justifyingtoreceptionstaffwhytheyneededanappointment.Severalpeoplealsocommentedthattheyhadnochoiceoverappointmentdaysortimes,evenwhenbookinginadvance,whichwasaconcernforworkingparents.

Afewpeopleatthegrassrootsengagementactivitiessaidthatitwasparticularlyimportantthatreceptionstaffarefriendlyandhelpful,ratherthanabarriertocare.Severalwereconcernedthatreceptionstaffactas‘gatekeepers’askinginvasivequestions,whichpeoplefeltshouldbeconfidential,andotherscommentedthatthemoodofreceptionstaffinfluencetheservicedelivery.Somecommentedthatreceptionistsshouldhavetrainingforhowtospeaktopeoplewithlearningdisabilitiesandhowtodealwithsensitivematters.

Manypeoplefeltthatthereshouldbealternativewaystobookappointments,suchasonline,bytextorinpersonatallpractices.However,othersexpressedconcernsaboutonlinebookings,oronlineGPappointments,astheywereconcernedthatthosewhodidnotknowhowtousecomputerswouldbeleftout.

SeveralpeopleattheKingstonandRichmondgrassrootsengagementactivitieswantedmorecontinuitywiththeirGPs.TheywerefrustratedthattheywouldseeadifferentGPeverytime,whichmeantthattheycouldnotbuildrelationshipsandtrustwiththeirGPsandhadtoexplaintheirhealthconcernseachtime.Theyalsocommentedthatthismeantthatadvicegivenwasofteninconsistent.


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OtherssuggestedthattheydidnotmindseeingdifferentGPsifitwasaone-off,butnotiftheirappointmentwaspartofanongoingcondition.

Referrals

SomepeoplefeltthatalthoughtheyhadnoissuesgettinganappointmentwiththeirGP,thereareseriousissueswhenitcomestoreferrals.Somecommentedthatreferralstakealongtimeandsometoldanecdotesofreferralsbeinglost,eitherinthepostorduetootheradministrationerrors,andthatitwasthenlefttothepatienttofollowup.Somepeoplefeltthatthereneededtobemoreinformationaboutthereferralprocess,whereafewcommentedthattheyhadtowaitseveralweeksfortestresultswhichmadethemanxious.AfewpeopleattheRichmondgrassrootsengagementactivitiessuggestedthatsomeservicesshouldallowforself-referral.

Accessibility

Severalpeoplecommentedonaccessibilityissues:

• AfewpeoplecommentthatGPsamorereluctanttomakehomevisitswhichcausesanissuewiththosewhohaveaccessibilityneeds.

• Somepeoplefeltthatcallingappointmentsbeingviaascreenisnotappropriateforthosewithbadvision.

• OtherscommentedonthelackoftranslationservicesofferedatGPpractices,whichleadstomisdiagnosis,delayedorcancelledappointments,andissuesmakingappointments.Specifically,afewpeopleatthegrassrootsengagementactivitiesinKingstoncommentedthattherearelimitedstaffofKoreandescentandthatthisimpactsaccesstoservices,giventhelargeKoreanpopulation.

Patientcentredcare

Peoplecommentedontheneedforpatientcentredcare,treatingthepersonholisticallyandemphasisinghealthlifestyleandprevention.Somepeoplewelcomedtheconceptofacarenavigator,especiallyforpeoplewithmultiplecomplexconditions.Formoredetailsonthediscussionsurroundingpreventionseesection3.2.4.

Afewpeopleatthegrassrootsengagementactivitiesfeltthattheirillnesseswerenotbeingtakenseriously,orthatduetoalackofGPknowledgetheirillnesstookalongtimetodiagnose.SomespecificallycommentedthatGPsneedtohavemoresensitivitytowardsME.

SomepeopleattheRichmondandKingstongrassrootsengagementactivitiesfeltthatGPswereunsupportivewhendiscussingmentalhealthconcernssuchasautism,ADHD,anxietyanddepression,andthatappointmentsweretooshorttotalkopenlyaboutsuchissues.SomesaidthatGPsweredismissiveofmentalhealthissuesandquicktoprescribemedicationasopposedtosuggestingotherservicesthatmayhelp.Formoreinformationonmentalhealth,seesection3.2.5.

SomepeoplecommentedthattherewasnotenoughinformationforcarersthatGPsshouldplacemoreemphasisonthementalwellbeingofcarers.

Somepeoplecommentedonissueswithprescriptions.PeopleexpressedfrustrationaroundthedelayinprescribingPrEPmedicationtothoseatriskofHIV.Individualsneedtobetreatedwithin72


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hoursofexposureandthereisconfusionaroundprescribingthismedication;whichoftencomesdowntowhoisfundingit.OtherscommentedthatitwasdifficulttogetB12injectionsprescribedforpatientssufferingfromME.

Otherconcerns

AfewpeoplecommentedthatitwasdifficulttoregisterwithaGP,andsomenotedthattheKingstonChurchesActiononHomelessnesswashelpingsomeregister.Homelesspeopleatthegrassrootsengagementactivitiesfeltthattheirpersonalcircumstancesrestrictedthemfromseekingmedicalhelp.

Afewpeopleatthegrassrootsengagementactivitieswereconcernedaboutsmallerpracticesclosingandmergingintohubs.PeoplebelievethatthismeansthatpatientswillneedtotravelfurthertoseeaGP,whichcouldbeparticularlydifficultforolderpeople,andmayencouragemorepeoplegoingtoA&E.

AfewpeopleattheKingstonandRichmondgrassrootsengagementactivitiescommentedonthelackofappointmentsavailablewithachiropodist,suggestingthatthereshouldbemorefrequentappointments,andmoreplacesthatofferchiropodyservices.


WhilepeoplewerebroadlysupportiveofthefocusonpreventionandearlyinterventionintheSTP,theyalsocautionedagainstthinkingitwouldbeeasytochangepeople’sbehaviour.Somesuggestedthatinformationandcommunicationisanimportantfirststepsothatpeopleunderstandwheretheycangoforwhatkindofsupport.Somepeoplelikedelementsoftheplan,suchasthefocusonpromotinghealthierlivingandaddressingobesity.

Localityteamsandcommunication

Severalpeoplesaidtheyliketheideaoflocalityteams,howevertherewerequestionsandconcernsabouthowtheseteamswouldfunctioninpractice.Oneparticipantwasconcernedthatintroducinglocalityteamswouldmeananotherlayerinanalreadycomplexhealthcaresystem.Anotherwasconcernedabouthowtoensurelocalityteamswouldbeintheplacestheyareneeded,withenoughlocalprovisionforall.OthersstillqueriedhowlocalityteamswouldworkinpracticegiventheshortageofGPs.

MostpeoplefeltcommunicationandinformationsharingbytheNHSamongstpractitionersandwithpatientswascurrentlyunsatisfactory.SomepeopleofferedsuggestionsforhowcommunicationandinformationsharingcouldworkbetterintheSTP.Suggestionsincluded:

• theneedforGPsandotherpractitionerstobeawareofallavailableservicesinanareaandcommunicatethisinformationtopatients;

• improvedonlinepublicinformationtosignpostservices;and

• provideenhancedcommunicationbetweenpractitionersaboutpatientstoreducetheneedforpatientstotellthesamestoryrepeatedly.


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Useofapps

Somehealthandcareforumpeoplelikedtheideaofusingsmartphoneappstohelpmanagetheirhealthandcare.Forexample,theycouldseebenefitssuchasbeingabletochecktheirownbloodpressure.However,theyalsoquestionedwhetherthisinformationwouldonlybeavailabletothepatientorwhetheritwouldbesentthroughtotheirGPoranotherhealthprofessionalwhocouldrespondiftherewassomethingconcerning.

Otherpeoplenotedthatdigitalappswillnotworkforeveryoneandthereshouldbealternativestosupportdiverseneedsandpreferences.Therewasalsoaconcernthatpatientsmightfeeltheyhavebeen‘fobbedoff’bybeingdirectedtoanapp,ratherthanbeingabletoseeahealthprofessional.

Workingwithnon-NHSresourcestosupportprevention

Peopleatthehealthandcareforums,aswellasthegrassrootsengagementactivitiesconsideredtheroleofcommunitysupport,andaperceptionthatGPsmaycurrentlybedealingwithanumberofpatientswhoseneedsaresocialratherthanmedical.Peoplefeltthatifsupportfromfamilies,friends,communitiesandthevoluntarysectorwasencouraged,thiswouldsupportthepreventionandearlyinterventionagenda.Oneparticipantdescribedthisasaculturalshiftinhowpeoplethinkabouttheirhealthandcare.

Therewasbroadagreementthatthevoluntarysectorcouldbemoreinvolvedinpreventionandearlyintervention,aslongastheydonotreplaceothermorehighlytrainedprofessionals.OneexampleofwherevolunteerscouldprovidesupportinadditiontocliniciancarewasvolunteersintheeyeunitatKingstonHospital,whoareperceivedtoplayavaluableroleinprovidinginformationandsupportaboutsightloss.Theparticipantwhosharedthisexamplefeltasimilarmodelcouldbeusedforotherconditionssuchasstrokes,buttheyemphasisedthatthevoluntarysectorneedsresourcestobeabletoprovidetheseservices,andsaidthattherewasahighinitialset-upcostforthisservice.

3.2.5 Mentalhealth

TherewereseveralconcernsaboutthequalityofexistingmentalhealthservicesinSouthWestLondon,withspecificreferencetoSt.George’sHospitalandTolworthHospital.OneparticipantdescribedattendingTolworthHospitalasastressfulexperienceforsomeonewithamentalhealthissue,withlongwaitingtimes,specialistsnotavailableandoftenonlylocumpsychiatrists.DespitecurrentandfutureconcernsaboutmentalhealthservicesandtheNHS,severalpeoplefeltRichmondmentalhealthserviceswereverygood.Thisqualityofcarewasattributedinparttohavingstronglocalvolunteersupportformentalhealthcare.

PraisewasgivenbypeopleattheKingstongrassrootsengagementactivitiesfortheRecoveryCollegeprovidedbySouthWestLondonandStGeorge’sMentalHealth.Oneindividualusedtheservicesandfeltitreallyimprovedherwellbeing.OtherscommentedthatvoluntaryserviceswerebetterthanNHSsupportandsomespecificallymentionedSoundmindBattersea.


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Improvementstocurrentservices

Atthegrassrootsengagementactivities,severalpeoplecommentedthatthereislittlesupportforthosesufferingfrommentalhealthcrises.PeoplementionedthatsomecarersturntoA&Eindesperationandfewcommentedearlydischarge,beforetheproblemhasbeentreated,contributestothis.

PeopleatthegrassrootsengagementactivitiesfeltthatthereisalackofparitybetweenthetreatmentofphysicalillnessandmentalhealthillnessbytheNHSandbelievethatphysicalhealthconditionsaretreatedbeforementalhealth.Peoplealsofeltthattherewasstigmaattachedtomentalhealthconcerns.Itwassuggestedthatmorementalhealtheducationwasneededforfrontlinestaffinprimaryandsecondarycare(includingreceptionists)tolearnhowtobemoresensitivetothosewithmentalhealthneeds.

Peoplediscussedfundingformentalhealthservices.Somehighlightedthatthebudgetallocatedformentalhealthwasunjustifiablylowgiventhehighprevalenceofmentalhealthissues,leadingtogapsinexistingmentalhealthprovision.Therewereafewsuggestionsthatbudgetsfromdifferentdepartmentsshouldbepooledtoprovidementalhealthservices,includingbudgetsfromtheNHS,localauthoritiesandpolice.

PeopleatthegrassrootsengagementactivitiesinRichmondcommentedthatpsychiatriccareisoftenchangedwithoutnotifyingpatients.Manyalsoraisedtheissueofhowlongtheyhadtowaittobereferredtoaspecialistserviceandthatitwasdifficulttogetadiagnosisformentalhealthissues.

Itwasalsonotedthatdiagnosisformentalhealthconditionssitsbetweendifferentorganisations,whichleadstoadisjointed,inefficientsystem.Manyadults(agedbetween35–52)spokentoatthegrassrootsengagementactivitieshadonlyrecentlybeendiagnosedwithADHD.Theynotedthattheyhadgonethroughthemajorityoftheiradultlivesbeingtoldtheyanumberofmentalhealthconditionssuchaspersonalitydisorders,depressionandanxietyinsteadofADHD.Severalpeoplenotedthatlatediagnosiscanhaveasignificantimpactandleadstothewrongmedicationbeingprescribed.

Responsetoproposals

PeoplewereinbroadagreementthatA&Eshouldnotbethefirstportofcallbecauseitisadisturbingplaceforsomeonewhoisinamentalhealthcrisis.Theyfeltitisparticularlyimportantfortheretobeout-of-hoursmentalhealthcaresomewhereotherthanA&E,sothatpeoplecanbetakentoamoreappropriateplaceofsafety.

Peoplesupportedtheideaofhavingcarenavigatorsformentalhealthbecausetheyfeltitwouldhelpreducetheneedtorepeatyourself-whichisparticularlydifficultduetothesensitivityoftenassociatedwithmentalhealthissues-andtosignposttotherightplaces.Oneexampleofaservicethatwasthoughttooffervaluablesignpostingtoothermentalhealthserviceswasthe‘CrisisCafé’inMerton.Somepeoplefeltthatprovidinginformalspacesforpeopletogainsupportforemergingorenduringmentalhealthissueswerejustasimportantasprovidingsupportduringcrises.


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PeopleraisedsomeconcernsabouttheplansformentalhealthintheSTP.Theserangedfrom:whethertherightresourceswereavailableforGPsandotherprofessionalstobetrainedtorecogniseandtreatmentalhealthissues,towhethersmallermentalhealthcharitieswouldexperienceincreasedcompetitionwithlargermentalhealthcharities,whichwasnotseenasidealbecauseitmightlimitthevarietyofservicesavailableinalocalarea.Althoughpeoplelikedtheideaofapsychiatricdecisionunit,somewereconcernedthiscouldmeanpatientswouldnotgetseenbyaspecialistuntiltheconditionhasprogressedtobeingclassifiedas‘severeorenduring’.

ManypeoplealsohadquestionsabouttheplansformentalhealthintheSTP.Forexample,oneparticipantwantedtoknowiftheproposalsaimedtokeeppeoplewithseriousmentalhealthissuesoutofresidentialcare.Otherpeoplewonderedhowphysicalandmentalhealthcarewouldbejoinedupinpractice.TherewerealsoafewRichmond-specificquestionsincludingwhattheoutcomeswouldbeforthePsychiatricUnitatSpringfieldHospital.

Makingtheproposalswork

Severalpeoplehadsuggestionsforwhatcouldmaketheproposalswork.Theseideasincludedrecognisingandaccommodatingdiverseneedsinmentalhealthservices(i.e.LGBTpatients,adolescentpatients,perinatalpatients),workingbetterwitharangeofvoluntarysectororganisationstoimprovecommunitycollaboration,morecoordinationbetweenNHSpractitioners(i.e.betweenGPsandIAPTprofessionals),andimprovingmentalhealtheducationtoalleviatestigmasomorepeopleaskformentalhealthsupportsooner.PeopleatthegrassrootsengagementactivitiesinKingstoncommentedthatthereisaparticularstigmasurroundingmentalhealthintheKoreancommunitywhichneedstobeovercome.

Mentalhealthservicesforchildrenandyoungpeoplewerediscussed.Somepeoplefeltthatmoresustainedsupportshouldbeprovidedforyoungpeople,fromanearlystageinanymentalhealthcondition,andthataholisticapproachshouldbetakentoprovidingthissupport.Theyfeltthatparentsandschoolsarecurrentlylefttomanagebythemselvesfortoolongbeforeanysupportisavailable.

ManypeoplefeltthattheNHSwasnotasgoodasitcouldbeatworkingwithavarietyofservicesthatpromotementalhealth.PeoplediscussedadesirefortheNHStoprioritisecollaborationbetweenandsignpostingtomentalhealthservices,aswellasotherservicessuchasschools,voluntaryorganisations,organisationsthatsupporthomelesspeopleorveterans,andthecriminaljusticesystem.

Somepeopleatboththeforumsandgrassrootsengagementactivitiesalsofeltthatthepublicshouldbebetterinformedabouthowtosupportpeoplepresentingmentalhealthissuesandthatschoolsandcommunityorganisationscouldbesensibleplacestopromotementalhealthawareness.


Severalpeopleatthegrassrootsengagementactivitiescommentedontheprovisionsforpatientswithlearningdisabilities,andtheirparents.Theythoughtthatparentsofchildrenwithlearningdisabilitiesshouldhavemoresupportfortheirownhealthandwellbeing.


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PeoplealsocommentedontheaccessibilityofGPpracticesforpatientsinwheelchairs.Forexample,oneparticipantmentionedthatthereneededtobemoreaccessrampsattheSurbitonhealthcentre.

ItwasnotedthatnotallGPsurgeriesinvitepeoplewithalearningdisabilitytoanannualhealthcheck.PeopleinthegrassrootsengagementactivitiesfeltstronglythattheGPsshouldwritetothepatientinadvancetoremindthemtobooktheseannualchecks.EveryonefeltthattheannualhealthcheckisanextremelyimportantappointmentandGPsshouldtakethetimediscussandexplainwhattheyaredoing.However,manypeoplehadneverheardofthisservice.

Peoplenotedthatthereisalackofcommunicationbetweenservicesandthishasanimpactoncarethatisbeingdeliveredforpatientswithcomplexissues.


Peoplewhodiscussedtheproposalsforchildren’sservicesagreedthatthereisaneedforchangeinthisarea.PeoplehadconcernsabouttheperceivedlackofNHSfundingandwonderedhowtheNHScouldmaketheproposalsforchildren’sservicesworkinpractice.Forexample,peopleworriedaboutnothavingenoughtrainedGPsandmidwives.Oneparticipantfeltthat24-hourcarewouldnotbepossiblebecauseofinsufficientstaffavailabilityandanothersuggestedthatamalgamatinghealthbudgetsandsocialcarebudgetsmayalleviatepressureonservices.

AvoidingunnecessaryA&Eusage

TheyagreedthatunnecessaryvisitstoA&Eshouldbediscouraged,butfeltthataccesstoGPsisnotworkingformanyparents.Somehighlightedthatexistingalternativeservices,suchastheNHS111service,arenotalwayseffectiveforparentsiftheyareworriedabouttheirchildastheyfeelmorereassuredbyseeingsomeoneinperson.

MostpeoplefelttheNHSdoesnotcommunicatewellwiththepubliconoptionsforwhereparentscantakeillchildren.PeoplehadarangeofsuggestionsforhowtheNHScandeterparentsfrommakingA&Etheirfirstportofcall.Suggestionsincluded:

• signpostingparentsandcarerstootherservicesuponarrivalatA&E,

• GPsandnursesbeingbetterinformedtosignpostparentstootherservicesduringregularappointments,

• targetinglocalschoolswithinformationaboutchildren’sservices,and

• providingcommunitypaediatricnursesinlocalityteams.

AccesstoGPswasimportantforpeopleandtheyemphasisedthatparentsneedGPappointmentstobeavailableafterworkhoursandsevendaysaweek.Somesuggestedthattherecouldbededicatedappointmenttimesavailableforchildren;someweresupportiveofusingtechnologysuchasSkypeforremoteappointments;andawalk-inclinicforfirst-stagediagnosiswasalsosuggested.Ifchildrendoneedtogotohospital,specialistunitssuchasthepaediatricassessmentunitatKingstonHospitalwerereferredtoasgoodmodelsofcare,orafurthersuggestionwashavingaccesstoaGPinahospitalsetting.


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Isolationwasraisedasasignificantbarriertotheimplementationofchangestochildren’sservices.Peoplesaidthatwhenparentsareisolatedwithfewsocialnetworks,theyaremorefearfulandlessconfidentabouttheirchild’scare,sotheyaremorelikelytogotoahospitalasthefirstportofcall.TheyfeltthiscouldparticularlybethecaseforpeoplewithEnglishasasecondlanguageandpeoplesuggestedtheSTPcouldbetteraddresstheneedsofdiverseorvulnerableparents

ChildandAdolescentMentalHealthServices

Peoplefeltthatspecialistsupportforchildrenwithmentalhealthissuesneedstobeaddressedmorethoroughlyintheproposals.Thisshouldincludeclarityaboutwhatamentalhealthissueforchildrenis;availabilityofpractitionerswhospecialiseinchildren’smentalhealth;andsupportforparentswithchildrenwhohavementalhealthissues.

Forparentswithchildrenwithspecialeducationalneedsanddisabilities,peoplesuggestedthatdirectroutestoservicessuchasoccupationaltherapy,speechtherapy,andnursescouldhelpthechildgetwhattheyneedandreducetheburdenonGPsandhospitals.

Person-centredcare

Althoughingeneral,peoplewereinsupportofout-of-hospitalcareforchildren,theyemphasisedtheimportanceofflexibleservicesthatmeetdifferentparents’needs,insteadoftakinga‘onesizefitsall’approach.

Atthegrassrootsengagementactivitiespeoplecommentedthatthereisalackofspecificsupportforchildrenwhoaretransgender,anddespitetherebeingresearchtosuggestthatautisticchildrenhaveahigherrateofbecomingtransgenderthanotherindividuals,thereisnospecificservicesinplacetosupportthem.

SomepeoplecommentedthatthereneedstobemoreawarenessintheNHSofthelinkbetweenchildrenwithhearinglossandbehaviouralissuesandprovideaccesstoCAMHSservicesspecificallyforthesepatients.

SomecommentedthattheprivateservicesarebetterthanNHStherapistsforthosewithspeechandhearingissues,astheyaremoretailoredandconsistent.Afewmentionthatthereisadifferenceinservicesofferedtochildrenwithunilateral(hearinglossinoneearonly)andbilateralhearingloss(bothears).


Peopleagreedwiththeoverallproposalsformaternityservicesandthatchangeisneeded.Theirownexperiencewasthatthereiscurrentlyalackofcontinuityofcare,andtheyweresupportiveoftheaspirationtoaddressthisissueandtoimprovepersonalisationandchoice.

Generally,peoplethoughtpre-natalcareinRichmondwasgood,birthingcarewasverygoodandpost-natalcarewaspoor.Kingstonwashighlythoughtofbothintermsofcareandprivateroomsandstaffwerehighlypraisedbyseveralpeople.Conversely,somepeopleexpressedcriticismforthelevelofcareatKingstonHospital,sayingthatlocumnursesdidnotseemtocareaboutthemotherorchildren.


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Therewasafeelingthatmorepersonalisedmaternitycarewouldenableamoreholisticapproach,wherewomenfeellistenedtoandunderstood,ratherthanexperiencing‘box-ticking’exercises.However,somepeoplequeriedwhatchoicereallymeansinthecontextofmaternitycareandwhetheritextendsbeyondchoosingwhichhospitaltogivebirthin.

Therewereconcernsaboutacurrentlackoftrainedmidwives,andpeoplequestionedhowthiswouldbeaddressedaspartoftheSTP.AtleastoneparticipantfeltthatthiswouldbeexacerbatedbyBrexit.Peoplegenerallythoughtthatprovidingadequatestaffformaternitycareshouldbeprioritisedoverprovidingpregnantwomenwithchoicesabouthercare.Forexample,oneparticipantwasconcernedthatifwomenhadmorechoiceovertheircareduringandafterpregnancy,somewouldnotmakesafeorhealthychoiceswithoutadviceorguidancefromapractitioner.Atleastoneparticipantthoughtpersonalisedcarewasmoreimportantafterthemotherhadgivenbirth,ratherthanbefore.

PeoplefelttheSTPproposalsshouldgivemoreconsiderationofoutreachtoindividualswithdiverseneeds.Thisincludessupportnotjustforthepregnantpatient,buttoherpartner,ortootherfamilymemberswhomaybesupportingher;aswellastopregnantwomenfromcommunitieswithEnglishasasecondlanguageandherfamily,orpregnantwomenwhodonottypicallyaccesshealthcare.

Peoplewereconcernedaboutsafeguardingpregnantpatientsandsomepeoplethoughtamedicalisedapproachtomaternitycareisabarriertohavingconversationswheresafeguardingrisksandconcernscouldcometolight.Forexample,somepeoplefeltpersonalisedandholisticcareandoutreachcouldhelpidentifywomenwhoareexperiencingorareatriskofdomesticviolence,especiallyduringpregnancy.

Peoplealsodiscussedthetypesofsupporttheythoughtweremostimportanttoprioritiseforpregnancyandpost-partumcare.Peoplefelttherewasaneedforpost-natalclassestobeavailabletowomenaftertheyhavegivenbirth.AtleastoneparticipantfelttheNHScoulddomoretoencouragenewfatherstoparticipateinpost-natallearningtohelpcarefornew-bornchildrenormothers,especiallyifthemotherwassufferingfrompost-partumdepression.Anotherparticipantemphasisedthatmentalhealthsupportfordepressionduringpregnancywasimportant.

Overall,peoplesupportedtheideaofhavinggreaterconsistencyincarefrommidwivesandhavingpost-natalhealthvisitorsforadditionalsupport,thoughtheyemphasisedtheneedforrecruitingandretainingmoremidwivesaswell.

3.2.9 Cancer

Severalpeopleatthegrassrootsengagementactivitiescommentedoncancerservices.Afewsaidthatsupportshouldbegiventopatientsafteradiagnosis,withconcernsspecificallyforpeoplelivingalonewhocanfeelisolatedafteradiagnosis.

Peopleexpressedtheimportanceofanearlydiagnosis,andmanysharedexperienceswherediagnoseswerewrong,ortheprognosiswasdeliveredtactlessly.Peoplenotedthatitwouldbehelpfultohaveafollowupappointmenttodiscussanyquestionsthatmaynothavebeenaskedimmediatelyupondiagnosis.


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Peoplesaidthatthequalityofcaretheyreceivedvarieddependingonwhattimeofyeartheywerediagnosedwithcancer,duetothestaffchangeoverinJuly,andwereconcernedthatthiscouldinterruptcare.PeoplealsofeltthatGPsshouldbemoreinvolvedintheirtreatment,findingouttheresultsofsurgeriesandcaringaboutthepatient’swellbeing,asopposedtomerelytreatingthecondition.

SomepeoplepraisedtheWestMiddlesexCancerservicesandtheRoyalMarsdenforthetreatmenttheyreceived.Afewpeoplecommentedthattheyhadusedthe‘onestopshop’centreinKingstonandsaiditwasefficientfortestingandtreatment,butitwasnotgoodatemotionallysupportingpatients.Severalpeoplecommentedthattherewasabiglackinsupportfollowingcancertreatment.

3.2.10 PlannedCare

Manypeoplecommentedontheneedforadequatetransportforplannedhospitalappointments.Severalsaidthatthereareusuallydelayswithtransportation.Somealsocommentedthattypicallyseatedambulancesarebooked,andthatthesearenotalwaysappropriate.Forexample,peoplewithMEcanstruggletositforlongperiodsoftime.

AlthoughKingstonHospitalisconsideredveryaccessibleintermsofpublictransport,fortheindividualswhoneedtodrivepeoplefeltthatcarparkingchargesshouldbefreeoratareducedcost.

Severalpeoplecommentedonalastminutecancellations,orlongdelaysforplannedhospitalappointments.InparticularpeoplecommentedonthelongwaitingtimesatKingstonHospitaleyeclinic.

AfewpeoplecommentedthattheyhadpoorexperiencesofdoctorswithinKingstonHospital,nothavingaclearunderstandingofMEandhowtodiagnosisthecondition.


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3.3 MertonandWandsworth




14thMarch,2017 44






AcrossthehealthandcareforumsandgrassrootsengagementactivitiesinMertonandWandsworth,threediscussiontopicswereverypopular:careclosertohome,preventionandearlyintervention,andmentalhealth.Sevendayacuteserviceshadamoderatelevelofinterest,andthematernityservicestopicwasslightlylesspopular.

MostpeopleinMertonandWandsworthwereveryengagedwiththeSTPplans,andwelcomedtheproposals.However,therewereconcernsfrompeopleabouttheabilitytoimplementtheseproposalsduetoarangeofconstraints,includingfundingandstaffingpressures.

Formanypeople,theirprimaryconcernwasuncertaintyinNHSfunding.Theyfeltthatitwasnotclearwherefundingwouldcomefromandwhetheritwouldbesufficienttodeliveronthetransformationgoals.Someclarificationoradditionaldetailsofthefinancialmodelsupportingtheplanswererequested.

Otherswereconcernedabouthowstaffwouldbeattractedandretainedtodelivertheplans,especiallyinlightofupcomingchangessuchasBrexitandtheriseoflivingcostsinLondon.

Theproposednewrolesofcarecoordinatorsandlocalityteamswereseenpositivelyashelpfulandappropriateadditionstothecaresystem.Thereweremanyquestionsregardinghowthesewouldwork,andpeopleaskedformoredetailandspecificinformationabouttheseproposedchanges.Therewerealsorequestsformoreinformationaboutthehospitalbedreductiontargets.Somepeopleexpressedconcernthatthesetargetswouldnotbemet,andaskedforassurancesthattherewasprovisionforadditionalresourcesduringthetransitionperiod.OthersquestionedhowaccesstoGPswouldbeimproved,emphasisingtheimportanceofaddressingthisissuetosupporttheotheraspirationsintheSTP.

Peoplesupportedtheideaofencouragingindividualstotakemoreresponsibilityfortheirownhealthandlifestylesbutemphasisedthatacultureshiftisrequiredforthistobesuccessful.


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Overallpeoplesupportedtheproposalsforsevendayservicesintheory,andlikedtheflexibilityandopportunitiesforspecialisationitwouldoffer,butwereconcernedthattheywouldbechallengingtoimplementandthatitmightbecomeover-centralised

ThereisaneedtoeducatepeopleaboutwhichalternativeservicesaremostappropriatetouseinsteadofA&E,andpotentiallychargepeopleformisuseofservices

SomeconcernsaboutalternativesasGPsarealreadyverybusy,andmanywerenotawareofNHS111.

Therewassupportforlocalityteamsaslongastheyhadsufficienttimetocareforpatients.

PeopledescribedpoorexperiencesinA&Eandacuteservicesincludinginappropriatewaitingareas,abrupthealthcarestaff,communicationissuesandearlydischarge


Mostpeoplesupportedtheproposalsforhavingmorecareclosertohomeandfeltthatsuccesswouldbereliantonfunding,training,goodaccesstopatientdata,strongconnectiontolocalinfrastructureandimprovedITsystems.

PeoplereporteddifficultiesgettingGPappointmentsanddiscomfortwithreceptionistsactingas‘gate-keepers’.TherearesomeconcernsaboutcommunicationwithGPs,withsomespecificexamplesofculturaldifferencesleadingtoproblems

Mostwerecomfortablewithaskingpharmacistsforadviceaslongasprivacycouldbemaintained,althoughtherewereconcernsaboutcapacity

TherewereconcernsaboutNHS111,andsomefeltitwoulddirectmorepeopletoA&E,ratherthanless.

Therewassupportforincreasedintegrationwiththevoluntarysectorwithexamplesofwherethisworkswell

Peoplewantmoreinformationaboutcarenavigatorsandsupportedtheideaofhealthchampionsonlocalityteams

Somewouldwelcomeincreaseduseoftechnologybuthadmixedexperiencesandraisedconcernsaboutthesecurityofonlineservices

TherewereconcernsthatGPsaretooquicktomedicalisementalhealthconditions


Whilesupportingtheneedforchangepeoplewantedmoreinformationaboutthedetailsoftheprevention


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Peoplewereconcerneditwouldbedifficulttofundpreventionaswellastreatment,althoughtheyrecognisedtheneedtoinvest

Theyfeltbehaviourchangewouldbeneededinstaffaswellaspatientsinordertoimprovepreventionoutcomes

Theylikedtheideasoflocalityteamsinthiscontext,althoughwantedtomakesurethisdidnotexcludetheinvolvementofcommunitybasedorganisations

Therewassomeconcernthatthevoluntarysectormightbereliedupontooheavilyunlessfundingwasavailabletosupportthem

Mentalhealth

GeneralagreementthatMHneedsarenotcurrentlybeingmetandadesireformoreinformationabouttheplansintheSTP

Viewthatthereisnotsufficientfundingcurrentlyandquestionsaboutwhethermorewouldbeavailable

SomeconcernaboutincreasedemphasisonGPs,givendifficultyinaccessingappointmentsandtendencyforGPstomedicaliseMH

RecognisedaneedforincreasedMHeducationinthecommunitythrougharangeofchannelstodemystifyMH

Encouragementtoensureearlyinterventionaswellasimprovingcrisiscare

Supportforplanstointegratementalandphysicalhealth

ConcernsaboutChildren’sMHservicesincludinglongwaitingtimesanddifficultytransitioningtoadultservices.


Limitedpeoplerespondedbutemphasisedimportanceoftailoringservicestoindividualneeds,balancedwithaneedforconsistencyintheservicesavailable.


Fewerpeoplecommentedontheseservicesbutthosewhodidsupportedtheproposalsoverall.

TheythoughtprovidingalternativestoA&Eisimportant,andhighlightedtheimportanceofmoreflexibleaccesstoGPs

Theywereopentouseoftechnologyandtelephoneappointmentstosupportflexibleaccess

Thedifficultytransportingunwellchildrenwasidentifiedasanimportantconsiderationwhenmakingchangestoservices

Communicationofrangeofservicesisimportant,andshouldstartduringpregnancy

Itisimportantthattheplansprovideforholisticandpatientcentredcarethatisabletomeettheadditionalneedsofchildren–forexamplethosewithautismorleadingdisabilities.


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Maternityservices

Viewedthematernityplansaspositivebutunambitious

Agreedwithinclusionofperinatalandmentalhealthservicesintheplan,andthoughttherearesomegoodservicese.g.inWandsworth,thatMertoncanlearnfrom

Reflectedonnationalshortageofmidwivesandimportanceoffocussingonwhatthepatientreallyneeds,whilealsohelpingmidwivestakecareofthemselves

Supportiveofplanstoincreasechoice,butalsorecommendedmanagingexpectationssothatmothersarenotdisappointedlater

Someconcernthatcurrentservicesare‘hitandmiss’andthatstaffcouldbenefitfrommoretrainingtoensureconsistentcarelevels

Needformoresupportaftermiscarriage

Cancerservices

Therewerenotmanycommentsaboutcancer.Issueswithreferrals,supportandthewaydiagnosiswasdeliveredwerethemainpointsraised

PlannedCare Fewpeoplementionedplannedcareexcepttosaythatwaitinglistsaretoolongforarangeofservices.


Overall,peoplesupportedtheproposalsforsevendayacuteservicesandbelievedtheyweregoinginasensibledirection.TherewereconflictingviewsinWandsworthastowhethertheplanswouldworkinpracticeandMertonpeoplefeltpracticaldetailswereneededtoincludemorespecificsaboutthesavingsandhowmuchfundingwouldbeprovidedforthechanges.

Feasibility

ManypeopleintheWandsworthhealthandcareforumthoughttheplanwouldnotbesuccessful.ThemainreasonswereaperceptionthattheNHSdoesnothaveatrackrecordofmanagingchangewellandthattheNHSdoesnothavesufficientfundingtodeliverthechangeseffectively.ManyWandsworthpeoplefeltthechangeswerebeingproposedtoolate.Severalpeoplewerefrustratedthatwaitingtimeswerelongandbuildingswereinpoorconditionandfelttheseissuesshouldhavebeenaddressedsooner.Oneparticipantsaidthescaleofchangescouldnotbedeliveredin5yearsandtheNHSwouldneedmoretimeforimplementation.

Peopleraisedconcernsaboutpracticalconstraintsthatcouldhinderthesuccessoftheproposals.Therewereconcernsaboutstaffrequirements,particularlywhenthereisashortageofGPswithinthecurrentmodelofcare.Somepeoplewereconcernedthatcommunityserviceswouldbeaskedtotakeagreatercaseloadwithoutadditionalfundingorcapacityandoneparticipantwasconcernedaboutadipinservicequalityoverweekends.Therewerealsoworriesthatlargerhospitalswouldlosetheadvantageofbeinga‘one-stop-shop’forservicesifdepartmentshaddifferenttimetables.


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Otherchallengesraisedwerealackofsocialcarefundingtosupportpatientsoncetheylefthospital;andalackofinformationandknowledgeaboutwherepatientscanaccesscareoutsideofhospitals

SomepeoplesharedpositiveviewsabouttheproposalsforsevendayservicesintheSTP.Forexample,Mertonpeopleinthehealthandcareforumsviewedsevendayacuteservicesasflexibletosupportdifferentneedsandthoughtthisapproachwouldreducecongestion.

AfewWandsworthpeoplesaidtheyhadgoodexperienceswithcareinthearea(e.g.quickaccesstoavarietyofservices;additionalcarelocationsacrosstheriverareeasytoaccess),andfeltthatbecausethereareoptionsforcare,thattheproposedchangeswouldnotsignificantlyimpactthem(negativelyorpositively).

AlternativestoA&E

MertonpeopleagreedwiththeproposaltoreduceA&Evisits,butwereconcernedthattherewerefewalternatives,forexamplemostreporteddifficultygettingaGPappointmentwhentheyneededone,althoughonlinebookingwasseenasimprovingconvenience.Theyfeltthatmorepeoplewouldneededucationaboutwhichalternativeserviceismostappropriate,anditwassuggestedthatthiswouldparticularlybenefitthosenotfamiliarwiththeUKhealthsystem.Peopleatthegrassrootsengagementactivitiesnotedthattherewerefewalternativeoptionsforurgenthealthneedsafter6pm.

AcoupleofpeopleattheWandsworthhealthandcareforumssaidthatthehospital’stieredapproachtoA&Ecare(i.e.differentareasdependingontheseverityofneed)wasefficient.ThesepeoplealsosuggestedthatpatientscouldbechargedformissingappointmentsormisuseofA&EtohelpreducetheinstancesofunnecessaryvisitstoA&E.PeoplealsoquestionedwhypatientswhodonotneedtobeinA&Earenotsenttootherlocationsuponarrival.

PeoplefeltthatmoreeducationandpromotionwasneededaroundNHS111andwhentouseit.AfewpeoplesharedpositiveexperiencesusingNHS111.Oneparticipantexpressedthatachild’shealthwastooimportanttoriskusingNHS111,andtheywouldalwaysgotoA&E.

PeopleattheMertongrassrootsengagementactivitiescommentedthatiftheywereunabletogetaGPappointmentthattheywouldtrytogotoawalk-inclinic,suchasWilsonHealthCentreortheCroydonwalk-inservice.TheycommentedthatthiswasmorepleasantthangoingtoA&E.Somepeopleatthegrassrootsengagementactivitiescommentedthatalthoughtheserviceatthehubsisgood,itislesspersonalthangoingtoalocalGP.

SpecialisationoflargersiteswassupportedbyMertonhealthandcareforumpeople,whobelievedthetrade-offintravelwouldbeneededtoconcentratemedicalexpertiseandhighqualityservices.Somepeoplecautionedaboutover-centralisation,astheywereconcernedthatthiscouldleadtoareductioninthequalityofcommunityservices.Tosupportthis,additionalresourcesforcommunityservicesweresuggestedforthetransition.

Localityteams

Peopleatthehealthandcareforumsexpressedsupportfortheproposedlocalityteams,andfeltitwouldallowmorecareathometoreducehospitalusage.Peoplewouldlikehealthvisitorstohave


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moretimetocarefortheirpatients,ratherthanwhatsomefeltwasoverlycomputerisedmedicinemanagement.Theyalsoexpressedconcernsaboutthecurrentdifficultyinrecruitingandretainingnurses,andtheimpactthiscouldhaveonimplementationoftheproposalforsevendayacuteservices.

ExperiencesofA&E

PeopleattheWandsworthgrassrootsengagementactivitiesnotedthatStGeorge’sA&Ehasaparticularlypoorwaitingareawhichisnotfitforpurpose.Theysaidthatstaffwerebadatkeepingpatientsinformedastowhentheywouldbeseen.SomepeoplealsonotedthelongwaitingtimestopickupprescriptionsatStGeorge’s.

AnumberofpeopleattheMertonandWandsworthgrassrootsengagementactivitiescommentedthatnursescouldberudeandabrupt.Severalpeoplesharedanecdoteswherenurseswerenotacceptingofchildrenwithlearningneeds.Itwasfeltthathospitalstaffshouldundergotraininginhowtotreatapatientwithautism.

AfewpeoplecommentedthatmentalcrisisisnottakenseriouslyinA&Eandthatstaffneededtobetterunderstandmentalhealthconditions.Theyfeltthatthereneededtobeaquieter‘safe’spacetowaittobeseen.Formoredetailsonmentalhealthservices,seesection3.3.5.

Acutehospitalservices

Severalpeoplenotedcommunicationissues,wheredoctorsaskedforembarrassinginformationwithoutreadingpatients’filesandsomecommentedthathospitalstaff’sbedsidemannercouldbeimproved,particularlyatCroydonUniversityHospital.

Peopleatthegrassrootsengagementactivitiesexpressedtheviewthatpatientswerebeingdischargedfromhospitalwithoutbeingmedicallyfitandthatlittleinformationisgivenaboutat-homecare.

AnumberofpeoplecommentedonthesinglesexwardsatStHelier,andnotedcaseswheretransgenderpatientswereputonthesamewardastheirbirthgenderwhichmadethemfeelveryuncomfortable.Peoplealsocommentedthattheyfeltuncomfortabledisclosingtheirgenderwhichcouldimpactcare.

PeoplefeltfrustratedthatparkingwassoexpensiveatStGeorge’s,asthiscanaccrueabigfareandalsoputspeopleoffvisitingrelatives.


PeopleattheMertonandWandsworthhealthandcareforumssupportedproposalsforhavingmorecareclosertohome.Theyidentifiedseveralkeysuccessfactorsincludingfunding,training,accesstopatientdata,strongconnectiontolocalinfrastructureandimprovedITsystems(forexampletolinkdifferentservicesorprofessionalsinvolvedinapatient’scare,ortouseSkypewithpatients).


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Feasibility

Despitehigh-levelsupport,manypeopleidentifiedchallengestoachievingtheplanandtherewassomescepticismabouthowitcouldworkinpractice.Thesechallengesincluded:

• Alackofintegrationbetweenhealthandsocialcare,includingpatientsremaininginhospitallongerthannecessarybecausenosupportwasavailableoutsideofhospital,andinsufficientcommunicationarrangementsbetweenservices;

• InsufficientcoordinationofNHSservicesandstaffinternally;

• AlackofGPs;

• AlackofinformationandawarenessonalternativestoA&E,meaningpeopleoftendidnotknowwhereelsetogo.

Workingwiththevoluntarysector

Mertonhealthandcareforumpeoplesuggestedthatintegrationwiththevoluntarysectorwasimportantandneededtobeimproved.Forexample,inendoflifecarehospiceswouldpotentiallybeabletoreduceNHScaseload.Theyalsofeltthereshouldbebetterintegrationwiththelocalauthority,becausetheythoughtthiscouldfacilitateaquickerdischargefromhospital.TheyreferredtoWellbeingteamsasgoodexamplesofacommunitybasedapproachtocare.

TherewereadditionalservicesMertonpeoplewantedtobedeliveredclosertohome,includingchronicillnessmanagementthroughschemessuchasLiveWell(alocalvoluntarygroup)whichmatchedpeoplewithprofessionalsandvolunteers.

Carenavigatorsandlocalityteams

Peoplewantedmoreinformationaboutthelocalityteams,andwhethertherewasadditionalfundingforthismodel.Wandsworthhealthandcareforumpeoplesupportedtheideaofcarenavigatorsbutfelttheyshouldbeusedmorestrategically,makingthemavailableinpublicplaceswherepeoplegotoanywaysuchasneighbourhoodshoppingareas.

PeoplewerefrustratedthatGPswereunabletosignpostpeopletodifferentgroupsorservices.Somepeopleliketheideaofcarenavigatorstohelpdeliverjoinedupcare.ManyhadtodotheirownresearchtofindsupportgroupsandIAPTservices.Somepeoplefeltthatmoreshouldbedonetoencouragesocialprescribing.

PeopleintheMertonhealthandcareforumfeltanexpertinapatient’smedicalconditionwasneededonlocalityteamsandtheysupportedtheideaofHealthchampionsforthispurpose.

PeopleinWandsworthalsofeltitwasimportanttoprovidemoresupportforfamiliesandcarers,especiallytomanagetheneedsofageingpatients.OneparticipantsaidhavingdieticiansmorereadilyavailablecouldhelpkeeppeopleoutofA&E.

GPServices

Appointments


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ManypeopleattheMertonandseveralattheWandsworthgrassrootsengagementactivitiesdislikedthecurrentGPappointmentssystemandexpressedfrustrationthattheystruggledtogetsame-dayGPappointments.Somesaidthattheywouldbeonholdforuptoanhourwhentryingtomakeanappointmentandotherscommentedthattheycouldnevergetthrough.Somecommentedthatoncetheydidgetthroughafterthelongwait,allappointmentswouldalreadybegone.AfewsaidthatwhentheywereunabletogetanappointmenttheywouldgotoA&E.

Despitethis,somepeopleattheWandsworthgrassrootsengagementactivitieshadnotencounteredanydifficultygettingaGPappointment.Oneparticipantcommentedthattherearetwowalk-inclinicsaweekinherareaandanothersaidthattheyhadapositiveexperienceusingtheGPPoolingserviceswhereiftheirGPsurgeryisclosedortheycannotgetanappointment,theyarereferredtoanotheronenearby.

SeveralpeopleatthegrassrootsengagementactivitiesnotedthatGPappointmentswerenotlongenoughandexpressedfrustrationthattheyhadtobookdoubleappointmentsiftheyhadmorethanoneissuetodiscussandafewpeoplecommentedthattheydidnotlikethelackofcontinuityintermsofwhichGPtheysaw,whichtheyfeltdisruptscare.

GPCapacity

SomepeoplenotedthattherewasashortageoflocalGPsandtherewassomeconcernthatGPswerenolongerdoinghomevisitstothemostsickandvulnerable,whowouldstruggletocomeintoasurgery.AfewfeltthatGPsurgeriesshoulddomoretostoppatientsmissingappointments,suchaschargethem.

Receptionists

Manypeoplecommentedthatreceptionstaffareusedas‘gatekeepers’andseveralfeltuncomfortabledisclosingconfidentialinformationtoanon-clinician.Receptionists‘triaging’patientsseemedtobeacauseofanxietyforolderpatients,andtherewereconcernsaboutwhetherthereceptionswerequalifiedtomaketheseassessments.Therewasalsosomefrustrationsurroundingreceptionstaffgivingpatientstestresults,astheywereunabletoansweranyfollow-upquestions.

Referrals

SeveralpeopleatbothMertonandWandsworthgrassrootsengagementactivitiescommentedthatreferralstohospitalappointmentshadbeenlost,andithadbeenuptothepatienttochasethem.Theseadministrativeerrorsledtolongwaitingtimesforreferrals.PeoplefeltthatGPsandhospitalconsultantsshouldbeabletotalktoeachotherdirectlywithoutthepatientbeingthemiddleman.Severalcommentedthatimprovementsneededtobemadetothereferralssystemtoimprovethesedelays.

Communication

PeoplewantedtoseemoreinteractionbetweenGPsandpatients,forexamplegivingremindersforbloodtestsandappointments.SomefeltthatGPsdidnotcareaboutpatientsastheydidnotfollowup.OtherscommentedthatGPsseemeddisinterestedduringconsultations.


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AfewpeoplecommentedonculturalissueswhichtheybelievedhadimpactedonthequalityofcarethattheyreceivedfromaGP.SeveralpeopleinMertoncommentedthatMertonGPsurgeriesnolongerdoHIVtesting.ItwasfeltthatmoreshouldbedonetopromoteHIVtesting.

Manypeoplecommentedonalackofawarenessofspecificservices.Forexample,afewsaidtheywereunawareofannualhealthchecks.

SeveralpeoplecommentedthatGPsshouldbetrainedinhowtocommunicatewithchildrenwithlearningdisabilitiesandautism.

Pharmacy

AlmostallWandsworthhealthandcareforumpeoplesaidtheywouldfeelcomfortableaskingapharmacistforadviceifissuesofprivacy,includinghavingaprivateplacetomeetwiththepharmacist,wereaddressedandwellmanaged.Despitethissupport,variousconcernswereraised:

• pharmacieswouldnotbeabletomanageallthecommunityneeds;

• pharmacieswerebeingclosed;

• theremightberesistancetodirectingpeopletopharmacistsfromGPsurgeriesasitmightbeagainsttheGP’sbusinessinterests;

• personalviewsorbeliefsofpharmacistsmightinfluencethetreatmentandadvicetheyprovide.

SomepeoplehadqueriesaboutoperationaldetailsofusingpharmacistsinsteadofGPs,suchaswhetherandhowcommunicationwouldbesharedbetweenpharmacistsandGPs;howpatientinformationgatheredbypharmacistswouldbestored;andwhetherpharmacistswouldbefinanciallycompensatedforhavingalargerworkload.

NHS111

WandsworthpeoplewereconcernedaboutthecurrentNHS111service.Forexample,theywonderedhowtheservicewouldfitintotheplansincetheyfeltNHS111oftendirectspeopletoA&E,ratherthannon-A&Esites.Further,somepeopledidnotliketheideaofusingNHS111morebecausetheypreferredspeakingtoapractitionerinperson,whilesomefeltNHS111staffdonotcommunicatewell(e.g.staffasktoomanyquestionsduringacall).

Useoftechnology

AfewpeopleattheMertonandWandsworthgrassrootsengagementactivitiescommentedthattheywouldliketheabilitytobooknon-urgentappointmentsinadvance,andsomewelcomedtheprospectoftelephoneconsultationsbutrequestedmoreinformation.SeveralpeoplelikedthattheyreceivedatextfromtheirGPtoremindthemofwhentheirappointmentwas.

Peoplehadmixedexperienceswithonlineservices.Somehadused‘PatientOnline’butmostwereunawareitwasanoptionandsaidthattheywouldnotusetheserviceastheydidnotusetheinternet.Othersweremorepositiveandsaidtheywouldconsiderusingitandfeltthatitshouldbe


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betterpromoted.Aparticipantwhohadusedtheservicescommentedthatitwasdifficulttonavigatethebookingssystem.Afewpeoplefeltthattheirprivacywouldbecompromisedbyusingonlineservices,andwereconcernedaboutdatahackingandleaks.Somepeoplelikedthefacttheycouldemailtheirsurgery.

MentalHealth

PeopletheMertonandWandsworthgrassrootsengagementeventsfeltthatGPsweretooquickatprescribingmedication,particularlyformentalhealthconditions,ratherthanseekingalternativeoptions.Peoplenotedthatthesecanoftenbeaddictive,arenotexplainedproperly,andtacklethesymptomsinsteadofthecausesofmentalhealthissues.

SomefeltthattheirGPsdidnotunderstandmentalhealthconditionsandpeoplewantedmoresupportforthemselvesandtheirfamiliestounderstandtheirmentalhealthconditioninmoredetail.Anexamplewouldbecounsellingfromthecommunitymentalhealthteamforfamiliesandcarerssothattheyareabletounderstandwhattheindividualisgoingthrough.FormoredetailsonmentalhealthservicesinMertonandWandsworth,seesection3.3.5

PeopleattheMertongrassrootsengagementactivitiesfeltthattheirconditionswerebeinglookedatone-by-oneinsteadofasawholepersonandthattherewasadisconnectbetweenphysicalandmentalhealthissues.Theysuggestedthatanintegratedandcoordinatedapproachtohealthcarewouldparticularlybenefitpatientswithlearningdisabilities,whooftenhaveavarietyofmedicalproblems.

PeoplealsofeltthatNHSservicesshouldworkmorecloselywithsocialcare.OneparticipantcommentedthatGPsshouldhavebetterknowledgeofexistingservicesandthatinformationshouldbeeasilyrelayedbetweentheseservicesforjointupcare.

Other

SomepeopleattheMertongrassrootsengagementeventsfeltthattherewasaneedforanewGPhub,asthecurrentsurgeryisrundown.TherewasmuchpraiseforthenewlybuiltNelsonHealthcentre,andpeopleappreciatedhavingseveralcomplimentaryservicesunderoneroof.

PeoplecommentedthatthegeneralenvironmentinGPsurgeriesshoulddisabilityfriendly.

Somepeopleexpressedfrustrationwiththecurrentcomplaintssystems,andfelttheseshouldbeupdatedtoallowforface-to-facecomplaints.


Overall,whilesupportingtheneedforchange,peopleattheMertonandWandsworthhealthandcareforumswantedmoreinformationaboutthedetailsofthepreventionservices.Mertonpeoplecautionedagainstcontinuedconsultationwithoutafinalplan,aswellassuggestingtheneedtotakelearningsfromprevioustransformations.

Mertonpeopleraisedconcernsoverlackoffundingandresources,aspeoplebelievedpublichealthfundinghadbeencutandtheNHSwouldstruggletofundpreventionaswellasacutecare.Manyfeltthatpreventionwasveryimportantasanagingpopulationwouldmeanmorecomplexneedsin


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thefutureunlessinterventionwasimplementednow.Astheybelievedearlyinterventionworkhasanimpactonhealthoutcomes15–20yearslater,theythoughtchangeswouldnotseeareductionindemandforservicesintheshortterm.Oneparticipantfeltthefocusshouldbeonqualityofyearsnotjustlongevity.

Peopleidentifiedseveralchallengesrelatingtobehaviourchangeandeducation.Somefeltthereisacurrentalackofinterestinpreventionandearlyinterventionfrommanyhealthprofessionals,whilstotherpeoplethoughtencouragingpreventionandearlyinterventioncouldbedangerous(e.g.oneparticipantfeltindividualsmightunderestimateahealthissueanddecidenottoseeksupport).Mertonhealthandcareforumpeoplesupportedpromotinghealthylifestylestomorepeople,andthoughtsignpostingtoservicesinlocalareaswouldhelpsupportchangingbehaviour.Theybelievedthepublicdidnotknowaboutalloptions,suchasmentalhealthservicesinthearea,andsuggestedGPshavealistofservicestheycouldsignpostto.Morerealistichealthylivingadvocatesandrolemodelsweresuggestedtoencouragepeopletoseekmoreinformation.

Localityteams

PeopleattheMertonandWandsworthhealthandcareforumslikedthelocalityteamsworkingtosupportpeoplefromdifferentagenciestogether,providingintegratedhealthcareintheircommunity.However,someWandsworthpeoplewereconcernedthatcommunity-basedorganisationscouldbeforgottenasausefulresource,andoneparticipantfeltlocalityteamspresentedariskbecausetheywereanun-testedservice.

Peoplehadquestionsabouthowlocalityteamswouldbeimplemented,whowouldcoordinatethem,whichprofessionalswouldbeincluded,whatareatheywouldcover,howtocontactthem,andthelevelofsupportthatwouldbeprovidedforpatients.Otherquestionsraisedbypeopleincluded:

• theroleofcarenavigatorsastheyfelttheseroleswerenotclearlydefined,forexample,howwouldthisroledifferfromreceptionistswhodirecttoservices;

• moredetailsaboutinterventionsforobesityanddiabetesandhowthiswouldbemanagedbyaGP;

• howworkplaceswouldbeinvolvedinmeetingtheobjectivesofthepreventionandearlyinterventionplansintheSTP.

Voluntaryorganisations

Mertonhealthandcareforumpeoplealsodiscussedtheroleofvoluntaryandcommunityservicesinthistransformationplan,whichsomefeltmightbereliedupontooheavily.Somepartnershipswereworkingwell,suchasLiveWell(alocalvoluntarygroup),asthesegroupsunderstandtheneedsincommunity.However,alackoffundingandcommunicationbetweenserviceswouldbeachallengetothesepartnerships.Adirectoryorforumtoshareideaslocallywassuggested,whichcouldhelpsupportthetransformationplan.

Peoplealsomadethefollowingsuggestions:

• thereshouldbeadditionalservicesforrecoveryandreablement,aswellasprevention;


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• makinguseoftechnology,includingapps,couldmakehealthcaremoreaccessible(however,othersthoughttechnologywouldnotbeuniversallyaccessible);

• socialprescribingorusingmorecommunity-basedhealthcareoptionswouldimprovehealthoutcomes.

3.3.5 Mentalhealth

ManyattendedtheMertonmentalhealthdiscussion,andagreedthatchangewasneeded.Theyfeltthereisaseriousneedformentalhealthservicesintheareawhichisnotbeingmet.Forexample,oneparticipantsaidtherewereincreasingnumbersofpeoplewithmentalhealthneedsinstatutoryservicesoronthestreet,aswellasinadequatesupportforcarers.

SomepeoplefelttherewasalackofinformationabouthowtheSTPproposalsformentalhealthwouldbecarriedout.Theywantedtoknowmoreabout

• whatamentalhealthteammightlooklike;

• thePsychiatricDecisionUnit,whetheritcurrentlyexistsandhowitwouldworkinpractise;

• whetherGPshavesufficientcapacityandtrainingtoworkwitharangeofmentalhealthpractitionersinthecommunitytoimprovecare.

Feasibility

Concernswereraisedaboutthefeasibilityofproposals,giventhefundingchallengesintheNHS.Mertonhealthandcareforumpeoplebelievedtherewasnotenoughfundingformentalhealthservices,suchastalktherapy,meaningpatientsdidnotgetthefulltreatmenttheyneeded.Understaffedandunderpaidworkerswasalsoaconcern,asthenationallackofnurseswasmademoredifficultinLondonduetoexpensivelivingcosts.Theyquestionediffundingforchangeswouldbetakenfromexistingservices.

TherewereconcernsabouttheincreasedemphasisonuseofGPsinmentalhealthprovision.ManyWandsworthhealthandcareforumpeoplethoughtcurrentproblemsinaccessingaGP,includinglongwaitingtimesandinsufficientGPcapacity,couldhinderthementalhealthproposalsintheSTP.Asoutlinedabove(InSection3.3.3),someWandsworthpeoplefelttherewasatendencyforGPstoprescribemedicationsratherthanprescribingnon-medicalapproachessuchastalkingtherapyorsocialprescribing.SomepeopleattheMertongrassrootsengagementactivitiesnotedthatlonelinesscanoftencauseorexacerbatementalhealthproblemsandthatthisrequiredcommunitysupport.SeveralpeoplethoughttherethatGPslackedanoverallawarenessoftheIAPTprogramme.

Peoplealsosaidcarefordifferentvulnerablepopulations(e.g.ageing,young,orparents)wascurrentlyinconsistentandshouldbeimprovedaspartoftheproposals.Manypeoplecommentedonthelongwaitingtimesfor‘talkingtherapies’,whichforsomehastakenoverayear.


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SpringfieldUniversityHospital

PeopleattheMertonhealthandcareforumandgrassrootsengagementactivitiescommentedonSpringfieldUniversityHospital.SomepeopleexpressedconcernsthatreducingtheuseofbedsinSpringfieldHospitalwouldleadtolongertraveltimesforpatients.OtherscommentedthatthenegativepublicopinionofSpringfieldwasnotgoodfortheirmentalhealthiftheywereadmittedthereandsomewereirritatedthatwhenyoucallSpringfieldyouneedtoprovidealotofpersonalinformationwhichmadepeoplefeelnervous.PeoplefeltthatitwouldbehelpfulifpatientsatSpringfieldweregroupedbyconditionontheward.

Education

Peoplefelttherewasaneedtoengagewiththecommunity,todemystifyandtakeactiononmentalhealth.TheSpringfieldHospitalofRecoveryCollegewashighlightedasamodelforpeersupportinrecovery.Wandsworthhealthandcareforumpeoplethoughtthatthevoluntarysectorcouldbemoreinvolvedinprovidingmentalhealthsupportincommunitysettingssuchasinpubliclibraries,sopeoplecanfindsupportinamoreinformalsetting.

Peoplemadevarioussuggestionsformentalhealthawarenessraisinginitiatives:

• schoolsshoulddomoretoeducateyoungpeopleandchildren,supportinghealthyhabitsparticularlywithtechnologywithdirectdiscussioninclassrooms;

• localfurthereducationcollegescouldbeusedtoeducateandfundcoursesforpeopleinrecoverymovingintolearningandemployment;

• signpostinginGPsurgeries;

• runningmentalhealthawarenesscampaigns;

• moretrainingforNHS111stafftosignposttomentalhealthsupportandservices;

• trainingforawiderrangeofprofessionalsabouthowtosupportsomeonewithamentalhealthissue.

Earlyintervention

Earlyinterventioninmentalwellbeing,notjustcrisis,washighlightedwithmodelsinWandsworthandMertongivenasexamplesofwhattheyfeltwasgoodpractice.Forexample,faith-basedcommunityleadersweregivenMentalHealthFirstAidtraining,suchasagroupof12pastorsofblackmajority-ledchurcheslearningabouttherapyandhowtosupportfamilieswithmentalhealthconditions,andasimilarschemewasbeingimplementedforImamsandmosques.AtleastoneWandsworthparticipantfelttherewerenotcurrentlyenoughstaffintheNHStoimplementapreventativeapproachtomentalhealth,especiallyforchildren’smentalhealth.AtWandsworthgrassrootsengagementactivitiespeoplefeltthereshouldbemorevisiblesupportformenwhomaynotseeksupportduetothestigmaaroundmentalhealthissues.


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Integration

Theplansforintegratingmentalandphysicalhealthweresupported,andpeoplegavetheexampleofapilotschemeatStGeorge’sHospitalgivingmentalhealthsupportduringcancertreatments.SomeMertonpeoplefeltitwasimportanttoexplaintheimportanceofhealthyeatingandexercisetomentalhealth.Similarly,perinatalmentalhealthsupportbeforeandafterbirthwasneeded,forexamplehavinganassessmentduringhomevisitstoidentifysignswhenamotherisnotcoping.

Crisissupport

PeopleatMertonandWandsworthgrassrootsengagementactivitiescommentedthattherewasalackofsupportwithintheNHSforthoseexperiencingacrisisandsuggestedthatthereneededtobeanincreaseinwalk-inservicesandoutofhour’sservicestosupportindividualswhentheyneeditmost.

ManypeopleattheMertongrassrootsengagementactivitiescommentedthatthecrisislinehadbeenunavailablewhenrequired.Oneparticipantcommentedthatafterhewasdischargedfromhospitalhavinghadamentalhealthcrisis,hewasnotofferedanyfollowupsupport,buthadtoseekithimselfandsuggestedthatthissupportshouldbemorereadilyavailable.

SomepeoplenotedthattheNHSinSWLaresettingup‘CrisisCafes’inpartnershipwiththevoluntarysector.Peoplefedbackthatthismodelassumesthatpeopleunderstandtheirowntriggersandknowwhentoseeksupport.Somealsocommentedthatitwasimportantthesearepromotedeffectively.

ChildandAdolescentMentalHealthServices(CAMHS)

SeveralpeopleattheWandsworthgrassrootsengagementactivitiescommentedonmentalhealthtreatmentforchildrenoradolescents.SeveralindividualscriticisedthelongwaitingtimesforCAMHS,butmostfoundthatoncetheywereinthesystem,theservicewasgood.

Afewpeoplecommentedthattherewaslittlesupportforparentsafterthediagnosisoftheirchildrenandthatitwouldbeusefulforparentstobegivenusefultipsonhowtomanagedifficultsituations,especiallyiftheyhavechildrenwithbehaviouralissues.AfewpeoplecommentedthatthetransitionfromCAMHStoadultserviceswasdifficulttonavigateandpatientsgotlostinthesystem.

Formoreinformationofchildren’sservices,seesection3.3.7


PeopleattheWandsworthgrassrootsengagementactivitiesdiscussedissuessurroundingcareforpatientswithlearningdisabilities.Theyfeltthatthespecialistcareforchildrenwithdisabilitiesispoorandnottailoredtoindividual’sneeds.Severalpeoplecommentedthatthereisalackofsupportforcarersofdisabledchildren.Afewpeoplealsocommentedonthelackofconsistencyreceivedforspeechandlanguagetherapyoutsideofschool.


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Veryfewpeopleparticipatedinthisdiscussioninthehealthandcareforums,howevertheysupportedthechildren’sserviceproposalsoverall.PeoplehadconcernsaboutreducingA&Evisits,astheyfeltthiswouldnotbeachievedwithoutmoreflexibleaccesstoGPsforparents.

Alternativeservices

UsingaspecialistnurseatthelocalGPhubwasunderstoodtobesuccessfulinRichmond.Anothersuggestionwasthattechnologycouldbebetterutilisedtogiveadvicetoparentsmorequickly,suchasskypeappointmentstoassessthingslikedermatologicalconditions.

SomepeopleattheWandsworthhealthandcareforumfeltthattelephoneconsultationscouldworkwellforparentswithchildrenwhoareunwell,especiallyifthiskindofservicewasavailableoutofhours.However,othershadconcernsabouthowreliableadviceanddiagnosescouldbeifconsultationsarecarriedoutoverthephone.Somenotedthattelephoneconsultationsrelyontheparentbeingabletoaccuratelydescribethesymptomswhichmightnotalwaysbeappropriate.

Peopletalkedaboutneedingservicesintherightplaceforparentsastransportationcanbedifficultwithasickchildortovisittheminhospital.Inaddition,therewerequestionsaboutwheretheproposedspecialistnurseunitwouldbelocated.

Raisingawareness

Peoplealsotalkedaboutprovidingeducationandraisingawarenessofserviceswithparents.Theybelievedparentsshouldbeempoweredwithknowledgeofthechoicesavailabletothemandwhenitisappropriatetousethem,givingthemconfidence.Peoplesuggestedmoreengagementabouttheirneedsatlocalparentgroupscouldbeagoodoptionforseveralreasons:engagingwithparentsinanenvironmenttheyarecomfortablein;anopportunitytobothlearnwhattheyneed;andraiseawarenessofexistingornewservices.

Anotherparticipantexpandedonthis,believingthatthiscommunicationshouldstartduringpregnancy,tobuildatrustintheNHSandknowledgeofservicesthroughoutthechild’slife.AtthegrassrootsengagementactivitiesinMerton,peoplefeltthatthereshouldbegreateraccesstoadviceandsupportfromthestartwhenachildisdiagnosedwithalong-termcondition.

Holisticandpatientcentredcare

OneparticipantinWandsworthhealthandcareforumfeltthatthereshouldbeaculturechangeinhowchildrenarecommunicatedwithaspatients.Theyemphasisedthatchildrenshouldbeaskedabouttheirsymptomssothatthemedicalprofessionalhearsdirectlyfromthemratherthansecond-handthroughtheirparent.Intheirview,thisapproachcouldalsofosteraculturewhereyoungpeoplefeelmoreconfidentbeingpeopleintheirowncare,helpingtomovesocietyfurthertowardsapatient-centredapproach.

SomeoftheMertongrassrootsengagementactivitieswerecentredaroundpreventionofhealthissuesforchildren.SeveralcommentedthatGPshadnottriedtosolvehealthissuesthroughhealthyeatingandotherscommentedthattheywereunawarethatachildwithalearningdisabilitywaseligibleforanannualhealthcheck.Formoredetailsonprevention,seesection3.3.4.


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Childrenwithadditionalneeds

PeopleattheWandsworthgrassrootsengagementeventscommentedontheimportanceofseeingthesameprofessionalwhendealingwithchildrenwithadditionalneeds.Somealsoexpressedconcernthattherewereoftenlongwaittimesanddelaysinthewaitingroomsofspecialists,whichcanbedifficulttomanagewithanautisticchild.Othersmentionedthatawaitingareferraltoaspecialistcantakealongtimewhichshouldbebettermanaged.

Manycommentedthatstaffshouldhavefulltrainingonhowtomanagepatientswithautism.


PeopleattheMertonhealthandcareforumsfelttheproposalswerepositivebutunambitious,asthesethingsshouldpreviouslyhavebeeninplacewithonepersonsayingthesewereproposed25yearsago.Therewasalackofawarenessabouttheplans,withpeoplefromthelocalauthorityfeelingtherewasnotenoughinformationforthemorlocalcounsellors.

Peoplewerepleasedtoseethatmentalhealthandperinatalserviceswereincludedintheproposals,butfeltstaffatStGeorge’sHospitalcouldbedoingmoretosupportmentalhealth.AttheWandsworthhealthandcareforums,peoplewereconcernedthatitisnotalwayseasytoidentifywhoisnotcoping,especiallyifmothersfeelstigmaassociatedwithdisclosingthisinformation.Thesepeoplefeltthatmorepersonalisedcareandgoodrelationshipsbetweenwomenandtheirmaternitycareprofessionalsisvitaltosupportthisaim.

PeopleintheMertonhealthandcareforumbelievedtherewereseveralareasofLondonwithexcellentperinatalservicessuchasWandsworth,Chelsea,andWestminster,whichtheyfeltMertoncouldlearnfrom.Inaddition,theyfeltthattheycouldlearnfromtransformationssuchasBasildonorMorecombeBay,orfrominternationalleaderssuchasSweden.

Peoplenotedthenationalshortageofmidwives,whichtheyfeltneededtobeaddressedintheplans.Theyfeltqualitycarewasmoreimportantthanhavingonepersonconsistentlythroughoutpregnancy.Peoplebelievedgoodmaternitycarewaslessaboutcomplexprocedures,insteadcompetentbasiccarewithagoodbedsidemannerwaskey.Theyhadconcernsthatmidwiveswerebeinggiventoomany‘tickbox’procedurestocarryoutratherthanthinkingaboutwhatapatientreallyneeds.Forexample,aparticipantnotedthatwomenwhowererefugeeswouldhaveverydifferentmaternityneedstoasamesexcouple,oranoldermother.Somedisagreedaboutuseofbedspostbirthproposals,assomefeltthatpatientscouldbemovedtoalessurgentcareward,whileotherssaidmothersshouldbedischargedtogohomemorequickly.

AttheWandsworthhealthandcareforums,discussionscentredaroundtheproposalsforpersonalisedmaternitycareandchoice.SomepeoplefeltthatcontrolandchoiceissometimestakenawayfromwomeninpregnancyandlabourandtheysupportedtheaspirationsintheSTPtoempowerwomentohavemorechoiceintheirmaternitycare.Somenotedthatchoiceforwomenmustalwaysbebalancedwithmedicaldecisionsaboutwhatissafestformotherandchild,butthatthatthereisscopeforthebalancetoshiftmoretowardswomencomparedtotheirexperienceofcurrentpractice.


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OneparticipantnotedtheimportanceofmanagingexpectationsandfortheNHStoberealisticaboutwhatitcanprovide,ratherthanraisingexpectationsandthennotmeetingthem.Forexample,lettingwomenknowthattheymaynothavethesamemidwifethroughouttheirpregnancybutthattherewillbeateamofmidwivesavailable.Thisparticipantfeltthatbybeinghonestinthiswaywomenwouldn’tfeelsoletdown,forexampleiftheyseeadifferentmidwifewhentheirusualoneisnotavailable.

AttheMertonhealthandcareforumspeopleagreedthatpatientexperiencevariedandtherewasa‘hit-and-miss’elementtotheservices,suggestingthatmoretrainingisneededtoensuremoreconsistentcarestandards.Forexample,oneparticipantsaidKingstonandStHelierhospitalhadexcellentmaternityunits.

SomeforumpeopleandtheMertongrassrootsengagementeventsweregenerallypositiveabouttheirexperienceofStGeorge’s.WhereaspeopleattheWandsworthgrassrootsengagementeventswerelesspositive,includingonecommentthatthehealthvisitoronlygaveverygeneraladviceandsomecommentsthattheserviceswere‘disgusting’.

Peoplesaidmoresupportwasneededpost-miscarriageandforfathersinsupportingpregnantpartnersandtheirownneeds.Aparticipanthighlightedthelackofpreventionplansintheproposalsformaternityservices,suchaseducatingyoungpeoplemoreaboutsexualhealthandpregnancy.

Finally,peopleraisedconcernsaboutmidwivesbeingoverworked.Linkedtothis,theyfeltthattrainingformidwivesshouldincludehelpingthemtotakecareofthemselvessothattheyareabletogivethebestcaretowomen.Peoplewereworriedthattheemphasisonproductivitycouldcausemidwivestoburnoutandnotbeemotionallyavailabletosupportwomeneffectively.

3.3.9 Cancer

TherewerenocommentsoncancerservicesinMerton,howeverafewpeoplecommentedoncancerservicesatthegrassrootsengagementactivitiesinWandsworth.Oneparticipantnotedthattheircancerdiagnosiswasdeliveredinsensitivelyandthattherewasnosignpostingtoadditionalsupportservices.Theyalsomentionedthattheyhadissueswiththeirreferral.Anothercommentedthattheyhadtodotheirownresearchintocommunitysupport.OneparticipantmentionedthattheirtreatmentattheMarsdenwasexcellent.

3.3.10 PlannedCare

FewpeopleattheMertonandWandsworthgrassrootsengagementactivitiescommentedonplannedcare.

AfewpeopleattheMertongrassrootsengagementactivitiescommentedthattherewerelongwaitingtimesatStGeorge’sforoutpatientappointments.

SomepeopleattheWandsworthgrassrootsengagementactivitiescommentedthattheaftercarewasnotgoodandthatchangesinstaffweverydisruptive.Oneparticipantcommentedthatthatwaitinglistforthepainclinicwastoolong.


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3.4 Sutton



GrassrootsEngagementActivities



WhilepeopleatthehealthandcareforumweresupportiveoftheaspirationslaidoutintheSTP,manyfeltthattheplanlackeddetailandtheywantedmoreinformationincludingoveralltimelinesandachronologicalplan.SomequestionedwhethertheSTPisanydifferentfrompreviousplans,expressingfrustrationthatplansareconstantlyproducedbutlittlechangeappearstotakeplace.Othersfeltthattheplansareunsustainableandaretooambitiousinthecurrentfinancialclimate.

PeoplebroadlysupportedtheSTPaspirations,buthadquestionsabouthowitwouldbeimplementedincludinghowstaffshortageswouldbemanagedandwhereserviceswouldbelocated.PeoplealsofelttheSTPdidnotprovideenoughdetailabouthowthechangeswouldworkinpracticeandwantedtoknowmoreandwhatdecisionshadalreadybeenmade(e.g.whichhospitalwouldbeclosed).


ConcernthatthereisinsufficientcapacityinA&Eandthatclosingadepartmentwouldexacerbatewaitingtimes.

UnclearwhetherNHS111willreduceA&Eusebasedontheirpastexperience.

SuggestiontochangeconfigurationofA&EtohaveGPs/socialcareavailablethere,ratherthantrytochangebehaviour.

StrongsupportforStHelierHospitalandconcernthatrelianceonalternativeA&Eserviceswouldleadtoincreasedtraveltimeswhichtheyfeltcouldputpeopleatrisk.

SomeconcernaboutcommunicationwithinStHeliers,andbetweenStHeliersandotherorganisations.

MoreCareClosertoHome

VariableexperienceofGPservices,withsomegreatexperiencesandothersreportingdifficultyaccessingappointmentsandaperceptionthatreceptionistswereundertakingtriageforappointments.

AviewthatGPsneedtoimprovethewaytheysupportandcommunicatewithpatientswithadditionalneeds(e.g.deaf,learningdisabilities,mentalhealth).


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Someconcernsaboutincreasingrelianceonpharmacistsaspeoplewereunsurewhethertheywouldhavetherightskills/training.

Onlinebookingworkswellforthosewhocanuseinternet,butimportanttokeeptelephoneoptionforthosewhocannot.

Prevention&EarlyIntervention

Broadsupportforideaofincreasingtheemphasisonprevention,butmoreevidenceneededtoconvincepeopleitwillhavethebenefitsanticipatedintheSTP.

WillrequirechangestobothNHSstaffbehaviour,andpeople’sbehaviour–bothofwhichwillbechallenging.

Specifically,peoplewantmoreinformationabouthowlocalityteamswillworkandhowtheywillinteractwithotherlocalservicesinthepublicandvoluntarysectors.

MentalHealth

Concernedaboutacurrentlackofresourcesandfundingformentalhealth,especiallygivenrecentclosures,thelackofalocalcrisiscentreandlongwaitinglists.

Felttheywouldbenefitfrommorelongtermmental-healthsupportoncepatientshavebeendischarged.

ScopefortheNHStoimprovetheinformationavailabletopatientsaboutmentalhealthservicesincludingcommunityandvoluntarysectorservices.

GPssometimestooquicktoprescribemedicationandshouldinvolvespecialists.

Feltthatsomegroupshavespecificneedsthatarenotaddressed,forexampleprovidingcounsellinginsignlanguage,providingaclearroutetogettingmentalhealthsupportforyoungpeopleandsupportingcarers.


VeryfewcommentsinSutton.

Suggestionmorecouldbedonetoincreaseprofessional’sunderstandingofLDandautism.

Children’sServices

AfewpeoplefeltfrustratedwithhowlongittooktobereferredtoCAMHS.TherewasafeelingthatthelocalCAHMSserviceisoverstretched.Peoplewereunsurewheretofindhelp.

MaternityCare

Thereweresomeconcernsaboutaccesstomaternitycare,aspeopledidnotwantittobeprovidedinalargeGPsurgery.

TheNHSshoulddomoretoraiseawarenessofmaternityservices,aswellastailorinformationaboutrelevantservicestoindividualneeds.

Somequestionsaboutpersonalisedmaternitycareandprovidingmorechoicetopatientsandhowtoensurethiswouldbesafe.

Cancer VeryfewcommentsinSutton.


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Viewthatfollow-upcarecouldbeimprovedforpatientsandcarers.

PlannedCare

VeryfewcommentsinSutton.

SomepositivecommentsabouttheSouthWestLondonElectiveOrthopaedicCentre.

Aperceptionthatfollow-upcare,includingphysiocouldbeimproved.

Somementionedpoorcommunicationinhospitalleadingtowastedtime.

3.4.2 SevendayAcuteServices

Overall,therewassignificantconcernthatallfiveexistingA&Eservicesarealreadyoperatingabovecapacity.PeopleatthegrassrootsengagementactivitiesbelievethatthiswillbeexacerbatedbythegrowingpopulationinSutton.Asaresult,peopleatalleventswereconcernedaboutpossiblenegativeimpactsofremovingoneormoreacuteservices,includingthepotentialforwaitingtimestobeevenlongerthantheyarenow,andabouthavingtotravelfurtherforurgentcare.TheseconcernswerecompoundedbyworriesthatA&Ealternatives,suchaswalk-incentres,wereclosing.Incontrast,afewpeopleacceptedthattravelingfurtherforspecialistcaremightbenecessarytoimprovethequalityofcarereceived.

SomepeopleatthegrassrootsengagementactivitiescommentedthattheydidnotknowwheretogootherthanA&Einanemergency;somehadnotheardofNHS111,ordidnotwishtouseitastheyfeltithadapoorreputation.Additionally,manypeopleatthehealthandcareforumwereconcernedaboutanincreasedrelianceonNHS111forsignpostingpatientstocare.SomesaidNHS111hadsentthemtoA&Einthepast,sorelyingontheservicecouldincreasedemandforA&E.TheythereforesuggestedthattheNHS111servicewouldneedtochangeiftheplansweretobesuccessful.

Similarly,peoplequestionedwhetheritispossibletochangepeople’sbehaviourtostopthemgoingtoA&Eunnecessarily.Instead,therewasasuggestiontomovethelocationofsomeGPsandsocialcareservicestothesameplaceasA&E.

Shorttraveltimestocarewereimportanttopeopleandmanywereconcernedthatgettingtocarequicklywouldgetharderovertimeastrafficincreases.Althoughtechnicallycloser,peopletoldusthatCroydonUniversityHospitaldoesnothaveagoodreputationandsomethoughttheironlyoptionwouldbetravellingfurthertoStGeorge’sHospitalifStHelierA&Eclosed.

Atthegrassrootsengagementactivities,therewasstrongsupportforStHelierHospital,wherepeoplehavehadmostlygoodexperiences,althoughmanysaidmorecouldbedonetospeedupdischarge.Severalpeoplenotedthelengthywaitforpatienttransporttotakepatientshomeaftertheyhavefinishedtheirappointmentsinhospital.Somepeoplesharedtheirexperiencesofhavingbeendischargedatunsociablehours,withoutcarebeingarrangedathomeandotherssaidthattheyweredisappointedatlevelofcarepost-dischargeandsuggestedthattherewasnosupportoutsideofhospital.AfewpeoplealsocommentedthattheNHSandsocialcareservicesneededtowork


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togethermoreclosely,toavoidpatientsstayinginhospitallongerthantheyneededto,whensocialcareservicescouldhelp.

SomepeopleatthegrassrootsengagementactivitiessharedanecdotesaboutcommunicationissuesatStHeliershospital,givingmixedfeedbackaboutstaffattitudes.Peopleraisedinstancesofrudeness,abruptnessandbeingsenttothewrongwards.Otherscommentedthathospitalstaffhavenotbeentrainedtocommunicatewithpatientswithautism.SomepeoplecommentedthatthereislittlesupportformentalhealthneedsinA&E.FordetailsaboutmentalhealthservicesinSutton,seesection3.4.5.

AfewpeoplealsocommentedonthelackofprovisionfordeafpatientsatStHelier.Whilsttherewerevaryingviewsontheavailabilityofinterpreters(somefelttherewasnooneonhand,whereasotherssaiditwaseasytobookinadvance)onecommentedonthelackofafreeTVoptionsforthosehardofhearingandafewpeoplecommentedthatastherewasnoWi-Fiinthehospital,theycouldnotengagewithonlineinterpretationsoftware,whichwouldbeusefulintheabsenceofaninterpreter.

SomepeopleatthegrassrootsengagementactivitiesnotedthatthereisalongwaitinglisttobereferredacrossdepartmentsatStHelierHospitalandonecommentedthattherewasanissuewithreferralsbeinglostfromEpsomHospital.

AfewrespondentsatthegrassrootsengagementactivitiescommentedontheStHelierbuilding,andmaintenanceneeds,forexamplethatthetoiletdoorsdonotlock.

3.4.3 MoreCareClosertoHome

Discussionsaboutmorecareclosertohomeraisedmanyquestionsamongpeople.Theseoftencentredaroundhowtheplancouldworkandbesustainableinwhatwasperceivedasanenvironmentoffundingcuts.Somepeoplewereconcernedthatcareclosertohomecouldmeanserviceswouldbemorebasicthantailoredandspecialised.Forexample,oneparticipantasked,“whatarewewillingtolosebyputtingcareintothecommunity?”.

Mostpeopledidnotthinktheywouldgotoapharmacistasafirstchoiceforcareandwerescepticalabouthowthischangewouldworkinpractice.Manypeoplebelievedthatpharmacistswerenotskilledenoughtomanagemedicalproblemscomparedtoadoctorandpharmacistsandmaynothaveappropriatecommunicationskillstoworkwithpatients.Atleastoneparticipantfeltspecialistdoctorsandnursesarebestplacedtoservepatientsandwasfrustratedabouttheshiftawayfromthismodelofcare.Somepeoplefeltanursewouldbebetterplacedthanapharmacisttoprovidealternativecareforpatientstohelpmakecareclosertohomefeasible.

Somepeoplehadsuggestionsforwhatchangesneededtobemadeforpatientstofeelmoreconfidentaboutgoingtoapharmacist.SuggestionsincludedmoreeffortbytheNHStochangepeople’stendencytogotoA&Easafirstresort,encouragingpeopletousetheNHS111servicemoreoften,andinvestinginfurthertrainingforpharmaciststocommunicateandofferadviceregardingarangeofhealthproblems.


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ManypeopleatthegrassrootsengagementactivitiessharedtheirpositiveexperienceswithGPsinthelocalarea,particularlyatManorSurgery.Otherscommentedthatthereshouldbeaclearercomplaintssystem,andseveralexpressedconcernswhichareoutlinedbelow.

ManypeopleatthegrassrootsengagementactivitiescommentedonthedifficultyofgettingaGPappointment,sayingthatitcantakeupto2weeks.Peoplealsoexpressedfrustrationsthatreceptionstaffatpracticesaretriagingpatientsforappointmentsandmakingdecisionsonwhethertheirconcernshouldbetreatedasanemergency.Somepeoplecommentedonthelengthoftimeforreferralsandtheirfrustrationswhenreferralsgotlost,whichmeantthattheyhadtochasetheirGPs.

ThereweresomespecificconcernsaboutGP’sresponsivenesstodifferentpatientneeds.Forexample:

• AfewpeoplecommentedGPs’lackofknowledgeontherightsofdeafpatients.Forexample,peoplecommentedthatmanyGPswereunawarethattheyshouldbookinterpreters,andthatadoubleslotshouldbeoffered.Peoplealsocommenteditwasparticularlydifficultfordeafpeopletophoneupforanemergencyappointment,soitwassuggestedthatanothermethodofappointmentbookingbeintroducedformoreequality.

• Afewpeopleatgrassrootsengagementactivitiesdescribedthelackofsupportforparentswithchildrenwithlearningdisabilities,andmanypeoplecommentedonthelackofsupportforcarers,wheresomecommentedthatGPsshouldplayabiggerroleinidentifyingthehealthandwellbeingneedsofcarers.

• SomepeoplefeltthatGPswereunabletodirectpatientstomentalhealthcommunitygroupsandafewfeltthatGPswerequicktoprescribemedicationformentalhealthissuesasopposedtalking.

• SomealsofeltthatGPsdonotprovideinformationondiet,wellbeingandmentalhealth.

SomepeopleatthegrassrootsengagementactivitiescommentedonthebenefitsofPatientOnline,sayingitwassomewhateasiertobookanappointmentthenightbeforeandthatithasmadeitaloteasiertocollectprescriptionsfromtheirpharmacyofchoiceatatimeconvenienttothem.OthersexpressedconcernthattheNHSismovingtowardsbookingonlineappointmentsandaccessingmedicalnotesonlineastheydidnotknowhowtoconnecttotheinternet.Peoplesuggestedthattelephoneappointmentscontinueforthosewhodonothaveinternetaccess.

SeveralpeopleatthegrassrootsengagementactivitieswantedinformationatGPsurgeriestobepresentedinamorereadableformat,assomeofthejargonusedcanbedifficulttounderstand(andsomeespeciallyaskedfortheretobemoreinformationaroundeyeconditions.)

3.4.4 Prevention&EarlyIntervention

SomepeopleatthehealthandcareforumfelttheSTP’sfocusonpreventionandearlyinterventionwaslogical.However,mostpeopleraisedchallengesandquestionsaroundfinancialfeasibilityandhow,ifatall,socialcareresourceswouldbeincluded.AfewpeoplesaidtheydidnotthinktherewasenoughevidenceintheplantodemonstratehowpreventionandearlyinterventionwouldmaketheNHSworkbetter,suchashowtheplanwouldreducethenumberofpatientsinA&Ein


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practice.Oneparticipantwasconcernedthatafocusonpreventionandearlyinterventioncouldcompromisethecareforconditionsthatcannotbeprevented.

PeoplefelttherewasnotenoughinformationintheSTPabouthowlocalityteamswouldfunction.Forexample,manypeoplewantedtoknowmoreaboutwhowouldmanagethelocalityteams,whowouldchampionthelinkingofservicesandpractitioners,andwherethemembersoflocalityteamswouldbephysicallysituated.

Peoplesaidchangingpeoples’behaviourwouldbechallenging;however,theyagreeditwasakeycomponenttomakingpreventionandearlyinterventionwork.SomepeopleofferedsuggestionsincludingchangingNHS111tofocusonprevention,usingthevoluntarysector(thoughnotrelyingonthesector),andtargetingspecificgroupsforpreventionandearlyinterventionssuchaselderlyviacarehomes,smokers,orpupilsinschool.

SomepeoplefelttheNHSwouldneedtochangeitsinternalcultureandapproachtopatientstomakepreventionandearlyinterventionwork.Forexample,manypeopleperceivedtheNHSdoesnotcurrentlyfosteracultureofpreventionandearlyinterventionandthatinternalpoliciesandstaffwouldneedtochangetosupportpatients’behaviourchanges.Atthegrassrootsengagementactivities,somepeoplecommentedthatfreegymmembershipwouldhelppeoplelivehealthierlives.

3.4.5 MentalHealth

Manypeopleatthehealthandcareforumsaidtheywereconcernedaboutacurrentlackofresourcesandfundingformentalhealthcare.Severalpeopleworriedthatdespiteanidentifiedneedtoaddressmentalhealthmoreholistically,severalmentalhealthcentresintheSuttonareahaveclosed(i.e.the‘MemoryLane’serviceandamentalhealthdrop-incentreinWallington).TheyalsonotedSuttondoesnothaveamentalhealthcrisiscentre.Thus,peoplediscussedthenegativeimpactonpatientsofneedingtotravellongdistancestoaccessmentalhealthcare.Patientswerealsoconcernedaboutlongwaitingtimestoaccessmentalhealthservicesandlimitedsupportforpatientsandcarersonceinitialtreatmentiscompleted.Forexample,severalpeopleatthegrassrootsengagementactivitiescommentedspecificallyonthelackofmentalhealthsupportafterbeingdiagnosedwithfibromyalgia.

Somepeopleatthegrassrootsengagementactivitiessuggestedthatthereshouldbemorelongtermmental-healthsupportoncepatientshavebeendischargedfromcaretostopthemgoingintocrisisagain.Theyalsonotedaneedtoconnectmentalhealthserviceswithotherphysicalhealthservicestoimprovecareinamoreholisticway.Otherscommentedthatpeopleneededmoreeducationintohowphysicalandmentalhealtharelinked.

PeoplealsofelttheNHScouldimprovetheinformationavailabletopatientsaboutmentalhealthservicesincludingcommunityandvoluntarysectorservicesintheirarea.Somepeoplefelttherewasaneedforgreaterawarenessaboutearlymentalhealthintervention,suchasincorporatingmentalhealtheducationintheschoolcurriculum.

AfewpeoplecommentedthatGPswerequicktoprescribeantidepressantswithoutconsideringalternativetreatmentmethods.Theysuggestedthatmoreshouldbedonetotreatthecauseandnot


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justthesymptoms,andthatthereshouldbemoreemphasisonreferralstomentalhealthspecialists.

SeveralpeopleattheSuttonhealthandcareforumwereconcernedthatsomegroupswerenotrepresentedatthediscussion,notingthatdifferentgroupswouldhavedifferentmentalhealthneeds(e.g.homeless,ex-offenders,migrants,LGBT,teenagers)2.Somepeopleatthegrassrootsengagementactivitiessaidthattheywereunsurehowtonavigategettinghelpforchildmentalhealth,whereseveralfoundgettingreferralsfortheirchildrendifficultandotherscommentedthattheSuttonCCGcurrentlydoesnotofferBritishSignLanguagecounsellingfordeafpeople.Atthegrassrootsengagementactivities,somepeoplecommentedthatcarers’mentalhealthshouldbespeciallyconsidered,


Afewpeopleatthegrassrootsengagementactivitiescommentedthatmoretrainingandawarenessaroundlearningdisabilitiesandautismwouldbehelpful.

3.4.7 Children’sServices

Nopeopleattendedthechildren’sservicessessionsattheSuttonhealthandcareforum.AfewpeoplefeltfrustratedwithhowlongittooktobereferredtoCAMHS.TherewasafeelingthatthelocalCAHMSserviceisoverstretched.Peoplewereunsurewheretofindhelp.

3.4.8 Maternity

Threepeopleatthehealthandcareforumsattendedthediscussiononmaternityservices.Peopleexpressedconcernsaboutaccesstomaternitycare.ManyfeltitwasimportanttohavematernitysupportclosetohomeandideallynotinalargeGPsurgerywherepeoplefeltcarewouldbecomprisedwithhighnumbersofpatientscompetingforappointments.

PeoplesaidtheNHSshoulddomoretoraiseawarenessofmaternityservices,aswellastailorinformationsharedduringappointstoindividualneeds.Forexample,peoplethoughtGPsandmidwivescouldprovidemoreinformationtopatientsaboutavailablesupport,provideinformationindifferentlanguages,accountforculturaldifferencesinhowwomenprefertoreceivecare,andprovideat-riskmothersandfamilieswithadditionalsupport.

Somepeoplehadquestionsaboutpersonalisedmaternitycareandprovidingmorechoicetopatients.Oneparticipantwasunsureaboutwhatmorepersonalisedcarewouldmeaninpractice.Anotherparticipantfeltthatbyallowingpatientstochoosematernitycareforthemselveswithouttherightinformation,womenmightmakechoicesthatcouldharmtheirhealth,ratherthanempowerthem.

2AlthoughnotallthesegroupsarenecessarilyrepresentedinSutton,thegrassrootsengagementactivitiesweredesignedtoensurethatpeoplefromseldomheardgroupshaveavoice


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3.4.9 Cancer

AfewpeoplewhoattendedthegrassrootsengagementactivitiescommentedoncancerservicesinSutton.Severalmentionedthatthefollowupsupportserviceswerelacking,forthosewhohavegonethroughcancertreatment.Peoplealsofeltthatthereshouldbemorecounsellingservicesforthoseaffectedbycanceraswellastheircarers.

3.4.10 PlannedCare

Severalpeopleatthegrassrootsengagementactivatesraisedconcernsaboutthecancellationandpostponingofoperations,aswellasalackofcommunicationinhospitalwhichledtoeventssuchascheckingbloodpressuretwiceinarow,anddelayeddischarge.

PeoplegavealotofpraisefortheSouthWestLondonElectiveOrthopaedicCentrealthoughsomewereconcernedthatthepre-opassessmentquestionnairecouldbefeelinsensitiveandveryimpersonal.

Somepeopleexpressedconcernsaboutrecoveryfromoperations,andseveralfeltthatsupportwithphysiotherapywaslacking.Onesaidthattheyweregivensomephysiotherapysessionsandthesewereabruptlystoppedandafewotherswereexpectedtoengageinphysiotherapyontheirownathome.Somepeoplewantedtoseemoresupportinthecommunityafteranoperation,includingphysiotherapyandcommunityactivities.

4. NextstepsTheSustainabilityandTransformationPlaninsouthwestLondoniscurrentlyundergoingarefreshinordertoensurethattheworkmovestowardslocalplanninganddeliverytokeeppeopleoutofhospitalandensurethatdeliveryiscentredaroundtheLocalTransformationBoards(LTB).ItisexpectedthatarefreshedplanwillbepublishedinNovember2017.Alloftheoutputsfromtheengagementactivities(healthandcareforumsandgrassrootsengagementactivities)willfeedintothisrefresh.Inaddition,theareafeedbackwillbetakentoeachLocalTransformationBoardfortheirconsideration.Itwillbesavedasarepositoryofinformationwhichcanbedrawnuponwhencommunityintelligenceisneededaboutalocalservice.Thegrassrootsengagementprogrammehascontinuedinto2017/18–andthefeedbackwillbeconsideredataLTBlevel.


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Client NHSSWL

Company OPMGroup

Title PublicengagementontheSustainabilityandTransformationPlan

Subtitle ByLocalTransformationBoard(LTB)area

Dates lastpublished05/09/2017lastrevised30/11/2017

Status Draft

Classification

ProjectCode 10799

Author(s) BethanPeachPerlaRembiszewskiAnnaBeckett

QualityAssuranceby AnnaBeckett

Mainpointofcontact AnnaBeckett

Telephone 02072397800

Email [email protected]

Ifyou,orsomeoneyouknow,wouldlikethisdocumenttranslatedorinanotheraccessibleformat(example-largeprint),pleasecontactusviathedetailsbelow.Writetous:SouthWestLondonHealthandCarePartnership,3rdFloor,120TheBroadway,Wimbledon,SW191RHEmailus:[email protected]:www.swlccgs.nhs.ukFollowusonTwitter:@swlnhs

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