Governing Body (Public) Meeting...Note: the update within the report of the differing workstreams and the progress made. Executive summary The south east London Community Based Care

DATE: 30 January 2014

Title South East London Community based Care Update

Recommended action for the Governing Body

That the Governing Body: Note: the update within the report of the differing workstreams and the progress made.

Executive summary

The south east London Community Based Care (CBC) Strategy was approved last year by the six CCGs in south east London. The strategy sets out aspirations for community based care which all south east London CCGs have committed to deliver. Each CCG started from a different point and through their operating plans set out plans for year one delivery. These were then embedded into contracts with providers or developed into specific work programmes such as service redesign and other change programmes to be implemented throughout the year. There are three major work programmes:

- Integrated Care - Primary and Community - Planned Care

To be effective, the strategy has adopted an approach of ‘Shared Standards, Local Delivery’ whereby each CCG is committed to delivering to a standard as set out in the strategy through working with its member practices, local authority and providers. The premise of the shared programme is that by working collectively we can get further faster, learning from one another and implementing some programmes collectively and at scale. The urgency to deliver improvements means that local programmes in place are being developed so that over time there will be an increasingly common approach to community based care. Since the programme was set up, we have appointed clinical leads, sponsors and project managers to assist with managing the programme. This report provides an overview of progress after 6 months.

Which objective does this paper support?

Patients: Improve the health and wellbeing of people in Bexley in partnership with our key

ENCLOSURE: L Agenda Item: 15/140

Governing Body (Public) Meeting

stakeholders

People: Empower our staff to make NHS Bexley CCG the most successful CCG in (south) London

Pounds: Delivering on all of our statutory duties and become an effective, efficient and economical organisation

Process: Commission safe, sustainable and equitable services in line with the operating framework and which improves outcomes and patient experience

Organisational implications

Key risks (corporate and/or clinical)

Fragmentation across SEL meaning widespread goals not achieved. Slow implementation when delivering across wider geographical areas

Equality and diversity

Patient impact

Financial

Does not deliver required savings and efficiencies across SEL

Legal issues

Ensuring governance sits with statutory functions

NHS constitution

Consultation (public, member or other)

Per individual programmes

Audit (considered/approved by other committees/groups)

SEL wide governance groups

Communications plan Per individual programme

Author Julia Brown, Annabel Burn (SEL)

Clinical lead Howard Stoate

Executive sponsor Sarah Blow

Date 13 January 2014

South East London Programme Management Office: Working on behalf of six CCGs in south east London – Bexley, Bromley,

Greenwich, Lambeth, Lewisham and Southwark.

1

South East London Community Based Care First Six Months 2013/14

Introduction

The south east London Community Based Care (CBC) Strategy was approved last year by the six CCGs in south east

London. The strategy sets out aspirations for community based care which all south east London CCGs have

committed to deliver. Each CCG started from a different point and through their operating plans set out plans for

year one delivery. These were then embedded into contracts with providers or developed into specific work

programmes such as service redesign and other change programmes to be implemented throughout the year. There

are three major work programmes:

See appendix 1 for detailed aspirations against these workstreams.

To be effective, the strategy has adopted an approach of ‘Shared Standards, Local Delivery’ whereby each CCG is

committed to delivering to a standard as set out in the strategy through working with its member practices, local

authority and providers. The premise of the shared programme is that by working collectively we can get further

faster, learning from one another and implementing some programmes collectively and at scale. The urgency to

deliver improvements means that local programmes in place are being developed so that over time there will be an

increasingly common approach to community based care. Since the programme was set up, we have appointed

clinical leads, sponsors and project managers to assist with managing the programme (see appendix 2).

Primary &

Community

including urgent

care

Planned care for

people with short

term conditions

Integrated care

for people with

longstanding

health needs

including mental

health



2

Key achievements November 2013 Primary and Community Care:

o NHS 111 has gone live across south east London enhancing access to primary care 24/7. In Bromley,

Bexley and Greenwich this includes access to local GP out of hours providers via NHS 111, while in

Lambeth, Southwark and Lewisham patients can contact their local GP out of hour’s provider

(SELDOC) either via NHS 111 or directly.

o All CCGs have committed to a major development to improve general practice through three

programmes of work: (i) improving quality through reducing variation between practices using peer

review; (ii) providing services to populations at scale; and (iii) developing practice capability through

organisational development.

o A major winter communications campaign #YellowMen has been launched across south east London

to direct people to community based services where appropriate.

Integrated Care

o All six CCGs in south east London bid to become Integrated Care Pioneers due to the level of

development in place already. Lewisham and Greenwich were shortlisted and the latter was recently

appointed. This gives an excellent opportunity to spread learning from all 14 national Pioneers

within south east London

o A south east London bid to Health Education South London has been successful to fund a training

needs assessment package for care homes across the area. The intention is to understand the

themes of high emergency attends and admissions and develop an effective, bespoke care home

training package.

o Bromley CCG in partnership with Bromley Healthcare won an award from AHSN on improved leg

ulcer care and additional monies for diabetic care.

o The Southwark and Lambeth Community diabetes teams received a Commendation from the Quality

in Care for diabetes for good practice and collaboration in diabetes.

Planned Care

o The workstream has agreed to focus on diagnostics, referral management and booking processes

and pre- and post-operative assessments and care and learning on these areas are being shared

across boroughs and commissioning intentions for next year will scale up work in this workstream.

Progress in 2013-14

Metrics

High level measures were agreed by the CBC Transformation Board in June 2013 and are being used to benchmark

progress:

A&E attendance

Emergency readmission rate

Patient satisfaction measure

Outpatient attendance

First-to-follow-up rate

Emergency admission rate

Length of stay/bed day saving

Analysis of these metrics shows that CCGs are in a good position on a number of these indicators. For instance, in

2012/13 all six CCGs had a lower emergency admissions rate per 1000 population than the England average, with

strong performances in Bromley, Bexley and Greenwich who are in the top quarter nationally. All six also have lower



3

than average rates for admissions for respiratory conditions and circulatory diseases. A positive position is also

reported for outpatient usage with all CCGs being in the top 50 per cent nationally and Greenwich, Lewisham and

Southwark being near or better than the top quarter. While positive this does mean that the level of the challenge in

south east London is to show further improvement and requires us to innovate to push performance further. Please

see appendix 3 for detailed graphs.

A report on the metrics being tracked by the CBC Transformation Board is available and can be found on the new

south east London intranet portal

http://nww.selprojects.southwarkccg.nhs.uk/CommunityBasedCareProgramme/Pages/Home.aspx

These are being further developed by the CBC metrics group to include additional health and Local Authority

measures.

CCG QIPP

Due to the rising and ageing population in south east London, rising incidence of long term conditions and cost of

services provided, all CCGs need to make changes to current spending plans to release funding to invest to meet

demands for services. As CCGs make plans for future years they each set a target amount that they need to release

from their budgets on a recurrent basis. The spending review settlement for the NHS including the transfer of NHS

money to local authorities (ITF) are now known but the full impact of the new allocation formula is being consulted

on. Each CCG has set out its expected QIPP challenge (further to final guidance) for coming years - see below:

Estimated south east London QIPP programme

2013/14 QIPP is excluded as assumed to be already in baseline contracted values

Each CCG is developing commissioning intentions and CBC will be a key element in 2 year operating plans (2014-16).

Before Social Care ITF transfer After Social Care ITF transfer

CCG 2014/15 2015/16 2016/17 2017/18 Total 2014/15 2015/16 2016/17 2017/18 Total

Bexley 12 5 5 6 28 13 14 5 6 38

Bromley 19 6 7 8 40 19 20 7 8 54

Greenwich 9 2 4 6 21 9 13 16 18 56

Lambeth 25 12 12 12 61 25 25 12 11 73

Lewisham 18 8 10 8 44 19 19 10 8 56

Southwark 23 10 11 9 53 23 20 11 9 63

Total 106 43 49 49 247 108 111 61 60 340

http://nww.selprojects.southwarkccg.nhs.uk/CommunityBasedCareProgramme/Pages/Home.aspx



4

Delivery of Shared programmes Each CCG has agreed to take these three workstreams forward in their CCGs and are committed to learning from one

another about what works so that we can progress further, faster.

Primary and Community Care

The primary and community care workstream draws clinicians and commissioning leads across each of the CCGs and

from NHS England to develop and drive forward a shared programme of work at pace and scale. The workstream

has agreed a common framework of delivery across each of the six boroughs focused upon three key areas:

Development of primary care quality improvement plans to understand and address variation in outcomes

now.

Establishment of Primary and Community care strategies across each borough that seek to respond to the

emerging London case for change and give focus to improved quality, outcomes and effectiveness through

population focused commissioning and a locality approach to commissioning across all six boroughs.

Development and delivery of significant change management programmes in each borough focused on

organisational development within primary care to address issues of scale and capacity, supporting the

adoption of new models of ‘at scale’ delivery.

The workstream has recognised the local context within which each CCG operates and the different starting

points that each borough has in embarking upon this work. Working together the CCGs have developed a

common approach to major issues in order to drive and co-ordinate action across south east London.

Working collaboratively and within an agreed common framework CBC implementation in this area has resulted in:

A single and agreed approach to assessing variation and outlying practices with the NHS England Primary

Care Contracting team which will result in individual and locality quality improvement plans across south

east London. The CBC Transformation Board has received and agreed funding proposals to support this

work and the development activities that will result. This single process has been road tested in each

borough over the last quarter and will ‘go live’ in January 2014.

The development of CCG Primary and Community Care strategies in each borough that provide a robust

commissioning response to the aspirations set out in the CBC Strategy and the emerging case for change for

London. Throughout 2013/14 CCGs will launch their commissioning approaches that provide a consistent

population focus based upon localities of delivery via networks of Primary and Community care.

The delivery of significant and funded organisational development plans in each borough for the

development of primary care delivery through new models of care at scale. Working together each borough

has recognised that this work will need to engage the entirety of general practice in south east London

responding to very local development needs and aspirations – co-ordinated borough based plans are already

in place and are being progressed. Over and above this the workstream has developed and will seek to

launch a pioneer programme across the six boroughs that will support those groups of providers that wish to

move further, faster in testing and implementing new models with a commitment to share and disseminate

best practice / learning to the wider general practice community.

Agreed non-recurrent investment in supporting the delivery of commissioning strategies and organisational

development activities over the full period of the CBC strategy.

Collaboration between the boroughs has also provided a common voice and involvement in wider development

work across London. The programme is now represented on the London Primary Care Programme Board and Clinical

board at Chief Officer and Governing Body clinical lead levels and will contribute to and shape pan London

approaches to this area.



5

The workstream has also be instrumental in identifying and disseminating best practice through a regular digest to

boroughs and through hosting key learning events, the most recent of which engaged teams from every borough in

discussion with the Vitality Partnership from Birmingham, showcasing their approach to ‘at scale’ delivery of general

practice for a population of over 60,000 patients

Planned care

A range of planned care schemes are underway at an individual CCG level. Lessons learnt and challenges from these

projects have been, and will continue to be, co-ordinated and shared across the south east London CCGs through the

CBC Planned Care Workstream Group. Some example schemes include:

• Bexley CCG is undertaking a number of Prime Contracting procurements using COBIC (Commissioning for

Outcome-Based Incentivised Contracts). Contracts will offer the best possible outcomes for patients and

CCG. Pathways include MSK, cardiology and diabetes. These programmes will go live late in 2013/14.

• Bromley CCG has Community Gynaecology and MSK services in place and has been able to share key lessons

learnt with the other CCGs.

• The Greenwich Referral Management and Booking Service (RMBS) has been piloted since September 2011.

Participation in the RMBS has been rolled out incrementally with all Greenwich practices participating since

February 2013. Reporting from the RMBS is indicating a downward trend in bookings to secondary care and

an increase in community bookings. Mental health referrals are now being routed through the RM&BS at the

request of GPs to improve navigation for patients. Greenwich now achieves 98% for use of Choose & Book.

• Lewisham CCG has transformed its Diabetes Pathway utilising various mechanisms to enhance diagnosis

across Primary Care, including ‘Peer2Peer support’ which involves a dedicated clinical lead supporting

practices by providing hands on in-practice advice and guidance. This has helped to strengthen and improve

the number of patients taken through the 3Rs process (Register, Recall and Review) and the 9 Care Processes

(NICE standard).

• Lambeth CCG is working with the ‘Transforming outcomes through the imaging group’ set up by the GSTT

charity to review a number of diagnostic pathways.

• Southwark Community Dermatology Service now offers a single point of referral for GPs to send routine

dermatology referrals alongside a newly developed advice and guidance function for practices. This will help

strengthen the education component of the service whilst it continues to offer treatment, including minor

surgery, for a wide range of dermatology conditions.

In addition to the individual CCG schemes currently underway, CCGs are agreeing pan south east London

opportunities for delivery next year. Areas being analysed include:

• Diagnostics

• Referral management and booking processes

• Pre and post-operative assessments and care

To refine the scope for diagnostics, a diagnostics workshop is being organised for November which will focus on

areas which have emerged through initial discussions with GPs including the:

• Extent of GP access to various diagnostics

• Waiting times and access for patients

• Quality and speed of reporting

• Ease of access to results

• Duplication of services

South East London Programme Management Office: Working on behalf of six CCGs in south east London – Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark.

6

Integrated care

All boroughs are driving forward integrated care programmes:

Greenwich

The National ‘Pioneer Project’ will build upon the existing integrated care system which is delivering coordinated services for older people and people with physical disabilities in

Greenwich. It will enable Greenwich Health and Social Care partners to rebase integrated services within clusters of GP practices to further improve care for patients and

contribute to delivering community based care across south east London. The service provides:

• A core multi disciplinary team of: GPs; district nurses; community matrons; continence, podiatry, and memory services; social care; Improving Access to Psychological

Therapies; domiciliary care; physiotherapists; occupational therapists and community psychiatric nurses supported by telecare/health as appropriate

• A service focussed on prevention, early identification and co-ordinated care for people at high risk of ill health and hospitalisation, with integral support for carers

• Clear pathways to secondary acute and mental health services and other related services such as housing

Lambeth and Southwark

An integrated approach across the two boroughs and the

development of an Academic Integrated Care

Organisation (AICO) to ensure integrated delivery to the

target population. Benefits to service users include:

A home (virtual) ward and enhanced rapid

response to manage service users in their own

homes

Integrated care for service users with long term

conditions and the frail elderly

Bexley

A case-management approach to identify patients with complex

needs and integrated care services for older people across

health and social care. Benefits to services users include:

• Keeping care managed in a community setting,

supporting them to remain healthy

• Reducing the likelihood of admission to hospital or

long-term care

Bromley

Locality pilot underway with a core team including community

provider and GP practices identifying complex patients

requiring case management. Benefits to service users include:

• Holistic approach using generic assessment forms

• Proactive assessment and support of service users in a

community setting

• All information about individuals’ care in one place

Lewisham

Lewisham’s population-based programme builds on work to integrate services in a number of areas:

bringing district nurses into the Advice and Information Team

integrating LA reablement and provider intermediate care team to create a single service to avoid unnecessary hospital admissions/readmissions and reduce need for high level health & care services

creating MDT working with primary car

undertaking risk stratification of GP adult population

including community development to support and improve health and wellbeing

introducing a virtual electronic patient record across the system



7

Enabling workstreams To deliver this programme effectively, five enabling workstreams were identified at the outset. Each has made

progress:

Communications

A pan south east London winter campaign to support admissions avoidance, self-care, and appropriate use

of health services is being launched in the next two weeks. This was developed drawing on detailed insight

work with our local populations and drawing on evidence about what works to change people’s behaviour.

This bold #YellowMen campaign is expected to gain attention and support behaviour change amongst the

local population. The campaign will be visible within boroughs on buses, billboards, through the local

authority, websites and social media. CCGs are also supporting engagement with groups locally. It is planned

that the campaign will be developed further to ensure that its impact is not lost following the winter period.

The south east London Stakeholder Reference Group (SRG) is examining plans and engagement to ensure

this is robust and appropriate and this is proving to be a helpful way of engaging partners and stakeholders

across south east London

Self-management

It is believed that supporting patients to manage their own health could derive benefits to patients and to

the NHS. A programme to support CCGs own local programmes is in place to support self management using

a range of tools (including booklet aimed at parents/carers of 0-4 year olds) and to enhance self-

management for those people with long term conditions through the integrated teams.

Information

A scoping report is being prepared, with a first draft available soon, and discussions to support the main

workstreams, and specifically Integrated Care, are in progress. This area has been affected by the change in

provider landscape in south east London but is now ready to move forward.

Workforce

Health Education South London (HESL) has agreed funding to support workforce development, including a

baseline audit that has been identified, and development of enhanced skills in care homes following

submissions from across the six CCGs.

Estates

An audit of all community based south east London estates is being undertaken to inform the development

of a south east London estates strategy.

Contract Levers

A high level scoping exercise has been undertaken in order to understand the current contract levers in place

in acute and community contracts. Particular areas of focus have included identifying which levers and

incentives are being enforced, variation in contractual approaches and any learning that may be shared.

Building on this work, two strands of work are being taken forward: o Acute contracts – developing a consistent

approach across south east London towards productivity and performance indicators / benchmarking. o Community contracts – a ‘stock take’ of main community contracts to identify if there are any common

measures and areas where it would be beneficial to implement across south east London.



8

CBC Cost An investment of 1% or greater of CCG budgets to deliver the system change in primary and community care and

QIPP targets was confirmed in September 2013.The shared investments is tracked through the Programme Executive

Group and reported to the south east London CBC Transformation Board. Local delivery components of the

programme are tracked by each CCG as part of their QIPP tracking. Each CCG will provide detail to its Governing

Body as agreed locally.

Next steps

CBC helping the health economy to managing through the winter

CBC has an important part to play in the preparation of south east London for the winter surge in unscheduled care.

Some of the schemes that CBC has brought into existence will be implemented during winter and some which are

already operational will be enhanced following successful bids for winter monies. Examples include the bespoke

#YellowMen communication campaign designed to help signpost people to access the right service first time, and

additional resources for integrated care teams.

NHS Direct has been the provider for NHS111 for SEL since March 2013 and has announced that it is removing itself

as a 111 provider nationally. The London Ambulance Service NHS Trust (LAS) has been selected as the alternative

provider for SEL NHS 111 and will continue to operate from the existing call centre based in Beckenham, using

current NHS Direct staff members. Detailed transfer plans have been put in place, which have been subject of

considerable oversight to ensure the safe transfer of services from the 19th November 2013. Although not an ideal

situation in the early days of winter we are assured that LAS can run a safe and suitable service for our population.

Strategic Planning for an improved sustainable health economy

Each CCG is developing its five year strategy and a south east London strategy will also be developed. As part of this

the south east London CBC strategy will be refreshed. It is still fit for purpose but as the wider strategy is developed

opportunities for linking the CBC strategy with hospital and mental health service changes will be explored further.

Commissioning Intentions and continuing focus on delivery

Specific CBC commissioning intentions are being defined and will drive QIPP plans as part of the two year operating

plans for each CCG. A significant component of this is the Integrate Transformational Fund being transferred to LAs

and each CCG is using this to further enhance its integrated working with their local authorities.

Conclusion This is the first half year report of the south east London CBC Strategy and describes strong delivery in the first 6

months.

There has been significant change since initiation of this programme (new CCGs, changed provider landscape,

financial settlement) and the south east London CBC Strategy needs to continue to adapt and develop to remain fit

for purpose. The strategic planning approach implemented in south east London providers a suitable vehicle to do

this.

Annabel Burn SRO for South East London CBC & CO for NHS Greenwich CCG

Julia Brown Director, South East London PMO including CBC



9

Appendix 1

The three major CBC implementer workstreams and their aspirations are:

Primary and community care (PCC) Working to ensure that the public will:

• Have access to public health programmes that support prevention and early detection of diseases by

proactively finding people at risk of losing their good health.

• Be supported to manage their own health and any illnesses that they have and be given confidence to take

decisions about their own care, including navigating access to specialist services where needed.

• Have access to telephone advice and triage for all community health and care services 24 hours a day, seven

days a week either through their General Practice or through a telephone single point of access.

• Have access to primary care service/advice 24 hours a day, seven days a week for urgent needs through a

combination of appointments and walk in services, telephone appointments, 111/NHS Choices or same day

urgent care etc.

• Receive high-quality care that meets agreed quality standards and outcomes, provided through teams

working in networks across primary care, community and specialist services that may be based in the

hospital.

• Know that their local commissioners (CCGs) proactively plan how to meet the health needs for the

population they have responsibility for and have confidence they are supporting hard to reach groups of

patients.

Planned care Working to ensure that the public will:

• Be well supported when they are at risk of being admitted to hospital, receiving the expert advice, tests or

access to equipment they need promptly to ensure they will only go to hospital if absolutely necessary.

• Be confident that as soon as they are referred to hospital their Community Based Care Team will be working

with staff in the hospital and the community to coordinate an individual discharge plan, including

intermediate care, reablement and rehabilitation, to support efficient discharge from the hospital within 24

hours of being declared medically fit, knowing they will receive the right continuing care in the community.

• Have access to relevant and complete information, in the right formats, to inform personal choice and

decisions.

• Experience consistent quality of care and access to services anywhere is south east London, based on agreed

standards, protocols, access times and approaches to referrals and diagnostics such as radiology,

phlebotomy, ECG and spirometry.

• Receive treatment for planned specialist diagnostics and care in specialist hospitals, but be able to access

other planned routine outpatient appointment, diagnostics, pre- and postoperative appointments in settings

closer to home or via telephone / web consultations to reduce unnecessary travel.

Integrated care Working to ensure that the public will:

• Receive targeted and more personalised care appropriate to their needs, as a result of systems that allow to

proactively identify and support more patients before a crisis.

• Play an active part together with their health professionals and carers in developing a care plan that sets out

what they and those involved in delivering their care will do to support them staying as healthy as possible,

or what should happen in the event of problems.



10

• Have a named ‘care coordinator’ who will work with them to coordinate their care across health and social

care. This role will be clearly defined and clinical accountability for care will remain with their GP.

• Know that their GP is working within a multi-disciplinary group of health professionals to co-ordinate and

deliver care, incorporating input from primary, community, social care, mental health and specialists.



11

Appendix 2

Appointment of clinical leads and sponsors

Since the programme was set up, we have appointed the following clinical leads, sponsors and project managers to

assist with managing the programme:

Marc RowlandCBC Clinical Chair

Angela BhanWorkforce

Andrew EyresSelf Management

Sarah BlowPlanned Care

Martin WilinsonInformation

Systems

Andrew EyresIntegrated Care

Sarah BlowContract Levers

Andrew BlandPrimary and

Community Care

Martin WilkinsonCommunication and Engagement

Jonty HeaversedgeClinical Lead

Alison BasaPMO

Jemma GilbertKey Stakeholder

Jay SticklandClinical Lead

Charlotte HannafordPMO

Rachel BartlettKey Stakeholder

Hany WahbaClinical Lead

Shabana JanjuaPMO

Jane CleggKey Stakeholder

Julia BrownProgramme Director

Annabel BurnSRO

Howard StoateClinical Lead

Rachael CramptonPMO

AHSNKey Stakeholder

Andrew ParsonClinical Lead

Alison BasaPMO

Julie ScreatonKey Stakeholder

Adrian MclachlanClinical Lead

Alison BasaPMO

LPfITKey Stakeholder

Bill CotterClinical Lead

Shabana JanjuaPMO

David SturgeonKey Stakeholder

Eugenia LeeClinical Lead

Molly BaackPMO

SRGKey Stakeholder

Implementation Projects Enablers

CBC



12

Appendix 3

South East London Activity Charts



13

Documents

Governing Body (Public) Meeting...Note: the update within the report of the differing workstreams and the progress made. Executive summary The south east London Community Based Care