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NorthCentralLondonSustainabilityandTransformationPlan21October2016DRAFT

KeyinformationNameoffootprintandnumber:NorthCentralLondon,no.28Nominatedleadofthefootprint:DavidSloman,ChiefExecutive,TheRoyalFreeNHSFTOrganisationswithinfootprint:CCGs:Camden,Barnet,Islington,Haringey,EnfieldLAs:Camden,Barnet,Islington,Haringey,EnfieldProviders:Barnet,EnfieldandHaringeyMentalHealthNHSTrust,CamdenandIslingtonNHSFT,CentralLondonCommunityHealthcareNHSTrust,CentralandNorthWestLondonNHSFT,MoorfieldsEyeHospitalNHSFT,NorthMiddlesexUniversityHospitalNHSTrust,RoyalFreeLondonNHSFT,RoyalNationalOrthopaedicHospitalNHSTrust,TavistockandPortmanNHSFT,UniversityCollegeLondonHospitalsNHSFT,WhittingtonHealthNHSTrust

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Contents

1 Foreword..........................................................................................................................................................3

2 Executivesummary...........................................................................................................................................5

3 Context.............................................................................................................................................................7

4 Caseforchange:ourchallengesandpriorities.................................................................................................104.1 Healthandwellbeinggap...........................................................................................................................104.2 Careandqualitygap...................................................................................................................................114.3 Baselinefinancialgap.................................................................................................................................13

5 Vision..............................................................................................................................................................15

6 Strategicframework........................................................................................................................................166.1 Prevention.................................................................................................................................................176.2 Servicetransformation...............................................................................................................................19

6.2.1 Achievingthebeststartinlife.......................................................................................................................196.2.2 Healthandcareclosertohome.....................................................................................................................216.2.3 Mentalhealth................................................................................................................................................256.2.4 Urgentandemergencycare..........................................................................................................................286.2.5 Socialcare......................................................................................................................................................296.2.6 Optimisingtheelective(plannedcare)pathway...........................................................................................306.2.7 Consolidationofspecialties...........................................................................................................................346.2.8 Cancer............................................................................................................................................................366.2.9 Specialisedcommissioning............................................................................................................................37

6.3 Productivity................................................................................................................................................386.3.1 Commissionerproductivity(BAUQIPP).........................................................................................................386.3.2 Providerproductivity(BAUCIP)andsystemproductivity.............................................................................39

6.4 Enablers.....................................................................................................................................................406.4.1 Digital.............................................................................................................................................................406.4.2 Estates............................................................................................................................................................436.4.3 Workforce......................................................................................................................................................466.4.4 Newcommissioninganddeliverymodels.....................................................................................................48

6.5 Measuringoursuccess...............................................................................................................................49

7 Deliveryplans..................................................................................................................................................50

8 Bridgingthefinancialgap................................................................................................................................518.1 Normalisedforecastoutturnbyyear..........................................................................................................528.2 2017/18forecastoperatingplan.................................................................................................................538.3 Capitalexpenditure....................................................................................................................................538.4 Nextstepstoaddressthefinancialgap......................................................................................................54

9 Howwewilldeliverourplan...........................................................................................................................599.1 Deliverythrough2yearcontractsinNCL....................................................................................................599.2 Decisionmakingintheprogramme............................................................................................................60

9.2.1 CollectivegovernancearrangementsforCCGs..............................................................................................609.3 Programmearchitecture............................................................................................................................61

9.3.1 Futureprogrammearchitecture....................................................................................................................629.3.2 Healthandwellbeingboards.........................................................................................................................639.3.3 Overviewandscrutinycommittees...............................................................................................................63

9.4 Programmeresourcing...............................................................................................................................63

10 Engagement....................................................................................................................................................6510.1 Ourfutureplans.........................................................................................................................................6510.2 Publicconsultation.....................................................................................................................................6710.3 Equalitiesanalysisandimpactassessment.................................................................................................67

11 Conclusionandnextsteps...............................................................................................................................68

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1 ForewordWelcometotheSustainabilityandTransformationPlan(STP)forthehealthandsocialcareservicesthatservethepopulationofNorthCentralLondon(NCL).TheaimoftheSTPistoensureNCL isaplacewiththebestpossiblehealthandwellbeing,wherenoonegets leftbehind.This STP is awork in progress andwewelcome your comments and input aswe furtherdeveloptheplans.Forthefirsttime,wehavecometogetherashealthandsocialcarepartnerstoplanhowwewilldeliverexcellent,future-proofedservicesforourlocalpopulationoverthenext5years.Weknowthatthehealthandsocialcareneedsofour localpeoplearechanging,andthatthereareseriousissuesfacinghealthandcareservicesinNCL.Peoplereceivedifferentcaredependingonwhere theygo toobtain it:waiting times for servicesandhealthoutcomesvary, and the quality of care and people’s experience of health and social services issometimesnotasgoodasitcouldbe.On top of this, our financial situation remains challenging. Demand for health and socialcarecontinuestogrowyearonyearandthegrowth indemandisrunningfasterthanthegrowth in funding. Ifwe do nothing,we estimate thatwewould face an unprecedentedfinancial gap in relation to health services alone of nearly £900m in NCL by 2020/21. Inaddition,asiswellknown,thetrendisforpeopletolivelongerandinturnthisiscreatingpressureonsocialcareservicesandfunding.We believe the best approach tomeeting these challenges is towork together to tacklethemheadon,workingtogethertofindsolutionsatscaleandaligningasasystemaroundthe interestsof localpeople rather thansolely focusingonour individualorganisations. Ittakestimetobuildrelationshipsandtrustinthecontextofasystemthatisfragmentedandunderincreasingpressure,butwearecommittedtothisjointendeavouracrossthewholepartnership.TheSTPsetsoutourcommitmenttotransformingcaretodeliverthebestpossiblehealthoutcomesforourlocalpopulation;shiftingourmodelofcaresothatmorepeoplearecaredforinoutofhospitalsettings-throughprevention,moreproactivecare,andnewmodelsofcare delivery – and reducing reliance use of secondary care. We have made significantprogress indevelopingourspecific ideas forhowwewillachieve this.Wehavesetup13differentworkstreamsandhaveworkedhardontheseoverthelastfewmonthstodevelopthinking, building on evidence and involving hundreds of members of staff drawn fromeveryorganisationinNCL.Wehaveheldpublicmeetingsineachoftheboroughstostarttodevelopadialoguewiththelocalcommunity,althoughwerecognisethereismuchmoretodoonengagementinthemonthsahead.

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The plan sets out a mixture of both radical service transformation and incrementalimprovements we believe we need to make in order to deliver real benefits for ourpopulation: increasingtheemphasisonprevention;shiftingcareclosertohometoreducedemand on hospitals; reducing variation in quality; improving productivity and reducingwaste.But theplanas it standsdoesnothaveall theanswers.Therearesomepartsof theplanwhichwehavenothadtimetodevelop indetail thatrequiresignificantlymorework.Werecognise thesheerscaleof thechanges thatwesetoutcurrently in theplanwill stretchourcapacitytodeliver,soweneedtostresstesttheplantoensurewefocusonthemostimportant improvement first. And fundamentally the plan does not yet balance thefinances,eithernextyearorby2020/21.Unlesswecandoso,wewillnotbeabletoaffordalloftheinvestmentsandimprovementsweaspiretodeliver.Asaresultweknowthatwemay face some really tough decisions about where we can invest for improvement andwherewewillneedtoprioritiseormakechoices.Weneed to resolve thesequestionsbetweennowandChristmas.Wewill ensureweareprioritising the areas which will add the most value (in terms of increasing health andwellbeingforpeople; improvingthequalityofcarepeoplereceive;andensuringvaluefortaxpayers’money) to focusourenergiesonachievingmaximumbenefit.Thiswill includetrying to attract as much investment into NCL as possible. We will continue to developfurtherideasinthepartsoftheplanwhicharenotfullydeveloped.Andwewillreviewthephasing of our specific priorities for the first 2 years of our plan in the context of thesignificantfinancialchallengeweface,seekingspecificallytoidentifyareaswherewecangofurtherandfaster,andareaswherewecandeferourinvestmentoreffort.Werecognisethere ismuchmoreworktodo,and it iscrucial thatour localresidentsareinvolved in this. We are at the beginning of truly transforming care for our population,whichwill require significant input and contribution from thepeoplewhouse services inNCL. We look forward to working with our local population to make designing andimplementingtheplanasuccessasitevolves.

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2 Executivesummary

TherearesomeexcellenthealthandcareservicesinNorthCentralLondon(NCL).However,servicesarenotconsistentandthereareexamplesofpoorpractice.Wealsofacesignificantchallengesoverthenextfiveyearsandneedtoshiftourmodelofcaresothatmorepeopleare cared for inoutofhospital settings. This SustainabilityandTransformationPlan (STP)has been produced by all themain healthcare organisations and local authorities withinNCL.Itsetsouthowweareplanningtomeetthechallengeswefaceanddeliverhighqualityandsustainableservicesintheyearstocome.

Weknowfromourtrackrecordthatwehavethecapabilitytodeliverexcellentservicesandtodeliversignificantchange.However,wearenotcurrentlyabletodeliverservicesacrossNCL consistently to the standards we would like. We also face a number of significantchallengesaroundthehealthandwellbeingoflocalpeople;andthecareandqualityofourservices.Our current system is focussedondealingwith illness, rather thanorientated topreventionandhelpingpeopletolivewell.ThereisasubstantialfinancialchallengefacinghealthorganisationsinNCL;thehealthsystemisalreadyindeficitand,ifnothingchanges,thiswill worsen over the next 5 yearsmeaning that by 2020/21we estimatewewill bec.£900m in deficit. Local authorities are also facing significant financial pressures due todemographic changesandpolicy inflation:by2020/21 the combinationsofpressuresandcontinuedlossoffundingwillresultinacombinedsocialcarebudgetgapofc.£300m.

OurvisionisforNCLtobeaplacewiththebestpossiblehealthandwellbeing,wherenoonegetsleftbehind.Todeliveronourvision,wehavedesignedaprogrammeoftransformationwith4fundamentalaspects:

1. Prevention: We will increase our efforts on prevention and early intervention toimprovehealthandwellbeingoutcomesforourwholepopulation.

2. Service transformation: To meet the changing needs of our population we willtransformthewaythatwedeliverservices.

3. Productivity:Wewill focus on identifying areas to drive down unit costs, removeunnecessary costs and achieve efficiencies, including working together acrossorganisationstoidentifyopportunitiestodeliverbetterproductivityatscale.

4. Enablers: We will build capacity in digital, workforce, estates and newcommissioninganddeliverymodelstoenabletransformation.

Delivering these plans will result in improved outcomes and experience for our localpopulation,increasedqualityofservicesandsignificantsavings.

Despitethis,wecurrentlyexpectthattheoverallfinancialpositionofNHSorganisationswillbe a £75m deficit in 2020/21. We have identified a number of areas for further workbetweennowandChristmaswherewebelievetheremaybeadditionalsavingstobefoundthatwouldaddressthisresidualgap.

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Toensureweareabletodeliverasasystem,buildingontheprogresswehavemadetodatewewill develop a robust governance structurewhich enablesNHS and local governmentpartners to work together in new ways to drive implementation. We will put in placededicated resources to support delivery. It is crucial thatwhole system is aligned arounddeliveryoftheSTPandwewillensurethatthedevelopmentofthe2yearhealthcontractsthat are being put in place for 2017/18 - 2018/19 are consistent with the STP strategicframework.

Werecognisethereismoreworktodotofinalisethegranulardetailofourdeliveryplansandaddresstheresidualchallengeweareforecasting.Todevelopourplansinmoredetailwewanttofullyengagepeoplewhouseservicesandthepublic inourthinkingtoensurethey are reflective of their needs. We are committed to being radical in our approach,focusing on improving population health and delivering the best care in London. Ourpopulationdeservesthis,andweareconfidentthatwecandeliverit.

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3 Context

NorthCentral London (NCL) comprises fiveClinicalCommissioningGroups (CCGs):Barnet,Camden,Enfield,HaringeyandIslington,eachofwhichiscoterminouswiththelocalLondonBoroughs.Approximately1.45m1liveinthe5boroughs.Wespendc.£2.5bnonhealthandc.£800m2onadultandchildren'ssocialcareandpublichealth.Thepopulationisdiverseandhighlymobile,withalargenumberofpeoplelivingindeprivation3.

TherearefouracutetrustswithinNCL:TheRoyalFreeLondonNHSFoundationTrust(sitesincludeBarnetHospital, Chase FarmHospital and theRoyal FreeHospital inHampstead),University College London Hospitals NHS Foundation Trust, North Middlesex UniversityHospital NHS Trust, and Whittington Health NHS Trust. There are two single specialisthospitals: Moorfields Eye Hospital NHS Foundation Trust and the Royal NationalOrthopaedicHospitalNHSTrust.GreatOrmondStreetHospitalforChildrenNHSFoundationTrust iswithin theNCLgeography,but currentlyoutof the scopeof theSTP.Communityservices are provided by Central and North West London NHS Foundation Trust, theWhittingtonHealthNHSTrust,andCentralLondonCommunityHealthcareNHSTrust.

Mentalhealthservicesareprovidedby theTavistockandPortmanNHSFoundationTrust,Camden and Islington NHS Foundation Trust and Barnet, Enfield and Haringey MentalHealthNHSTrust.Thereare2204GPpractices,andtheout-of-hoursservicescontractwasrecentlyawarded to theLondonCentralandWestUnscheduledCareCollaborative.Thereare497activesocialcaresitesregisteredacrossNCL, including273registeredcarehomes(47ofwhichprovidenursing)5.CarehomesareparticularlyhighinnumbersinthenorthofNCL,forexampleinEnfieldwherethereare97registeredcarehomes(incontrasttothe12carehomes registered inCamden)6. In addition, thereare214 registereddomiciliary careproviders7.

TheorganisationofservicesinNCLmakestheareaquiteuniqueandthishasramificationsforplanning:thereisaparticularlyhighconcentrationofspecialisedservicesacrossmultipleproviderscoveringasmallgeographicarea.ThismeansmanyofthepatientstreatedinNCLdo not live in NCL and consequentially, a large proportion of the income paid to ourproviderscomesfromcommissionersoutsideofthearea.

AsindividualorganisationsinNCL,wehaveahistoryofworkingtogetherindifferentwaysto meet the needs of our population, and there are numerous excellent examples ofcollaboration as a result.However,working collectively across all organisations remains arelativelynewendeavourandwecontinuetobuildthetrustrequiredtoenableustodoso.

1ONS,Mid-yearpopulationestimates,201522015/16 3Officefornationalstatistics,IMD20154LatestfiguresfromNHSEngland,updatedsincepublicationoftheNCLcaseforchange5LocalAuthorityCareQualityCommissionreports,20166LocalAuthorityCareQualityCommissionreports,20167LocalAuthorityCareQualityCommissionreports,2016

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We are home to 4 national Vanguards: The Royal Free London NHS Foundation Trust isdeveloping a provider chainmodel; University College London Hospitals NHS FoundationTrustVanguardisfocusedonwhatcanbedonetoimprovetheend-to-endexperienceforpeople with cancer; Moorfields Eye Hospital NHS Foundation Trust is developing anophthalmology specialty chain; and, theRoyalNationalOrthopaedicHospitalNHSTrustisoneof13partnersdevelopingaUK-widechainoforthopaedicproviders.NCLisalsohometotwodevolutionpilots:oneseekingtooptimisetheuseofhealthandsocialcareestate,andanother focusedonprevention inHaringey. Inprimarycare,GPpracticesarealreadyworking together in a number of GP Federations to provide extended services to ourresidents.

InNCL,everyboroughhas itsownuniqueidentityandlocalassetswecanbuildon.Manypeopleleadhealthylives,butiftheydogetsickwecanoffersomeofthebestcareinthecountry.Wehaveareputationforworldclassperformanceinresearchandtheapplicationof innovation and best practice, and we can harness the intellectual capacity of ourworkforcetoensurethebestoutcomesaredelivered.Therearemanyexamplesofexcellentpracticeacrosshealthand social care inourarea,whichwe intend touse tohelpensurethatexcellentpracticecanbeofferedtoallourresidents.

Ourtrackrecorddemonstratesthatwehavethecapabilitytodeliverexcellentservicesandalsotosignificantlychangeourserviceswhenneeded.Ourambitionisthateveryoneisabletogetthecaretheyneedwhentheyneedit.Thismeansensuringpeoplehavethebeststartinlife,andsupportingthemtolivehealthylives.Whenpeopledoneedspecialistcare,wewantthemtobeabletoaccessitquicklyandinthemostappropriatesetting,andtobefullysupportedtorecoverinthesettingmostsuitedtotheirneeds.

However,wearenotconsistentlydeliveringourambitiontothestandardswewould like.We face significant challenges around the health and wellbeing outcomes for ourpopulation,thequalityofourservicesandthefinancialsustainabilityofthehealthandcaresystem. These are outlined in this document and set out in more detail in our case forchange8.

ThenationalrequirementtoproduceanSTPisanopportunityfortheNCLsystemtoaddressthesechallengestogetherandwidenthescopeofourcollaborativeworking.Thisdocumentarticulates:

• ourcollectiveunderstandingofthechallengesweface• ourvisionforhealthandcareinNCLin2020/21• theplanstodeliveronourvisionandaddressthechallenges• thedeliveryframeworkwhichwillenableustoimplementourplan• theimpactweexpecttoachievethroughthedeliveryofourplans• ourplansforsecuringbroaderpublicsupportandengagementwithourproposals• our next steps for further developing proposals and responding to our residual

financialgap.

8https://www.uclh.nhs.uk/News/Documents/NCL%20case%20for%20change.September%202016.pdf

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Exhibit1:OverviewofNCL

Source:Populationfiguresfrom2014ONSdata.

London Ambulance ServiceEastofEnglandAmbulanceService

Barnet,EnfieldandHaringeyMentalHealthNHSTrust(mainsites,incl EnfieldCommunity)CamdenandIslingtonNHSFT(andmainsites)NorthMiddlesexUniversityHospitalNHSTrustTheRoyalFree LondonNHDFTUniversityCollegeLondonHospitalsNHSFTWhittingtonHealthNHSTrust(incl IslingtonandHaringeyCommunity)CentralandNorthWestLondonNHSFT(CamdenCommunity)CentralLondonCommunityHealthcareNHSTrust(BarnetCommunity)Specialistproviders

EnfieldCCG/EnfieldCouncil~320kGPregisteredpop.~324kresidentpop.49GPpracticesBarnetCCG/BarnetCouncil~396kGPregisteredpop.~375kresidentpop.62GPpracticesHaringeyCCG/HaringeyCouncil~296kGPregisteredpop.~267kresidentpop.45GPpracticesIslingtonCCG/IslingtonCouncil~233kGPregisteredpop.~221kresidentpop.34GPpracticesCamdenCCG/CamdenCouncil~260kGPregisteredpop.~235kresidentpop.35GPpractices

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4 Caseforchange:ourchallengesandpriorities

InNCLwesharemanyofthesamechallengesfacedbyhealthandcareorganisationsacrossthe UK (and indeed internationally). We have undertaken significant work to identify,articulateandquantifythespecificgapsinhealthandwellbeing;careandquality;andourbaselinefinancialposition.Acrossthesystemwehavealignedbehindthisworkandweallagreeon thenature and scaleof the challenge,whichwehavedescribed inour case forchangewhichwaspublishedinSeptember2016.

4.1 Healthandwellbeinggap

Wehaveadiverseandhighlymobilepopulation. Therearepeople froma rangeofBlackand Minority Ethnic (BME) groups: these groups have differing health needs and healthrisks. A quarter of our local people do not have English as their main language9, whichcreateschallengesfortheeffectivedeliveryofhealthandcareservices.Themobilityofourpopulation,with8%oflocalpeoplemovingintooroutofNCLeachyear10,hasasignificantimpactonaccesstoservicesanddelivery.

Poverty is a crucial determinant of health, and is widespread among both adults andchildrenlivingintheboroughsthatmakeupNCL11.Significantinequalitiesexist,whichneedtobeaddressed;forexample,meninthemostdeprivedareasofCamdenliveonaverage10yearsfewerthanthoseintheleastdeprivedareas12.Wefacechallengesinaddressingotherwider determinants of health, for example, there are high levels of homelessness andhouseholds in temporary housing with all five boroughs in the top 10% for number ofhouseholds in temporary accommodation13. Social isolation also remains a critical issueacrossthesub-region.

ThechildrenofNCLdonotalwaysgetthebeststarttolife.30%ofchildrengrowupinchildpovertyand6%liveinhouseholdswherenooneworks.60childrentakeupsmokingeveryday14.Althoughtherehavebeensomeimprovementsrecently,Londonasawholehasthehighestratesofobesitynationally:1in3childrenareobeseinYear6(age11)andweneedtodomoretotacklethis,particularlyworkingwiththeschoolsinNCL15.Althoughmanyofour residents are healthy and people are living for longer, good health does not alwayspersistintooldage.Ourolderpeoplearelivingthelast20yearsoftheirlifeinworsehealththantheEnglandaverage16.

Almosthalfofpeople inNCLhaveat leastone lifestyle-related clinicalproblem (e.g.highbloodpressure)thatisputtingtheirhealthatrisk17.However,theyhavenotyetdeveloped

9NCLcaseforchange,201610ONSmid-yearpopulationestimates201411Census201112IMD2015,ONS13https://www.gov.uk/government/statistical-data-sets/live-tables-on-homelessness14CENSUS201115Publichealthoutcomesframeworktool,2015 16 OfficeforNationalStatistics,HSCICCCGIndicators,2014-15 17CamdenandIslingtonGPLinkedDatasetprojectedtoNCLlevel

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a long term health condition. Many of these lifestyle-related clinical problems are riskfactorsforNCL’sbiggestkillers-circulatorydiseasesandcancer.Thesediseasesarealsothebiggestcontributorstothedifferenceswhichexistinlifeexpectancy.

TherearehighratesofmentalillnessamongstbothadultsandchildreninNCL18,andmanyconditionsgoundiagnosed19.50%ofallmental illness inadultsbeginsbefore14yearsofageand75%by1820.Childrenwithmotherswithmentalillhealtharemuchmorelikelytodevelopmentalhealthissuesthemselves.Threeofourboroughshavethehighestratesofchildmental health admissions in London21 There are high rates of early death amongstthosewithmentalhealthconditions22,particularlyinHaringeyandIslington,andtherateofinpatientadmissionsamongstthispopulationisabovethenationalaverage.Astrongfocusonmentalhealthiscentraltoourapproachwithaclearaimoftreatingmentalandphysicalillhealthinajoinedupwayandwith“parityofesteem.”

4.2 Careandqualitygap

Currently, our systemdoesnot sufficiently invest in thosepeoplewith a life-style relatedclinical problem, which would help stop them from developing the long term conditionswhichinaggregateareahugeburdenonourhealthandcaresystem.Only3%ofhealthandsocialcarefundingisspentonpublichealthinNCL23,andthatisdespiteevidenceshowingthat between 2012 and 2014 around 20% (4,628) of deaths in NCL could have beenprevented24.Thereisa largeopportunity inrefocusingoureffortstowardspreventionandmaking every contact count. This focus should also address the wider determinants ofhealthsuchaspoverty,housingandemployment,allofwhichhaveasignificantimpactonindividuals’healthandwellbeing.

Diseaseand illness couldbedetectedandmanagedmuchearlier, andmanagedbetter incommunity.Itisthoughtthattherearearound20,000peopleinNCLwhodonotknowtheyhavediabetes,while13%ofthepopulationarethoughttobelivingwithhypertension25.Itislikely thatpeoplearebeing treated inhospital for long termconditions (LTCs)when theycouldbebettermanagedbyindividualsthemselveswiththesupportofprofessionalsinthecommunity.ManypeoplewithLTCs–over40%inBarnet,HaringeyandEnfield–donotfeelsupported to manage their condition26. This would help avoid the high levels ofhospitalisationweexperiencefortheelderlyandthosewithchronicconditions.

One of the disease specific challenges we face is in the provision of cancer care. Latediagnosisof cancers is aparticular issue, alongside low levelsof screening for cancerandlowawarenessofthesymptomsofcancerinsomeminorityethnicgroups.Waitingtimesto 18QOFdata2014/1519NHSEnglandDementiaDiagnosisMonthlyWorkbook,April201620DunedinMultidisciplinaryHealth&DevelopmentResearchUnit.WelcometotheDunedinMultidisciplinaryHealthandDevelopmentResearchUnit(DMHDRU).21Fingertips,2014/1522HealthyLives,HealthyPeople201023Basedon2015/16publichealthbudgetofeachNCLcouncil24PublicHealthProfilesDataTool,PHE,2012-1425QOF2014/1526OfficeforNationalStatistics,HSCICCCGIndicators,2014-15

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seeaspecialistarelong,andsoarewaitingtimesfordiagnostics.Additionally,referralstospecialists have almost doubled in five years. There is a huge shortfall in diagnosticequipment and workforce, and a lack of services in the community, particularly atweekends.Afurtherissueisthatsomehospitalsareseeingsmallnumbersofpatientswithsometypesofcancer,insomecaseslessthantwoperweek.

Therearesomechallengesinprimarycareprovision,however,thisisamixedpicturewhichcreatesinequity.TherearetoofewGPsinBarnet,EnfieldandHaringey,andlownumbersofregistered practice nurses per person across all areas, but particularly in Camden andHaringey.

There are high levels of A&E attendances across NCL compared to national and peeraverages27,andveryhigh levelsof firstoutpatientattendances28,which indicatepotentialgaps in primary care provision. Acute providers are not consistently meeting emergencystandards.

Intheacutesettingtherearedifferencesinthewaythatplannedcareisdeliveredandthisneedstobeaddressed,withvariationbasedondifferences inclinicalpracticerather thanpatientneed.ThenumberofpeopleseenasoutpatientsinNCLishighandthereisvariationinthenumberofreferralsbetweenconsultantsinthesamehospital,thenumberoffollow-upoutpatientappointmentsandtheproportionofplannedcarethatisdoneasadaycase.

Weareusinghospitalbedsforpeoplewhocouldbecaredforathome,orinalternativecaresettings. 59% of acute bed days are used by people with stays over 10 days, and themajorityof thesepeopleareelderly. 85%of thementalhealthbeddays inNCLare frompatients stayingover30days.Delayeddischargesarealsohigh in somehospitals. Stayinglonger than necessary in hospital is not good for people’s health, especially the elderlywhosehealthandwellbeingcandeterioraterapidlyinanacuteenvironment.29

We face challenges inmentalhealthprovision.Peopledonotalwayshaveeasyaccess toinformation and community based support, and community mental health services areunderhugepressure.Thereisalsonohighqualityhealth-basedplaceofsafetyinNCL.Manypeople receive their first diagnosis of mental illness in Emergency Departments. Highnumbersofpeopleareadmittedtohospital–manyundertheMentalHealthAct.Thereisvariableaccess to liaisonpsychiatry,perinatalpsychiatryandchildandadolescentmentalhealth services (CAMHS) within urgent care: most of the liaison psychiatry and CAMHSservices in hospitals in NCL do not see children within one hour at weekends andovernight30.ThereislimitedperinatalcommunityserviceinNCL,inthenorthernboroughsthereisnospecialistteamandinthesouthernboroughstheservicedoesnotmeetnationalstandards31.

27RightCareAtlasofVariationinHealthcare,September201528NHSEnglandActivityData2014-1529Philipetal. (2013)Reducinghospitalbeduseby frailolderpeople: results fromasystematic reviewof the literature.

InternationalJournalofintegratedcare.30 MentalhealthcrisiscareEDaudit,NHSEngland(London),201531MaternalMentalHealthEveryone’sBusiness

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Our use of information and technology does not currently support integrated health andsocialcareacrossNCL.Thereisavariablelevelofdigitalmaturityacrossprovidersandmostbeingbelowthenationalaveragefordigitalcapabilities,particularlytheircapabilitytoshareinformationwithothers.

Someofourbuildingsarenotfitforpurposeandthereareopportunitiestouseourestatesbetter.11sitesinNCLhavefacilititesmanagementcostsatleast10%morethantheCarterbenchmark(£319psq.m),withafurther3siteswithin10%ofthebenchmark.8siteshavea higher proportion of unutilised space than the 2.5% benchmark contained within theCarterreport,andoverhalfofthesitesanalysedwerefoundtohaveahigherproportionofnon-clinicalspacethantheCarterbenchmark(35%).

We have significant workforce challenges across health and social care, including a highturnover across a range of professions, an over reliance on agency staff and HR policieswhicharenottransferableacrossorganisations.

There is consensus across the system that the current approach to commissioning andprovidinghealthandsocialcareservicesacrossNCLcouldbebetteralignedtosupporttheimplementation of our emerging vision for the STP. In particular, the delivery of apopulationhealthapproachandgenuinelyintegratedcareissignificantlyconstrainedby:

• therigidseparationofcommissioningandprovidingresponsibilitieswithintheNHS• thelimitedexistingintegrationbetweenhealthandsocialcare• thefragmentationofprovidersofhealthandcareintomanysovereignorganisations• increasedfinancialrisksacrossCCGsandproviders• stretchedcapacityandcapabilityinthecurrentorganisationalform.

We need to design new commissioning and delivery models that enable us to delivertransformedcareinawaythatissustainable.

4.3 Baselinefinancialgap

Ourpopulationisgrowinganddemandisrising:peopleaccesshealthcaremoreoften,andare–positively–livinglonger,butoftenwithoneormorelongtermconditions.Meanwhile,theNHS’scostsarerisingmorethaninflationacrosstheUKeconomy(towhichallocationsarelinked).Theupshotofthisisthatnotonlyisthesystemrespondingtogreaterdemand,butalsothatthesumcostofactivityisgrowingfasterthanallocations.

Putsimply,fundingincreasesinNCLof£269moverthenext5yearswillnotmeetthelikelyincreasesinnumbersoflocalpeopleandgrowthindemandforhealthservicesofc.£483m,plusincreasesinthecostofdeliveringhealthcareofc.£404m.

ThismeansthatthereisasubstantialfinancialchallengefacinghealthorganisationsinNCL.Health commissioners and providers were already £121m in deficit in 2015/16 and, ifnothingchanges,thiswillgrowto£876mindeficitby2020/21.

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Exhibit2:The‘donothing’financialgapforNCL

The‘donothing’specialisedcommissioningfinancialchallenge isestimatedat£137m(thisestimate is currently being validated). This excludes Great Ormond Street Hospital NHSTrustandtheRoyalNationalOrthopaedicHospitalNHSFoundationTrustwhichwouldaddafurther£49mand£10mrespectively.Thespecialisedcommissioningchallengeisdrivenbyadvances in science; an increasingly ageing population with LTCs; and rising publicexpectationandchoiceforspecialisedtreatment. Inadditionthereareincreasingfinancialpressuresforspecialisedservices,includingtheincreasingvolumeofexpensivenewdrugs.Spendingonspecialisedserviceshas increasedatmuchgreatera rate thanotherpartsoftheNHS,andthisisexpectedtocontinue.

The current combined net budgets for the 5 boroughs in NCL is £760m for Adults andChildren's Social Care (CSC) and Public Health services. However,we know that between2010/11and2020/21theaveragereductioninboroughspendingpowerwillbe35%.AdultSocial Care (ASC) budget reductions during this period will total at least £154.5m. Thisreductioninfundingrequiresthatasignificantsavingsprogrammebedelivered.

Thecollective2016/17forecastbudgetpressuresforthe5boroughsinASCandCSCis£39m(£26mASC,£13mCSC).BothASCandCSCwill continue faceconsiderablepressures fromdemographic growth, inflation and increasingly complex care needs. By 2020/21 thecombinations of pressures and continued loss of fundingwill result in a combined socialcarebudgetgapofc.£308m,whichisequivalenttoa28%reductiononthecurrentCouncils'totalbudget.Councilsmayhave theoption to raisea2%precept for social care in futureyears,butthiswillbesubjecttopoliticalagreementandwillnotcomeclosetoclosingthegap.

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5 Vision

DevelopingourvisioninNCLhastakentime,andwehaveharnessedourhighqualityclinicalandpractitionerleadershipateverystageoftheprocess.ThevisionforNCLinitiallydrewonexistinglocalworkwhichwasunderwaybeforetheSTPprocessstarted.LeadersacrossthesystemtheniteratedthevisionataneventinSeptember2016.Thisprocess,alongsidetheseriesofborough-basedpublicengagementeventsinSeptemberandOctober,hasensuredthatourvision iscollectivelyownedacrossthesystem.Wearecommittedtofulfillingourvisionthroughthisplan,andhaveidentifiedasetofcoreprinciplestosupportourambition.

Ourcoreprinciples

• Wewillworkinanewwayasawholesystem;sharingrisk,resourcesandreward.• Health and social care will be integrated as a critical enabler to the delivery of

seamless,joinedupcare.• Wewillmovefrompilotsandprojectsto interventions forwholepopulationsbuilt

aroundcommunities,peopleandtheirneeds.Thiswillbeunderpinnedbyresearchbaseddeliverymodelsthatmove innovation in laboratoriestofrontlinedeliveryasquicklyaspossible.

• Wewillmakethebestthestandardforeveryone,byreducingvariationacrossNCL.• Intermsofhealthwewillgivechildrenthebeststartinlife,andworkwithpeopleto

helpthemremainindependentandmanagetheirownhealthandwellbeing.• Intermsofcarewewillworktogethertoimproveoutcomes,providecarecloserto

home,andpeoplewill onlyneed togo tohospitalwhen it is clinicallyessentialoreconomicallysensible.

• We will ensure value for tax payers’ money through increasing efficiency andproductivity,andconsolidatingserviceswhereappropriate.

• Todoallofthiswewilldothingsradicallydifferentlythroughoptimisingtheuseoftechnology.

• Thiswillbedeliveredbyaunified,highqualityworkforceforNCL.

OurvisionisforNorthCentralLondontobeaplacewiththebestpossiblehealthandwellbeing,whereno-onegetsleftbehind.

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6 Strategicframework

TodeliveronourvisionandachievethetripleaimassetoutintheFiveYearForwardView(toincreasehealthandwellbeing;meetthehigheststandardsofcareandquality;andimproveproductivityandefficiency),wehavedesignedaprogrammeoftransformationwith4aspects:

1. Prevention: Much of the burden of ill health, poor quality of life and healthinequalities inNCL is preventable.Wewill increase our efforts on prevention andearly intervention to improve health and wellbeing outcomes for our wholepopulation,whichwillreducehealthinequalities,andhelppreventdemandformoreexpensivehealthandcareservicesinthelongerterm.

2. Service transformation: To meet the changing needs of our population we willtransform the way that we deliver services. This involves taking a “populationhealth” approach: giving children the best possible start in life; strengthening theoffersandprovisioninthelocalcommunitytoensurethatwherepossiblecarecanbe provided out of hospital and closer to home – reducing pressure on hospitalservices;rethinkingtherelationshipsbetweenphysicalandmentalhealthtoensurethat mental health care is holistic and person-centred; and, reducing variation inservicesprovidedinhospital.Socialcareplaysakeyroleinservicetransformation.

3. Productivity: Inordertoensuresustainability,wewill focuson identifyingareastodrive down unit costs, remove unnecessary costs and achieve efficiencies. Forproviders,thisincludesimplementingrecommendationsfromtheCarterReviewandworking together across organisations to identify opportunities to deliver betterproductivityatscale.

4. Enablers:We will focus on delivering capacity in key areas that will support thedelivery of transformed care across NCL. This includes digital, workforce, estates,andnewcommissioninganddeliverymodels.

Exhibit3:TheNCLSTPstrategicframework

ServicetransformationImprovespopulationhealthoutcomes;Reduces

demand;Improvesqualityofservices1.Prevention

2.Healthandcareclosertohome

3.Mentalhealth

4.Urgentandemergencycare

5.Optimising theelectivepathway

6.Consolidationofspecialties

ProductivityReducesnonvalue-addingcost

EnablersFacilitatesthedeliveryofkeyworkstreams

A B

8. Productivity• BAUQIPP• BAUCIP• Systemproductivity

7.Cancer

C

9.Healthandcareworkforce10.Healthandcareestates11.Digital12.Newdeliverymodels13.Commissioningarrangements

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6.1 Prevention

Wewillembedpreventionandearlyinterventionacrossthewholehealthandcaresystemand deliver effective preventative interventions at scale. As a result, we will improvepopulationhealthoutcomesandreducehealthinequalitiesbyharnessingassetswithinandacross communities for example, from Council services, including social care and thevoluntary and community sector. This will positively impacting on the lives of residents,theirfamilies,andourcommunities.

Ourpreventionplansfocusoninterventionsandsystemchangeacrossthewholespectrumof prevention (exhibit 4), where there is strong evidence of effectiveness and return oninvestment within the 5 year period of the STP32. In addition, we have identifiedopportunitieswherewe could rapidlybuildupon successful local initiatives acrossNCL toachieveeconomiesofscale.

32 InterventionshavebeenidentifiedfromthePublicHealthEngland(PHE)SupportingPackforSTPsandthereturnoninvestmentworkundertakenforHealthyLondonPartnershipsbyOptimity.

Afrinlivesinhostelaccommodationandisdependentonalcohol.Heexperiencesseizuresalmostdaily.Afrinhasinthepast,withsupportfromtreatment,managedtogainabstinencebuthadarelapsewhichisduetodepressionbroughtonbyunstablehousingandeconomiccircumstances.Afrinhashadmanyunscheduledhospitaladmissionsinthelast6months.Infuture,onadmissiontohospitalAfrinwillbereferredtoanalcoholassertiveoutreachworker(AAOT)bythehospitalalcoholliaisonworker.Thissupportwillenablehimtoputinplacefoundationsthatwillhelphimtowardsabstinenceandrecovery.Afrinwillbesupportedtogiveupdrinking,withinputfromanaddictionsdoctoratacommunityalcoholservice.Aslowreductionplan,thatisachievableandminimisestheriskofseizureswhichinthepasthaveledtohospitaladmission,willbeputinplace.Afrinwillhaveregular1-2-1appointmentswithhisAAOT,whichwillincludepsychologicalhelp.

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Exhibit4:Approachtoprevention

Wewillconcentrateoureffortson:

• Creating a ‘workforce for prevention’ so that every member of the local publicsectorworkforceinNCLisachampionforprevention.Specific interventions:MakingEveryContactCount(MECC);MentalHealthFirstAid(MHFA);dementiaawareness

• Ensuring that the placeswhere residents and employees live andwork promotegood health. This will include: reversing the upwards trend in childhood obesity;supportingpeoplewithmental ill healthandother long termconditions to stay inwork;pioneeringnewapproachestotacklinggambling,alcoholmisuseandsmoking;and supporting the workforce across NCL (including our own staff) to becomehealthier.Specific interventions: Haringey Devolution Pilot; improving employmentopportunitiesforpeoplewithmentalillhealththroughindividualplacementsupport(IPS);HealthyWorkplaceCharter;HealthyEarlyYears/HealthySchoolsaccreditation

• Supportingresidents,familiesandcommunitiestolookaftertheirhealth:smokinganddrinkingless,eatingmorehealthily,andbeingmoreactive,aswellaslookingaftertheirsexualhealthandmentalhealthwellbeing.Thiswillall reducehospitaladmissions from preventable causes such as smoking, alcohol, and falls, andreductionsinassociatedillhealthandearlydeaths.Wewillprotectandensurehighqualityuniversalservicesforvulnerablefamiliesbystartingdirectconversationswithschools to proactively identify who these families are, and collaborating to mapacross primary care, social care, early years, therapies, paediatrics and secondarycare. We will ensure that smoking cessation programmes are embedded across

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maternityservicesandservicesforchildrenandyoungpeople,targetingparentsandolder children.Drawingon theexperienceofour local authorities in running largescale campaigns, we will design and delivera campaign across NCL to address avarietyofwellbeingor long termconditions througha singlepreventativemessagewithcommonNCLbranding. Specific interventions: smoking cessation; alcohol screening, liaison and outreachteams; weight management programmes; diabetes prevention programme;multifactorial falls intervention; long-acting reversible contraception; communityresilience;increasedaccesstomentalhealthservicesforchildrenandnewmothers;London’sdigitalmentalhealthprogramme.

• Diagnosing residents with clinical risk factors and long term conditions muchearlier to increase lifeexpectancy.Oncediagnosed,empowering themtomanagetheir own condition(s) alongsideproactivemanagementbyhealthprofessionals topreventthedevelopmentoffurtherconditionsandcomplications.Specific interventions: increasing awareness and case finding (including nationalcancerscreeningandHIVtesting)andappropriatemedicationstocontrolconditionsfor people with high blood pressure, diabetes, atrial fibrillation; self-care andstructured self-management for long term conditions; reablement offers in socialcareandcarenavigation.

WewillbuilduponontheindividualstrengthsthateachpartofthepublicsectorinNCLcanbringtopreventingdiseaseand illhealth. Aswellastraditional ‘healthprofessionals’ thisalsomeansworkingwithlocalauthorityhousingofficersandtheLondonFireBrigadein,forexample, preventing falls. We also recognise the key contribution that voluntary andcommunity sector organisations can make in achieving disproportionately greaterimprovementsinhealthforresidentswithmentalillhealthandlearningdisabilities,specificBME groups, and those in the most deprived communities, and we are committed toworkingmorecollaborativelywiththeseorganisations.

6.2 Servicetransformation

Tomeet thechangingneedsofourpopulationwewill transformtheway thatwedeliverservices, shifting the balance of care from reactive to proactive. This will be throughensuringpeopleachieve thebest start in life,developingour care closer tohomemodel,creating a holistic approach to mental health services, improving urgent and emergencycare, optimising the elective pathway, consolidating of specialtieswhere appropriate andtransformingcancerservicestoimprovetheend-to-endexperience.Socialcareplaysakeyroleinallaspectsofservicetransformation.

6.2.1 Achievingthebeststartinlife

Childrenmakeupbetween25%and30%ofthepopulationacrosstheNCLfootprintwhichmeansthatservicetransformationmustincludeaspecificfocusonourchildrenandyoungpeople.We recognise thatproviding childrenwith thebest start in life is critical for theirdevelopmentandhealth long term.Wehave identified interventionsacross thepathway,

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from prevention to acute care, that are focussed specifically on improving health andoutcomesforchildrenandyoungpeople.

In the context of a considerable body of research suggesting that fetal exposure to anadverse environment in-utero sets the trajectory for child and adult health in terms ofcongenital malformations, obesity, diabetes and cardiovascular disease, we will explorewaystolinkprimarycare,publichealthandmaternityservicestooptimisematernalhealthbefore, during and after pregnancy. In particular, smoking cessation, weight reduction,optimisation of blood sugar control in diabetics and improvement of diet in women ofreproductiveagehasthepotentialtoreducethehealthneedsofchildren.Wewillleveragethe work of our NCL Maternity Network to ensure that our local maternity systemimplements the findings of the nationalMaternity review: Better Births.We are keen totakepartintheNationalMaternityTransformationprogrammeasanEarlyAdopter.

Wewillpromoteactivetravel,sportandplayforchildreninschools,forexampleinvolvingschoolstodelivertheTake10,Active15,Walkadailymileinitiativesthatotherpartsofthecountryhaveadopted to support this.By2020/21,our aim is that4outof 5early years’settingsandschools inNCLwillbeaccreditedaspartofthehealthyschools,healthyearlyyearsorsimilarlyaccreditedprogrammeforpromotinghealthylives.

Wewilladdressmentalillhealthinchildrenasearlyaspossible:developingantenatalandpostnatalinterventionsformotherswithmentalillhealth;improvingservicesforparentingsupport, health visiting, and signposting; and creating targeted services that focus onvulnerablehighriskfamilies.WewillcapitaliseontheuniversalservicesofMIND,Place2Beand voluntary sector initiatives like Hope Tottenham that are already established andworkingdirectlywithfamiliesandyoungpeople.AspartofourChildandAdolescentMentalHealthServices(CAMHS)andperinatalinitiativeledthroughthementalhealthworkstream,wewill:

1. Develop a shared dataset for CAMHS to enable comparison and shared learningacrossthe5boroughs

2. Tackleeatingdisordersbyestablishingdedicatedeatingdisorderteamsinlinewiththewaitingtimestandard,servicemodelandguidance

3. Upskillourworkforcetomeetthementalhealthandpsychologicalwellbeingneedsof children and young people, including developing a children and young people’sIAPTworkforcecapabilityprogramme

Tai,14,suffersfromseveredepression.WiththeinvolvementofTai,hisfamily,andhisCAMHSpractitioners,TaihasbeenadmittedintoaTier4unitonaplannerbasis.Previously,itwaslikelythatTaiwouldhavebeenplacedfarfromhome.Infuture,withthelocalcommissioningofTier4hewillbeabletobeplacedclosetohome.ThiswillenablebetterlinkagewiththelocalCAMHScommunityteam,whichwillhavealsobeenenhanced.Together,thesefactorswillmeanTaihasabetterexperienceofcareandstaysinhospitalforashorterlengthoftime.WhenTaiisdischargedbackintothecommunity,hewillhaveanenhancedcareplantosupporthimtokeepwell.

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4. BuildonourTransformingCareinitiativebysupportingchildrenandyoungpeoplewith challenging behaviour in the community in order to prevent the need forresidentialadmission

5. Improve perinatal mental health services by developing a specialist communityperinatalmentalhealthteamthatservestheNCLpopulationandthephysicalhealthacutetrustswithinNCL

6. ImplementaChildHousemodelfollowingbestpracticetosupportabusedchildren7. Create a 24/7 crisis pathway for children and young people, including local

commissioning of Tier 4 CAMHS to eliminate out of area placements for non-specialistacutecareby2020/21;andreviewofS136

8. Developaco-commissioningmodelforyouthjusticeworkingwithNHSEngland.

TheprinciplesofTHRIVEwillbeusedasanoverarchingapproachtoourCAMHSwork,withthe aim that at least 32% of children with a diagnosable condition are able to accessevidence-basedservicesbyApril2019assetoutintheMentalHealthTaskforce.

6.2.2 Healthandcareclosertohome

Healthandcarewillbeavailableclosertohomeforall,ensuringthatpeoplereceivecareinthebestpossiblesettingatalocallevelandwithlocalaccountability.Wealreadyhavemanyhigh quality services outside acute settings acrossNCL, but our health and care closer tohomemodelwillfocusonscalingtheseservicesup,reducingvariationandmakingthisthedefault approach to care. Social carewill play a key role in the design, development andexpansionofthefuturemodel.

Wewilladdressthesustainabilityandqualityofgeneralpractice, includingworkforceandworkload issues. It is recognised that for some people, health and care being deliveredclosertotheirhomeisnotalwaysthebestchoice,andthereforehighqualityhospital-basedandcarehomeserviceswillcontinuetobeavailablewhenneeded.

Attheheartofthecareclosertohomemodelisa‘place-based’populationhealthsystemofcaredeliverywhichdrawstogethersocial,community,primaryandspecialistservices.Thiswillbeunderpinnedbyasystematicfocusonpreventionandsupportedself-care,withtheaimofreducingdemandonthesystemovertime.Wewilldelivertherightcareattherighttimetothewholepopulation.Thecareclosertohomemodelisoneofthekeyvehiclesby

MsSahniis87andhasfourchronichealthproblems.Previously,shehadtobookseparateappointmentswithdifferentprimarycareprofessionalstohavealloftherelevantcheck-upsandappointmentsthatsherequired.Infuture,MsSahniwillbeinaspecial“stream”ofpatientswhowillhavealloftheircareco-ordinatedbyaveryexperiencedGP.ThiswillallowhertoseethespecialistheartordiabeticnursesattheIntegratedCareCentrelocatedatherGPsurgery.Therewillalsobeacarenavigatorintheteamwhocanhelptosortthingsoutforherathome,includingcommunitysupportwhensheneedsit.

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which we will contribute towards the overall delivery of the Better Health for Londonoutcomes.

Exhibit 5:Deliveryof theBetterHealth for Londonoutcomes through thehealthand careclosertohomemodel

Specificinterventionsthatmakeupthescopeofthecareclosertohomemodelinclude:

• Developing ‘Care Closer to Home Integrated Networks’ (CHINs): CHINs may bevirtualorphysical,andwillmostlikelycoverapopulationofc.50,000people.Theywillbehometoanumberofservicesincludingthevoluntaryandcommunitysectorto provide a more integrated and holistic, person-centred community model,including health and social care integrated multi-disciplinary teams (MDTs), careplanningandcarecoordinationforidentifiedpatients.Interventionsfocussedonthestrengthsofresidents,familiesandcommunities;improvingqualityinprimarycare;andreducingunwarrantedvariationwillalsooperatefromCHINs, includingQualityImprovementSupportTeams(QIST)toprovidehands-onpracticalhelpforindividualGPpracticestoensureaconsistentqualitystandardandoffertoallpatients.Thiswillincludesupportforcasefindingandproactivemanagementofhighbloodpressure,atrial fibrillation and diabetes. We have already piloted CHINs, for example theBarnetIntegratedLocalTeam(BILT)33hubwhichprovidescoordinatedcareforolderresidentswithcomplexmedicalandsocialcareneeds,aswellasprovidingsupport

33 BarnetintegratedCareLocalityTeam,2016

Thereismoreopportunity todevelopskills

Lessstressasservicesworkbetter together

Moreopportunitytodevelopandimproveservicestomeettheneedsofpatients

Greaterassuranceaboutthequalityandsafetyofcare

Servicesareeasiertounderstand

Moreservicesareavailableclosertomyhome/work

Physicalandmentalhealthneedscanbemetoutsideofhospital

TheNHSandthelocalauthoritiesprovidecaretogether

Thehealth andcaresystemisfinanciallysustainable

Moreplannedcareinthecommunity

Greater confidenceinthesystemtosupport familiesandcommunities

Improvedoutcomes andreduced inequalities

ENABLERS:• JointlydesignedcarepathwaysthatconsistentlyWorkforcedevelopmentincluding joint training• Deliveryprioritised inpeoples’ jobplans• IM&T:ITinteroperability

ENABLERS:• Engagementofthepublicandusers• Engagementofallrelevantserviceproviderse.g.voluntarysector,schools, others• IM&T:Electronicrecordsharing

ENABLERS:• Supportive contracting &commissioning• Upfront investmenttodevelopOOHservices• Systemsfortimelymonitoring ofperformance enablingrapidlearningandadaptionofservices

Morecaregiveninthecommunity

Increasedworkforce andcapabilities

Greaterdiversityofstaffandservices

Morejointworking

Greatercapabilityforinnovation

Peoplelookingaftermeworktogether andknowmycareplan

Abletoaccesscareclosertomyhome/workandinlotsofdifferentways

Differentservicesavailableclosetohome

Peopleareinformed abouttheir ownhealthandkeepingwell

Servicesplannedtodeliverhighqualitycareforbestvalue

Professionals

Individualsusingservices

Populations

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tocarers.TheBILThubhasbeenopensinceApril2016andisajointfundedhealthandsocialcarepilot.

• Extendingaccesstoprimarycare:patientswillbeabletoaccessconsultationswithGPs or other primary care professionals in their local area for pre-bookable andunscheduledcareappointmentsbetween8amand8pm7daysaweek.

• Supportinghealthierchoices:inlinewithourpreventionagenda,thecareclosertohome model will include upscaling our smoking cessation activities by 9-fold toreduce prevalence and hospital admissions; increasing alcohol screening and thecapacityofalcoholliaisonservicesandalcoholassertiveoutreachteamsacrossNCL;scalingupweightmanagementprogrammeswithintegratedphysicalandwellbeingactivities;andreducingunplannedpregnanciesbyincreasingtheofferanduptakeoflongactingreversiblecontraception.

• Improving access through technology and pathways: telephone triage, virtualconsultationsandonlinebookingsystemswillbeavailableforallpatients.

• Supporting patients through social prescribing and patient education: the carecloser to home model will include a greater emphasis on social prescribing andpatienteducation.Supportwillbeavailableforpatients,carersandprofessionalstobeconfidentusersofinformationandITsolutionsthatenableself-managementandcare,aswellascarenavigationsupporttodirectpatientstotherightservices.

• 24/7 access to specialist opinion in primary care: primary care will be able toprovide more complex patients with a number of options for specialist opinionoutside of the hospital itself. These range from: 1) advice only 2) an urgent 'hotclinic' appointment in an out-patient clinic 3) assessment in an ambulatoryemergency care facilityand4) admission toanacuteassessmentunit. Inaddition,consultant-led clinical assessment and treatment services offered in CHINs willenablemorepatients tobemanaged in theprimary care setting. Specialties tobeconsidered include gynaecology; ENT; urology; dermatology;musculo-skeletal; andophthalmology.

• GP front door model in Emergency Departments: we will review the existingprovision acrossNCLofGP led triage, treatment and streaming for all ambulatorypatients will be provided at the front door of Emergency Departments. GPs andnursesonthedoormakedecisionsaboutwherethepatientisbesttreated–whichcould be in the urgent care centre or emergency department, or redirection toalternativeservices.

• Falls emergency response team and multifactorial intervention: multifactorialinterventions combining regular exercise, modifications to people’s homes andregular reviewofmedicationswill prevent people from falling in the first place. Ifthey do fall, falls partnership ambulance vehicleswill be availablewith advanced,multi-disciplinary practitioners. In addition, a specific falls service will supportpatientstoremainathomeafterafall.

• Enhancedrapidresponse(ERR):arapidresponseteamwillpreventanadmissiontohospital for those in crisis, providing enhanced therapy, nursing and social worksupporttosupportpeopletostayintheirownhome.

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• Acute care at home: where there is a medical need, acute clinical care will beprovided at home by aMDT to provide the best possible patient experience andoutcomes,andenablethepatienttobenefitfromholisticintegratedcare.

• Frailtyunits:adedicatedservice, suchas thatalready inplaceat theWhittington,that will be focussed on rapid assessment, treatment and rapid discharge of frailolderpeoplethatcouldpotentiallybeco-locatedwithintheEmergencyDepartment.Thiswillenableambulatorycareforpeopleagedover65.ThesewouldberolledoutacrossNCL.

• Enhancedcarehomesupport: provided to stabiliseand /or treat residents in thecarehomewhereappropriatetherebyreducingthelevelofconveyances,unplannedattendancesandadmissionstosecondarycare.Thecareclosertohomemodelwillpreventemergency readmissions fromcarehomes throughdevelopmentofa carehomebundle, includingaproactiveapproachtopreventionandearly identificationofcomplications.

• Endof life care:wewill supportpeopleat theendof life to receive the care thatthey need to enable them to die in their place of choice via rolling out the Co-ordinateMyCare(CMC)careplanningprogramme,andensuringthenewIntegratedUrgentCareservice(seesection6.2.4)hasaccesstoCMCplans.

Acheivingcareclosertohomewillneedtobeunderpinnedbystrongresilientcommunitiesthat are able to support residents live independently at home, where that support isneeded. The supportmay be needed from families, carers, neighbours or from voluntaryandcommunitygroupsallofwhomhavecentralrolestoplay.

We plan to bring together the funding currently used for Locally Commissioned Services(LCS)and the premium spent on Personal Medical Services (over and above GMS) andestablish one LCS contract framework for the whole of NCL. This LCS contract will haveagreed outcomes which are shared with the Health And Care Closer to Home Networks(CHINs) and the Quality Improvement Support Teams (QISTs) so that all local GPs areprovided with the necessary funding and incentives to fully engage with these vitalcomponents of the health and care closer to home work.Delivery of this whole systemalignment is partly dependentonNHSEngland (London)delegating commissioningof thePMSpremiumtotheCCGswhichiscurrentlyunderdiscussionwithallkeyparties.

In support of delivering our health and care closer to home model, Islington CCG hasexpressedaninterestinbecominganIntegratedPersonalCommissioning(IPC)siteinordertoimprovehealthandwellbeingoutcomesthroughpersonalisedcommissioning,improvedcareandsupportplanninganddevelopinganassetbasedapproachtosupportsolutions.

TheIPCsitewill:

• improve outcomes for patients with care delivered closer to home, and aim toreduceunplannedadmissions

• realign service provision in light of new service developments related to IPC andPersonalHealthBudgets

• reviewexistingcontractstoassessimpactandidentifyopportunitiesforrealignmentbasedonanumberofotherdevelopmentssuchasNewCareModelsandIPC.

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Improving outcomes will be the crucial measure of success of the care closer to homemodel. Using national and international evidence, we have estimated that some of theoutcomesthatourhealthandcareclosertohomemodelcouldpotentiallydeliverare:

• 70%ofpeopleattheendoftheirlifewillhaveacareplantosupportthemtodieintheirplaceofchoice

• 4%decreaseinunplannedpregnancies• a reduction in alcohol consumption with 10% fewer alcohol-related hospital

admissions• upto150,000feweremergencydepartmentattendances• 63,000fewernon-electiveadmissions• 35,000feweroutpatientattendances• 10%reductioninfalls-relatedhospitaladmissions• ahalvingofthenumbersoflateHIVdiagnoses• 50,000weightmanagementreferralsleadingtoareductioninexcessweight• 66%ofpeoplewithhighbloodpressurehaveitdiagnosedandcontrolled• 55%ofpeoplewithatrialfibrillationarereceivinganti-coagulants• 69%ofpeoplewithdiabeteshavecontrolledbloodglucose.

6.2.3 Mentalhealth

Wewilldevelopa‘stepped’modelofcare(seeexhibit6)supportingpeoplewithmentalillhealth to livewell, enabling them to receive care in the least restrictive setting for theirneeds.34Werecognisethekeyroleandaccountabilitiesofsocialcareforpeoplewithlong-standingmentalillhealthanddrawingonthiswillbecentraltothesuccessofthesteppedmodel.

Exhibit6:Thementalhealth‘stepped’modelofcare

34 AsidentifiedintheMentalHealthTaskforceReport

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Weaimtoreducedemandontheacutesectorandmitigatetheneedforadditionalmentalhealthinpatientbeds.ThiswillimproveoverallmentalhealthoutcomesacrossNCL,reduceinequalities for thosewithmental ill health, enablemore people to livewell and receiveservicesclosertohomeandensurethatwearetreatingbothphysicalandmentalillhealthequally.Wewillachievethekeymentalhealthaccessstandards:

• more than50%ofpeopleexperiencinga firstepisodeofpsychosiswill commencetreatmentwithaNICEapprovedcarepackagewithin2weeksofreferral

• 75% of people with common mental health conditions referred to the ImprovedAccesstoPsychologicalTherapies(IAPT)programmewillbetreatedwithin6weeksofreferral,with95%treatedwithin18weeks.

Initiativeswillcovermentalhealthsupportforallagegroupsandinclude:

• Improvingcommunityresilience:bothforthegeneralpopulation,andthoseatriskof developing mental ill health or of it becoming more severe. For the generalpopulationthisincludesapromotionaldriveaimedatincreasingbasicmentalhealthawareness includingself-awareness,normalisingmentalhealthneedsandreducingstigma.Fortheatriskpopulationfocuswillbegiventoimprovingaccessandsupportthrough training of non-mental health specialists to recognise mental ill healthsymptoms, improving service navigation, development of open resources, andprovisionof individualandgrouptherapies;employmentsupporttohelppeopletomaintainandgetback intowork includingthrough IndividualPlacementSupport35;and suicide prevention work to strengthen referral pathways for those in crisis,linkedtothelocalmultiagencysuicidepreventionstrategies.36ThiswillbedeliveredinconjunctionwithotherregionalandnationalschemessuchastheLondondigitalwellbeingplatform.Wewillcontinuetobuilduponcurrentwork;forexampleBarnetCCGandlocalauthorityarealreadyworkingtowardsadementiafriendlyboroughbyproviding lunch clubs, reminiscent therapy and engagingwith local shops to raiseawareness.

• Increasingaccesstoprimarycarementalhealthservices:ensuringmoreaccessiblementalhealthsupportisdeliveredlocallywithinprimarycareservices,developedaspart of the CHINs; enabling both physical health and mental health needs to be

35FiveYearForwardView-29,000morepeoplelivingwithmentalillhealthshouldbesupportedtofindorstayinwork(~725withinNCL)36FiveYearForwardView-Reducesuicideby10%

Maisiesuffersfromdementia,andiscaredforbyherhusbandAlbert.Previously,afterfallingathome,Maisiewasadmittedtohospital.Duetotheaccidentandchangeofsurroundings,Maisiewasagitatedandmoreconfusedthannormal.Infuture,thehospitalwillhaveCore24liasionpsychiatrymeaningthattheliaisonteamwillbeabletohelpthehospitalsupportbothMaisie’sphysicalandmentalhealthneeds.AsMaisiewillreceiveholisticcareitwillmeanthatsheisreadytobedischargedsoonerthanifonlyherphysicalhealthneedsweresupported.Maisie’shusbandAlbertwillalsobesupportedbythedementiaservice,allowinghimtocontinuetocareforMaisieathome.

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supportedtogether37.WewilloffersupportdirectlytopatientsandsupporttoGPsand other professionals; enablingmore people to access evidenced basedmentalhealthservices38,andmorecaretobeofferedthroughCHINsratherthanrequiringreferraltosecondarycarementalhealthservices.ServiceswillincludeincreasingtheIAPToffertoreach25%ofneed.39

• Improvingtheacutementalhealthpathway:buildingcommunitycapacitytoenablepeople to stay well and reduce acute presentations. This includes developingalternatives to admission by strengthening crisis and home treatment teams;reviewingHealthBasedPlaceof Safety (HBPoS) provisionwith the view to reducethenumberofunitsandtohaveasectorwideprovisionthatmeetsallrequirements;and investing in longer term supported living arrangements to ensure effectivedischarge,enablingmorepeopletolivewellinthecommunity.

• Developing a Female Psychiatric Intensive Care Unit (PICU): we will ensure localprovisionofinpatientservicestofemalepatientsrequiringpsychiatricintensivecare,where currently there is none. This will enable patients to remain close to theircommunities,with amore streamlined and effective pathway ensuring a focus onrecovery.40

• Investing inmental health liaison services: scalingup24/7 all-age comprehensiveliaison tomorewards and EmergencyDepartments, ensuring thatmore people inEmergencyDepartmentsandoninpatientwardswithphysicalhealthproblemshavetheirmentalhealthneedsassessedandsupported.

• CAMHSandperinatal:initiativesassetoutinsection6.2.1.• InvestinginadementiafriendlyNCL: lookingatpreventionandearly intervention,

supportingpeople to remainathome longerand supporting carers toensure thatwemeetnationalstandardsarounddementia,includingadementiadiagnosisrateofatleasttwo-thirdsoftheestimatednumberofpeoplewithdementia.

AnimportantenablerofanumberourinitiativesistheredevelopmentofboththeBarnet,Enfield and Haringey Mental Health Trust St Ann’s site and the Camden and IslingtonFoundationTrustStPancrassite(inconjunctionwiththeproposedrelocationofMoorfieldsEyeHospitalFoundationTrusttotheStPancrassite).

TheproposeddevelopmentsoftheStAnn’sandStPancrassiteswould:• transform the current inadequate acutemental health inpatient environments on

bothsites• providemoretherapeuticandrecoveryfocussedsurroundingsforpatientsandstaff• improveclinicalefficiencyandgreaterintegrationofphysicalandmentalhealthcare• release estate across the trusts, to enable development of community-based

integratedphysicalandmentalhealthfacilities• developworldclassresearchfacilitiesformentalhealthandophthalmologyenabling

practicetoreflectthebestevidence 37FYFV–atleast280,000peoplewithseverementalillhealthhavetheirphysicalhealthneedsmet(~7,000withinNCL)38FiveYearForwardView-moreadultswithanxietyanddepressionhaveaccesstoevidencebasedpsychologicaltherapies(~15,000withinNCL)39FiveYearForwardView40FiveYearForwardView-inappropriateoutofareatreatmentsforacutementalhealthcareshouldbeeliminatedinallareasby2020/21.

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• provide landforbothprivateandaffordablehousing,aswellassupportedhousingforserviceusersandhousingforkeyworkers.

6.2.4 Urgentandemergencycare41

Overthenextfiveyears,wewilldeliverurgentandemergencycare(UEC)servicesthatarereliable,workwelltogetherandareeasilyunderstood.Ourserviceswillbeconsistentandinspire confidence in patients and professionals; supported by the use of an integrateddigitalcarerecordthatcanbeaccessedacrossorganisations.Thefirst2yearswillfocusonreducingvariation inour servicesand the latter yearswill focuson transformationof theurgentandemergencycaresystem,aligningcloselywiththecareclosertohomemodel.

Ouraimsareto:

• Create a consistent UEC service across NCL: all UEC services in NCL will meetNational and London-wide quality standards42 which will promote consistency inclinical assessmentand theadoptionofbestpractice.Patientswill be seenby themostappropriateprofessionalfortheirneeds,whichmayincludedirectingthemtoanalternativeemergencyorurgentcareservice.

• Develop and implement a high quality integrated UEC service: all urgent careservicesacrossNCL (includingNHS111,GPoutofhours,UrgentCareCentres)willwork together tooffer consistent care.These serviceswillbe renamed ‘Integrated

41 ThisworkstreamincludesallaspectsofUrgentandEmergencyCareprovisiondeliveredintheacutesetting,includingsupportforpeopletoleavehospital.Alsoinscopeisthedevelopmentofahighquality,integratedurgentcaresystem. 42AsdefinedbytheNHSEUECdesignationprocess

Maryis83yearsoldandlivesathomewithherhusband.Maryhadafallathomeandinjuredherankle.Herhusbandwasunabletohelphergetupsohecalled999foranambulance.MarywastakentothenearestA&Eandadmittedtohospital,wheresheisdiagnosedwithaurinarytractinfection(UTI).Shewasreviewedbytheconsultant:aplanwasputinplacefortreatmentofherUTIandphysiotherapywasrecommendedforherankle.Overtheweekend,Mary’sUTIimproved,buttherewasnoconsultanttoreviewherconditionorphysiotherapisttoprovidehercare,soMarywasunabletogohome.Whengoingtothetoiletinthenight,Maryfellagainandstayedinhospitalforafurther2weeks.Marybecameincreasinglylessmobileandmorefrailanddependent.

InfuturewhenMaryfalls,herhusbandwilldial999,andaparamedicwillbedispatched.Whentheclinicalassessmentdoesnotsuggestanyfractures,thecrewwillaccessthelocaldirectoryofserviceswhilstonsceneandelectronicallyreferMarytotheAcuteCareatHomeservicewithrequestfora12hourresponse.MarywillthenbevisitedathomebythefallsteamthenextdaywhowilldesignapackageofcareforMaryincludingreablement,allowingMarytostayathome.ThefallsteamwillbeabletodetectifthereisanythingunusualaboutMary’sbehaviour,andmakearapidappointmentwithherGPiftheysuspectaUTI.Marywillthengettheantibioticssheneedstoresolvethisatanearlystage.

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Urgent Care’. We have commissioned a joined up new Integrated Urgent Careserviceprovidedbyoneprovider,LCW,whichgoesliveinOctober2016.ThisservicecombinestheNHS111andGPOut-of-Hours(OOH)services,andallowspatientstoaccessawiderskillmixofspecialisedcliniciansinanewNHS111clinicalhub.

• Develop high quality, responsive 7-day hospital UEC services: people will besupported to leave hospital as quickly as possible through building close linksbetweenacutecareprovidersandsocialcare.Wewillsupportshorterhospitalstaysby operating a simplified discharge or integrated ‘discharge to assess’ model:planning post-acute care in the community, as soon as the acute episode iscomplete,ratherthaninhospitalbeforedischarge.Thiswillbethedefaultpathway,withnon-acutebeddedalternatives for thevery fewpatientswhocannotmanagethis.

• Develophighquality,responsive7-daycommunityservices:wherepossible,peoplewillbesupportedandtreatedathomebycommunityandambulanceservices.Forthose people who do require ambulance transfer, the ambulance services will beabletouseanyUECservicesthatmeetsthepatient’sneed.

• DevelophighqualityambulatorycareservicesacrossNCL:wewilldevelopaservicethat reduces avoidable, unplanned admissions to hospital, such as that already inplace at the Whittington. All UEC services will create consistent ambulatory carepathways that support people to have their care on a planned basis, whereverpossible. This will provide same day emergency care to support patients to beassessed, diagnosed, treated and able to go home the same day without anovernightadmission.ThismodelwillberolledoutacrossNCL.

The focus on urgent and emergency care services will reduce the number of unplannedadmissions tohospital and supportpeople togohome fromhospital as soonaspossible.Thiswill improvepatientexperience, improveoutcomesandmake sure thatpeoplehavetheircareonaplannedbasiswhereverpossible.

6.2.5 Socialcare

Social care isacrucialpartofmanyofourworkstreams,particularlycarecloser tohome,TransformingCare,andmentalhealth,aswellaschildren'sandpublichealthinterventions.WeareconsideringhowlocalauthoritiescanworkwiththeworkforceleadsacrossNCLtodesign and develop proposals specifically for social care, including a focus on thesustainability of provider workforce, the sustainability of the registered workforce andstimulating the personal assistant workforce. We will ensure that our plans factor inpracticalstepsthatwecantakeaspartners toaddressproviderfailureandthehugerisksaroundcapacityandqualityinthedomiciliarymarket.

Theroleofsocialworkerswillbeessential todeliveringonourmodel forhealthandcareclosertohome,inadditiontotheroleofhomecareworkers,personalassistants,blendedrole between district nurses and care workers. The workforce workstream will considerthesecareerpathways,makingcareersintheseareasmoreattractivetosupportincreasedsustainabilityof theworkforce.Wewill quantify any investment thatmightbeneeded inworkforce from a social care point of view e.g. increasing numbers of domiciliary care

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workers and, drawing on learning from elsewhere, we will quantify the return oninvestment.

Social care is also built into our mental health model, including a broader dimension ofpublic service support suchas employment supportworkers. Learningdisabilities is a keyareaof focus given thathalf of social care spend is on this group, and that childrenwithspecialeducationalneedsandlearningdisabilitieshaveworselongtermoutcomesinbothhealth and education. We need to start supporting thosewith learning disabilities fromearly childhood to ensure early detection and appropriate intervention. Many of ourinterventions, including health visiting, early years, community paediatrics, CAMHS, andworkingdirectlywithschoolswillensurethatwebettersupportthesechildren.WeplantoscaleupourTransformingCareworktoimplementenhancedcommunityprovision;reduceinpatientcapacity;upgradeaccommodationandsupportforthosewithlearningdisabilities;androlloutcareandtreatmentreviewsinlinewithpublishedpolicytoreducelonglengthsofstayinhospitalsandimproveindependence.

AspartofourSTPwewillexplorecollaborationandconsolidationopportunitiesbetweenlocal authorities in areas such as the hospital discharge pathway and the mental healthenablementprocess.Wewillconsiderwhatcanbecommissioneddifferentlyand/oratscale- particularly across health and social care, for example nursing homes.Wewill focus onrampingup theuseofdataanalysisand risk stratification;workingcohesivelywithpublichealthacross thepatch; leveraging telecare;andsharingof ideasand learningaboutbestpracticeintermsofhealthandsocialcareintegration.Ourpan-NCLbedstateanalysiswillconsidernon-healthbeds,includingthe6,440carehomebedsinNCL,sothatwegainanin-depthunderstandingofwhypeopleendupinthesebedsandhowbesttheirneedscouldbemetelsewhere(aswellastheresourcesitwouldtaketodothis).

We recognise the co-dependencies between health and social care: any change in eithersectormayhaveasignificantimpactontheother.Aswecontinuetodevelopourplans,wewill ensure local authorities are involved throughout so that we can mitigate any risksaroundthistogether,andtransformthesystemsothatitistrulyintegrated.

6.2.6 Optimisingtheelective(plannedcare)pathway

Building on the opportunities identified through RightCare, we will reduce unwarrantedvariation in elective (planned) care across providers in NCL. This will include reducingvariation in the length of stay in hospital and the number of outpatient appointmentsreceived by patients with similar needs. Optimised pathways will ensure patient safety,qualityandoutcomes,andefficientcaredelivery.

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Wewilldrawon localexamplesofbestpractice, suchas theSouthWest LondonElectiveOrthopaedic Centre; and international best practice, such as Intermountain’s hipreplacement pathway redesign, which reduced the cost of total hip replacement by aquarter.43 Building on the evidence, we will redesign pathways with local clinicians,responding to local needs and opportunities. We will initially focus on areas with highvolume or high variability, where there is opportunity to achieve high impact bymakingchanges,suchasorthopaedics.

Wewillleveragethefollowingopportunitiesforimprovementtoelectivepathways:

• expertfirstpointofcontact:makingsurepeoplehaveaccesstotherightexpertisefromtheirfirstappointmentinprimarycare

• one-stop services: so that people do not need to attend multiple outpatientappointmentsbeforetheirprocedure

• efficientsurgicalpathways:toensuremaximumuseofstaffandtheatres• timelydischargeplanning:toreduceunnecessarytimeinhospital.

Todeliverontheabove,aseriesof interventionswillbeput inplaceateachstageoftheelectivepathway.Theseareillustratedinexhibit7.

43JamesandSavitz(2011).HowIntermountainTrimmedHealthCareCostsThroughRobustQualityImprovementEfforts�.HealthAffairs

Previously,John(whois75andhaspaininhisknee)madeanappointmentwithhisGP.TheGPreferredhimtothehospitalwherehewasseeninoutpatientsandsentforanMRIscan.AconsultantestablishedthatJohnneededakneereplacement.JohnwasabouttogoonatriptovisitfamilyintheUSAfor2months,sotheconsultantsenthimbacktohisGP.WhenhereturnedJohnsawtheGPagainaswellastheconsultant,whosenthimtopreoperativeassessment.Hewasfoundtohavehighbloodpressure,andwassentbacktotheGPfortreatment.Oncehisbloodpressurewasundercontrol,Johnwaslistedandthenadmittedforsurgery.Hespentabout5daysinhospital,andthenreturnedhome.Inthefuture,JohnwillseeanextendedscopephysiotherapistattheGPsurgeryforhiskneepain.ThephysiowillarrangetheMRI,anddiscusstheresultswithJohn.ThephysiowillidentifythatJohnhasraisedbloodpressurewhilecompletinghiselectronicreferraltemplatetotheconsultantatthehospital,andliaisewiththeGPtomakesurethisistreatedbeforeheisreferred.Johnwillhavehishospitalappointmentandpre-operativeassessmentonthesameday,andwillbegivenalltheinformationheneedstoprepareforaftertheoperation.

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Exhibit7:Interventionsthatsupportoptimisedelectivepathways

Fororthopaedics,implementationofthesehighlevelinterventionsincludes:interventionsincludes:

• Betteruseofnon-medicalsupportandeducation:promotingnon-medicalsupportstaffas the first line forminorconcerns (e.g.atgyms),greateruseofpharmacists,andgivingpatientsaccesstomoreinformationonline.

• Expert first point of contact: the first person thepatient comes into contactwithwouldbeaGPwithspecialinterestorexperiencedphysiotherapist,whowouldknowthe full range of treatment options available. As a consequence of this, moreoutpatient referralswouldhavediagnosticsalreadyperformedandpatientswouldbe supported by the right information when they are making decisions aboutonwardtreatment.

• Useofastructuredreferraltemplate:allowingallinformationtobeavailableatthefirst clinic appointment. Ideally, this would be an electronic form which wouldreduce the risk of unnecessary follow up appointments as all relevant diagnosticsand information are readily available to clinicans at the initial appointment.Structured referral templates are currently used by some providers andcommissonersinNCLtogoodeffect,butwouldbeusedmorewidelyaspartoftheoptimisedelectivepathway.

• Improved diagnostic protocols: administrative protocols would be ordered toensure that the appropriate tests are being conducted to diagnose patients. Thiswouldlimitrepetitivetestsbeingordered,whichisbetterforpatientsandoptimisesresourceuse.

• UseofNCL-widesharedprotocols:wouldensurethatpatientsarebeingmanagedina consistentway. Itwouldbuild relationshipsand teamsacross thewhole system,fosteringtrustandreducingduplicationintests,appointmentsandtreatementsasaresult.

• Onlywhenready:patientsareonlyreferredwhentheyarereadyandavailablefortreatment.ThisavoidsasecondGPappointmentandre-referral.

• Bettermonitoringandtransparency:peerreviewandsupportwouldbeestablishedto ensure referrals are appropriate, enabling clinicians to have an open dialogue

Thekeyinterventionsmaptodifferentstagesalongtheelectivepathway

Pre-primarycare Outpatientcare

Inpatientpre-

operativecare

Follow-uppost

discharge

Inpatientpost-

operativecare

Surgery

• Non-medicalsupportandeducation

• One-stopoutpatientclinics

• MDTclinic

• Consultant-levelfeedback

• Ring-fencedelective beds

• Theatreutilisation

• Enhancedrecovery

• Effectiveplanningfordischarge

• Nurseledorvirtualfollowup

• Preoperativeassessment

• Re-check priortosurgery

• Short-noticereservelist

Primarycare

• Expertfirstpointofcontact

• Onlywhenready

• Structuredreferraltemplate

• Diagnosticprotocols

• Sharedprotocols

• Monitoringandtransparency

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regarding the quality of referrals and continuously improve their own referralpractices.

• One-stopoutpatientclinics:access tosimultaneouspre-assessmentandadditionaldiagnosticsinasingleplace,reducingtheneedforunnecessaryfollowups.

• Multi-disciplinary team (MDT) clinics: clinics which consist of multiple differentpeople working together to triage to the most appropriate clinician. Consultants,extendedscopephysiosandGPswithspecialinterestswouldallworkingtogetherinasinglesettingtoformtheMDT.

• Pre-operative assessments conducted at the first outpatient appointment: ifpatientsarenotfoundtobefit,thentheirplanisreviewedthesameday.Thiswouldbesupportedbygreateruseofe-selfassessmentbypatients intheirhome.Rehabandpost-operative packages of carewould be arrangedprior to referral, enablingpatients who are at risk of staying for long lengths of time in hospital to beproactivelyidentified.

• Re-check prior to surgery: patients will be contacted 48-72 hours before theirsurgery to reduce the riskof latecancellations.This checkwillensurepatientsarestillwellenoughforsurgery,andwanttogoaheadwiththeplannedprocedure.

• Short-notice reserve list: to ensure that gaps caused by late cancellation can befilledbypatientswhoarereadyfortreatmentwhichallowstheatrestobeusedmostefficiently.

• Consultant-levelfeedback:transparencyoflistutilisationandcasevolumesperlist.This allows for peer challenge to take place between consultants, to ensure thehighestqualityandmostefficientpracticesarebeingmaintained.

• More effective planning for discharge: discharge planning serviceswill be offeredearlierintheprocess,beforepatientsareadmittedtohospital.Thiswillgivegreateraccesstocommunitysupportservices,andreducedelaysindischarge.

• Enhanced recovery pathways will be consistently applied: patients will have agreaterunderstandingoftheirexpectedlengthofstaywhentheyareadmitted,andbeadvisedonthebestcourseofactiontoavoidstayingforlonger.

• Ring fenced elective beds will be available: to reduce wasted theatre time, anddiminishtheriskofinfectionforelectivepatients.

• Theatreutilisationwillbeoptimised:byschedulingcasesandensuringthatcriticalequipmentisproperlyscheduledtomaintaintheorderandrunningoflists.

Inadditiontotheimprovementsbeingworkedthroughfororthopaedics,furtherspecialtieshavebeenidentifiedforfocusedpathwaydesign.Theseare:

• Urology• Generalsurgery• Colorectalsurgery• Hepatobiliaryandpancreaticsurgery• Uppergastrointestinalsurgery• Gynaecology• Gynaecologicaloncology• Ear,NoseandThroat(ENT)

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• Vascularsurgery• Breastsurgery• Musculoskeletal(MSK)• Ophthalmology• Generalmedicine• Gastroenterology• Endocrinology

As well as delivering efficiency savings, reducing variation in planned care will improvepatientoutcomesandexperiencethrough:

• improved access to information and support to help people manage conditionswithoutsurgicalintervention

• supportforpeopletoaccesstotherightprofessionalexpertisethefirsttime,ratherthanbeingreferredbetweenseveraldifferentprofessionals

• improvedaccesstosurgicalinterventionsascapacitywillbefreedup• patients receive a single outpatient appointment rather than needing to make

severalattendances• lesstimespentinhospital,meaninglesschanceofacquiringinfectionsandreducing

theriskoflostindependence• ensuring access to the right post-operative support, helping patients get back to

normallifemorequickly.

Reducingvariationwillalsoimprovestaffexperience,includingensuringaccesstotherightprofessional expertise when needed, better access to high quality diagnostics, improvedrelationships between professionals in different care settings and increasing sharing andlearningfrombestpracticeacrossthelocalprofessionalcommunities.

6.2.7 Consolidationofspecialties

We will identify clinical areas that might benefit from being organised differently (e.g.managingmultiple services as a single service), networking across providers, or providerscollaboratingand/orconfiguringinanewwayinordertodeliverhighimpactchangestomajor services. While changes of this sort can be challenging to implement andcontroversial with the public, we should not shy away from consideringmaking changes

InLondon,twothirdsofearlydeathsinpeopleunder75arefromcancerandheartdisease,thereisahighriskofheartdiseaseamongthelocalpopulationandthenumberofpeoplediagnosedwithcancerisgrowing.Specialists,technologyandresearcharespreadacrosstoomanyhospitalstoprovidethebestround-the-clockcaretoallpatients.IfweweretoimprovelocalsurvivalratesforheartdiseaseandallcancersinlinewithatleasttherateforEngland,over1,200livescouldbesavedeachyear.(Source:UCLHnews,14March2014)UCLH,BartsHealth,theRoyalFreeandanumberofothernorthLondontrustsimplementedasignificantservicereconfigurationtoaddresstheseissues.CardiovascularcareservicesprovidedatTheHeartHospital,TheLondonChestHospitalandStBartholomew’sHospitalwerecombinedtocreateanintegratedcardiovascularcentreinthenewbuildingatStBartholomew’s.For5complexorrarecancers,specialisttreatmentisprovidedincentresofexcellenceacrossthearea.Servicesforothertypesofcancerandgeneralcancerservices,suchasmostdiagnosticsandchemotherapy,continuedtobeprovidedlocally.

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wherewearesurethatsignificantimprovementsinthequalityofcarecanbeachieved.

We are not starting from scratch in this area: considerable service consolidation andspecialisationhasalreadytakenplaceinNCL.Recentexampleswherewehavesuccessfullydonethisinclude:

• Cardiac/cancer(seecaseexamplebox)• Neurosurgery• PathologyJointVenture• Renalmedicine• Hepatologyandhepatobiliarysurgery• Neurosurgery• Vascularsurgery• Ear,NoseandThroat(ENT)• BoneMarrowtransplantation• Uppergastrointestinal• Malignantgynaecology• Cardiology• Majortraumaservices• Strokeservices• Plasticsurgery• Respiratorysub-specialties• Cancer services including: pancreatic cancer, renal cancer, skin cancer, prostate

cancer,headandneckcancer

However, we recognise that theremay be other service areas which are or will becomevulnerable in the future. There aremany reasonswhy consolidation of servicesmight beconsideredas apossibleopportunity for improvement. First and foremost,weagree thatimprovingquality should be the key driver for exploring consolidation, particularlywherethere is clear evidence of patients achieving better outcomes.Where there is a ‘burningplatform’and it iswidely accepted that a serviceneedsurgent attention (forexample, inaddressing issuesofworkforcesustainability),consolidationwillbeexploredasanoption.Releasingcostsavingstosupportoverallsystemsustainabilityisanotherdriverforexploringpotentialconsolidationopportunities.

Thisworkisatanearlystage.Nodecisionshavebeenmade,butwehaveidentifiedserviceswherewewillreviewwhethersomeformofconsolidationmaybeworthconsideration.Itisrecognised that fundamental, large scale reorganisationmay take longer than the 5 yearstrategic horizon of the STP. As such,we havemade no assumptions of financial benefitfromthiswork.

To understandwherewe should focus furtherwork, senior clinicians have systematicallyassessedservicesbasedonwhetherconsolidationoralternativenetworkingisrequiredand/orcouldbebeneficial.Thishasenabledustoidentifyalonglistofservicespotentiallyinscopeforfurtherworkoverthe5yearperiod,forexample:

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• Emergencysurgery(outofhours)• Maternityservices,inthecontextoftheBetterBirthsinitiative(seesection6.2.1)• Electiveorthopaedics• Mentalhealthcrisiscareandplaceofsafety• Mentalhealthacuteinpatientservices• Histopathology• Generaldermatologyservices

Overthenextyeareachoftheseserviceswillbereviewed in lightofwhethertheywouldbenefitfromconsolidationornetworking.Weareintheprocessofdevelopingproposalstobring together some mental health inpatient services in order to drive significantimprovementsinqualityandpatientexperienceassetoutinthementalhealthworkstream(seesection6.2.3).Inaddition,workisunderwaytounderstandpotentialopportunitiesforconsolidationofmentalhealthplacesofsafety. 6.2.8 Cancer

WewillsavelivesandimprovepatientexperienceforthosewithcancerinNCLandbeyond.CommissionersandprovidersacrossNCL joinedtogethertoformourCancerVanguard, inpartnershipwithManchesterCancerandRoyalMarsdenPartners,withtheaimofachievingearlier cancer diagnosis, ensuring effective use of cancer outcomes information andadoptionofrecognisedbestpracticeacrossthefullspectrumofcancerpathways.

OurcancerworkstreamisderivedfromtheVanguardagendaandencompassesarangeofimprovementstocurrentpractice.Thekeyareasoffocusinclude:

• Earlydiagnosis:toaddressimpactoflatediagnosisonsurvivaloutcomesacrossNCL,wewill targetspecificcausesof latediagnosisandpoordetectionrates.Targetingcolorectal and lung pathways are a particular focus given the high percentage ofpatients receiving late stagediagnoses, often in EmergencyDepartments.Wewillroll out the Multi-disciplinary Diagnostic Clinic model for vague abdominalsymptoms,promoteadoptionofstraighttotestmodelsanddeliveraprogrammeto

PreviouslyMargaret,aged60,wenttoseeherGPwithpersistentepigastricpainforseveralweeks.Shewasotherwisewell,anddidnothavereflux,diarrhoea,vomitingorweightloss.Overthecourseofnext3weeks,Margaret'sGPorganisedtestsandruledoutanyinflammation,heartproblem,orgallstonesthatcouldcausethepain.HealsostartedMargaretonatablet(lansoprazole)totrytoreduceinflammationfromtheacidonherstomachlining.However,Margaret'spainwasmorepersistentthistimeandshewasstillworried.Inthenewsystem,Margaret’sGPwillbeabletoreferhertotheMultidisciplinaryDiagnosticCentreatUCLHdespitethefactthathersymptomsarenotconsidered“redflag”.Here,Margaretwillbeassessedforvagueabdominalsymptoms.Aclinicalnursespecialistwillseeher4daysafterreferral.TheteamwillidentifythatMargarethasearlystagepancreaticcancerandbecauseitispickedupearlyshewillbeabletoaccesspotentiallycurativekeyholesurgery.

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improveawarenessofcancersymptomsinprimarycare.• Newmodels of care: we are developing the case for a single providermodel for

radiotherapy in NCL, to help achieve financial sustainability, reduce variation inclinical protocols and improve patient access to research and clinicalinnovations. This is being explored between the North Middlesex UniversityHospitals NHS Trust, the Royal Free NHS Foundation Trust and University CollegeLondon Hospitals NHS Foundation Trust and also links with the hospital chainsVanguardledbytheRoyalFree.Wewill increaseprovisionofchemotherapycloserto home, establishing a quality kitemark for chemotherapy and supporting self-management. The first patient treatment in the home for breast cancer will beavailablebytheendofSeptember2016.

• Centre for Cancer Outcomes (CCO): to deliver robust outcomes data, improvepathway intelligence and address important population health research questionswewillproducebalancedscorecardswhichcanmadeavailabletoMDTs,providersandcommissionersthroughafreetoaccesswebbasedplatform.

• Researchandcommercialisation:wewill leverageouruniquepositionnationallyincancertoimprovecareforpeoplewithcancer,generateadditionalrevenuesacrossthesystem,andgenerateefficienciesbyavoidingunnecessaryinterventions.

6.2.9 Specialisedcommissioning

Specialisedservicesarethoseprovided inrelatively fewhospitals/providers,accessedbycomparatively smallnumbersofpatientsbutwithcatchmentpopulationsofusuallymorethanonemillion. These services tend tobe located in specialisedhospital trusts that canrecruit a team of staff with the appropriate expertise and enable them to develop theirskills.InNCL,themainprovidersofspecialisedacuteservicesareUniversityCollegeLondonHospitalsNHSFoundationTrust (with income totaling£317m)and theRoyalFreeLondonNHS Foundation Trust (with income totaling £273m). A further 10 providers receive anadditional £128m in income for the delivery of specialised services. This includes threespecialisthospitals:RoyalNationalOrthopaedicHospitalNHSTrust,MoorfieldsEyeHospitalNHS Foundation Trust, andGreatOrmond Street Hospital NHS Trust. Barnet, Enfield andHaringeyMentalHealthNHS Trust and the Tavistock and PortmanNHS Foundation Trustprovidesspecialisedmentalhealthservices.Aswellascaring for the localpopulation, thespecialised services provided by hospitals in north central London are also accessed by apopulationfromoutsideofNCL.

We recognise that planning for specialised services canhave an impact across the region(and potentially nationally), and are thereforeworking closelywithNHS England, Londonregion to develop plans in this area. At a pan-London level, 11 priority transformationinitiativesforspecialisedserviceshavebeenidentified.Theseare:

• Paediatrics• Cardiovascular• Neuroscienceandstroke• Renal• Cancer

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• Adultmentalhealth• ChildandAdolescentMentalHealthServices(CAMHS)• Trauma• Womenandchildren• Bloodandinfection• Medicinesoptimisation

On reviewof thesepan-London initiatives,our clinical leadership identified5areaswhichresonated strongly as opportunities where we could lead the way in transformingspecialisedservices.Weareintheprocessofprogressingplansinthefollowing5areas:

• Highcostdrugs:thisinvolvesreviewingandstrengtheningadherencetostartingandstopping rules forall high costdrugs. There is alreadyworkongoing inNCL in thisarea,whichhasrevealedthatcliniciansaregoodatstartingpeopleonthesedrugsbut poor at stopping them.Wewill set clear criteria around the use of high costdrugsatanNCLlevel.Inaddition,wewillreducethespendoncancerdrugsthroughthe Cancer Vanguard Pharma Challenge process, which includes programmes onbiosimilars,homeadministrationandsystemintelligence.

• Elective spinal surgery:wewill rapidly progress work on assessment, pre-surgicalpathways and stratification to ensure patients are directed to the best possibleplace.Thiswillhelpusbalancedemandandcapacitymoreeffectively.

• End of life chemotherapy: we will undertake a comprehensive review ofchemotherapyusage close to theendof life.Using theevidenceonwhen to stopendoflifechemotherapy,wewilldevelopprotocolsaroundthis.Wewillworkacrossthewholepathwayonthisissue,andlinkstoppingacutechemotherapytoendoflifediscussionsinprimarycare,workingcloselywiththeCancerVanguardtodeliverthis.

• Imaging: we will contain growth in imaging costs by eliminating the need for re-acquisition due to inadequate or unavailable scans. For patients, thiswill increasethespeedofdiagnosisandresult inareduction induplicatedcontrastorradiationexposure.Implementinganetworkingapproachtoimagingwillhelpustodeliveronthis,aswellasuseofinformationmanagementandtechnologytoenableproviderstoshareinformationonthescanswhichhavealreadytakenplace.

• Spinal cord injury: we will redesign the pathway locally to address patients arecurrentlywaiting in Intensive Care Unit (ICU) beds to access specialist spinal cordinjury rehabilitation services. Waiting in ICU beds can cause the onset of othersymptomsleadingtoworseoutcomesforpatientsandhighcostsforthesystem.

Werecognise thatourplanningonspecialisedservices is lessdevelopedthanmanyotherpartsoftheSTP.WewillcontinuetoworkwiththespecialisedcommissioningteaminNHSEngland,LondonRegiontodevelopmoredetailedplansinthisarea.

6.3 Productivity

6.3.1 Commissionerproductivity(BAUQIPP)

Wewillcontinuetodeliversignificant“businessasusual”efficienciesthroughoutthe5yearperiod. Business as usual (BAU) QIPP (Quality, Innovation, Productivity and Prevention)

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comprisessavingscommissionersexpecttodeliveraspartoftheirnormalactivities.Theseareefficiencies inareasofCCGspendnotcoveredbyourotherworkstreamsand includeopportunitiesinthefollowingareas:

• Mental health: this includes ongoing non-transformational efficiencies, consistentwith parity of esteem requirements. Examples of mental health QIPP are themanagement of out of sector placements and streamlining the pathways withspecialistcommissioningacrossforensicandmentalhealthservices.

• Community: spend on community services was c.£133m in 2015/16. There is anassumption of increased efficiency equivalent to 1.5% per annum supported bybenchmarkingworkandtransitiontonewmodelsofcare.

• Continuing care: spend on continuing care was c.£90m in 2015/16. There is anassumption of increased efficiency equivalent to 2.1% per annum supported byexistingframeworkagreements.

• Primarycareprescribing:spendonprimarycareprescribingwasc.£205min15/16.There is an assumption of increased efficiency equivalent to 2.5% per annumincludingtheadoptionofgenericdrugswherepossible,theadoptionoflocalqualityschemestoimproveconsistencyandeffectiveness.Thisisinthecontextofassumedgrowthof5-7%perannum.

• Programme costs (including estates): this includesmeasures to reduce void costsand better alignment of health and care services to reduce the overall estatefootprintwhilstmaintainingandimprovingservicequality.

6.3.2 Providerproductivity(BAUCIP)andsystemproductivity

Significantlyimprovingproviderproductivityisanessentialpartoftheworktoaddressourfinancial challenge. Our plans assume significant delivery of CIP (Cost ImprovementProgrammes),improvingproviderproductivity.

Wehaveidentifiedopportunitiesforsystemproductivity(definedasthoseareaswhereCIPdelivery is dependent on trusts working together) to deliver financial savings whilstmaintaining or improving quality. Our plans also assume savings from improvements tocontractingbetweenCCGsandtrustswhichwillberealisedsystemwide.

Specificinitiativestoimproveproductivityinclude:

• Workforce: we will establish a shared recruitment and bank function acrossprovidersmeaning thatstaffcanbedeployedbetweenproviders in thesystem;aswellasimprovingretentionofcurrentstaffandupskillingthehealthandsocialcareworkforcetoenabledeliveryofnewmodelsofcare.WecommittocomplyingwiththemaximumtotalagencyspendandhourlyratessetoutbyNHSImprovement.

• Procurement:wewillreducepurchasingunitcostswithincreasedvolumeandscaleacrossallprovidersbyreducingclinicalvariationinproductchoiceandundertakingjointactionondrugsandmedicinesmanagement.

• Back office:wewill create centralised functions for payroll and pensions, financeand estates in order to reduce our overheads and improve service resilience. Inadditionwewill:

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o Consolidate IT services to reduce costswhilst improving the resilience andqualityofservices

o Enhance the existing share procurement arrangements to reduce non-paycosts

o Pool our legal budgets and resources, considering options to consolidateoutsourcedresourcesorappointanin-houselegalteam.

• Operationalandclinicalvariation:wewillcollectivelyreduceaveragelengthofstay,maximisetheatreutilisationandstreamlineclinicalprocesses,inadditiontothechangesproposedthroughtheelectiveworkstream.

• Contractandtransactioncosts:Releasingsavingsfromstreamliningtransactionsandcontracting.Thiswillbedeliveredthroughimplementingnewcommissioningarrangements(whichmayfacilitatejointprocurementofservicesfromtheCommissioningSupportUnit(CSU),forexample)andleveragingtheopportunitiesassociatedwithjointcommissioningbetweenlocalauthoritiesandCCGs.

• Other:Additionalexistingproviderproductivityschemes:estates,clinicaladminredesign,servicetransformation,incomeetc.

6.4 Enablers

6.4.1 Digital

Wewillusedigitaltechnologiesandinformationtomovefromourcurrentmodelsofcaretodeliverproactive,predictive,participatory,person-centredcareforthepopulationweserve. Thereissignificantandimmediateopportunityfordigitaltotransformourcurrentdeliverymodels and seed completely new, integrated models of health and social care. Werecognise the strength of both the clinical and financial case for digital and its potentialimpact in strengtheningproductivity, providing easeof access to our services,minimisingwasteandimprovingcare.Ourambitionistobecomeanationalleaderinpopulationhealthmanagementenabledbyinformatics,toreducevariationandcostandimprovecare.Wewillprioritiseand increasepaceofappropriatedigital technologyadoptionwithinourorganisations, realigning the demand on our services by reducing the emphasis ontraditionalfacetofacecaremodels.Inaddition,wewillexplorenewdigitalalternativesthatwill transformour services,with the aimofmoving care closer to home, enabling virtualconsultationsandprovidingourpatientswiththeinformationandresourcestoself-manageeffectively, facilitating co-ordinated and effective out of hospital care. We will utiliseopportunities for real-time, fully interoperable information exchanges to provide new,flexibleandresponsivedigitalservicesthatdeliverintegrated,proactivecarethatimprovesoutcomesforourpatients.Our digital programme proposes the creation of an NCL Population HealthManagementSystem(exhibit8),whichsupportsprevention,servicetransformationandproductivity,andwouldenableustomeetthenationalmandateofoperatingpaperfreeatthepointofcareby2020.Through this systemwewillmove froma landscapeofdiversityandvariation tooneofsharedprinciples,consolidationandjointworkingforthebenefitofthepopulation.

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Exhibit8:NCLPopulationHealthSystemManagement

The6workstreamsthatmakeupourdigitalstrategyare:

• Activate: We will provide our citizens with the ability to transact with healthcareservices digitally, giving themaccess to their personal health and care informationand equipping them with tools which enable them to actively manage their ownhealthandwellbeing.

• Analyse:Wewill use data collected at the point of care to identify populations atrisk,monitortheeffectivenessofinterventionsonpatientswithestablisheddiseaseanddeliverwholesystemsintelligencesothattheneedsofourentirepopulationcanbepredictedandmet.

• Link:Wewill enable information to be shared across the health and care systemsseamlessly.

• Share:Wewillcreateandsharecarerecordsandplansthatenable integratedcaredeliveryacrossorganisations.

• Digitise:Wewillsupportourproviderstomoveawayfrompapertofullydigitalcareprocesses;includingdocumentation,ordering,prescribinganddecisionsupporttoolsthathelptomakecaresafer.

• Enable:Wewillprovideinfrastructurewhichenablesourcareprofessionalstoworkandcommunicateeffectively,anywhereatanytime,andfacilitatenewandenhancedmodelsofcareclosertohome.

Todeliveronourdigitalstrategywewillneedtoinvest£159m,withafurther£21min2020/21(seesection8.3).

Enable

Digitise

Link

Share

Analyse

Activate

InfrastructureNetwork; wifi; unified comms; email; collaboration tools; end user technology; virtual care services

Integration and messaging

Applications

Health Information Exchange; information and messaging standards; document, image and data exchange

Electronic health records; clinical documentation; ePrescribing and closed loop medication management; orders and results; device integration; alerts and decision support

Integrated care

Insights driven health system

Shared health and care records; care plans

Health system benchmarking; cohort stratification; patient tracking; case management; whole pathway decision support; predictive modelling

Digitally activated population Personal Health Record; Self management; remote monitoring; digital transactions

Info

rmat

ion

Gov

erna

nce

Dat

a Q

ualit

y an

d Va

lidat

ion

CCGs

Primary care

Social care

Acute, community, mental health and specialist providers

Care homes

NCL

Dig

ital

Del

iver

y M

odel

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6.4.2 Estates

Ourvisionistoprovideafitforpurpose,cost-effective,integrated,accessibleestatewhichenablesthedeliveryofhighqualityhealthandsocialcareservicesforourlocalpopulation.Theprioritiesfordevelopmentofourestatesstrategyare:

• torespondtoclinicalrequirementsandchangesindemandbyputtinginplaceafitforpurposeestate

• toincreasetheoperationalefficiencyoftheestate• toenhancedeliverycapability• toenablethedeliveryofaportfolioofestatestransformationprojects.

Thereanumberofbarrierstoachievingthis,including:

• thecomplexityoftheestatessysteminNCL,includingthenumberoforganisationsand the differences in governance, objectives and incentives between eachorganisation,whichoftenresultsinorganisationsworkinginsilos

• misalignedincentives,whichdonotencourageoptimalbehaviour• lack of affordability, specifically the inability for trusts to retain capital receipts,

budget “annuality” and the difficulty of accessing capital investment for re-provision

• thecomplexityofdevelopingbusinesscasesintermsofgettingtherightbalanceofspeed and rigour, and the different approvals processes facing differentorganisation types (for example, there are different capital approval regimesoperatingacrosstheNHSandlocalgovernment).

WeareworkingaspartoftheLondondevolutionprogrammetopilotdevolvedpowers inrelationtothehealthandcareestate.Aspartofthis,weareaskingfor:

• local prioritisation and investment of capital receipts, including those thatwouldotherwiseberetainednationally

• NHScapitalbusinesscaseapprovaltobeacceleratedandconsolidatedthroughtheimplementation of a jointly owned and collaborative NCL / national process (ordevolvedtosub-regionalorLondon-level)

• development of enhanced and revised definitions of value for money, whichconsider social value, wider community benefit and system sustainability at thesub-regionallevel

• new approaches for the accounting treatment of multi-year projects for non-foundationtrustproviders,insupportofourplans

• developinglocalflexibilitiesintermsandconditionsfortheprimaryandcommunityhealthestatetoimprovequalityandutilisation

• supporttoagreetheLondon-levelandNCLdeliveryoptionstoenhanceourwork• abilitytopayoffPFIsusingmoneyraisedfromcapitalsalesand/oracommitment

bynationalpartners to renegotiationof suchagreements,where theyhavebeenidentifiedasasignificantbarriertofinancialsustainabilityand/orthefacilityislessthan50%utilisedandnootherutilisationsolutionwilladdresstheissue.

Weanticipatethefollowingbenefits:

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• a whole system approach to estates development across NCL, with differentpartners working together on projects and developing a shared view of therequiredinvestmentanddevelopmenttosupportclinicalchange

• the ability to undertake better local health economy planning, includingestablishingestatesrequirements

• increasedaffordabilityofestateschangeacrossNCL• greaterincentivestodisposeofsurplusproperty,releasinglandforhousing• focused action on the development of the estates requirements to deliver care

closertohome• greater efficiency and flexibility in the estate, reducing voids and improving

utilisationandco-locationwhichwillsupportfinancialsavings

AcrossthesitesofMoorfields,StPancras,StAnn’swearebeginningtoevidencequalitativebenefits ofworking together to deliver estates value and improvement. The sector for anumberofyearshashadunresolvedestatesissuesrelatingtopoormentalhealthinpatientaccommodationandpotentiallysaleableandhighvalueestateatStPancrasHospital.The3providers are working together on this strategic estates project which aligns estatesprioritiesbetweenall3trusts.

Theproposedprogramme,which is still subject toconsultation,wouldseesalesproceedsfromsurplusassetsusedtodelivernewpurposebuiltmentalhealthaccommodation,andthe eventual relocation of Moorfields Eye Hospital to the St Pancras site. ClinicalimprovementswouldbeprioritisedthroughthebuildingofanewInstituteofMentalHealthand an integrated EyeHospital and Institute of Ophthalmology at the current St PancrasHospitalsite.

Thethreetrustsarecurrentlyrefiningtheiroutlinebusinesscases,withBoarddecisionsduein late 2016 and early 2017. Subject to consultation, further testing of economic viabilityandplanningpermission,thespecificbenefitsoftheworkwillinclude:

• development of a new world class research, education and clinical care facilityhousing an integrated Moorfields Eye Hospital and UCLH’s Institute ofOphthalmology, transforming ophthalmology facilities that are at present aconstraintoncontinuousimprovement

• improvementstotheestatetomeetCQC“mustdos”includingnewmentalhealthinpatients facilities forCamdenand IslingtonNHSFoundationTrust (includingtheintegration of physical and mental health and social care through an integratedpractice unit at St Pancras). Also, new facilities for Barnet, Enfield & HaringeyMentalHealthTrustatStAnn’sHospital,Tottenham

• a world class UCLH Institute of Mental Health and associated patient care andeducationalfacilitiesatStPancrasHospital

• potentialtodeliverc.1,500newhousingunitsinLondon,significantlycontributingtotheNHStargetforreleaseoflandforresidentialdevelopment

• improvements to environmental sustainability, as the new builds will deliver abalancebetweenBREEAMratingsfor‘green’initiatives,thecostofthecapitalbuildrequirementstodeliverthemandthewholelifecyclebenefitsintermsofcostsand

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amore sustainable future for our planet.Wewill design, build and operate in amannerthatsupportsrecyclinganduseoflowcarbontechnology.

The schemes are planned at a total capital cost of c.£400m (see section 8.3) with jointproviderengagementundertheumbrellaoftheestatesdevolutionpilotdrivingcompletionof thefinalschemeby2023. It isplannedthat£326mofthis is financedbysaleproceedswiththeremainderfundedfromavarietyofsources,includingphilanthropy.Progressing this schememay lead to a platform for sectorwide capital prioritisation andcreateanimprovedincentiveframeworkforassetdisposalandenhancedutilisation,whichwillgiverisetoalocallyoriginatedcapitalfundingstream.

InlinewiththefindingsofHealthcareforLondonin2014,ouranalysisshowsthatsignificantcapitalwork is required acrossNCL to improve the primary care estate. The primary andcommunityestateneedsimprovementinanumberofareas:

• developmentofCHINstoenablethedeliveryofthecareclosertohomemodel• expansionanddevelopmentofprimary care facilities toensure registration for a

significantlyexpandingpopulationandextendedhoursaccess• whilst some capital to enable delivery may be available through the estates

technologyandtransformationfund(ETTF),itisunlikelythatthiswillcoverthefullsetofrequirementsof£111m.Devolvedpowerswillenableustosecurecapitaltodeliver these much needed improvements and reduce the running costs of thisestate.

Exhibit9:NCLCHINestateplanning

North ValeDriveHealthCentre:ThesiteidentifiedisaLIFTbuildingandhenceitwillimproveutilisationEast FinchleyMemorialHospital:ALIFTbuildingwhichisanaturalhubandthiswillimproveutilisationSouth GroveMeadand/ornewColindaleHC:Anewhealthcentre/CHIN isplannedforColindale(ETTF&S106)West EdgwareCommunityHospital:ECHisanothernaturalactivityhubandalsoanunderutilisedsiteatpresent

North HampsteadGroup:Anextensiontoanexistingpracticeisplanned tocreateahealthcentre/CHIN(ETTF)NorthEast KentishTownHealthCentre:ALIFTbuildingwhichisanaturalhubandthiswillimproveutilisationSouth SomersTown:AnexistingpracticethatiswellplacedtoserveasaCHINWest WestHampstead:AnexistingpracticethatiswellplacedtoserveasaCHIN

NorthEast FreezyWater/OrdnanceCommunityCentre:Existingpracticesthatperformandarewellplaced(CHINTBD)SouthEast ForestRoadHCandEvergreenHC:LIFTbuildingsinEdmontonandthiswillimprovetheirutilisationSouthWest WinchmoreHill:AnETTFschemeaimstoextendanexistingpracticetodevelopahealthcentre/CHINhubNorthWest ChaseFarm/Cockfosters(HolbrookHouse):EitherontheRoyalFreehospitalsiteorwithinanewmixed-use

NorthEast SomersetGardens:AnETTFschemeaimstoextendanexistingpracticeintheWhiteHartLanere-genareaSouthEast Tynemouth:AwellplacedexistingpracticecurrentlyprovidingextendedaccessSouthWest HornseyCentral(Queenswood):ALIFTbuildingwhichisanaturalhubandthiswillimproveutilisationNorthWest BoundsGreen:Awellplacedexistingpracticecurrentlyprovidingextendedaccess

North Archway:AnETTFschemetodevelopanewbuildhealthcentre/CHINCentral IslingtonCentral:AwellplacedandeffectiveexistingpracticewhichcanserveasaCHINSouth RitchieStreet:AwellplacedandeffectiveexistingpracticewhichisabletoserveasaCHIN

NCLCCGCHINcurrentlocationalplanning(NBEarlystageandsubjecttofullconsultation)

BarnetCCG

CamdenCCG

EnfieldCCG

HaringeyCCG

IslingtonCCG

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6.4.3 Workforce

WeaimtoensurethatNCLbecomestheplaceofchoicetotrain,workandlivehealthylives.This includes co-creating, communicatingandcollaborativelydeliveringa compellingoffertoattract,developretainandsustainacommunityofpeoplewhoworkinhealthandcareinNCL. Our workforce needs tomove further towards a person-centred approach and thismeansdevelopingawholerangeofnewskills,trainingmodalitiesandnewroles.Our vision is for staff to be part of the wider NCL workforce, not just part of a singleorganisation.Throughthiswewillachieveefficienciesinemploymentbymanagingservicescollectively across the footprint. We will create sustainable career pathways to attract,developandsupportaworkforcefitforpurposeinthechanginghealthandcarelandscape.We will work with NCL organisations across all care settings (including social care) tosupport their collaborative efforts to be excellent employers – employers of choice,committed to looking after the wellbeing of staff whilst also preparing them to begindelivering the new caremodels. Thiswill supportNCL organisations to recruit and retainstaff, particularly where employee turnover rates are high or where there are staffshortages.Careerpathwayswillnotbelimitedtoasinglecaresettingandwillofferourstaffopportunities to experience a wide range of different opportunities which fit their ownaspirations. This processwill allowus towork towards thedevelopmentof an integratedemploymentmodelandapersonalcareerpassportforstafftodeveloptheircareeroverthelong-termwithinNCL.We aim to improve employee wellbeing and reduce avoidable sickness absence cost-effectively, therefore increasing lifetime productivity.Wewill focus on implementing thehealthyworkplacecharterinNHSorganisations,localauthoritiesandinsmallandmediumsizedbusinesses.

Throughequippingtheexistingworkforcewithnewskillsandwaysofworking,wewillbothensurethatourpeopleareworkingtothebestoftheirabilityaswellasadaptingrolestomeet the changing requirements of our services.We will support some of those peoplecurrentlyworkinginhospitalsettingswiththeskillsandconfidencetoworkacrossthecarepathway,reachingoutintocommunitycaresettingsanddeliveringthecareclosertohomemodel. We will similarly enhance the capabilities of those currently working in social,community and primary care. We will equip all our existing and future staff withmotivational and coaching skills, competence in promoting self-care and prevention, andtheenhancementofemotionalresilienceinthemselves,theirteamsandtheirpatients.AllfrontlineNHSandlocalauthoritystaffwillbetrainedonlineinMakingEveryContactCount(MECC),withkeyfrontlinestaffalsoreceivingface-to-facetraining.Allnon-medicalfrontlinestaffwillreceivetraininginMentalHealthFirstAid(MHFA).AllNHSandsocialcarestaffwillbetrainedinbasicdementiaawareness,withmoreadvancedtrainingforfrontlinestaffwhoaremorelikelytoencounterpeoplelivingwithdementia.

WhilemostofthepeoplewhowillbeengagedindeliveringtheNCLvisionarealreadywithus,workinginroleswhichwillneedtoadaptorchangeinsomeway,wewillalsosupportthe establishment of a small number of new roles, such as physician’s associates, care

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navigatorsandadvancedclinicalpractitioners.Wewillundertakeexpertstrategicworkforceplanningand redesign,andcommission training for skill enhancement, rolediversificationandnewroleimplementation.

To enable transformation, we will deliver system-level organisational development,supportingsystemleadersasindividualsandasteamsthroughthetransformationjourneytoenablepersonalresilienceandcourageousaction.Inaddition,wewilltraineveryoneinasingle approach to continuous quality improvement to create a culture of continuousimprovementtodeliverclinicalexcellenceandqualitycare.

Health,socialcareandpublichealthdeliveryisnotlimitedtoemployeesofourtraditionalemployers,andournotionofworkingwiththe‘widerworkforce’extendstothenumerouscarers,volunteersandcitizenswhoimprovethelifeofourpopulation.Inordertoimprovethegeneralwellbeingofourpopulationandmakeuseofthesubstantialsocialcapitalacrossourfootprint,wewilleducateandsupportpatients,carersandthoseintheircommunitiesin areas such as self-care, self-management, dementia and mental health awareness.Buildingonour‘widerworkforce’visionandaligningwithinitiativessuchastheAlzheimer’sSociety ambition for London to be a dementia friendly city by 2020,wewill support thetrainingofgroupssuchasbarbers,hairdressers, librariansandteacherstogatherabetterunderstanding of dementia andother long term conditions. AcrossNCL,wehave alreadybuiltfivestrongCommunityEducationProviderNetworks(CEPNs),andthesewillprovideaneffective vehicle for delivery of this aim. We will review the provision of learning anddevelopmentacrossNCLtoensurewemakethebestuseofexistingassets toencompassthewiderhealthcarecommunityincludingpatientsandcarers.Ourimmediateaimswillbetostandardiseandstreamlinestatutoryandmandatorytraining,align inductionandsharein-houselearninganddevelopmentcapacity.

Exhibit10:Integratedworkforcemodel

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6.4.4 Newcommissioninganddeliverymodels

As part of the STP development process, and in response to the changing healthcarelandscape in NCL, the 5 CCGs have been exploringways ofworkingmore collaborativelytogetherwhilst also seeking to strengthen joint commissioningwith local authorities.Wehave concluded that a more formalised degree of cooperation between the 5 CCGs willimprovehealthcommissioning,particularlyinresponseto:

• thedevelopmentofnewmodelsofcare,includinglargerproviderorganisationssuchtheRoyalFreeVanguard.

• increasingfinancialrisk• stretchedcapabilityandcapacity.

Our work has covered the development of a proposal for joint governance of strategiccommissioningdecisions(seesection9.2.1);thedevelopmentofacommoncommissioningstrategy and financial strategy; and, a review of CCGmanagement arrangements, with aviewtoshapingnewwaysofcommissioning.Withafocusonpopulationhealthsystemsandoutcomes and the transition to newmodels to deliver these, our objective is to furtherstrengthen strategic commissioningover thenext 2 years.Wehave agreed that anynewcommissioning arrangements need to balance the importance of local relationships andexistingprogrammesofworkwiththeneedtocommissionatscale.The governing bodies of each of the CCGs have agreed to the need for new executivemanagementarrangementsincludingsharedrolesacrosstheCCGs:anAccountableOfficer;aChiefFinanceOfficer;aDirectorofStrategy;and,aDirectorofPerformance.Additionally,inordertoensurethecontinuedroleofeachCCGinrespecttoitslocalcommissioningandjointworkwithlocalgovernment,localDirectorswithresponsibilityforlocalfunctionsandserviceshavebeenproposed.ThesenewleadershippositionswillworkwitheachoftheCCGs,aswellasthenewsharedgovernancestructuredescribedinsection9.2.1,toensurethathealthcommissioninginNCLdeliversthebestpossiblehealthandwellbeingforthelocalpopulationwhilstensuringvalueformoney.ThearrangementswillbefurtherconsideredbygoverningbodiesinNovemberwiththeexpectationthatthenewleadershipwillbeinplacenolaterthan1April2017.

Inparallel,commissionersandprovidersacrossthesystemhavebeenworkingtogethertodefineourdirectionoftravelintermsofnewdeliverymodels.Wealreadyhavesignificantwork we can build on relating to this, including the Royal Free London’s provider chainmodel; the UCLH Cancer Vanguard; theMoorfields Eye Hospital ophthalmology specialtychain; and, the Royal National Orthopaedic Hospital NHS Trustchain of orthopaedicproviders.

Wehaveconsultedwiththeleadersofallorganisationsacrossthesystemtogetviewsonthe different options for new deliverymodels, and the broad consensus includesmovingtowards:

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• wholesystemworkingwithapopulationratherthanindividualorganisationalfocus• a deeper level of provider collaboration, including collaboration between primary

care, community services, acute services, mental health services and social careservices.

• theestablishmentofsomeformof‘newdeliveryvehicle’or‘newdeliverysystem’tosupportthisprovidercollaboration.

• atransferovertimeofsomeelementsofwhatwecurrentlyconsidercommissioningfunctions(forexample,pathwayredesign)intothesenewdeliveryvehicles.

• a move towards some sort of population based capitated budget for the newdeliveryvehicles.

• the retention of a strategic commissioning function responsible for holding thedelivery vehicles to account, with accountability for outcomes rather than inputsbasedonprinciplesofcommissioningforvalue.

Further work needs to be done to resolve issues and differences of view around thefollowing:

• theorganisationalformforthenewdeliveryvehicles• theoptimalpopulationsizeforpopulationhealthmanagement• thegeographyoverwhichnewdeliveryvehiclesshouldoperate• theformandgovernanceofthestrategiccommissioningfunction• which commissioning functions should remain with the strategic commissioning

functionandwhichshouldbeundertakenthroughthenewdeliveryvehicle.• thescopeofthenewdeliveryvehicles• unresolved issues such as how tomanage patient choice, specialised services and

other flows outside of the delivery vehicle and a full understanding of the legalframeworkwhichmightimpactonimplementation

• speedofimplementation.

Discussions continue across health and care commissioners and providers in NCL toestablish agreement about the nature and scale of new delivery vehicles. Different caremodels are still being considered, and this work is being steered through the STPgovernanceframework.

6.5 Measuringoursuccess

We have established the anticipated impact of each of our workstreams to ensure weremainontracktoclosethekeygapsassetoutinourcaseforchange.However,toensurethat the breadth of our workstreams collectively meet the scale of our ambition, 11overarching outcomes have been developed by the London Health Commission for theBetterHealthforLondonstrategy.ThesehavebeenadaptedforNCLandendorsedbytheclinicalcabinetforourSTP.Wewillknowifwehavebeensuccessfulbymeasuringimpactagainsttheseoutcomesoverthenext4years.

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Exhibit11:NCLSTPoutcomes

7 Deliveryplans

A delivery plan has been developed for each of ourworkstreams, setting out the scope;objectives; financial and non-financial impact with trajectories; any investmentrequirements and the key risks to successful delivery.We will finalise the details of thedeliveryplansoverthenextfewmonthsasweagreethedetailedphasingandinvestmenttimetables.

Thedeliveryplanswillbelivedocumentsandwillcontinuetobeiteratedastheprogrammedevelops.Inaddition,eachworkstreamisrequiredtodevelopafullprogrammeinitiationdocumentwhichwillprovideareferencepointforeveryworkstreamtoensureplanneddeliveryisontrack,andtosupporttheeffectivemanagementofinterdependenciesbetweenworkstreams.

Ensurethatallchildrenareschool-ready byage5.Achievea10%reduction intheproportionofchildrenobese byYear6andreversethetrendinthosewhoareoverweight

Helpallourresidentstobeactiveandeathealthily,with70%achievingrecommendedactivitylevels

Reduceworkingdayslostduetosickness absence

Reducesmoking ratesinadultsto13%- inlinewiththelowestmajorglobalcity.

Reducethegapinlifeexpectancybetweenadultswithsevereandenduringmentalillness andtherestofthepopulation by5%

Increasetheproportionofpeoplewhofeelsupported tomanagetheirlong-termcondition tothetopquartilenationally

TransformgeneralpracticeininNCLsoresidentshaveaccesstotheirGPteams8am-8pm,andprimarycareisdeliveredinmodernpurpose-built/designed facilities

Work towardshavingthelowestdeathratesforthetop3 killers:cardiovasculardisease, Cancer,respiratorydisease andclosethegapincarebetweenthoseadmittedtohospital onweekdaysandatweekends

Fully engageourresidentsinthedesignoftheirservices, andachievea10pointincreaseonthepolldataregardingengagementindesigning services.

PutNCLatthecentreoftheglobalrevolution indigitalhealthandensurethisimproves patientoutcomes

Wewanttoreduceairpollution acrossNCL,toallowourresidents toliveinhealthierenvironments

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8 Bridgingthefinancialgap

The financial analysis that we have undertaken (see exhibit 2) shows the significant gapbetweenanticipatedgrowthindemand(andthereforecostgrowth)fortheNHSinNCLandthegrowthinfundingthattheNHSexpectstoreceiveoverthe5yearsoftheSTP.Withoutchangingthewaythatweworktogetherasasystemtoprovideamoreefficient,joinedupservice across organisations, this would leave us with an estimated £876m deficit in2020/2021.

TheSTP inNCLhasbroughttogetherorganisationsacrosshealthandsocialcareto jointlydiscusshowwecanaddressthisfinancialchallengeaswellasmakingprogressinimprovingthequalityof,andaccess,toservices.Basedontheplansandanalysissetout inthisSTP,which have been developedwith and by local clinical experts,wewill reduce the annualdeficitoverthenextfiveyearsto£75m(exhibit12)–whilstthisaddressesmorethan90%ofthefinancialgap,werecognisethatfurtherworkisneeded.

Thekeyelementsof theplanaresetout indetailelsewhere in thisdocument.Exhibit12showshowthesecontributetotheimprovementintheannualfinancialpositionoftheNCLsystemover5years.Thekeyareasofworkare:

• Careclosertohome:savingsof£114mhavebeenestimatedfromimprovingaccesstoprimarycare;proactively identifyingneedandearly intervention toavoid crisis;rapid response to urgent needs to prevent hospital admissions; providingcommunity-basedandambulatory-basedcare;andreducingdelaystodischarge.

• Prevention and the support of healthier choices: this is estimated to result insavingsof£10m.

• Mentalhealthoutreachandliaison:thisisestimatedtoresultinsavingsof£6m.• Optimising the elective pathway: savings of £55m have been estimated from

benchmarkingagainstbestpractice;workingcloselywithclinicians;optimisingflowthroughtheatres(increasingthroughput);andreducinglengthofstay-inadditiontotheexcellentworkthatourhospitalsandotherprovidersdotoimproveproductivityeachyear.

• AdditionalplansarebeingdevelopedrelatingtotheUCLHCancerVanguardschemeandRoyalFreeHospitalChainVanguardwhichareestimatedtodeliver£35m.

• Systemlevelproductivitysavingsof£98mareplannedtobeachievedalongsidethe‘business asusual’ cost improvementsacrossproviders inNCLof£218mand localcommissionerbusinessasusualefficiencies(QIPP)of£57m.

• We have identified a potential saving of £24m per year through ‘buying out’ anumber of Private Finance Initiative hospitals, bringing management of thesefacilities back within the public sector. We will continue to work with theDepartmentofHealthandotherstodeveloptheseplans,recognisingthatthereareanumberofconstraints.

• Althoughdetailedplanshavenotyetbeendeveloped,wehavebeenadvisedbyNHSEnglandtoassumethattheNCLproportionoftheLondonAmbulanceService(LAS)financial gap of £10m and the estimated specialised commissioning pressure of£137mwill be fully addressedby LASandNHSEngland respectively.NCLhospitalsprovideaverysignificantamountofspecialistcareanditisthereforeessentialthatNHSEnglandworkstogetherwiththeSTPonhowtheseservicescanflourishwhilst

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also addressing the financial pressures associated with the growth in specialistactivity(whichinmostdevelopedeconomiesishigherthangrowthinotherservicesduetonewtechnologies,drugsandclinicalinterventions).

• Furtherworkisongoinginrelationtodevelopingafullerunderstandingofthesocialcare financial position and pressures. At present no financial values have beenincluded as advised by NHS England, but this has not prevented the STP fromworkingverycloselyacrossbothhealthandsocialcare.InparticulartheNHSwithinNCL is seeking to learn from local authority colleagues best practice in relation toreducingcostwhilst improving theexperienceofpeoplewhouse servicesand thepublic.

These improvements cannot be achieved without investment. The plan is based oninvestmentof£64minpreventionandcareclosertohome,and£4minelectivecare.Wehave also assumed that £31m of our indicative £105m share of the Sustainability andTransformationFundwillberequiredtofundnationalpolicyprioritiesoverandabovetheseinvestments,inadditiontothatalreadyassumedwithinthe‘donothing’scenario.

Thesavingssetoutabovearepredicatedstronglyuponreducingsignificantactivityinacutehospitals, in particular reducing demand for inpatient care.We know that realising suchsavings can be difficult in practice and are contingent upon removing or re-purposingcapacitywithinacutehospitals.Assuch,throughworkingwiththeclinicalcabinetofclinicalleaderswithinNCLwehaveassumedthatthecostsavingsthatwillberealisedfromeachavoideddayofacutehospitalcarewillbesignificantlylowerthantheaveragetariffthatiscurrentlypaidtoprovidersbycommissionersforthiscare.This isreflectedina£53m‘riskadjustment’inthefinancialanalysis.

8.1 Normalisedforecastoutturnbyyear

Eachyeartherewillbeanumberofone-offcostsandincomestreamstothecommissionersand providers within NCL. Our 5 year financial analysis is initially based upon the“normalised”(orunderlying)financialpositionin2016/17whichisthenprojectedforward.Weestimatethat2016/17outturnwillbeanormaliseddeficitof£216m(£101monanin-yearbasis).Significantone-offfigureswithinthisincludeUCLH’stransitionalfundingthatitis receivingtocompensateforthefinancial impactofmovingcardiacservicestothenew,worldclasscentreatBartshospital,andtheRoyalFree’stransitionalfundinginrelationtothe merger with Barnet and Chase Farm. The underlying figure also includes a £40madjustment which is an estimate of the combined risk to the NHS provider andcommissioner forecast outturn. This has arisen as a result of potentially differentassumptions between NHS commissioners and providers about the value of workundertakenby theendof2016/17.Wehave reachedanagreedviewon forecastoutturnactivityandwillcontinuetoworkurgently toensureconsistencyofpaymentassumptionsbetweendifferentpartsoftheNHSwithinNCL.Allpartieshaveagreedamore‘openbook’approachtocontractagreementsthatwillensureaconsistent,system-basedapproach.

TheSTPplanshowsagradualimprovementinthefinancialpositionoverthe5yearsoftheSTP (exhibit 13). The normalised position improves year on year. This pattern is in partcausedbytherequirementformajorityoftheinvestmentintheearlyyearsoftheSTP,withbenefitsaccruinginthelateryears.

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8.2 2017/18forecastoperatingplan

In2017/18weestimate thatour in-yearpositionwillbea£95mdeficit forNCLagainstadraftsystemcontroltotalof£13msurplus(whichweanticipatewillchangeoverthecomingweeksduetoanumberoftechnicalissues).ThisincorporatessignificantinvestmentduringtheyearonservicetransformationanddeliveryoftheFiveYearForwardView:

• investmentinservicetransformation:£25m.Thisrelatestothecareclosertohome(£23.5m),elective(£0.8m)andoutpatient(£0.4m)workstreams

• otherrecurrentinvestmentbyCCGsandtrusts–includedwithintheCCGandtrustcostmovements it is estimatedat £25m in17/18 todeliver elementsof the5YFVpriorities

• othernon-recurrentcosts(estimatedat£20min17/18)forinvestmentinVanguardcosts,ITdigitalcosts,andSTPprogrammecosts.

InlinewithNHSEguidancewehavealsoassumedthatwewillreceiveour‘fairshare’ofthenationalSustainabilityandTransformationFund(£105m)in2017/18.Thiscomparestothe£52m currently notified to NHS providers, and additional a further £53m improves ourrevisedforecastoperatingplanpositiontoadeficitof£62m–seeexhibit14.8.3 Capitalexpenditure

We recognise that the national capital budget for theNHS is highly constrained over thecourse of this parliament, and will continue to work hard to minimise the need forsignificantcapitalinvestmentunlessthereisastrongreturnoninvestment.NCLalsohasanumber of creative proposals thatwill seek tomaximise disposal proceeds from sites nolonger required, and use these to reinvest in the priority areas of the STP aswell as thepotentialtoprovideadditional,much-neededhousingfortheresidentsofNCL.

There are a number of large capital schemes that are already approved and underwaywithintheSTPand,whilst far frombeing ‘businessasusual’ theseare included inthe ‘donothing’ scenario as their approval pre-dates the STP work. Total capital, before specificSTP-relatedinvestment,is£1.2bnoverthe5years.Thisincludes:

• UCLHnewclinicalfacilities:haematology-oncologyandshortstaysurgery–(£137m);Proton-beamtherapy(£130m),ENTanddentalfacilitytoconsolidatetwoexistinghospitalsontothemainUniversityCollegeHospitalcampus(£98m)andothermoreminorschemes.UCLHhaveapprovedDHfundingof£278m(£51mpublicdividendcapital(PDC)and£227mDHLoan)aswellasanticipated,ring-fenceddisposalproceedstofinancethesedevelopments

• RoyalFree-ChaseFarmredevelopment:(£183m),whichincludes£93mofapprovedDHfunding(£80mPDCand£13mDHLoan).

In addition to thesemajor developments there is of course significant business as usualcapital investment such as equipment replacement and building maintenance, fundedthroughdepreciation,cashreservesandothersourcesoffunding(includingdisposals).

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TheadditionalgrosscapitalrequirementstoimplementthetransformationprogrammesetoutintheSTPtotals£542m,withamuchsmallernetinvestmentrequirementaftertakingintoaccountdisposals,donationsandgrants:

• Estates redevelopment: relating to our St Pancras/St Anns/Moorfields proposals:£404m, assumed to be funded through disposals £326m), DH loans (£39m) andDonations (£37m), of which £272m (including short term bridging loans andrepayments)occurwithintheperiodcoveredbythisSTP(i.e.before2020/21)andisincludedabove.Thisscheme,includinganassumptionofDHloanfunding,hasyettobe agreed, and will be subject to normal Business Case processes through NHSImprovement.

• PrimaryCareforCareClosertoHomeand5YFVinvestment:£111massumedtobefunded predominantly through ETTF (£60m – all bids submitted), s106/CIL/GPcontributions(£26m),grantsandothersources.

• ITinvestment:£159mwithafurther£21min2021/22.AllassumedtobefundedbyETTF(circa£10m–bidssubmittedforthePersonHeldRecord/IDCR)orthroughthecentralDigitalTransformationFund.

Werecognisethatfurtherworkisneededtodevelopfullbusinesscasesfortheabove,andatpresent these figuresareestimated-particularly in relationtoprimarycareanddigitalinvestment. In developing these schemes we will seek to maximise the use of existingbuildingsandotherassets,andminimisetheneedfornewcapitalinvestment,togetherwithapplying a robust requirement for return on investment for each scheme. However, wefundamentallybelieve that investment inprimarycareanddigital technology iscentral tothetransformationofservicesthatisneededinNCLtoaddressthegapsinservicequality,accessandfinance,andwhollyconsistentwiththeFiveYearForwardViewandrequirementto be paper-free at the point of care by 2023. It would be wrong to assume that suchinvestment is not required and will not deliver value simply because of the stage indevelopmentoftheseplansthatNCLiscurrentlyin.TheestatesredevelopmentrelatingtoStPancras,StAnn’sandMoorfields,andtheestatesdevolution work, offers an exciting and compelling vision as to how existing assets,disposals, redevelopment and construction of new facilities can be financially efficient aswellasdeliveringsignificantbenefitstopatients,serviceusersandthewiderpopulation.In addition,wewill continue to engage as an STPwith thework being led by Sir RobertNaylor inrelationtopropertystrategyacrosstheNHS,tofurtherunderstandhowbeingapilotareainthiscanhelpNCLmakebestuseofitscurrentassetstosupportthedeliveryofourSTPvision.8.4 Nextstepstoaddressthefinancialgap

Weareveryclearthatwehavemoretodotoclosethefinancialgapsfortheremainderof2016/17andacrossthenext4yearsoftheSTP.Wewillthereforeundertakeaperiodoffurtherintensiveworkoverthenext8weeksbothto improve confidence in delivery of current estimates, whilst concurrently working onother areas to further improve the position. As far as possiblewewill aim to do this by

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Christmas,sothatouroperatingplansubmissionimprovesonthissubmission.However,wedo believe that there is a risk that the gap will not be fully closed in every year whilstensuringthatwecontinuetoprioritisequalityofandaccesstoservices,particularlyaswebalance theneed to invest in the early years to deliver transformational benefits in lateryears. It is alsoessential that STPs and their constituentorganisations and leadership aregiventheregulatoryheadroomtodeveloplongertermplans,andthatthe‘newmodelsofcare’ being developed give clarity of financial accountability to support the financialchallengesthattheSTPfaces.Wehaveidentifiedanumberofimmediateactionstoimproveourcurrentfinancialposition,whichinclude:

• earlydeliveryofhighimpactcareclosertohomeinterventions• accelerateddeliveryofstretchtargetsforhighimpactelectivepathways• increased effort in terms of delivering efficiencies through provider productivity

schemes• reducinganynon-valueaddedcontractingcosts• implementationof payharmonisation and sharedprinciples aroundusageof bank

andagencystaff• leveragingexistingcapacityinNHSproviderstoreduceoutsourcingofactivitytothe

independentsector• othernon-recurrentsavingsmeasures• assessingandincorporatingtheimpactof2017/18tariffchanges.

Therearealsoanumberofareasthatwewillexplorefurtheraswebelievetheremaybesignificantsavingstobefound.Theseinclude:

• maximising clinical productivity across providers, for example introducing sharedclinicalrotas

• developing alternative pathways for the London Ambulance Service to avoidconveyancetoEmergencyDepartments

• rollingoutstandardisedpathwaystoallspecialities• identifyingopportunitiestoreducethelengthofstayforpatientsreceivingspecialist

services• reviewinganyplansthatrequirecapitalandhavenotyetbeenagreedtoestablish

themostcosteffectivewaytodeliveragreedoutcomes• rapidimplementationofcancerinitiatives,includingearlydiagnosis,newmodelsof

care,endoflifeinterventionsandresearchandinnovation• re-providingcosteffectiveservicesforthec.20%ofpeopleweestimatearecurrently

inhospitalbedsbutaremedicallyfittoleave• putting in place a peer review challenge approach across all areas of spend to

identifyfurtheropportunitiestoreduceoravoidspend,andtoaidcollectivedeliveryofplans.

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Exhibit12:Bridgingthefinancialgapto2020/21

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Exhibit13:Normalisedforecastoutturnbyyear

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Exhibit14:Forecast2016/17outturncontroltotalto2017/18forecastoperatingplan

Note:The16/17 inyearFOTof£101mtogetherwith the£107m16/17normalizingadjustments represents thenormalized16/17positionexcluding thespecialist trusts

(RNOH,T&P).Includingthespecialisttrustsnormalised16/17position(£8m)bringsthecombined16/17normaliseddeficitto£216m(showninexhibit13).

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9 Howwewilldeliverourplan

9.1 Deliverythrough2yearcontractsinNCL

Delivering the STP is a priority for health and care commissioners and providers inNCL -thereforeitisessentialthatcommissioningintentionsandcontractsreflectthis.Inlinewithnational guidance, we are entering into a planning round for 2 year contracts covering2017/18and2018/19.Wewillusethisopportunitytoensureallcontractsarestrategicallyaligned to the STP, thus enabling its delivery. Whilst we recognise that implementationmightlookdifferentindifferentlocalareas,weknowthatitwillonlybepossibletodeliveron the STP if we are all pulling in the same direction. Setting up 2 year contracts basedaroundourSTPdeliveryplanswillbothenablerapidimplementationandsupportalongerterm move to new relationships between commissioners and providers, reducingtransactionalcostsandbuildingthefoundationforthedevelopmentofnewcommissioninganddeliveryarrangements.

Exhibit15:Highlevelplanfor2yearplanningroundtosupportdeliveryoftheSTP

We have developed a proposed process and a set of draft principles for managing thecontractnegotiations thatwill takeplaceover thenext coupleofmonths.Our leadershipgroup will meet regularly (every 2 to 3 weeks) to ensure leadership alignment, assessprogressonoperatingplans,andtoensurethatthebehavioursofteamsreflecttheagreedNCLapproach.

WehaveagreedthatoperatingplansandcontractswillneedtobestrategicallyconsistentwiththeSTP.Toachievethis,allfinanceandactivityalignmentwillbeoverseenbytheSTPfinanceandactivitymodellinggroup,withoverallplanalignmenttobeoverseenbytheNCLwideplanninggroupledbytheCCGs.All interimfinanceandactivitysubmissionsbyCCGsand trustsbetween21Octoberand23Decembershould thereforebealignedacrossNCL

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beforesubmission.WhilstorganisationswillindividuallyfollowupquerieswithNHSEnglandorNHSImprovementon2017/18controltotals,noorganisationwillagreetheir individualtargetunlessanduntilthereisapan-NCLplanagreed.

Therisksofdeliveryofoperatingplanswillbe identifiedand jointlyownedandmanaged,withthefollowingprinciples:

• simplicity• reducingtransactioncosts• incentivisingthechangesincaredeliveryassetoutintheSTP• incentivisingthedeliveryinimprovedproductivityassetoutintheSTP• locatingriskwhereitcanbestbemanaged• anopenbookapproach• useofagreedsourcesofdata.

Inthecurrentcontextofthefinancialpositionandmanagementcapacityacrossthesystem,wewillensureinthefirst2yearsoftheSTPthatweareprioritisingoureffortsintheareaswhich will add the most value in terms of increasing health and wellbeing for people;improvingthequalityofcarepeoplereceive;andensuringvaluefortaxpayers’money.Wewill focus our energies on achievingmaximumbenefit andwewill seek to identify areaswherewecanfurtherandfastertobuildconfidenceandmomentum.

Wewillidentifyresourcestotakeforwardareasoffurtherpotentialbenefit.Inaddition,wewill set up a process for independent peer review challenge of all areas of discretionaryspendinprovidersandCCGstoidentifyfurtheropportunitiestoreduceoravoidspendandtoaidthecollectivedeliveryofplans.

9.2 Decisionmakingintheprogramme

TheSTPisacollaborationbetweenarangeofsovereignorganisationsinNCL,eachwithitsown governance and decision-making structures. We have not to date introduced anycollectivedecision-makingstructures.HoweverwehaveworkedtogethertoproduceboththeCaseforChangeandtheSTP.

The STP is a work in progress and therefore has not been signed off by any of theorganisationswithintheSTP.WewilltakethisSTPthroughthepublicsessionsofeachoftheNHS provider boards, CCG governing bodies and Local Authorities for their support andinputintothenextsteps.

9.2.1 CollectivegovernancearrangementsforCCGs

Going forward, in order to support amore collaborative commissioning approach acrossNCL, the 5 CCGswill need amechanism for collective decisionmaking.Governing BodieshaverecognisedthisrequirementandhaveagreedtheprincipleofestablishingajointNCL-widegovernancestructureforsomeelementsofcommissioning.

Further work is being done on the details of the proposed joint governance structure.Engagementon thedesignhasbeenongoingduringOctober2016andwill continuewithfurtherdetailstobepresentedatGoverningBodymeetingsinNovember2016.

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9.3 Programmearchitecture

IncomingtogetherasanSTPfootprint,wehavedevelopedagovernancestructure,whichenablesNHSandlocalgovernmentSTPpartnerstoworktogetherinnewways.TheNCLSTPTransformationBoardbringstogetherexecutivesfromallprogrammepartnersmonthlytooverseethedevelopmentoftheprogramme.Ithasnoformaldecisionmakingauthority,butmembers are committed to steering decisions through their constituent boards andgoverningbodies.ThreesubgroupsfeedintotheTransformationBoard:theClinicalCabinet,theFinanceandActivityModellingGroupandtheTransformationGroup.

TheClinicalCabinetmeets fortnightly toprovideclinicalandprofessional steer, inputandchallengetoalltheworkstreamsastheydevelop.Membershipconsistsofthe5CCGChairs,the 8 Medical Directors, clinical leads from across the workstreams, 3 nursingrepresentativesfromacrossthefootprint,arepresentativefortheDirectorsofPublicHealthandrepresentativesfortheDirectorsofAdultSocialServicesandtheDirectorsofChildren’sServicesrespectively.

The Finance and Activity Modelling Group is attended by the Finance Directors from allorganisations(commissionersandproviders).Thisgroupalsomeetsfortnightly,tooverseethefinanceandactivitymodellingoftheworkstreamplansastheydevelop.

The Transformation Group is an executive steering groupmade up of a cross section ofrepresentatives from all organisations and roles. This group is specifically responsible fordrivingprogressbetweenmeetingsof theTransformationBoard,andmeets fortnightly todoso.MembershipincludestheSROsofallworkstreams.

Additionally,theNCLSTPhasafulltimePMOwhichfacilitatesandcoordinatesthemeetingsof the main governance groups, as well as delivering communications and engagementsupporttotheprogramme.

Exhibit16:NCLSTPcurrentgovernancestructure

Programmestructure

StatutorygoverningbodiesNCLSTPprogramme

Cam Enf Har IslBar

LACabinets/Committees

Cam Enf Har IslBar

CCGGoverning Bodies

Cam Enf Har IslBar

HealthandWellbeingBoards

Provider Boards

NMUHCLCH CNWL RFBEH C&I UCLH Whit

NCLTransformation BoardChair:DavidSlomanSROs:DavidSloman(Convenor), CathyGritzner, MikeCookeMembers

• NHSEnglandSpecComm• NHSEngland• NHSImprovement• GPproviders• HENCEL

• LAS• Healthwatch• UCLPartners• Clinical leads• Financelead• ProgrammeDirector

• Workstream SROs• NHSCCGs• NHSAcuteProviders• NHSCommunityProviders• NHSMentalHealthProviders• LocalAuthorities

FinanceandActivityModelling GroupLead:TimJaggard

Transformation GroupLead: DavidSloman

Clinical CabinetLead:JoSauvage&RichardJennings

Input/updatesprovided by/tootherrelevantorganisations,

programmesandforums

SeniorProgrammeDirector:DavidStoutHeadofProgrammeManagementComms andEngagementLeadProgrammeManagerSeniorAnalystProgrammeCoordinators

Supported bytheNCLSTPPMO

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The component workstreams of the NCL STP feed into the overarching governanceframework.Theworkstreamsareresponsiblefordevelopingproposalsanddeliveryplansinthe core priority areas. Every workstream has its own governance arrangements andmeeting cycleswhichhavebeendesigned tomeet their respective specific requirements,dependingonthecorestakeholdersinvolved.

9.3.1 Futureprogrammearchitecture

We recognise that as we move from planning to implementation that we will need toamendourprogrammearchitecturetoensurethat it is fit forpurpose.WewillworkwiththeTransformationBoardtoagreeanyrequiredchangestotheprogrammearchitecturesothatwearereadytomoveforwardwithimplementationfromthenewyear.

Ourinitialproposalfordiscussionissetoutinexhibit17.

Exhibit17:Proposedfutureprogrammearchitecture

Thisstructurewouldcomprisethefollowingnewgroups:

• STPOversightGroup:ThisoversightgroupwouldbemadeupofChairsandpoliticalleaders and would go some way to address the current ‘democratic deficit’ andrepresentationofviewsofthelocalpopulation.It isproposedthatthisgroupmeetquarterlyandmightbenefit fromanappointed IndependentChair.MembershipofthisgroupwouldensurescrutinyofthedeliveryofSTPdeliveryandensureabetterconnectionwiththeNHSboards,governingbodiesandlocalauthorityleadership.

• STPDeliveryProgrammeBoard:TodriveandoverseetheprogressionanddeliveryoftheSTP.Itisproposedthatthedeliveryboardmeetmonthly.ThiswouldreplacetheTransformationGroup.

NCLSTPDELIVERYPROGRAMMEBOARDChair:DavidSloman

AllSROsFrequency:Monthly

NCLSTPOVERSIGHTGROUPNHSChairs/Political Leaders/Healthwatch

Chair: Independent Chair,TBAFrequency: quarterly

ClinicalCabinet Finance&ActivityModellingGroup

NCLExecutive/Stakeholder

Leadershipevents

Workstreams

NCLSTPPMOSnrProgramme

Director

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• Executive leadership events: CEOs and other relevant executive directors andstakeholder representativeswouldmeet periodically as requested by the DeliveryBoardinordertoresolvedeliveryissues.

9.3.2 Healthandwellbeingboards

CCGsarerequiredtoinvolvetheirlocalHealthandWellbeingBoard(HWB)whenpreparingtheircommissioningplansothatHWBscanconsiderwhethertheirdraftplanstakeproperaccountofthelocalhealthandwellbeingstrategy.AsCCGcommissioningplanswillbesetwithinthecontextoftheSTP,itwillbeimportantthatweengagewithHWBsaswedeveloptheSTP.EngagementofHWBswillalsobeanimportantmeansofensuringengagementoflocalpoliticalleadershipintheSTPprocess.

9.3.3 Overviewandscrutinycommittees

Localauthoritieshavearoleinreviewingandscrutinisingmattersrelatingtotheplanning,provisionandoperationofhealthservicesintheirlocalarea.CommissionersandprovidersofNHSservices(includingNHSEngland,CCGs,NHStrusts,NHSfoundationtrustsandprivateproviders)mustconsult the localauthoritywhere theyareconsideringanyproposal forasubstantialdevelopmentorvariationofthehealthserviceinthearea.Ordinarily,wheretheservices inquestionarecommissionedbyNHSEnglandorCCGs (as thecasemaybe), thecommissioners carry out this exercise on behalf of providers. Providers of public healthservicescommissionedbythelocalauthorityarealsorequiredtoconsultthelocalauthorityinthesamewayascommissionersandprovidersofNHSservices.

ThelocalauthoritymayscrutinisesuchproposalsandmakereportsandrecommendationstoNHSEnglandandtheSecretaryofState forHealth.Legislationprovides forexemptionsfromthedutytoconsultincertaincircumstances,forexamplewherethedecisionmustbetaken without allowing time for consultation because of a risk to safety or welfare ofpatientsorstaff.Aspartoftheoverviewandscrutinyprocess,thelocalauthoritywillinvitecomment from interested parties and take into account relevant information available,includingthatfromHealthwatch.

WehaveaJointHealthOverviewandScrutinyCommittee(JHOSC)inplaceacrossNCLwhichhas already put the STP on its agenda as a standing item.Wewill ensure that we liaisecloselywith the JHOSCas theSTPplansdevelop so thatwecanplanahead forany likelyneed for public consultation. In addition, we will discuss plans with any relevant localauthorityoverviewandscrutinycommitteesaswemovetowardslocalimplementation.

9.4 Programmeresourcing

Wehavededicated resources inplace to support thedeliveryof the STP,withanagreedoverallprogrammebudgetof£5m in2016/17.EachworkstreamhasaSeniorResponsibleOfficer(SRO).Someworkstreamshavesharedleadership,whereamixedskillsetisrequired.All of these individuals are senior Executive level - Chief Executives,Medical Directors orFinanceDirectors -ensuring leadershipof thehighestquality.EachSRO is supportedbyadedicated programme manager, and in some cases a broader team of support. Aprogrammebudget for2016/17hasbeenallocated toeachof theworkstreamsbasedon

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theirproposedrequirements.STPpartnerorganisationsarealsogivinginkindtoeachoftheworkstreamstoensurehighqualityplanscanbedeliveredatpace.

Wewillreviewtherequirementsfor2017/18andbeyondaswefinalisethedeliveryplansandphasingofimplementation.A£10mresourcerequirementtodelivertheplanhasbeenfactoredintoourfinancialmodelling.

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10 Engagement

Wehavecomealongwaysincebeingaskedtocometogetheras22healthandsocialcareorganisationswithdisparateviews lastDecember. It takestimetobuildtrustanddevelopsharedasharedvisionofthefuturebetweenpeopleandorganisations,andtogeteveryoneworkingtowardsthesamegoals.Wearenowallalignedbehindacollectiveagendaandarereadytoshareitmorewidely,seekinginputandfeedbackonourdraftplanstodate.

Themost importantpeopleweneedtoengagewitharethosewhouseourservices–theresidents ofNCL.We have specifically created a shared core narrative for this purpose –ensuringitisinpatient-focusedandaccessibleinlanguagetobegintoinvolvepeopleintheprocess.Nowthatweareinapositiontocommunicateourcollectivethoughtseffectively,our intention is to engage residents, local Councillors, our workforce and other keystakeholderstogetfeedbackonourplans.Wehaveheldinitialpublicmeetingsineachofthe5boroughs tobegin theprocessof co-designwithpatients,peoplewhouse services,carers,familiesandHealthwatch.

Ourapproachgoing forwardwillbe tocollaboratemoreextensivelywithpeoplewhouseservicesandcarers,localpoliticalstakeholdersaswellasmembersofthepublic,toensurethatourresidentshelpinformourdecisions.Thisapproachisguidedbythefollowingcoreprinciples (often called the “Ladder of Citizen Participation”).Wewill undertake differenttypesofengagementassetoutontheladderasappropriate:

1. ‘inform’stakeholders2. ‘engage’withstakeholdersinopendiscussions3. ‘co-design/co-produce’serviceswithstakeholders

Feedbackfromourlocalresidentswillbefundamentaltoourdecisionmakingandwillhelpusshapethewaythefinalplanisimplemented.

10.1 Ourfutureplans

Wewillnowbuildonthesuccessofourinitialpublicengagementeventsby:

• holdingaquarterlyforumineachborough• holdingpan-NCLeventsonspecific issuesthatmayarise insupportoftheborough

levelevents• hostingmeetingswiththepubliconfocussedtopicssuchasurgentandemergency

care,primarycare,andmentalhealthtogetin-depthinputfromthecommunity• organising‘Tweetchats’onspecificareasofinterest• developingadesignatedYouTubechannelandpopulatingitwithrelevantresources.• using partner digitalmedia channels – Twitter, Facebook, Instagram– to promote

our public engagement programmes and information. We will also use thesechannelstotestideasandprogressonlocalprioritieswhichwillhelpusdevelopourplansfurther.

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Todothis,wewill:

• use Healthwatch, other patient representative groups and resident’s associations,localauthorityengagementnetworksandtherangeofothernetworksavailabletoreachouttothepublicandshareourdraftplans

• work inpartnershipwith communications teamsacrossNCLorganisationsandusetheirwide rangeofcommunitychannels to socialise theSTP, forexampleCamdenCCG’scitizens’panelandEnfield’sPatientParticipationGroupsNetwork.

• useexistingonlineengagementtoolsthatCCGs,localauthoritiesandprovidershaveto engage specific audiences and reach those who may be unable to attend ourevents.

Werecognise it iscrucial toensureour localpoliticalstakeholdersareactively involved intheoversightoftheplansastheydevelop.Weareplanningondoingthisby:

• planning regular face to facemeetingsbetween theSTP leadership teamand localcouncillorsandMPs,alongwithMinistersintheDepartmentforHealthifrequiredtoseektheirregularadviceonallproposedchanges

• continuingtoshareprogressupdatesoftheSTPatallmeetingsattheJointHealthOverview and Scrutiny Committee (JHOSC)ensuring that all political channelsthroughCCGs,localauthoritiesandprovidersarekeptfullybriefedontheSTPasitdevelopsandanypublicconcernsfortheregularengagementtheyundertakewithelectedleaders

• loggingallmediastoriesandregularlyupdatingtheTransformationBoardandthosemeetingwithelectedmembersontheSTPas itdevelops,mediadevelopmentandanypublicconcerns.

Thereisalsoaneedtoengagemoreofourownworkforceintheplanningprocess.Wewilldothisvia:

• the weekly STP newsletter that we have set up for those working within theorganisationsoftheSTP

• providingpeopleworkingwithinourorganisationswithregularupdatesonprogressthrough internal newsletters and bulletins, weekly / monthly updates from ChiefExecutives

• hosting sessions with a wider set of clinicians and social care practitioners to gettheir input intotheprioritiesanddeliveryareas.Thiswill includeworkingwithourGPFederationstoengageprimarycareproviderstoensureourworkforceisadriverandownerofchange

• runningeventswithinourmembershiporganisationstoshowcasetherangeofworkwhichishappeningacrossNCLandtoensurestaffunderstandthecurrentplans,andhowtheymayaffectthemasweprogressintoimplementation.

We will continue to build our communications and engagement capabilities across thesystem.Weareplanningtohostaworkshopwithcommunicationsleadsfromacrosssectorstoco-designthefutureengagementstrategy,havingnowidentifiedthekeyaudiencesthatweneed toengagewith across the5boroughs.The strategywill include thedesignofaprogrammeofdeliberative-styleeventswhichwillbringtogetherdifferentgroupstomore

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directly shapeourplans.Wewillestablishadesignatedcommunicationsandengagementworkstream to oversee delivery of the strategy, with a Senior Responsible Officer forengagement.

10.2 Publicconsultation

Aformalpublicconsultationisnotneededforeveryservicechange.However,itislikelytobeneededshouldsubstantialchangestotheconfigurationofhealthservicesinalocalareabeproposedasourplansdevelopandwearecommittedtoensuringweconsultwidelyandeffectively.

Wearealreadybeginningtodevelopacomprehensivepictureof localviewsandconcernsthroughourearlyengagement,buildinganextensivestakeholderandcommunitydatabaseand contacts which will enable us to develop a detailed plan of those affected by anyproposedchanges.

We also have an existing relationship with both general and specialist media outlets(includingdigital).WearealreadyworkingonSTPstorieswiththesestakeholdersandwillcontinuetodosowhetherformalconsultationisrequiredornot.

10.3 Equalitiesanalysisandimpactassessment

UndertheEqualityAct2010,wearerequiredtoanalysetheeffectand impactoftheNCLSTPinrelationtoequality.Wearecommittedtocarryingoutanequalityimpactassessmentto ensure our plan does not discriminate against disadvantaged or vulnerable people, orotherprotectedgroups.

Our equality analysis will consider the effect on different groups protected fromdiscrimination by the Equality Act to ensure any changes are fully effective for all targetgroups and mitigate against any unintended consequences for some groups. We arecommittedtoundertakinganEqualitiesImpactAssessmentasourplansbecomemorefullydeveloped.

WealreadyhaveagoodoverviewandanalysisofequalityinformationfromacrosstheNCLfootprint through our existing and ongoing partnershipworkwith the 5 local authorities,CCGs, providers and other representative organisations.We are building on local regularequalityauditsofresidents,patientsandstafftoensuregoodengagementwithprotectedgroups and others, so that we can better understand the actual or potential effect ofchanges to functions, policies or decisions through the STP. This will help us to identifypracticalstepstotackleanynegativeeffectsordiscrimination, toadvanceequalityandtofostergoodrelations.

Throughout our engagement to date, and building on the insight above, we have takenadvice on best practice to ensure that all our public facing work is as fully accessible aspossible,includingsharinginformationinavarietyofformatstoensureourweareabletoengageallourresidents,using interpretersorEasyReadmaterialwhererequired.Wewillcontinue to hold events andmeetings in accessible locations (accessible for people withdisabilities and easily reached on public transport, with adaptationsmade for attendees’

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communicationneeds).OuraimistoenabledifferentgroupstobefullyinvolvedastheSTPprogresses.

11 Conclusionandnextsteps

TheSTPisworkinprogressandwerecognisethatwehavemuchmoreworktodotodeliverthevisionwehavesetout.

TheimmediatenextstepsbetweennowandChristmasareto:

• totakestepstostabiliseourfinancialposition,developingmoredetailedideasintheareaswehavenotyetfullyexplored

• agreetheprioritiesforimplementationinthefirst2yearsoftheSTPtoensurethatwe focus initially on the improvements which will make the most impact on ourtripleaimsmostquickly.

Atthesametime,weareclearthatwewillnotlosefocusonthelongertermtransformationthatwillsupportsustainability.

Thereremainmanyissuestoresolveandweknowwedonothavealltheanswers.Butweare determined to succeed andwill continue toworkwith peoplewho use services, thepublicandourstafftofindsolutionsinthemonthsandyearsahead.