Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
2019
Healthier Lives in North Central London
NORTH LONDON PARTNERS NOVEMBER 2019
DRAFT
Contents of this document
Overview and introduction to our collective plan:
1. Introduction and purpose of this document
2. The population in North Central London is diverse and vibrant
3. There are many partners delivering our health and care services in North Central
London
4. We want residents to start well, live well and age well
5. We have been listening to what residents have told us is important
6. What will working in new ways mean for residents?
7. We will work as partners to integrate care
8. To deliver this, we need to spend public money in the best possible way as well as fix
the basics
9. We need to shift our focus to prevent ill health the factors that cause it
10. Supporting individuals to have personalised care for their whole needs
11. We need to plan services on a population basis
12. We need to support the development of out of hospital care and have our hospitals work
together more often
13. What happens next?
14. How can I share my views and help shape the plan?
Detailed sections on the changes we want to make:
Working more effectively as a system: Section 1. Listening to residents and communities Section 2. Through working as partners to integrate care Section 3. Moving to population health planning Section 4. Embedding personalisation
Detailed service transformation plans:
Section 5. Integrated out of hospital and community care Section 6. A simplified urgent and emergency care system Section 7. Improved cancer services Section 8. Coordinated Mental Health services and improved outcomes for our population Section 9. Transformed outpatient care with shorter waits Section 10. Evidence based action to prevent ill health Section 11. A more coordinated approach to children’s care Section 12. Focused work on improvements to care for learning disabilities and autism Section 13. Coordinated and proactive care for people with long term conditions Section 14. Delivering better births through improved maternity services Section 15. Managing medicines effectively and Pharmacy working in new ways
Supporting the delivery of these changes:
Section 16. Tackling the workforce challenges across health and care
Section 17. Taking advantage of the opportunities of digital technology
Section 18. Managing our estates in a coordinated way
Introduction and purpose of this document:
Our aim is to help residents to live the fullest lives possible, stay well, and to recover from ill
health more quickly. We want to tackle the long-standing problems in North Central London
(NCL) that mean some residents experience inequalities in their health.
The organisations that provide health, care and voluntary services in Barnet, Camden,
Enfield, Haringey and Islington (North Central London) are working together to try and have
the greatest positive impact on the lives of our 1.5 million residents. This document sets out
what we are aiming to achieve together to deliver improvements over the next five years,
and what this will mean for residents.
This plan will be the basis for continued engagement and the development of more detailed
work with our staff, local residents and our partners.
The health and care system has never been busier, caring for an ageing population with
more complicated needs, supporting people with long term conditions, and providing access
to new treatments that are more expensive. We know that families work hard to pay their
taxes and that’s why we will make sure every penny is invested on the things that matter
most, by getting the basics right, providing high quality lifesaving treatment and care for
patients and their families, reducing pressure on our staff and investing in exciting new
technologies.
To do this, we will work with partners to integrate services where this improves care and
reduces waste, spend public money effectively and support our staff to work in new ways
and improve the lives of our residents and communities.
For residents, this means that it will be easier for you to get the support and care that you
need. More care will be closer to where you live, with less time spent in hospital, if you need
to go there, and you will be actively involved in shared decision-making about your health
and care.
In this document, you will find:
A summary of our population and the services we provide
What we want to achieve for our residents over the next five years
How we need to work differently as partners to help residents start well, live well and
age well
How we will change services to:
o Develop a wide range of out of hospital and community services to improve
health and wellbeing of residents and communities
o Ensure hospitals will work together more often to deliver excellent, efficient
services
We have also included further detailed sections outlining specific changes over the
next five years in detailed sections on:
o Integrated out of hospital and community care
o A simplified urgent and emergency care system
o Improved cancer services
o Coordinated Mental Health services and improved outcomes for our
population
o Transformed outpatient care with shorter waits
o Evidence based action to prevent ill health
o A more coordinated approach to children’s care
o Focused work on improvements to care for learning disabilities and autism
o Coordinated and proactive care for people with long term conditions
o Delivering better births through improved maternity services
o Managing medicines effectively and Pharmacy working in new ways
This is supported by information on how we will deliver these changes through work
to:
o Provide better support for our staff across health and care
o Take advantage of the opportunities of digital technology
o Manage our estates in a coordinated way
o Ensure finance supports the changes we need to make
This plan builds on work we have already started, (see our 2017 plan here) and sets out how
we will continue in our work to deliver the national priorities outlined in the NHS Long Term
Plan.
Across North Central London, there are lots of great examples of how we have already been
working closely together to improve the lives of residents:
We’ve already developed integrated networks based around GP practices: this will
make it easier to get appointments in primary care and the community and will help
to improve the quality of care, such as improving proactive community support for
residents of care homes to avoid hospital admissions.
We’ve worked to help make sure people are treated closer to home: for example, we
have invested in a unit to treat women who require intensive mental health care
closer to their family and communities, and residents are able to refer themselves to
a physiotherapist in their GP surgery.
We have worked with local authorities to support improved care in care homes by
supporting those working in care homes to access training that helps them support
residents.
We’ve worked in collaboration with partners to launch asthma friendly schools
training teachers to support children with asthma manage their health.
We’ve been working to simplify urgent and emergency care: ensuring more residents
and clinicians calling 111 speak to a clinician, as well as making discharge from
hospital quicker and safer.
We’ve been improving planned care and outpatient care: GPs can now access
specialist advice without referring a patient to hospital.
We’re using workforce and digital to drive and support change: we’re investing in
joining up health and care records to better organise care and launched a portal to
support recruitment of social care staff.
We want to keep what is working well, and make changes where we think we can do better
for residents by working differently and more collaboratively with partners.
We want to involve communities and staff in how we to continue to improve this plan. Please
see the section 1 for how to get involved.
The population in North Central London is diverse and vibrant…
North Central London is a great place to live and work and we want to ensure all local
people have an equal chance to live a healthy life here. It is a diverse area with vibrant
communities. North Central London is home to many of London’s historical and cultural
landmarks, and has excellent sporting facilities, green spaces and cuisine from around the
world.
The total estimated resident
population of NCL in 2019 is
approximately 1.5 million
people. Over 11% of our
population is aged over 65,
ranging from around 9% of
the population in Islington to
around 14% in Barnet. The
population is expected to
increase by 9% over the next
decade, with the fastest
growth expected amongst
those aged 65 and over, by
28%.
Poverty and deprivation are key
determinants of poor outcomes in health
and wellbeing, with higher levels of
deprivation linked to numerous health
and social vulnerability including chronic
illness and behaviours that pose a risk to
good health. 30% of NCL children are
growing up in poverty1. There continues
to be growing demand for housing and
increasing levels of homeless
households. Housing is often one of the
main causes of poor health and
wellbeing.
1 NCL Sustainability and Transformation Plan – Case for Change – September 2016
Levels of ethnic diversity vary across NCL,
ranging from 32% of people in Islington from
a Black and
Minority Ethnic (BME) group to 44% in
Enfield. The largest BME communities in
NCL are Turkish, Irish, Polish and Asian
(Indian and Bangladeshi) people. There are
also high numbers of people from Black
Caribbean and African communities,
particularly in Haringey and Enfield. The
number of people from BME communities is
much greater in younger age groups.
Health needs vary across BME communities. For example, there is a greater risk of
diabetes, stroke or renal disease for some BME people compared to White British people;
and people from some BME communities, including Black Caribbean, African and Irish
communities, use hospital services more frequently. The number of BME people across NCL
is expected to increase slightly from 37% in 2012 to 38% in 2020. The biggest increases in
BME communities are forecast in Barnet and Enfield.
Overall, around a quarter of people in NCL do not have English as their main language.
This diversity presents challenges, both in addressing potentially new and complex health
needs, and delivering accessible healthcare services.
All NCL residents have seen an increase in life expectancy over the past decade, with
current life expectancy for men and women higher than the England average, with the
exception of Haringey and Islington. There are stark differences in life expectancy between
those living in the most affluent areas compared to the most deprived. Across the NCL
boroughs, Camden has the highest life expectancy gap for men, with those living in the most
deprived areas living on average 10 years less than the least deprived.
Despite the higher life expectancy, overall, residents spend approximately 20 years of their
life living in poor health. Trends in healthy life expectancy show there has not been a
significant change in the number of years people are living healthy lives.
Significantly
better than
England
average
No significant
difference
compared to
England
average
National
Comparison:
It is estimated that there are 211,000 people living in NCL with a disability2. There is a total
of 17,550 people in receipt of carers allowance across NCL in 2018. This equates to 1.5% of
the total 18+ population. Of all the 5 NCL boroughs, Enfield has the highest percentage of
people receiving carer’s allowance (1.9%), and Barnet the lowest (1.1% of the total
population).
We recognise that to reduce health inequalities and improve the health and wellbeing
outcomes of our most vulnerable residents we need to work with communities themselves,
including through the voluntary and community sector. Engagement with local people and
understanding their needs is central to how we are developing our plan and services. Please
see section 1 on listening to our resident and communities for more detail.
There are many partners delivering our health and care services in
North Central London…
NCL is a diverse area covering five local authorities and Clinical Commissioning Groups, 12
NHS Trusts and 203 GP practices, as demonstrated by the diagram below.
In addition to this, we know there are 230 care homes, over 100 care home providers, and
countless voluntary sector organisations and community groups providing essential support
to communities and some of our frailest residents outside of hospital.
2 2017/18 Family Resource Survey (FRS) estimates that there are 14% of people aged 16-74, and over living with a disability in the inner London region. According to FRS, a person is considered to have a disability if they
have a long-standing illness, disability or impairment which causes substantial difficulty with day-to-day activities.
These partners work to meet the health and care needs of all local people, delivering a wide
range of services. Across NCL, each year there are:
523,000 GP appointments
22,600 babies born
1,454 A&E admissions due to childhood asthma
5,000 people in residential care or nursing care homes
16,000 people being supported with community care to stay in their own homes
122,410 people living with long-term conditions
12,000 orthopaedic operations
The health and care that we need to provide to local people is changing. People are living
longer, and many have long term conditions, such as diabetes, heart disease, dementia or
respiratory disease. We need to provide care that meets these changing needs and
understand what will help local people live healthier lives.
We recognise the important role that health and care services play within the local economy
as employers and part of local communities. Our staff are our greatest asset, and are as
diverse and varied as our communities, with a broad range of skills and experience. We
need to value and support them to work differently, for example in multi-disciplinary teams
where doctors, nurses, physiotherapists, health visitors and social care teams will work
closely together to support communities.
We want residents to start well, live well and age well…
Evidence shows that as little as 10% of a populations health and wellbeing is linked to
access to health care. We need to work with partners to look at the bigger picture, including:
fulfilling work
our surroundings
money and resources
housing
education and skills
the food we eat
transport
the support of family, friends and communities
As partners, there is a clear case for evolving the way we plan and provide health care and
other services to focus on the needs of populations, communities and individuals rather than
the institutions that deliver care.
To do this, we will need to work differently as partners to address the underlying challenges
we face in North Central London, and to make the best us of our people and other resources
to deliver the best possible outcomes for NCL residents.
We have been listening to what residents have told us is
important…
From a wide range of engagement with residents and communities across North Central
London we have heard what is important to local people.
We have listened to these priorities and concerns and thought about where these priorities
can be included in our plans to improve. Below are some examples of how we are taking
these forward:
Residents’ priorities Some examples of what we are doing…
Better access to services
Introducing care navigators to signpost
people to the right services
Embedding a ‘no wrong door’ approach to
mental health care and support
Patients involved in discussions and shared
decisions about their care
Children and young people with epilepsy
and their families being involved in the
development of local epilepsy services
Access to clear and accessible information,
including easy read versions and access to
interpreters
Healthy Futures providing clear, accessible
information for people with diabetes on how
to look after their condition
Empathy and understanding around cultural
or disability-related needs
Trialling a new pathway for women who do
not take up a smear test by offering them a
self-sampling kit
Patients given knowledge about how to
keep themselves well and support
wellbeing
Social prescribing in GP practices to
support people to stay active, eat well,
reduce isolation and contribute to their
communities
Patients given choice and care is planned
and delivered to meet each individual’s
needs
Residents supported to have personal
health budgets, including for mental health,
to best meet their individual needs for care
Use of technology both to increase access
to services and to health information
Residents to have access to online
consultations and video consultations
Better joint working between health and
social care
Working across NHS, public health and
social care to identify people at risk of
conditions, such as diabetes,
cardiovascular disease
A focus on prevention and proactive care
Increase community teams and ensure
physical health checks for adults with
serious mental illness and learning
disabilities are being carried out
Everyone gets the same care, regardless of
where they live
Whole system approach to tackle some
issues, such as childhood asthma, to
ensure everyone gets the same high-quality
care
You will find more detail on all of these in the each of the detailed sections on service
changes.
What will working in new ways mean for residents?
To bring these changes to life, we have worked with partners to develop a resident’s story
for each of the speech bubbles above. Below are Joan’s and Ali’s stories, for all the other
residents’ stories, please see our public facing leaflet here (link here).
We will work as partners to integrate care…
Where we can have a greater impact and there is a benefit for residents, we will work
together as partners rather than acting as individual organisations.
We have fantastic organisations with nationally recognised and world class services and we
need them to continue this amazing work and spread this best practice across North Central
London. For example, NCL has some of the most advanced radiotherapy services in the
country, with a number of large specialist centres, and one of only two proton beam units in
the country (at UCLH).
Our partnership will work to build on the strengths of organisations and their staff. We
recognise the important role that health and care services play within the local economy as
employers and part of local communities.
We will work together to simplify how the system works for residents and staff and plan and
deliver better services, that meet the needs of residents and their communities. Our
clinicians are part of wider networks across London, as well as within North Central London,
to share learning, spread best practice to improve the quality of services so that residents
will have access to the same care across the system.
Integrated care means teams and organisations that are responsible for health and care
working together, sharing resources and information to support the needs of individuals,
increasing our impact and reducing waste, and delivering our collective North Central
London vision locally. This integration of health and care services will happen in different
ways:
• Teams work together as partners at a neighbourhood level. This will mean
teams, with staff from across health and care, working to proactively support you and
your communities to stay well and live full lives. For example, GP practices will be
working with care workers and health visitors to make sure residents have access to
support around employment and community activities where this will support them to
live fuller lives, in addition to any clinical care they might need.
• Borough partnerships will work at a borough level to plan, coordinate and
develop services to best meet local community’s needs. For example, working
as partners to ensure that an area with a large proportion of older people has the
right level of health and care services and that these teams work closely together as
a single supportive service, rather than as separate organisations.
• There will be some pieces of work where partners work together across North
Central London – we are calling this ‘system working’. This will be where we
work together to tackle long term issues where no one organisation can solve it on
their own. For example, working together to tackle air pollution or reduce childhood
obesity. It will also mean working together to reduce unnecessary paperwork. For
example, having a single health and care record so residents don’t have multiple files
at different organisations.
This will require us to work with partners across health, the public sector and voluntary and
community groups, more information on how we are developing an integrated care system
can be found in the detailed section on this topic.
To deliver this, we need to spend public money in the best possible
way as well as fix the basics…
Across NCL we collectively spend over £4 billion per year on our health and care services.
We need to make sure we are making the best use of this money.
We also know that not everything in the health and care system is as well organised and
works as well as we would like.
We are committed to fixing the basics across the health and care system. We know that
these make a big difference to residents’ experience of care and tackling these will also
reduce the costs to the system. As part of our work on this plan, partners have agreed to
make sure they are working as efficiently and effectively as possible. We need to get the
basic things right first time to make our more ambitious plans successful. This includes
efficient administration and organisation, clear and accessible patient information, residents
able to access the services they need and health and care professionals having the right
equipment and information to do their jobs well.
To do this, we need to work together as partners to:
• Reduce waste in the system – for example, reducing the need for unnecessary
repeat tests by joining up information across the system, and reducing the number of
cancelled operations through better coordinated care across organisations.
• Support staff, our biggest asset, to work in new ways – for example sharing
nurses across organisations, placing pharmacists in GP surgeries, and developing
multi-disciplinary teams across health and social care.
• Invest in proactive care, support people to better look after their own health
and prevent ill health through closer working – for example, making sure people
with high blood pressure have the right medication early, and working across health
and social care to ensure older people can live in their community and stay active.
We need to shift our focus to prevent ill health the factors that
cause it…
This plan sets out both how we will treat people when they need it, and prevent them from
getting ill in the first place.
We want to support people to live longer, healthier lives by helping them to make healthier
lifestyle choices and treating avoidable illness proactively.
Much of the burden of ill health, poor quality of life, and health inequalities in North Central
London is preventable. Between 2012 and 2014, an estimated 20% (4,628) of deaths in our
community were from preventable causes.
By focusing on helping people to stay well, we will improve health and wellbeing outcomes
for our whole population, reduce health inequalities, and help manage demand for health
and care services in both the immediate and longer term. We know that better quality
housing and good quality employment helps improve the quality of life and our ambition is to
work with partners to improve these for communities in North Central London.
While an integrated service offer means patients can access help ranging from talking
therapies and medicines management, to assistance with day to day tasks and help with
social and housing needs and advice on benefits. For example, specialist mental health
support for older people provided by Camden and Islington brings together a team including
specialist inpatient and community health professionals and social workers to support
patients to manage their mental and physical health needs.
To tackle this we will…
Work as a system to tackle the wider determinants of health: Through partnership
working we can tackle issues that no one organisation can solve on their own, through
integrated planning such as air pollution and social isolation.
Embed evidence-based prevention and early interventions across the whole health
and care system to tackle risk factors such as smoking, alcohol and obesity. This will
include working with council services, social care and the voluntary and community sector to
maximise the impact we can have.
Work to become more proactive in the care we provide to residents. For example,
through earlier detection of disease and optimising treatment, such as atrial
fibrillation and hypertension, to prevent deterioration or episodes of ill-health, such
as heart attack or stroke. This proactive approach to prevention is embedded across our
service transformation programmes.
This includes maximising the opportunities that patient contact and hospital admissions bring
to help people to improve their health.
Below is a diagram showing our approach to prevention across the partnership. You can
read more about the specific interventions we will deliver in the detailed section on evidence
based action to prevent ill health.
Supporting individuals to have personalised care for their whole
needs…
Personalised care gives people the same choice and control over their mental and physical
health they have come to expect in every other aspect of their life.
Personalised care helps a range of people, from those with long term illness and complex
needs through to people managing mental health issues or struggling with social issues
which affect their health and wellbeing. It helps them make decisions about managing their
health so they can live the life they want to live based on what matters to them, working
alongside clinical information from the professionals who support them.
This is in response to a health and care system that in some circumstances simply cannot
meet the increasing complexity of people’s needs and expectations. Evidence shows that
people will have better experiences and improved health and wellbeing if they can actively
shape their care and support. For example, a specialist hospital admission was successfully
avoided through the deployment of intensive community support and creative use of a
personal budget to help a 13 year old patient with autism and an eating disorder.
To do this we will be embedding new ways of working such as shared decision making and
personal health budgets so they can control their own care, improve their life experiences
and achieve better value for money. By 2020/21 we will have recruited 30 social prescribing
link workers in Primary Care Networks to support patients across NCL, including to access
non-medical support and this is planned to grow to 148 in 2023/24.
We need to plan services on a population basis…
There is huge potential to use data, insight, and evidence more systematically and effectively
across our local public services in North Central London. This will help to improve the health
and wellbeing of our patients, residents, and communities, reduce health inequalities, and to
make more efficient use of our resources.
While there are some pockets of good work, our approach to using data and analytics has
historically been fragmented. This means that we are not routinely using data and analytics to
drive change in population health outcomes at scale, or to identify ‘gaps in care’ and
opportunities for quality improvement. There is great opportunity to use data to proactively
enable improvements in place-based systems, such as boroughs and neighbourhoods,
including on the wider determinants of health. .
We have already made some progress and we have big aspirations to change the way we
collaboratively work together, including with communities, patients and residents, to make
improvements. While appreciating the need to understand ethical risks and acceptability, we
also want to capitalise on the emergence of newer digital and analytical technologies, such as
machine learning. We also want to make best use of the capabilities of our partners outside
of North London Partners, including those at regional and national levels, and within local
academia and other organisations to make this a success.
We consider this a key and cross-cutting enabler to achieve our ambitions for better health
and wellbeing within our long term plan — that will also allow us to measure and evaluate
impact — which is why we are prioritising it. You can read more of the detail in the section on
population heath here xxx.
We need to support the development of out of hospital care and
have our hospitals work together more often…
We want to invest in and boost out of hospital care, centred on the needs of communities. We
now have integrated networks of care for the whole population in North Central London, based
around GP practices and these are the focus for bringing health and care professionals
together to provide proactive, well organised care close to home.
We are investing in those networks to develop capacity to treat people for their non-clinical
needs, for example, through the creation of new roles such as social prescribing link workers
and clinical pharmacists. This will support closer collaboration with community services,
enabling more proactive care as well as a more rapid response in a crisis.
We also want to support hospitals working together more often to deliver improvements to
care. In North Central London we have some world class hospitals and we know that through
sharing valuable staff and working in a more coordinated way, we could cancel fewer
operations and provide better quality care to more people.
Working as a partnership allows us to understand where we can change services to improve
care, involving residents in how we make these changes to the benefit of local communities.
An example of this is the work we have been doing to review orthopaedic services, where a
proposal for new ways of working would reduce the number of cancelled hip and knee
operations and provide higher quality care for patients.
What happens next?
Some of the changes outlined in the previous pages will take some time to deliver. Below are
a few examples of when you might expect to see improvements in your care.
As partners, we are going to be working to deliver the detailed plans set out in the appendices
of this document. As part of this, each year, we will share our plans for the year through
organisational boards and meetings. This will help us to know if we are on track to deliver what
we have set out in our plan.
We will also share progress, good news and stories on our public website.
How can I share my views and help shape the plan?
The plan will only be successful if it is based on the lived experience of residents and
communities and designed and supported by those who work in the health, care and
voluntary services in North Central London.
We want partners, staff and residents to review and help us develop our plan. We will also
be developing measures based on what residents tell us is important – this will make sure
we can monitor our success and determine if we are achieving our aims. We want your help
with this.
You can get involved:
• By joining our Residents’ Health Panel:
https://conversation.northlondonpartners.org.uk/
• In developing your local borough Integrated Care Partnership:
www.northlondonpartners.org.uk
• Review our more detailed plans: www.northlondonpartners.org.uk/draftresponseLTP
• Get updates on progress by signing up for our newsletter:
https://mailchi.mp/d5a0aa77bde9/signupnewsletter
Our detailed plans for services:
Please find our detailed plans below. These have been developed through working with
clinicians and staff across the partnership and represent our current plans. They will
continue to develop and improve as we engage with residents, partners and staff.
Working more effectively as a system: Section 1. Listening to residents and communities
Section 2. Through working as partners to integrate care
Section 3. Moving to population health planning
Section 4. Embedding personalisation
Detailed service transformation plans:
Section 5. Integrated out of hospital and community care
Section 6. A simplified urgent and emergency care system
Section 7. Improved cancer services
Section 8. Coordinated Mental Health services and improved outcomes for our population
Section 9. Transformed outpatient care with shorter waits
Section 10. Evidence based action to prevent ill health
Section 11. A more coordinated approach to children’s care
Section 12. Focused work on improvements to care for learning disabilities and autism
Section 13. Coordinated and proactive care for people with long term conditions
Section 14. Delivering better births through improved maternity services
Section 15. Managing medicines effectively and Pharmacy working in new ways
Supporting the delivery of these changes:
Section 16. Tackling the workforce challenges across health and care
Section 17. Taking advantage of the opportunities of digital technology
Section 18. Managing our estates in a coordinated way