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Strategy & Transformation TeamProgress update May 2013
On Tuesday 19 February the Joint Committee of Primary Care Trusts (JCPCT) made the decision
to change significantly the way care is delivered across North West London.
Leading up to this decision, there has been extensive work with all eight Clinical Commissioning
Groups (CCGs) and provider organisations across North West London to deliver the best model of
care, both in and out of hospital.
The implementation arrangements for Shaping a Healthier Future are now being confirmed, with
highlights including:
• Implementation Programme Board being held on 25 April
• Development of a Project Initiation Document, setting out the scope,
principles and approach to the delivery of the different elements of the
programme
• Holding meetings with CCG Chairs and provider implementation leads to
discuss the implementation arrangements
• Receiving nominations from the CCGs and providers for their implementation
SROs and implementation leads
• A clinical risk workshop with leading clinicians from the CCGs and
providers on 18 April
Shaping a Healthier Future
Lead : Kevin Atkin [email protected]
Mount Vernon
Harefield
RNOH
Hillingdon
Northwick Park
Ealing
West Middlesex
Central Middlesex
Hammersmith
Charing Cross
St Mary’s
Chelsea and Westminster
Royal Brompton
Royal Marsden
Specialist hospital
Local and Specialist hospital with obstetric-led maternity unit
Local and Elective hospital
Local and Major hospital
Local hospital
Local and Major hospital and specialist eye hospital and
Hyper Acute Stroke Unit
M
M
The Strategy and Transformation Team works in collaboration with all eight CCGs - supporting them to undertake major strategic change… 1
During 2012/13 the Strategy and Transformation Team worked on a wide range of projects within major programmes,
many of which contributed to the development of Shaping a Healthier Future.
As Shaping a Healthier Future moves into the next phase the team is working with CCGs across North West London to
support programmes that underpin delivery of the strategy; out of hospital transformation, provider transformation and a
number of cross cutting workstreams. This newsletter brings you updates and highlights as the work progresses as
well as information on how you can get involved.
The major and local hospital sites
A col laboration of e ight CCGs
across North West London
Strategy and Transformation programme 13/14
Equalities, travel and access, information management
Finance and modelling
Workforce: OOH and transitionComms and engagement
Shaping a Healthier Future
Strategy & TransformationCCGs Acute
OOH transformation Provider transformation
Business casesLocal hospitals
Primary care estates
Primary care transformation
Whole systems/ integrated care
Mental health transformation
Networks of care
Clinical pathways and qualityCro
ss
cutt
ing
QIPP (CCGs)
CIP (acute)
Whole system
Monitoring delivery
Major hospitals
The Whole Systems Integrated Care (WSIC) project is addressing the systemic barriers that
commissioners across health and social care face in delivering their local integration initiatives
and integrated care elements of their Out of Hospital strategies. After discussions with
commissioners and providers from health and social care we have planned a dual-phase
programme:
• an initial co-design phase to create solutions, tools and products
for boroughs to implement locally
• an implementation phase with flexible timescales for each locality.
We will be engaging with CCGs/Boroughs individually to understand
how their local programmes and delivery can link with the WSIC programme, and are
preparing to launch the co-design phase.
Norman Lamb, Minister for Care and Support, has announced his intention to
launch a new wave of large-scale, locally led ‘pioneer sites’ in integrated
care across the country. We believe that NWL as a collaboration of
health and social care organisations is well positioned to be a pioneer
site and that the WSIC programme could develop a strong application.
The patient voice will sit at the heart of the programme’s progression,
and we will work to align all programme stakeholders around
a common set of patient-centric values or principles which are core to
delivering integrated care at scale and pace across NWL.
Whole Systems Integrated Care
Lead : Hina Zaman [email protected]
2The Strategy and Transformation Team works in collaboration with all eight CCGs - supporting them to undertake major strategic change…
Initial workshop underway
2
Whole systems/
integrated care
Across North West London, CCGs have three asks of their community providers; deliver more care closer to home
(to support the realisation of out of hospital strategies), increase productivity and efficiency, and deliver more
consistent higher quality care.
Over the past eight weeks we have worked with Central London, West London, Hammersmith & Fulham, Hounslow
and Ealing CCGs and their community providers to develop new operating models for community nursing services.
These models align community nursing teams to patient populations across defined groups of practices. In future
this could support a more integrated model of care where a wider range of services are brought together around
agreed patient populations.
The next phase of work in Central London, West London and Hammersmith and Fulham CCGs is the
implementation of a programme plan, agreed with CLCH, that includes:
• Implementation of the new operating model
• The development of network/locality level community nursing dashboards
• The phased roll out of single IT/joint patient record systems
• Mapping allocation of resource to the needs of the population
Engagement with community providers is underway in Ealing and Hounslow and we will similarly
support implementation of the plans in those CCGs.
Managing services in the community - Community Nursing
Lead : Gabrielle Darby [email protected]
Networks of care
The Strategy and Transformation Team works in collaboration with all eight CCGs - supporting them to undertake major strategic change…3
Through an intensive process of stakeholder engagement, economic modelling and consultation, we have
collaboratively developed a ‘Child Health GP Hub Model’. This model builds on successes from existing
integrated paediatric pilots in NWL (including paediatric outreach, sickle cell, and diabetes) and is designed
to improve outcomes for children and their families by improving access to services and drawing paediatric
expertise and community support into primary care, where the needs of the child and family are known and
can be managed effectively.
The hub model is designed to connect professionals from primary, secondary and tertiary care, to
encourage: shared learning and development; a whole person approach to caring for families; patient,
parent and professional confidence in the provision of child health services in primary care settings.
The proposed hub model positions the GP Surgery as the central point for child health, and comprises three
components, which General Practices could adopt discretely or in combination:
• Co-production (practice champions, peer support, self management).
• Paediatric Outreach (GP-based child health outreach clinics; joint case
discussion; email/ phone support).
• GP Open Access (same-day telephone access to paediatric advice from a GP
or Senior Nurse, or, where needed a same day appointment for those under 16).
We are undertaking further consultation to develop the model in detail and agree
a phased approach to implementation and commissioning that aligns with GP
network developments.
Connected Care for Children – Integrated Paediatric Care
Lead: Lucy Reynolds [email protected]
Whole systems/ integrated care
Children
Young People
& their Families
GPs
Practice Nurses
Health Visitors
Schools & Children’s Centres
Paediatricians
Specialist Nurses
Other Specialists
Co-production &
Community Champions
Specialist Advice
A col laboration of e ight CCGs
across North West London
The North West London mental health strategy will improve clinical outcomes and quality of
care by integrating services and increasing the proportion of care delivered out of hospital. We
are bringing together service users, carers, clinicians, commissioners and local authorities to re-
design mental health services.
We have already initiated a pan-North West London project, reviewing urgent mental health
assessment, and held a successful co-design workshop on 12th April that brought together
senior stakeholders from across NW London. Outputs from this session are being used by
CCG Mental Health leads to complete their Primary Care Mental Health
Learning and Development Programme training, sponsored by Norman
Lamb.
Over the next three months we will be establishing further multi-
organisation co-design projects (e.g. rehabilitation services; Psychiatric
Liaison), and will continue to provide support for local and North West
London-wide Mental Health programme boards.
Transforming Mental Health Services
Lead : Sam Benghiat [email protected]
Mental health transformation
Mobilisation workshop
Get in touch…For more information on any of our programmes, get in touch with the
lead – or contact Salman Ugradar on 0203 350 7725
who will be pleased to direct your enquiry.
Thirza Sawtell
Director of Strategy & Transformation
NHS North West London
Collaboration of 8 CCGs
The Outer North West London Integrated Care Programme (ONWL ICP) is a vertically integrated
model of care for patients with long-term conditions. The model uses multidisciplinary case
conferences and care planning for high risk patients to:
• reduce non-elective admissions and A&E attendances across Brent, Ealing, Harrow and
Hillingdon; and
• improve clinical care outcomes and quality of life for patients.
The programme now covers a GP practice population of 1.2 million patients, and has catalysed
the development of approximately 8,000 care plans for patients to date. Launches are currently
taking place for the new COPD and Cardiac care pathways across BEHH.
During 2013/14 the ONWL ICP will build on these achievements:
• expanding the programme from specific pathways to all patients at high
risk of admission
• Improving processes to track and monitor the quality of care planning;
• improving our risk-stratification and benefits tracking tools; and
• developing a more proactive approach to care planning.
Outer North West London Integrated Care Programme
Lead: Sheik Auladin [email protected]
Care plan in creation
Whole systems/
integrated care
The Inner North West London Integrated Care Pilot (INWL ICP) is an ambitious project, set up
to engage a range of health and social care providers across Inner North West London in
proactive working for a targeted group of high risk patients.
To date :
• the INWL ICP is working with over 100 GP practices and 14 provider organisations across four
CCGs – Central London, West London, Hammersmith & Fulham, Hounslow
• some 25,000 people have had proactive care plans; and
• 220 multi-disciplinary case conferences have been held, discussing over
1600 people and the care they need.
The ICP initially focussed on two specific groups of patients and care pathways, namely those
people that are over 75 years of age and those with diabetes,
however it will soon be moving to an approach based more on
at-risk population.
At present the ICP is working with CWHH CCGs to decentralise the
current model and embed it into local out of hospital working.
Inner North West London Integrated Care Pilot
Lead: Susan Sinclair [email protected]
Emergency activity/1000 diabetic and elderly patients in ICP practices
15.00
16.00
17.00
18.00
19.00
20.00
21.00
22.00
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12R
ate
of
em
erg
en
cy a
dm
issi
on
s p
er
1,0
00
pat
ien
ts
Date
Rate of NELRate of emergency admissions for elderly and diabetic patients at Imperial and C&W Hospitals per 1,000 ICP patients2012 (exc. ZLOS)
Whole systems/
integrated care
Evidence of programme working
