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‘The biggest challenge we’ve got is how to get the resources’

Jane Milligan 2016_cmyk.jpg

By aharrold
27 April 2017

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We see the STP as an opportunity to develop a strategic partnership approach to address health inequalities and the challenges of performance and quality. We have three sub-systems to do that and we loosely talk about them as accountable care partnerships or accountable care systems. They are the Barking, Havering and Redbridge sub-system, near the Barking, Havering and Redbridge Hospitals University Trust (BHRUT) and North East London Foundation Trust (NELFT), which is the mental health provider. Then there’s Waltham Forest, East London and the City Care Collaborative (WELC), which is Waltham Forest, Newham and Tower Hamlets working across the Barts Health footprint, and with East London Foundation Trust as a main mental health provider. 

And the third sub-system is City and Hackney, working with Homerton University Hospital. We also have flows of patients coming in from Essex and going out into University College Hospital (UCLH) and Guy’s & St Thomas’. 

We are developing a provider alliance for demand and capacity issues. For example, we concentrated elective orthopaedics in one or two hospitals as part of the Barts Health merger, so Newham is an elective trauma and orthopaedics centre. We want to enable the Royal London Hospital, which is our trauma centre and hyper-acute stroke unit, to take more specialised work. We need to look at how commissioners work together and make sure we are focusing as an STP on the things we can do once, then drive the change to happen at a local level – the three local sub-systems. 

Around 90% of care takes place in general practice and community care, but we recognise that getting an appointment with a GP is a real challenge for a lot of people.  

The first piece of work we did was a comprehensive joint strategic needs assessment across all of the seven boroughs plus the City of London. We’ve got three key areas to focus on, and the killers relate to that. They are cancer, cardiovascular disease and health problems caused by workplaces.

The question is whether they need to see a GP or they would be better with an app or community pharmacy. We want to ensure consistent standards on access. 

We want to get communities and practices to work together to ensure a more holistic approach. 

Social prescribing is an example. People are not necessarily accessing the right part of the system. We need routes in, whether that’s the GP or community pharmacist or a community group, which then might signpost patients in the right direction.

If I had to pick one thing we need to focus on, it would be workforce

We need to figure out how to incentivise health workers, how to develop career pathways and how to commission working with Health Education England (HEE). So far, one borough pays a certain rate and another borough pays a different rate. So we’ve all been fishing in the same pond but not doing it in a joined-up approach.

Of course, not everybody will necessarily want to use the digital aspects and we still need to find a way for face-to-face contacts.

Nothing ever stands still in health and social care. I’m sure we’ll make mistakes along the way. To an extent we depend on the digital infrastructure that supports that to join up electronic patient records across doctors, nurses and other health professionals, London ambulance services and social care. We also have to ensure we’ve got practice-based systems as well.

The feedback from our integrated care programmes is that most people don’t want to be in hospital. It’s the last resort, and we often don’t offer the tools to be able to support people or they are not available 24-7. That’s often where we get the breakdown between services, so we must look at the system as opposed to individual organisations, and how they work. We must incentivise them to work together in a different way. But patients are a key part of that.

Tower Hamlets and Newham have had quite a lot of growth because of new developments, particularly on the Olympics site

That area has a population of 1.95 million, and population growth in the next 15 years is forecast to be 18%, or almost 400,000 people. We’ve now got Barking coming along as a big development and developments around Spitalfields. 

Also, that movement creates a lot of GP list churns, so for some practices we’ve got 40-50% turnover each year, which is a significant issue. And people are coming into the patch who are not used to our health system. So GP registration is a big issue.

We want a real focus on smoking cessation

Another challenge we had in PCTs is trying to implement the same methodologies in different working cultures and working relationships. So we won’t necessarily dictate what needs to happen; we’ll have frameworks and models of care that people can take, and we’ll use our clinical leads to support those discussions.

I think the biggest challenge we’ve got is how to get the resources. A lot of our commissioning budget goes to acute hospitals, and we need to shift some of that into supporting community and primary care. One solution might be to use different commissioning models for community health services, but there’s more to do on that.

And our local populations are pretty diverse across the patch – Tower Hamlets is very different from Newham and very different from City and Hackney.

We want a real focus on smoking cessation. We also want to concentrate on health in the workplace, across all of our big workforce providers. We’ve got Canary Wharf where half a million people come in every day, and the City of London, which has another half a million. 

With cancer, significant numbers of people present at A&E with a first diagnosis, which we have to tackle.

Our cancer survival rate at one year is around 69%. We want to reach 75%. I think that comes down to how we commission and how we get our community and general practice providers to deliver in terms of very early diagnosis or access to care. 

We need to support care at an earlier stage

We want to put more resources into supporting care at an earlier stage – whether that’s prevention, working with the local authority, or at a community and primary care level. 

Sometimes it might not be about cash, but how we commission acute hospital consultants, whether in mental health or physical health, to provide consulting advice to support decision-making. So it’s not all about point of contact, it’s about how we best use the skills and resources.

We’ve got some old estates, such as Whipps Cross, where we’re trying to make sure we’ve got the right model of care

We’ve got acute hospital land and opportunities, and a mix of foundation trusts and normal trusts. So what we’re waiting for is the London devolution agreement, to enable a London-wide approach to the management of capital receipts, which we would be part of. 

At the moment, that’s not uniform so some of the opportunities might not necessarily manifest themselves as much as we want. 

But we don’t want to have any hospital trust land sold if we might use some of it to develop primary integrated health and social care or primary care units. Or we might work with housing associations or local authorities to develop land for key working. That’s being worked through at the moment. 

This might not necessarily mean an all-singing, all-dancing hospital is needed. Acute beds will be required but as the population is quite elderly it might be a different mix and we’ll work with other agencies to arrive at the whole package. 

In terms of primary care, we’ve got quite a mix of facilities, and we’re going to work with local authorities about how we generate capital across the patch to support some of those developments through the community infrastructure levy (CIL). Last week, we opened a new practice in Tower Hamlets on that basis. We need to do more of that. 

We need to integrate all our initiatives 

We’ve got business-as-usual savings. When you add it up, it looks like big numbers, but there are efficiency targets for CCGs and providers every year, so it’s about looking at that in the round. In the past, we’ve had silo organisations with quality improvement plans (QIPs) and cost improvement plans (CIP). We’re now looking at those together so we don’t double-count it. 

Of course, some savings will be through productivity efficiencies, making sure we get the best out of the resources we’ve got. In some cases, we haven’t got the right workforce, so we’re wasting money on agencies and external contractors because we can’t get the right flow. 

In other areas we should look at preventive measures, early diagnosis and early support to stop people ending up in hospital, and then becoming even more ill. 

The timescale for the STPs or the Five-Year Forward View is quite short so we need to be realistic. Some of it will take a consistent approach over a number of years to get traction. 

But it can be done. We can demonstrate that in areas where we’ve managed to get good results (blood pressure management, plasma glucose monitoring) the impact shows in reduced strokes, heart attacks and amputations. 

So we essentially try to address that, and then be honest about the gaps. Frankly, that will still be a challenge – working with our populations and looking at things that might need to be done differently or using other services like community pharmacy.

Frankly we don’t have the right workforce coming through

We need to think how best to use the skills and workforce we have in the best way. Part of that is having an opportunity to transform how we use services.

This should extend to how we see patients – instead of everybody having to visit patients face to face, with the high travel times, we should use Skype or other options – telephone even. That’s a national challenge.

Also we should look at how we support staff who are working in acute hospital settings to go into those community-based services. 

There’s a real chasm between the two, and there’s sometimes a misunderstanding between what happens in the community and what happens in hospital. But we’ve got fantastic models of care where we’ve got self-directed teams working on tissue viability and wound care, for example. And we’re rolling out something we did years ago in Tower Hamlets called open doors, where we support acute hospital staff – nurses particularly – to move into primary care roles.

In the past we have sponsored hospital nurses to go into training programmes and then mentored and placed them in practices to become practice nurses or nurse practitioners. That’s been quite successful.

Barts Health has a good mentoring scheme. There’s also a university technical college in Newham that’s just started in Tower Hamlets that has an IT, health and social care focus, and that’s about attracting local people from the community into those roles. We’re building on that. 

There is a challenge in terms of making health and social care roles attractive. In many respects, social care is where the biggest workforce crisis is. And the impact of Brexit is yet to be seen. 

But we need to work with HEE, hospitals, primary care and community organisations to find ways of growing our own. That might be through mentoring, apprenticeships or healthcare assistant schemes. 

But one of our real priorities is to make north-east London a place for people to work and live, because the key thing for us is the cost of housing. We’re trying to kick off with a health and housing forum, which would not just look at the care, because a lot of housing associations provide care and support, but also how we develop affordable housing schemes on the patch. These could be particularly targeted for staff in this area. So we need to be on the front foot and again, to work with our local authority colleagues.

We need more capacity for maternity 

We’re still interpreting the numbers, but we know there are going to be more births. So part of the maternity piece is looking at what capacity we’ve got across the whole patch. We’ve got two birthing centres, and I think we’re unique in that. Now we’re looking at how we use the capacity in total – whether it’s hospital based, community based, or helping people have children at home. There might be midwife-led units or birthing centres. Then we need a central approach to booking people into the system and developing focused birth plans for them. 

This goes back to how we share resources across the patch. Again we’ve  got a vanguard pilot for some of that to support more births at home. Part of that is ensuring that when a woman has
a positive pregnancy test there’s one route in. We might use digital apps to help with that as well. 

We have a lot more work to do with mental health

We’re trying to develop a comprehensive mental health strategy across the whole patch. And we work closely with London on that as well as nationally. So we’re looking at how we deliver the early intervention psychosis standards and the improving access to psychological therapies (IAPT) scheme as well. The digital part will be about supporting people to access mental health services or support from a digital platform. 

We’re thinking about what’s realistic in terms of the suicide rate reduction, and also how we link mental health liaison services with urgent care. We’ve got that in some parts but not necessarily universally. 

Resources are the hundred-million-dollar question for all of this. We do have resources coming into the system, but whether that matches the population growth and changes is obviously
a challenge. 

We are committed to ensuring that the mental health targets or services are commissioned to the level we need, and in terms of our demographics, we’ve got significant issues in north east London. But we want to make sure we don’t have mental health being managed in a separate room, that it’s much more integrated as part of the whole.

Additional reporting by Alice Harrold

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