The move towards integrated care systems is acknowledged and understood by most senior leaders in our trusts, clinical commissioning groups and local authorities but is often less well understood by staff working directly with patients, carers and citizens.
This meeting of the London Clinical Senate Forum focussed on exploring what this new landscape, including shared responsibilities for population health, means in practice and the implications this has for leadership skills and behaviours at all levels of the system, but especially for staff below board or governing body level and those working at the front line.
This event was held on Thursday 17 May 2018 09:00-13:00 at the King’s Fund and the programme is available here.
The Forum aimed to identify and develop the opportunities and benefits for staff, carers and patients of working in an integrated way. Getting the most from such opportunities will require effective leadership at all levels in the system as we recognised there are barriers to overcome; for example, organisational barriers, budgets, relationships, culture, behaviours, attitudes or simply a lack of experience, knowledge or understanding about how to make these changes work. We identified the obstacles likely to impede change most and ways in which we can address them. We drew on learning from changes that have been introduced at different levels of the system to inform this.
The aims of the event were to:
- Create a shared understanding of what the change from organisational leadership to integrated system leadership, including the responsibility for population health, will mean in practice and the competencies it requires.
- Identify the both the enablers and barriers to developing system leadership skills at different levels and across teams.
- Agree the steps required to support leadership development and facilitate the delivery of integrated care systems that will benefits patients, carers and our fellow Londoners
The presentations delivered at the event were as follows:
- How is system leadership developing in Integrated Care Systems? – Chris Ham, Chief Executive, The King’s Fund
- The South East London Integrated Care Systems – Julie Lowe, Programme Director, South East London STP
- A system-wide perspective for cancer – Professor Geoff Bellingan, Medical Director, Surgery and Cancer Clinical Board, University College London Hospitals NHS Foundation Trust
- HIV services in London and Integrated Care Systems – Professor Jane Anderson, Homerton University Hospital NHS Foundation Trust and Dr David Asboe, Clinical Director for HIV Medicine and Sexual Health, Chelsea and Westminster Hospital NHS Foundation Trust
- Integrated Care in Barking and Dagenham, Havering and Redbridge – Dr Jagan John, Chair, Barking and Dagenham Clinical Commissioning Group
- Epsom and St Helier – Integrated Care – Dr Ruth Charlton and Dr James Marsh, Joint Medical Directors, Epsom and St Helier Hospitals NHS Foundation Trust
- Working towards system leadership – Haringey and Islington Wellbeing Partnership – Rachel Lissauer, Director, Islington and Haringey Well Being Partnership, Dr Josephine Sauvage, Chair, Islington Clinical Commissioning Group, and Beverley Tarka, Head of Adults and Health, London Borough of Haringey
- Patient-clinician collaborative pairs: finding ways to integrate as equals – Oonagh Heron and Ellen Sykes
The Forum concluded with a panel discussion where the panellist provided their key reflections and thoughts from what they had heard during the morning. The panellists were:
- Samira Ben Omar, Head of Systems Change, Integrated Care System, North West London Collaboration of Clinical Commissioning Groups
- Nicola Kingston, London Clinical Senate Patient and Public Voice Group Member
- Julie Lowe, Programme Director, South East London STP
- Dr Anatole Menon-Johansson, Clinical Lead for Sexual Health, Guy’s and St Thomas’ NHS Foundation Trust
- Beverley Tarka, Head of Adults and Health, London Borough of Haringey
- Dr Jane Wilson, Medical Director & Consultant Obstetrician and Gynaecologist, Kingston Hospital, NHS Foundation Trust
A summary report with key messages from this Forum will be available shortly.
Transforming general practice is critical to transforming the wider health and care system. It is relevant to everyone. “Transforming Primary Care in London: A Strategic Commissioning Framework”, published in November 2014, set out an ambition to deliver more accessible, coordinated and proactive primary care for all patients. Since then, we have seen significant changes both in the way that primary care is delivered across London, and health and social care’s political and regulatory landscape.
It is widely recognised that collaborating at scale is a vital enabler for general practice to deliver the ambitions it outlined. Collaborating at scale supports greater resilience and sustainability of the general practice workforce, as well as investment in development and innovation in areas such as estates and digital technology.
Integration and collaboration across general practices and primary care is already taking place in London. The majority of general practices belong to an at scale organisation, such as a federation or a super-practice. However the nature and extent of collaboration beyond provision of extended access varies considerably. Developing a more explicit commitment to general practice at scale is an essential driver to transforming care in London, ensuring a consistent vision and pace of change to support new models of integrated care. Work is currently taking place across London to set out what “good” general practice at scale looks like i.e. how care is delivered, how it functions and how it participates in the wider system. This will help determine what is needed to achieve it.
This meeting of the Clinical Senate Forum supported this work. Chaired by Dr Vin Diwakar, Medical Director, NHS England London Region and Clinical Senate Forum co-Chair, it enabled participants to contribute to co-creating a vision for general practice in London and determining the next steps we need to take, in particular, how we can use, align and develop our people, processes, systems and resources to deliver. The programme is available here and aimed to:
- Develop a shared view about how general practice needs to transform to create a sustainable, integrated health and care system and effectively participate in new models of care across London;
- Agree what needs to happen to achieve this vision and the early priorities.
In the opening session, several speakers discussed developing general practice at scale, from different perspectives, sharing views and learning about why change is important, examples of how this could be achieved and critical factors and considerations in doing so.
What is important about General Practice? Patients’ views
Trevor Begg, Patient Representative
Why we need to change? A regional perspective (click here)
Dr Jonty Heaversedge, Medical Director for Primary Care and Digital Transformation, NHS England (London Region) and Dr Michelle Drage, Chief Executive, Londonwide LMCs
An introduction to Primary Care Home – an integrated, multi-professional approach (click here)
Dr Nav Chana, Chair of the National Association of Primary Care
Next steps for general practice in London: learning from international organisations (click here)
Dr Rebecca Rosen, GP and Senior Fellow, The Nuffield Trust
Organisational development is essential to support system change – lessons from London’s Primary Care Quality Academies (click here)
Professor Rebecca Malby, School of Health and Social Care, London South Bank University and Nick Downham, Independent Improvement Expert, Primary Care Quality Academy, London South Bank University
New models of care: Insights from the national vanguards
The second part of the meeting provided space for participants to consider the vision and journey so far for general practice at scale within London’s five Sustainability and Transformation Partnerships and to consider the next steps and what would assist this. In a final session, key themes from discussions were shared.
A summary report with key messages from this Forum is available here.
Outpatients have probably been a feature of hospitals for as long as they have existed, but the current structures seem to have started in the seventeenth century, with the Royal College of Physicians starting their clinic in 1696 (BMJ 1:6118;974-977). Little has changed since! Transforming outpatient access and care is a key area for London’s Sustainability and Transformation Partnerships (STPs). All have identified the need for alternative and innovative ways of responding to these issues: How do we build Patients and GP access to specialist advice when they need it? How do we empower patients with shared decision-making and support self-care with access to information and advice when they need it? How do we develop patient centred pathways that seamlessly span primary and secondary care? For many, patients and professionals alike, the traditional outpatient clinic and pathway is an outdated approach. Reasons are varied and multiple:
- we need to improve patient experience;
- we must strive to improve efficiency and value – for GP, patient and hospital;
- patients’ needs are changing with more people are living with long-term conditions increasingly managed through self-care and by a wider team in primary care;
- there are issues of workforce capacity, availability of staff and skills, and different types of “specialist” not always recognised;
- referrals and waiting times are rising and DNA rates are high, but the variation between and within practices, hospitals, and populations suggests improvement is possible.
Developments in out of hospital care, particularly primary care transformation, use of technology and digitally enabled solutions, empowering people, and optimising skills and experience of different workforce groups all present significant opportunities to improve. However, one size will not fit all. This meeting of the Clinical Senate Forum explored these issues and: 1. Considered what is important to patients and clinicians in accessing specialist advice 2. Shared and learned from different models designed to improve access to timely advice within the context of an effective, person centred pathway, building consensus on what good looks like 3. Identified the most critical factors that need to be addressed to enable implementation of proven models at greater scale across London and considered how this could be achieved The programme for the meeting is available here. Dr Vin Diwakar, Medical Director, NHS England (London Region) and Clinical Senate Forum Co-Chair set the scene for the Forum’s discussions with a presentation reflecting on the history of outpatient care, the current context for the NHS and opportunities to improve people’s experience and outcomes by transforming the way care is delivered. We then heard different perspectives on what is important in accessing specialist advice and how pathways could be improved, including traditional approaches to outpatient care. Howard Bluston shared a patient’s perspective; Dr Mark Spencer provided a GP’s perspective and shared experience as a carer; Dr Mike Gill gave his views as a secondary care doctor now working in a “one stop practice” for people with complex needs); Dr Elizabeth Mumford shared experience of caring for people in outpatient services as a junior doctor and Rosalie Barratt, an Advanced Practitioner Physiotherapist, shared an allied health professional’s perspective, highlighting that several clinical groups provide specialist advice and care. A key aim of this Forum was to stimulate discussion and learning about what works, key factors for success, challenges and barriers and the conditions that need to be in place to overcome them. The majority of the meeting involved participants exploring different approaches, learning and impact with colleagues involved in developing and delivering them. Examples of shared from London and elsewhere, including companies involved in the DigitalHealth.London Accelerator (see information below): The East London Community Kidney Service [click here] Flare to Care (pathway for inflammatory bowel disease) [click here] City & Hackney Referrals Management [click here] OurPath – a digital behavioural change programme [click here] City and Hackney primary care mental health service [click here] DrDoctor – using technology to improve outpatient pathways Ealing Community Musculoskeletal Service [click here] Diabetes Appointments Online: the Newham Experience [click here] Moving towards sustainable eye care services Eye Health Network for London: Achieving Better Outcomes Evaluation of a minor eye conditions scheme delivered by community optometrists Improving Cancer Pathways: implementation of the Recovery Package and Stratified Follow-up [click here] Recovery Package & Stratified Follow-up Precis Following these discussions, Dr Nicola Burbidge, Chair of Hounslow CCG, gave an overview of the approach and underpinning principles for outpatient pathway transformation in North West London [click here], illustrating one STP’s approach. In the final session, participants came together in London’s five STP geographies: to share and discuss what they had learnt; to consider what changes and innovations could have greatest impact in ensuring improved, patient centred pathways; and to give advice about the pan-London enablers and support that would assist most in achieving change.
A SUMMARY REPORT with views and recommendations from this Forum is available here. This includes key messages from the meeting plus information on all of the examples of change and innovation shared with contact details of people involved to help with follow-up conversations. It also provides links to some further information and resources. Please also the read this blog written by two of the Clinical Senate’s junior doctor fellows to share their reflections on the Forum and the issues discussed.
The Patient and Public Voice Group met on 13 June 2017.
The notes of the meeting on 13 June were signed off at the July meeting:
The Clinical Senate Forum in January 2017 focused on out of hospital care and shared experiences and learning from a range of different initiatives being implemented across London, exploring factors that enable successful and sustainable change. We noted then that enhancing and expanding care out of hospital is a core, and critical, part of London’s five sustainability and transformation partnerships’ plans (STPs) and so we continued this theme in May 2017 and focused on improving health in care homes, which is a key part of the overall approach that STPs are taking to meet older people’s needs and one that requires an integrated, whole system response. Meeting the needs of a growing and ageing population is one of the key challenges for our health and care systems. Whilst overall London has a younger population than other parts of the country, the number of Londoners aged over 80 is rising and is predicted to increase by 40% over the next 15 years. As the greatest users of health and care services we need to consider how to best meet the needs of older people, particularly the frail elderly, supporting them to have the best possible quality of life and care. The recently published Next Steps for the NHS Five Year Forward View, describes the task clearly; “As people live longer lives the NHS needs to adapt to their needs, helping frail and older people stay healthy and independent, avoiding hospital stays where possible. To improve prevention and care for patients, as well as to place the NHS on a more sustainable footing, the NHS Five Year Forward View called for better integration of GP, community health, mental health and hospital services, as well as more joined up working with home care and care homes”. Many people living in care homes have complex needs, for example limited mobility, falls risks, dementia, incontinence, cardiovascular and cardiorespiratory disease, often with multiple prescribed medications. There is significant evidence that a more proactive approach and more responsive support can improve health and quality of life, breaking the cycle of emergency admission, delayed discharge, reducing independence and subsequent re-admission that many frail older people experience. Next Steps for the NHS Five Year Forward View highlights early results from parts of the country that have started doing this – the “care home vanguard” areas, which include the Sutton Homes of Care Vanguard in South West London, are seeing slower growth in emergency hospitalisations and less time spent in hospital compared to the rest of the country, with the difference particularly noticeable for people over 75, and meaningful savings from reducing unnecessary prescribing costs. Approximately 29,000 people live in nursing or residential homes in London, though there is significant variation in provision across our boroughs. It is well recognised that many challenges exist within the care home market, and we need to acknowledge that challenges also exist in provision of domiciliary care. The framework for enhanced health in care homes, developed by NHS England’s New Care Models team with the six care home vanguards, describes the care and quality, financial and organisational barriers that in many parts of the country are holding back the care for people living in care homes or who are at risk of losing their independence. London is no exception. The framework provides an approach to tackling these issues with a suite of evidence-based interventions, which are designed to be delivered within and around a care home in a coordinated manner to improve the quality of life, healthcare and planning for residents. Enhancing health in care homes through more integrated working should be everybody’s business. Through this meeting we:
- Considered the needs of ageing and frail elderly Londoners living in care homes and the opportunities to improve their health and well-being as a key part of wider health and care transformation plans;
- Improved participant’s understanding of London’s care home market and the issues faced by providers of care and commissioners; and
- Shared examples of innovation and good practice to improve health and well-being, quality of care and care planning and the impact they are having and consider how these initiatives could be progressed at greater scale across London.
This programme for the meeting is available here. Professor Oliver Shanley OBE, Regional Chief Nurse, NHS England and NHS Improvement (London Region) opened the meeting, outlining the aims of this Forum and its relevance in supporting improvement across London (click here for slides).Suzanne Peppitt then very powerfully talked about making care homes a new beginning: a relative’s perspective. Aileen Buckton, Executive Director for Community Services, Community Services Directorate, London Borough of Lewisham & London ADASS Branch Chair, then gave an overview of London’s care home market (click here) and William Roberts, National Lead for Enhanced Care in Care Homes, New Care Models Programme, NHS England shared learning from the care home vanguards (click here). With the scene firmly set and the opportunities to enhance health in care homes and the benefits clear, nine examples of innovation and good practice were shared and discussed to explore and disseminate approaches, impact and learning. Information on each is included below. Sutton Homes of Care Vanguard, one of six care home vanguards within NHS England’s New Care Models programme, shared the vanguard’s overall programme of work with a focus on three key elements: Quality and Assurance; Workforce Education and Training and the Hospital Transfer Pathway (aka “the red bag”). The Health Innovation Network (HIN) shared an overview of the HIN’s work in residential and nursing homes and learning about developing a care home network and adoption and spread (illustrated through adoption and spread of “the red bag”). Health 1000: The Wellness Practice shared learning from supporting care homes in considered whether enhanced primary care in nursing homes in Havering is effective. Focused, coordinated care for people living with long term conditions. IUC Pilots: Fast Access to a GP via the *lines for health care professionals. Colleagues shared learning from pilots introduced last winter to respond to pressures across the urgent and emergency care system, which included testing an improved response to calls from care homes with Fast access to a GP. The Argyle Surgery in Ealing, North West London, shared outcomes and learning from a proactive multidisciplinary team approach to intensive management of nursing home patients four years on. The Argyle Care Home Service and infographic. The London Dementia Network shared models of service delivery which have proved effective in supporting care home staff in meeting the needs of people with dementia and behavioural and psychological symptoms; and care pathway overview. St Christopher’s Hospice shared the approach and learning through reaching out to implement an end-of-life care programme in care homes (see the summary report). Mouth Care Matters – improving the oral health and general health of older adults. This is a programme developed by Health Education England to educate staff about the importance of identifying and meeting people’s mouth care needs, an area often neglected in care homes. Mouth Care Matters. The vital role our senses play in ensuring good physical and mental health are often overlooked. Colleagues from NHS England and the NIHR NWL CLAHRC discussed why good sensory health is important to quality of life and independence for older adults and shared models of delivery. Eye health needs for older adults; What Works – hearing loss and healthy ageing; Commissioning services for people with hearing loss.
A SUMMARY REPORT with reflections and recommendations from this Forum can be accessed here. It also includes key messages from each speaker; further information about the examples of good practice shared and discussed with contact details of colleagues leading their development and delivery; key points from STP group discussions and links to some further resources to support enhancing health in care homes.
The London Clinical Senate Council met on 22 May 2017.
The notes of the meeting on 22 May were signed off at the Council meeting in July 2017.
The Patient and Public Voice Group met on 16 May 2017.
- PPV 2017 05 16 AGENDA
- Item 3 – Framework for Enhanced Health in Care Homes
- Item 4 – Preparation for Senate Council workshop 2017 05 16
- Item 5 – NHS England PPV expenses policy extract 2017 05 16
- Item 7 – Clinical Senate Forward Plan 2017 05 16
The notes of the meeting on 16 May were agreed at the PPV meeting in June 2017.
The Patient and Public Voice Group met on 28 March 2017.
- PPV 2017 03 28 AGENDA
- Item 3 – PPV Members Guide extract 2017 03 28
- Item 6 – Clinical Senate Forward Plan 2017 03 28
The notes of the meeting on 28 March were agreed at the PPV meeting in May 2017.
The London Clinical Senate Council met on 21 March 2017.
- LCSC 2017 03 21 AGENDA
- Item 5 – London’s Improvement Architecture – Healthy London Partnership 2017 03 21
- Item 7a – 2017 03 15 – supporting STP delivery
- Item 9a – 2017 03 15 Clinical Senate Forward Plan
The notes of the meeting on 21 March were signed off at the Council meeting in May 2017.
The Patient & Public Voice Group met on 28 February 2017.
- PPV 2017 02 28 AGENDA
- Item 4 – Review of Senate principles 2017 02 28
- Item 8 – Clinical Senate Forward Plan 2017 02 28
The notes of the meeting on 28 February were agreed at the PPV meeting in March 2017.