London's Regional Vision for End-Of-Life Care: Improving Population Health Collaboratively

1. London regional vision for End Of Life Care Malti Varshney Associate Director London Clinical Networks and Senate 2nd May 2019

2. 8,825,000 people - 16% England population 1 in 4 under 20, 1 in 8 65yrs and over Life expectancy 80.4 (m) 84.2 (f) Healthy Life Expectancy 63.5 (m) 64.4 (f) 1089 LSOAs in most deprived quintile, compared to 524 in the most affluent ‘Huge inequalities in income and wealth have created a dysfunctional housing market that is pricing many people out of the city, changing the nature of communities and creating difficulties in terms of delivering public services, as well as contributing to a surge in homelessness’ (KF 2018)

3. London’s health and care system is complex…. Population Health Governance arrangement in London Source: Kings Fund (2018) The role of cities in improving population health: international insights

4. London’s health and care partnership journey London’s health and care partners have been on a journey towards greater integration and collaboration for a number of years, this journey is illustrated below.

5. Focussing the mind on maximising the benefits of regional collaboration In November 2017, London and national partners signed a Devolution MOU, focused on: NHS Estates and capital receipts Prevention Health and care Workforce Digital innovation and adoption Integration of health and care Transformation e.g. deployment of funding Source: https://www.gov.uk/government/publications/london-health-devolution-agreement/london-health-devolution-agreement

6. Strategic partnerships supporting local delivery London governance and delivery interfaces with local and sub-regional governance and delivery through STP and local system leaders London Health Board Political oversight; chaired by the Mayor of London London Health and Care Strategic Partnership Board Strategic and operational leadership and oversight for London-level activities Governance 5 STPs Transformation Funding Oversight Group London Digital Partnership Board London Estates Board London Workforce Board London Prevention Partnership Board Each STP contains smaller borough and multi-borough partnerships

7. Healthy Children Healthy Mind Healthy Places Healthy Communities Healthy Living The five pillars of the London Health Inequalities Strategy 2018-28 https://www.london.gov.uk/what-we-do/health/health-inequalities-strategy

8. Maximising the opportunities of the NHS Long-Term Plan Welcome focus on prevention and health inequalities: Targeting support to more deprived areas Support for key excluded groups – rough sleepers, carers, gambling problems Healthy NHS premises and reducing air pollution Smoking cessation, inc maternity pathways Personalised care and social prescribing Children and young people mental health https://www.longtermplan.nhs.uk/

9. Integrated care systemsWho does what? Level Pop. Size Purpose • Primary care network • Comprehensive MDT care • Proactive & integrated models for defined population Neighbourhood ~50k • Typically borough/council level • Integrate hospital, council & primary care teams / services • Hold GP networks to account Integrated Care Network ~250-500k • System strategy & planning • Hold places to account • Implement strategic change • Manage performance and £ Strategic Planning Partnership 1+m • Agree system ‘mandate’ • Hold systems to account • System development • Intervention and improvement Region 5-10m Each level performs specific functions under the following common headings • Leadership, engagement and workforce • Care redesign • Accountability and performance management • Strategy and planning • Managing collective resources

10. London’s Vision is to be the Healthiest Global City Now and for future generations A life course approach 1. Start well Giving every child and family the best possible start 2. Live well Creating a positive place to live in and work 3. Age well Building communities that support people as they grow older From: Greater focus on medical and specialist needs An holistic and person-centred approach To: Greater focus on community and independence

11. Guiding principles • Parity of your physical and mental health • You can choose what matters to you (personalisation) • You will experience seamless care regardless of which organisation provides services (integration) • Better outcomes regardless of who you are or where you live (inequalities)

12. The NHS’s contributionMedium term objectives 2019-2024 • Maternity • Reducing deaths • Smoking • BAME • Perinatal MH • Personalisation • Mental Health in schools • Immunisation • Children • Mental health • Asthma • Autism • LD a. Primary prevention, community action & self-care b. Integrated community models. c. Specialist services and provider networks • Neonatal networks • Children’s cancer • Children with diabetes and epilepsy • Tier 3 and 4 CAMHS access standards • Move to 0-25y services • Congenital heart disease 1. Start well Giving every child and family the best possible start, and supporting those with chronic and/or complex needs • Smoking cessation • Alcohol Support • Detection of high blood pressure, AF • Diabetes Prevention Programme • NHS health checks • Ban on HFHS foods on NHS premises • Emergency/crisis mental health • Community mental health standards • Mental health • IAPT • Suicide prevention • Social prescribing 2. Live well Creating a positive place to live in, and providing proactive and holistic support to those who need it 3. Age well Building communities that support people to remain independent as they grow older and provide genuinely integrated care • Stroke thrombectomy • Acute frailty units • NHS App and 111/999 as the single point of access to the urgent care system • Population based health management of multiple LTCS in primary care networks • Cardiac and pulmonary rehab • Stroke and neurorehab • Community rapid response • Detection and prevention of frailty • Enhanced care in care homes • Personalised health care budgets and choices Personalised care and choices

13. London vision statements ***DRAFT***

14. Emerging priorities, commitments and guiding principles To be tested through political, public and stakeholder engagement: Health inequalities Personalisation Parity of mental & physical health Integration ***DRAFT***

15. NHS London’s priorities are set by nationally defined clinical programmes (blue) or by London’s STPs (pink)

16. Regional Governance Structure London Regional Executive Team London Mental Health Parity Board SRO: Khadir Meer, NHSE / I London Mental Health Transformation Board SRO: Jane Milligan, NEL STP lead, and Oliver Shanley, NHSE / NHSI London Diabetes Transformation Board SRO: Vin Diwakar NHSE/I Regional Medical Director Vin Diwakar, NHSE/I London Maternity Transformation Board Chair: Jane Clegg, NHSE/I London Cardiac and Stroke Transformation Board SRO: Angela Bhan, Chief Officer, Bromley CCG Vin Diwakar NHSE/I London Urgent and Emergency Care Transformation Board Cardiac and Stroke Transformation Board SRO: Diana Lacey NHSE/I • Cardiac CN • Clinical director: Huon Gray • Improving detection and diagnosis of heart failure • Managing CVD risk in primary care • Clinical input into syncope and hypertension • Respiratory CN • Clinical director: Vincent Mak • Improving detection rates and accurate diagnosis of people with respiratory disease • Increasing access to and completion of pulmonary rehab • Ensuring correct prescribing and effective use of inhaled medicine • Mental Health CN • Clinical directors: • Phil Moore, Vincent Kirchner) • Providing clinical expertise to Transformation Board and wider system • SMI mortality • Primary care mental health • Perinatal mental health • IAPT • EIP • * Joint with Healthy London Partnership • Diabetes CN • Clinical director: Stephen Thomas • Providing clinical expertise to Transformation Board and wider system • Support for national diabetes prevention programme (DPP) • Implementation of transformation funding bids • Work with STPs for optimal treatment pathways • Maternity CN • Clinical directors: • Donald Peebles, Philippa Cox • Providing clinical expertise to Transformation Board and wider system • Implement vision of Better Births, incl establishment of 5 local maternity systems • Reducing maternal morbidity and mortality; reducing stillbirth • Develop new models of care • Improve postnatal care • Improve patient experience and choice • Dementia CN • Clinical director: Jeremy Issacs • Supporting CCGs to go beyond 2/3 diagnosis rate • Reducing variation in memory services and supporting the 6 week pathway ambition • Working with CCGs and providers on care planning and care coordinators • Delayed discharge deep dive project (acute hospitals) Funded through Office of CCGs • Stroke CN • Clinical director: Tony Rudd • Maintaining high standard of care in HASUs and SUs • Development of stroke operational delivery networks • Stroke prevention through management of atrial fibrillation • Frailty CN • Clinical director: Bettina Wan • improve identification of people with frailty • Utilise community assets to produce enabling environment for healthy ageing • Enhance workforce capability and promote shared competency • End of Life Care CN • Clinical director: Caroline Stirling • Support STPs to embed high quality EOLC (cancer, dementia, LD, UEC) • Personalisation and choice through 6-pt commitment • Shared EOLC records, decisions and care plans Reports to Accountable to Each Clinical Network has a delivery mechanism embedded in the local system involving local clinicians, commissioners and third sector

17. Setting our priorities 2. Changes requiring regional levers 5.Delivery in 3-5 years 1. A big health burden 3. Joint commitment to action 4. Evidence base of effectiveness NHS London’s Clinical Network Priorities Supporting the implementation of London Health Inequalities strategy

18. NHS London’s clinical networks have a number of unique capabilities and capabilities which overlap with other improvement organisations Independent clinical peer review and monitoring of clinical outcomes Clinical subject matter expertise Shared and wider distributed Clinical Leadership Integrated NHSE/ I Assurance & Delivery System Leadership for priority clinical conditions National Clinical Directors buy in Development of pan London Standards Independent and impartial clinical advise and arbitration Where we are unique Specific HLP/ CN alignment (MH, Digital etc) Quality improvement STP delivery support Agreed regional priorities by CCG Chief Officers Embedded resource Augmented nat/ reg’/ local delivery chain Areas of cross over & collaboration Deliver national & regional local priorities Horizon scanning for opps Evidenced based guidelines/ standards Attract additional funding Once for London activity Capability development Research Data driven approaches to improvement Patient & Public Voice Bench-marking Capturing and sharing learning CNs Other agencies Programme Activity KEY 18

19. Integrated care systemsWho does what? Level Pop. Size Purpose • Primary care network • Comprehensive MDT care • Proactive & integrated models for defined population Neighbourhood ~50k • Typically borough/council level • Integrate hospital, council & primary care teams / services • Hold GP networks to account Integrated Care Network ~250-500k • System strategy & planning • Hold places to account • Implement strategic change • Manage performance and £ Strategic Planning Partnership 1+m • Agree system ‘mandate’ • Hold systems to account • System development • Intervention and improvement Region 5-10m Each level performs specific functions under the following common headings • Leadership, engagement and workforce • Care redesign • Accountability and performance management • Strategy and planning • Managing collective resources