April 2019

1. April 2019 CCF

3. Applications for Fourth Governing Body GP now open!

4. High Intensity User Service2019-2020 Presenters- Di Falco-Langham - HUHFT Hugh Grant-Peterkin - ELFT Tim Kent - Tavistock Andrew Horobin - ELFT Katie Fifield - ELFT Lauren Tobias – Volunteer Centre Hackney

5. "The High Intensity User (HIU) Service is a one-year collaborative pilot project between HUHFT, ELFT, Tavistock and Portman, Volunteer Centre Hackney & Family Action, with the aim of reducing attendance to Homerton Emergency Department and calls to London Ambulance Service/111 within City and Hackney."

6. What is HIUS? • For several years HUHFT have had a ‘Frequent Attenders’ service which reviews anyone attending ED >5 a month • The HIUS builds on this by expanding capacity as well as incorporating mental health provision and voluntary sector organisations • Threshold from 1st April will now be HUHFT A&E 5+ attendances within one month or 10+ attendances within a year (excluding wound care and sickle cell). The patient will meet the threshold as soon as they reach 10 attendances, a full year does not need to have passed before the patient is eligible for the service. • City and Hackney LAS 5+ calls within month / 12+ calls within 3 months • City and Hackney 111 6+ calls within 3 months

7. Who is in HIUS • HIUS Lead (HUHFT) – 0.4 • Assistant psychologist (ELFT) – 0.6 • Care Planning & Navigation Nurse Specialist (ELFT) – 1.0 • Psychotherapist (Tavistock) – 0.4 • Befriending and Peer Support Project Manager (Volunteer Centre Hackney) – 0.4 • Data Coordinator (HUHFT) – 0.4 • Family Action – 1.0

8. What will HIUS offer? • Initial assessment – • Thorough review of all notes including ELFT, HUHFT, EMIS, CMC • If appropriate liaison with relevant professionals • Once above done then phone call to person • Action plan will then be emailed to GP • Dependent on assessment and phone call then offer a wide range of interventions ranging from sign-posting to psychotherapy.

9. How can you contact the service? Email: huh-tr.HighIntensityUserService@nhs.net

10. GP Involvement Pre- & Post-HIU Team Intervention • Details for HIUs will be sent by the HIU Team to GPs by email by the 20th of each month (same as is already done for 5+ attendances per month) • Incentive forms to be returned by email to HIU by end of the month • e.g. March data to be sent to GPs by 20th April. Forms to be returned to HIU Team by 30th April. HIU then discuss, decide a plan of action and this will be conveyed to GP.

11. Documentation • Completing CMC remains with the GP practice, but HIUS will share plans of care which can be checked & then transferred by the GP onto CMC.  HIUS do not initiate the plans but will monitor whether the information is useful, e.g. to LAS to decide about conveyance and offer support to the GPs to do this. • HIUS will be responsible for adding High Intensity User flags onto existing CMC plans where this is not already done.

12. Where will the bi-monthly MDTs take place? • These will take place at the Homerton Hospital and are currently scheduled for the 3rd Wednesday of every second month (next is 15th May). • Only a few more of the more complex HIUs will be discussed at these meetingsand GP practices will be informed at least one week in advance if one of the patients from their practice is to be discussed • For these patients, the feedback form should be emailed to the group in advance of the meeting, instead of at the end of the month. • GPs are invited to attend, along with key workers, community teams and other professionals that know the patient

13. Can I refer patients directly to you? • The service is set up to manage HIUs attending ED/calling 111 or LAS. • Patients who fit this criteria will “feed-in” to the service via the Homerton ED data & LAS/111 data.

14. How long will the waiting time be from identification to intervention? • Patients for a particular month will be identified by the 20th of the following month • It is difficult to give an exact waiting time initially, but we would envisage that we will be offering an initial phone assessment and subsequent action plan within 2-3 weeks • This will gauge which service may be appropriate for them

15. Nature and extent of interventions offered? • HIU Assistant Psychologist – undertake assessments, help senior nurses in HIUS to collect history and liaise with GPs. Coordinate and disseminate plans. Hold a small clinical caseload to offer psychoeducation, support patients’ engagement with plans and/or facilitate signposting. Active involvement in evaluation of the HIUS project. • Tavistock & Portman psychotherapy • Volunteer Centre Hackney - match volunteer befrienders to address isolation and support to achieve personal goals. • Family Action

16. If this is a pilot, will all patients be able to finish their course of therapy? • Difficult to answer but we will ensure all patients are looked after and handover plans made if needed • The success of the pilot will be monitored continuously from the beginning by a data coordinator • Formal plans for sustainability will commence at 6 months

17. A Presentation for the Clinical Commissioning Forum (CCF)Janette CliffeQuality Improvement Lead Homerton University Hospital NHS Foundation TrustTelephone: 020 8510 5555 Ext 4191janette.cliffe@nhs.net

18. What’s happening in the Homerton • In context links are in place in the Homerton from EPR and RiO work in progress to view through HIE which will allow single sign • CMC Intranet page for HUH staff to reference • Centralisation of CMC log ins to be signed off and implemented • Clean up of HUH CMC data completed to improve accuracy of reporting • CMC roll out project underway for view and editing in ACERS, ACRT, IIT, ACNs, ACU, ED, to include creation in ECU and Palliative Care • Other areas expressing interest Mary Seacole nursing home

19. Homerton Urgent Care Services SOP written agreed and signed off for Urgent Care Servicesthis includes ED, OMU, ACU, on call medical doctors and site managersRelaunch of CMC in ED on 1st April alongside new mortality board, CMC to be a standing item, all consultants reissued logins Process for new starter to receive a log in when they rotate into ED lead by service managerChampion identified is Dr. Anna Johnson in ED and Dr Carlo Prina in ACU Frequent attenders team using HIU (high intensity user) alert in CMC

20. CMC in other areas SOPsWritten agreed and signed off for ACERS and ACRT SOPs written in ECU, Palliative Care, IIT, ACNs, awaiting sign offNamed champions identified ECU = Dr. Cianan O'Sullivan, Palliative care = Jacqui Reyner, ACERS = Jane Osei-Wusu, ACRT= Kinda Nasser , IIT= Wayne GillonTheir roll is to lead on CMC, ensure it’s a standing item in MDTs, help others with system and help to spread and sustain usage

21. CMC in other areas Training Completed in ED, ACERS, ACRT, Palliative CarePlanned for ACNs in May and JuneAwaiting confirmation for dates ECU and IITTraining on Advanced Care Planning and difficult conversations to be run by CMC for key Homerton staff RelaunchPasswords requested ready for ED relaunch on 1st AprilPasswords requested ready for ACER and ACRT relaunch on the 8th April

22. CMC in other areas Phase twoRelaunch of CMC in IIT expected in MayPlanned for ACNs in May and June will be structured into clustersOver see of transition of CHUSE to Homerton to ensure good CMC practices are maintainedRevision of SOPs and usage with each team at 3 and 6 months to ensure embedding and best practice

23. Recommissioning of City and Hackney’s drug and alcohol treatment services April 2019

24. Current Hackney Recovery Service Treatment Model • The Treatment Centre • The Clinical Hub • Criminal Justice • In patient and community detox • Assertive Outreach • Prescribing • Hospitals • Needle Exchange/ harm reduction • Brief and structured interventions • Complex groups • Clinical Management • RECOVERY • Digital • BBV services • Family and Carers • Visible recovery • Mutual Aid • Recovery Groups • The Recovery Hub • Counselling

25. City of London existing integrated substance misuse and tobacco control service – 2015 to present Service elements • Provider management: Management function, organisation and clinical governance for the service, and contractors. Single point of entry and referral pathways, emergency assessment and managing delivery locations • Open access and advice: Initial contact and first step information and advice. Triage model assessment of needs and referrals. Awareness and harm reduction advice services with businesses, rough sleepers and residents • Custody suite and drug alcohol assessments: Treatment pathway, harm reduction, information and advice for criminal justice system • Substance misuse treatment, advice and casework: Holistic advice service for more intensive specialist support, clinical attention and case management requirements • Smoking and tobacco cessation and control: Not included within this commission

26. Why recommission?

27. Consultation Exercise Service users Current staff Wider stakeholders Potential providers

28. Methods Workshops / focus groups 1:1 Interviews Surveys Current staff Stakeholder consultation day Current service users Wider Stakeholders Homeless forum Non-service users Potential providers HRS staff Previous service users LGBTI WDP SMH Key stakeholders Healthy life style coaching clinics JCP

29. Proposed timetable – subject to change

31. LTC Contract indicators for April CCF

32. Issues • QoF has removed many indicators • Added referral to pulmonary rehab so we will look at numbers attending • Introduced frailty as an exclusion • CEG are working on codes, likely to be the frailty index • LTC contract needs to be above QoF for VFM • Look at targets in July when QoF range and payments known • CVD prevention part of LTP but not till 2022 • Debate about prevalence of at risk DM and CVD, big practice variation, PH investigated. • We will expect practices to run and action CEG prevalence searches • No specific target unless unexplained very low prevalence. • Is the stroke checklist helpful or not?

33. LTC contract indicators

34. LTC contract indicators

35. LTC contract indicators

36. LTC contract indicators

37. LTC contract indicators

38. Further ideas THIS YEAR: Cancer screening – could patients be asked whether they have attended screening during annual reviews for LTCs (relevant age groups only)? • NEXT YEAR: • Epilepsy annual reviews? • Hepatitis B – searches and referral to virtual clinic? • Group Consultations • Pneumoccocal vaccination for LTCs • Asthma - phone review plus face time for inhaler technique • Alcohol primary prevention and referrals? • Take account of national CVD prevention initiatives • Other ideas?

39. City & Hackney Neighbourhood Health and Care Services Programme Learning from whole system workshops and next steps Update to Integrated Commissioning Boards, March 2019

40. The strategic context for integrated care • City and Hackney face a number of pressing health needs, changing demography and ongoing pressure on inpatient resources, but this is set against a strong track record of primary and community care delivery with high performing services already leading to great numbers of patients receiving care closer to home. • Within this context health and care services in City and Hackney perform well, however the changing nature of the local disease burden – specifically the continuing impact of lifestyle factors, the need to more effectively address the wider determinants of health and the predicted growth of patients living with two or more long-term conditions – is likely to render these service models unsustainable.

41. A focus on integrated care in out-of-hospital services • Out-of-hospital services will be the building blocks of integrated care. These services feature heavily in both the recently published NHS Long-Term Plan and the new GP contract proposals. • By moving away from multiple silo-ed, ‘one size fits all’ services towards more targeted, preventative and joined-up care, they have the power to dramatically improve the lives of patients and have a much wider effect on the rest of the local health and care system. • By local out-of-hospital services we mean the following services and spending: • community health services (£33m), • related social care (£18m of Better Care Fund pooled services, £18m of Hackney social care services and £2m of City of London social care services), • mental health services in the community (£21m), • whole-population (non-delegated) primary care services (£11m) • acute urgent care and GP out-of-hours services (£4m). • The funding envelope for these services in City and Hackney is approximately £120m annually. We refer to these services together as out-of-hospital services because we want to emphasise their combined significance despite them having been historically commissioned separately.

42. Our approach to redesigning care • The Neighbourhood Health and Care Services Programme was set up to consider the transformation of out-of-hospital services. Our original intention was for this work to inform a formal service redesign and procurement exercise starting in March 2019. • We held a series of workshops in January 2019 to ask staff and stakeholders to inform this process. The workshops indicated a willingness and desire from the partners on the ground to deliver integrated care across organisational boundaries, and to develop new models of care, but they also highlighted a number of major barriers and obstacles. • Staff reported that current commissioning arrangements, financial incentives and outcome measures do not support joint work across organisations to co-ordinate care. However, the majority of barriers identified were cultural and behavioural in nature, requiring system leadership, shared values, and investment in collaborative learning and solution building. • It was clear from the workshops that the programme as originally envisaged was focused too narrowly on the structure and process of redesign but did not fully address the behavioural and leadership aspects of change management necessary to deliver a system-level transformation of care.

43. We held workshops throughout January with staff from across health and care in City and Hackney Wide representation of partners from across the local system: • CCG, patient representatives, primary care, Homerton (acute and community), ELFT (mental health), Learning Trust (schools), local authority (social care), charity and voluntary sector 8 Approx.200 participants workshops held

44. We asked staff to define the integrated patient-centred care they wanted to provide – which aligned closely with what residents have told us they want… Workshop definition of integrated care: Resident statements: “What is important to me and what I value for my health, care and wellbeing:” Patient at the centre Joined-up care Equality between staff and the public - working together, clear communication and speaking the same language People are listened to and heard Responsible patients and staff Money is used well Community and neighbourhood Accountable and transparent staff and politicians Public are involved including in decisions Properly funded services Flexible support adapted to local and individual need Equal for all including equitable access Tackling causes and better prevention One-to-one care Equal treatment of mental and physical health Greater happiness and wellbeing Recognise people’s skills and empower them to help themselves More training, education and employment for people Continuity of care Free health care • Care which addresses the holistic needs of patients as human beings, both physical, mental and social, and which is preventative and empowering; • Care which is experienced by patients as consistent and co-ordinated, delivered in a joined-up way either at home, from a GP practice or local community location at Neighbourhood level or virtually, and only in hospital when truly necessary; • Patients supported to make the best use of their own resources, rather than being treated like illnesses to be managed or problems to be solved; • Patients being the owners of care plans which are based on patient-centred goals; • Care delivered by staff who are empowered to work together as they see clinically fit in order to provide patients with more-coherent, less fragmented support; and • Services and teams which are focused on supporting cohorts of patients to stay well rather than organised narrowly around professional or disease-specific specialisms.

45. Workshop participants identified seven key barriers to effective joint working as a system… • A culture of ‘them and us’ between different organisations and professions, and between generalists and specialists, based on a lack of trust, and lack of awareness of different approaches and viewpoints; • The current system of contracts and commissioning, where different teams and organisations are held to different performance standards and funding arrangements, and thresholds and referral criteria make it hard to operate more flexible clinical judgement; • The way that time and space are managed, specifically with staff time heavily regulated by process – leaving them little ability to be flexible, with the same challenges also applying to the opportunity to share infrastructure resources such as buildings and equipment; • The effects of mental and physical organisational boundaries such as complex referral systems, differing priorities, lack of collaboration, silo-ed working and thinking, and passing patients back and forth between organisations rather than taking more joint responsibility for finding solutions; • Different contracts and funding arrangements leading organisations to be protective of resourcesand capacity, making it harder to flexibly align resources adaptively around the needs of patients; • The lack of coherent common goals and values role-modelled by leaders, that endorse the need for collaboration and joined-up working and thinking, as well as organisational commitment to multi-agency working; and

46. Participants also identified changes they wanted from leaders – challenging them to build on the relationships between organisations: • By ensuring that leaders in partner organisations collaborate and role-model the necessary commitment and common purpose; sharing resources and enabling staff to change the way they work; • By empowering teams to work differently, engage with partners and to increase ambitions around multi-agency working – removing competitive or monolithic practices that serve to disempower teams or fragment or confuse responsibility for care; • By changing how success is measured, so that focus moves away from proscriptive process measures towards population outcome measures, underpinned by a whole-system agreement to enable a more values-led, trusting and adaptive system environment.

47. Primary Care Networks • As part of the NHS Long Term Plan a five year framework to change the GP contract was announced. A key part of this is the development of Primary Care Networks (PCNs) for populations of 30-50,000 • In the first year each network will receive funding to employ one social prescriber and 70% of the cost of hiring one pharmacist • Each network will be led by a GP in the role ofpart time clinical director • By 2024 each network will have: • 5 pharmacists • 3 social prescribers • 3 first contact physiotherapists • 2 physician associates • 1 community paramedic • The hope and expectation is that PCNs in City and Hackney will operate on the same footprint as neighbourhoods • We also need to make sure these additional resources work seamlessly with the rest of the local system

48. From competition to collaboration • To achieve our strategic objectives, and to effectively co-ordinate care for patients, the health and care system in City and Hackney will require much deeper integration and very different ways of working across organisations. • Given what staff told us and what we know about the level of change required to deliver system transformation, we questioned whether a formal procurement is the correct approach to achieve this system change • The whole-system integrated care programme in City and Hackney is achieving results. The shared values, ambition and commitment from staff across the system is clear. The CCG intends to use its commissioning responsibility to ensure the public get the best economic and social value from the services we commission. As an aspirant ICS, all partners, including the CCG, will be using collaborative frameworks much more creatively to achieve this.

49. The case for a change programme • Overcoming competitive behaviours and building trust and collaboration between clinicians in different organisations will be key to delivering integrated care in out-of-hospital services, in whatever form it is commissioned. As stated recently by the King’s Fund, “the principal benefits of integrated care result from clinical integration rather than organisational integration”. • This change cannot be owned by one organisation in the system on its own, be it the CCG or any of our key partners; a system-level approach is required, owned collectively. • We propose a system-level change programme with the following elements: • Visible system-level leadership, role-modelling the behaviours that will deliver integrated care; • Action to address organisational processes and behaviours that hinder collaboration on integrated care, particularly in multi-agency clinical teamwork and service co-ordination; • System-level learning projects in priority areas where maximum benefit could be achieved from deeper integration, with change developed from the bottom up by clinical teams • Investment in more trusting relationships across the system, focusing more on common values, goals and outcome measures and less on organisational differences

50. Next steps… • We propose to create better alignment between the Neighbourhood Health and Care Services Programme and the Neighbourhoods Programme by merging them, creating a new programme which will be our main vehicle for whole-system change and transformation work in out-of-hospital services • As a first step, the CCG will invite partners to notify them of any current KPIs or elements of service specifications that hinder collaborative working. The CCG undertakes to remove impediments to system-wide working where legally possible • For each of the four care workstreams, the new programme will include a pilot focus on a whole-system area where tangible early progress could be made; for example by integrating community gynaecology and womens’ sexual health services in the Planned Care workstream • We will agree as a system critical success factors to judge the impact of changes to out of hospital services – for example improving our performance of delayed transfers of care, hospital length of stay an patient satisfaction • The programme will stimulate, foster and build on partnership approaches between organisations, and challenge these partnerships to achieve truly patient-centred care whilst making the most effective use of resources within system-wide constraints