North London Partners in health and care

Responses to specific questions from residents


Question 1

Will you now withdraw the present draft plan (from October 2016) so that you can conduct a consultation that engages with a sufficient cross section of the population, that is proportionate to the importance of the NHS and to the scale of the changes being contemplated, and which complies fully with the Court of Appeal’s rules, namely 

  1. that consultation is undertaken at a time when proposals are still at a formative stage;
  2. that it includes sufficient reasons for particular proposals to allow those consulted to give intelligent consideration and an intelligent response;
  3. that you give adequate time for this purpose; and
  4. that you conscientiously take into account the product of the consultation when the ultimate decision is taken?

Response

No, the draft plan will not be withdrawn. It is in the public domain and has stimulated conversation and provided valuable feedback into the process. On the basis that the STP is draft and explicitly a work in progress, it has been shared at a formative stage.

The draft plan has provided an opportunity for feedback from a wide range of stakeholders and a platform to discuss how they can participate in the process of further development.

The people of North Central London are at the heart of our plan. We want North Central London to be a place where people have the best opportunity to live happier, healthier and longer lives. We have many good health and care services in our footprint but there are also many areas that can be improved through transforming the way we work and by reducing inefficiencies and waste. To get the best outcome for people who use health and care services we know that we must include them in this process.

We are working collaboratively with the five Healthwatch organisations in the North Central London patch as well as the five local authorities and all the local healthcare organisations to further develop the draft plan on the basis of the further work since October 2016 and taking into account views we have received.

Each of the identified areas of work (workstreams) within the STP are developing their thinking, including development of a communications and engagement plan. This is to ensure each area of work has identified their stakeholders and appropriate ways to engage with them on the proposals. Each workstream has also developed an initial Equalities Assessment to identify cohorts of residents or service users that may require additional consideration or support to make sure they have the opportunity to participate.

As we develop our more detailed thinking, we welcome residents, service users, carers, staff and other interested parties input into this process. We will provide adequate time for people to respond as well as enabling people to provide feedback via email and our soon to be online website and feedback form.

We are also attending the monthly Joint Health Oversight and Scrutiny Committee meeting. In December the JHOSC submitted a report to the North Central London STP seeking a commitment to a number of principles and made recommendations to how we can improve our process. The report and recommendations can be found here:

Recommendations from the north central London JHOSC on the Sustainability and Transformation Plan

Our response to the JHOSC report is available here: Response to North Central London Joint Health Overview and Scrutiny Committee report - December 2016

We will produce an updated version of the draft plan by early April 2017 that takes into account the comments we have received since the draft plan was published in November 2016.

(Please note that the calling of the General Election and rules surrounding public engagement during Purdah, or the pre-election period, meant that whilst we were able to publish the updated plan on partner websites we could not carry out all of our intended public engagement on the updated plan until after the election.)

Question 2

By what legal power are the plan makers acting? How is this compatible with the responsibility imposed by Parliament on the Clinical Commissioning Groups?

Response

The STP is a collaborative of sovereign organisations in North Central London, each with its own governance and decision-making structures. We have not to date introduced any collective decision-making structures. However, we have worked together to produce both the Case for Change <insert link to document> and the strategic narrative <insert link to document> that outlines the plan.

The STP remains a work in progress and therefore has not been formally signed off by any of the organisations within the STP. The draft plan as submitted in October 2016 has been discussed at the public sessions of each of the NHS provider boards, CCG governing bodies and Local Authorities for their support and input into the next steps.

We will continue to work on the draft plan up until early April 2017 when we will publish an updated version.

(Please note that the calling of the General Election and rules surrounding public engagement during Purdah, or the pre-election period, meant that whilst we were able to publish the updated plan on partner websites we could not carry out all of our intended public engagement on the updated plan until after the election.)

Going forward, in order to support a more collaborative commissioning approach across North Central London, the Governing Bodies 5 CCGs have agreed to establish a Joint Committee for some elements of commissioning. This will be put in place in April 2017. 

  • All acute services including core contracts and other out of sector acute commissioning
  • All learning disabilities contracting associated with the Transforming Care programme
  • All integrated urgent care (through the Urgent & Emergency Care Boards including NHS 111/ GP Out-of-Hours services)

 An appointment has been made to a new single Accountable Officer for the five CCGs across North Central London. Work is underway on finalised other parts of the structure.

Question 3

Please explain the meaning of the statement (below) quoted from page 54 of the draft plan.

“It is also essential that STPs and their constituent organisations and leadership are given the regulatory headroom to develop longer term plans, and that the ‘new models of care’ being developed give clarity of financial accountability to support the financial challenges that the STP faces”.

Response

This paragraph is intended to highlight the challenges of achieving financial balance on an annual basis while at the same delivering the service transformation to achieve sustainable services in the longer term. The role of regulators is to support local organisations to balance these two imperatives.

Question 4

Please give us your professional estimate of how much additional funding would be required:

  1. to render the aims of the plan assured rather than challenging;
  2. to provide sufficient investment up front to support the plan, rather than gamble on recouping it downstream;
  3. to ensure that there is no increase of overall risk to patients or staff during the implementation period.

Response

Our draft plan contains a chapter that sets out the initial financial analysis of required investment, and the projected financial impact over the period to 2020/21. The draft plan projected a financial deficit of c£75m by 2020/21 and also deficits in the intervening years.

 The draft plan highlights the need to do further work to identify further means of reducing the residual deficit and to undertake more detailed work on the ideas set out in the draft plan.

 We are in the process of developing more detailed plans, exploring additional options to close the gap and modelling the impact of these options.

Question 5

What are the benefits and what limitations to care may there be for patients with a change to capitated budgets?

Response

Clinical Commissioning Groups already hold capitated budgets for their populations and hold contracts with providers for delivery of care. However, the draft plan highlights that the current system has shortcomings.

We are committed to exploring whether alternative approaches might offer benefits to patients and also what the limitations may be. We will not make any changes without further details of the pros and cons being fully explored and shared with local people.

Question 6

How do the plan makers propose to engage and retain sufficient skilled staff for the new service, within the financial limits outlined, to ensure that there are no detrimental effects on the quantity or quality of care provided for NCL residents?

Response

NHS employers in North Central London are all working on addressing recruitment and retention challenges for their own particular organisations and their own distinctive labour markets with, in many cases considerable success. In addition the STP has provided some investment to support collaborative approaches across the North Central London footprint and work is going on to determine which retention approaches have proved most effective and lend themselves to a collaborative approach.

Question 7

How will the plan makers ensure that the employment of less qualified staff does not result in unnecessary morbidity and mortality?

Response

Health and social care employers in North Central London have a responsibility to ensure the safety of patients and service users and the staff that care for them have the right skills and experience for the responsibilities with which they are charged. Employers will continue to be responsible for ensuring that staff deliver care in accordance the appropriate regulatory frameworks for their profession and with the right level of management and supervision.

Question 8

How are the lessons learnt from Mid Staffordshire going to be applied within this draft plan, and what measures will be taken to ensure that they are effective?

Response

The explicit objective of the STP is to address gaps in health outcomes and quality of care as well as financial pressures. The Health and Care Cabinet, which is made up of senior doctors, nurses and social care professionals from across North Central London, has a responsibility to ensure that our plans do not compromise safety or quality of care.

Question 9

Which parts of the NCL estate will be sold off, which parts downgraded and how many outpatient clinics and inpatient beds will be closed? Will the sale proceeds be ring-fenced for expenditure on replacement estate or buildings or other capital investment; or will they be vired (transferred) to revenue spending, thus reducing the capital assets of the NHS?

Response

The STP contains the specific plans that are needed to achieve the improvements in services and health outcomes described in the STP. Our ambition is to modernise mental health in-patient care through upgrading the facilities on the St Ann's site and releasing some of the site to pay for the costs of the new building, i.e. the money would be used to pay for the replacement services. Camden and Islington Mental Health Trust also has plans to modernise facilities on the St Pancras hospital site. Moorfields also has plans to redevelop its facilities. All CCGS have plans to create GP led primary care hubs and these are listed in the STP.

The North Central London STP would wish to keep the proceeds of any sale of an NHS property in NCL to fund improvements in health facilities for the residents of North Central London. However, it should be noted that the department of health and NHS England set the rules for the use of receipts ‎ for non- Foundation trusts, and properties owned by LIFT Cos and NHS property services.

Question 10

What elements of New Models of Care will replace the services removed and what elements will be to obviate the demands made by an increase in population (approximately 12%) and to replace the otherwise required 400 beds?

Response

Delivering care closer to home is not intended to replace services but instead recognises the increasing pressure on care services due primarily to greater numbers of people with one or more long term condition and an ageing population.  We are identifying ways to ensure each service provider has the capacity to do what they do best so care is provided in the right place at the right time.  This means increasing capacity in primary care so people with long-term conditions can be cared for closer to home where clinically appropriate and suitable for the patient.

We are planning to invest in more community nurses, specialist nurses, therapists, GPs, local mental health teams, social workers and pharmacists to work in very local teams with other local authority services, specialist medical support and voluntary sector services so care is provided closer to home and people can maintain and improve their health, independence and mobility for longer.  We are building on the existing local multi-disciplinary teams (often called networks, localities, neighbourhoods) which are already proactively managing some patients with complex needs and investing in them to broaden their remit and bring more capacity and a wider skill set into that very local service.  This will enable patients and carers to access support at home much more quickly and in a way that addresses their needs promptly, preserves their independence, mobility, confidence and support networks and reduces the risk of personal upheaval, disorientation and possible risk of infection which comes with hospital admission.

Question 11

What evidence is there that, within the constrained finances, enough high quality community care (to prevent clinical need for hospital based services) can be given to a sufficient number of patients to enable the reduction (and obviate the development) of hospital-based resources as planned?

Response

The evidence base for our proposals is set out in this document which highlights other similar initiatives which have successfully reduced the need for hospital based care. See attachment.

The evidence indicates that a proactive approach by health services working with social care to build capacity within the community to support people and their families in their own homes is an effective way to manage a greater proportion of care closer to people’s own homes. By ensuring that care providers, both community nursing and personal care service providers are enabled to provide seamless care for individuals so reducing duplication in the system and multiple handoffs and result in improved person centred coordinated care.

Question 12

What evidence is there that families, friends and neighbours are available and/or able and/or willing to take up caring roles? In what percentage of cases do you estimate that such care is available, and for what percentage of the caring workload is it available?

Response

The ability of families, friends and neighbours to help support people will vary across all areas but there is evidence that the strength based (also known as asset based) approach is very effective at delivering improved health and wellbeing.  The local teams will be responsible for assessing the level of such support available to people needing it and tailoring each individual’s care plan to their specific circumstances.

For more information and evidence please email Daniel.morgan4@nhs.net

Question 13

Is the voluntary sector being asked to help with community care? What happens if they also cannot step up to the mark due to lack of resources, how then can they make their “key contribution”? Has anyone outlined the size of this task and asked them?

Response

Voluntary and community organisations have been engaged at local levels to support the work around integrated care.  There is recognition that there have not been as many opportunities for them to access resources, however with the right partnerships and support from some of the larger Voluntary Care Organisations (VCOs) this historical deficit will be addressed. There is some evidence of good practice of engaging with the VCOs across North Central London and we plan to share this learning widely.  Local integrated (health and social care) teams will be asked to work with voluntary sector services and where appropriate identify where additional resources are required to better meet local need.

Question 14

What measures are being taken to ensure that all patients are able to benefit from the telephone-based and digi-tech developments to health care? How will this “equality” issue be monitored?

Response

Each area of work (workstream) has undertaken an Equalities Impact Assessment as part of their work plan. It is via this process that each senior responsible officer identifies and commits to implementing strategies to embed equality in the health and care services to people of NCL. This will be monitored throughout the implementation stage and reviewed as it is an integral part of the work plan.

The assessment of our digital plans will identify cohorts of residents and/or service users that may require additional consideration or support to make sure they are not disadvantaged through the use of new technologies. 

Question 15

What is it in particular that will improve mental health outcomes across NCL?

Response

The STP has put together a plan for mental health in North Central London which aims to improve outcomes by attempting to intervene earlier and provide a wider range of integrated support for people who need help in the community. The plan also looks to combine the opportunities, in some areas, to bring together resources and expertise across North Central London with the development of locally based services which reflect the specific needs of different boroughs.  The Plan has identified six workstreams which, together, we believe will strengthen provision and improve outcomes for mental health service users.  These are:

  • Prevention and early intervention
  • Development of primary care mental health services
  • Strengthening the acute care pathways to provide a greater range of alternatives to inpatient admission
  • Expanding mental health liaison services in acute hospitals
  • Building up perinatal service and crisis provision for CAMHS
  • Developing a female Psychiatric intensive care service in North Central London

Plans are at a relatively high level and implementation plans are currently being developed.  At this stage, inevitably, not all the details of our plans are fully developed. 

Question 16

Is there a plan to use “non-mental health” specialists to diagnose and refer problems?  If so how will this be managed?

Response

There are no plans to build use “non-mental health” specialists to diagnose problems.  We do think there is a value in strengthening mental health awareness amongst a wider group of organisations in a variety of sectors who can often have a key role in supporting people with mental health problems.  This includes statutory agencies such as schools but also those voluntary and community agencies to whom people with mental health problems can often first come to seek help.  In addition to mental awareness training, and training people in mental health first aid, we would also hope to develop links with mental health services so that it is easy to sign post people to seek more formal help when that it is needed.

Question 17

What individual and group therapies, who will receive them and who will deliver them?

Response

A range of therapies are already delivered across North Central London and it would be our intention to continue this and to improve access to psychological interventions as part of the implementation of the STP.  It is however too early to be able to give a detailed answer to this question.

Question 18

Are you planning to close all psychiatric inpatient sites other than St Pancras and St Anne’s?  If there is a reduction in hospital beds, how will you ensure there is no increase clinically avoidable suicides and monitor this situation?

Response

A key aspect of the STP for mental health is the redevelopment of the St Ann’s site which will achieve a much needed improvement in the quality of inpatient provision in the northern part of the sector.  It is anticipated that alongside this there may be some consolidation of inpatient provision.  The details of this are not yet fully determined and it is not intended to reduce the number of current beds.  Camden and Islington Mental Health Foundation Trust is also looking to develop new world class inpatient facilities to replace the wards at St Pancras, alongside the development of new community premises to provide easy access and high quality care and treatment for our service users. The St Pancras wards were originally built as workhouses in the 19th century, and do not work for modern, high quality inpatient care. No decision has been made on re-location of facilities - the trust is currently considering options and examining potential sites, including St Pancras.

Alongside this, there are plans to invest in strengthening community provision such as crisis cafes, recovery houses and home treatment teams which help provide appropriate alternatives to admission.   The impact of these changes will be monitored closely and clinically avoidable suicides would be a key issue for all providers in the sector.

Question 19

What level of resource do the draft plan makers think is needed to provide sufficient interventions in all the areas of population health improvement so as to assure the success of their changes? What happens if population health cannot be sufficiently improved even though hospital based services have been reduced?

Response

The draft plan sets out the initial financial analysis of required investment and the projected activity and financial impact over the period to 2020/21. We are continuing to work on the details of the draft plan and will publish an updated version in early April 2017.

We will closely monitor the impact of any interventions and investments that we make to ensure that we are able to assess delivery. Clearly, we will amend the approach if the impact is not as anticipated.

Question 20

On a scale of zero to 10, with zero signifying no confidence and ten signifying unqualified certainty, how confident are you that you will be able to deliver on this commitment?

Response

The STP is work in progress and we recognise that we have much more work to do to deliver the vision we have set out.

We are taking steps to stabilise our financial position, developing more detailed ideas in the areas we have not yet fully explored. We have agreed on the priorities for implementation in the first two years of the STP so that we focus initially on the improvements that can be implemented quickly and have the most impact on our aims.

At the same time, we are clear that we cannot lose focus on the longer term transformation that will support sustainability. There remain many issues to resolve and we know we do not have all the answers.

We are determined to succeed and have assembled a highly qualified and committed group of people to lead the workstreams. We will continue to work with the NCL community. Those people who use services, our residents and our staff to find new and better ways to deliver health and care now and  in the years ahead.