North London Partners in health and care

STP Newsletter - October 2018

World Mental Health Day – 10th October 2018 


Tomorrow is World Mental Health Day. This year’s focus is on young people and mental health in a changing world. 

Let’s talk young people; millennials, Gen-z, the i-Pad generation. I do not believe in a snowflake generation, I believe the world is changing and changing so fast that our young people are struggling to cope with new responsibilities, new expectations, peer pressure, to make sense of all the changes and to look after themselves at the same time. 

Here are some thought-provoking facts: 10% of children and young people (aged 5-16 years) have a clinically diagnosable mental health issue but the average delay between a young person first showing symptoms of mental ill health and getting help is ten years. 1 in 10 primary school children say they suffer from a low sense of wellbeing. Suicide is the most common cause of death for people aged 5-19. Read that last sentence again. It’s, well, shocking, isn’t it? 

We cannot ignore the rising number of children, and young adults who are frightened, confused and struggling to cope, who are struggling to find meaningful support.


My name is Chris and I lead the mental health programme of the North Central London STP. During my years of working in psychiatric hospitals, on wards and in the management offices, I was always committed to my patients. Now, working across the five boroughs of NCL, I am committed to the people, the residents of north central London - young and old, in all walks of life. I would like to take time to talk about what we’re doing to help our children and young people, our future generations and tomorrow’s leaders. 

Mental ill health often starts in young adulthood. It is vital that we give children and young people access to the support they need to grow up happy, healthy and resilient. As a father, I cannot imagine the confusion and helplessness my children would feel if they were experiencing mental ill health and I cannot imagine how I would have the strength and patience to help them through the “darkness”. 

Children and young people are resilient, teenagers can be challenging but there are some key signs to look out for that may indicate that there is more going on than the usual changes in mood and personality. Anyone who works with or cares for a young person has the opportunity to play an active role in supporting their mental wellbeing. Starting a conversation that is supportive and non-judgmental with them can be the first step on that journey to support. 

There are some simple things you can do to help children and young people you meet, including:

  • Read these tips on how to start a conversation
  • Download this list of resources for young people
  • And please do and share this slide deck with your colleagues. 

So let’s talk about the issues that young people are facing in the world today and start the conversation about what they need to grow up happy, healthy and resilient. After all, as Frederick Douglass said: "It's easier to build strong children than repair broken adults".

STP news: successes and achievements

We are committed to being open and transparent about the work we are doing across health and social care as a partnership of 21 organisations in North Central London (NCL). We encourage you to forward this newsletter to your teams and more broadly within your organisation.

ICS simulation event

Last week I hosted an event to start thinking about how integrated care systems (ICSs) could help north central London (NCL) overcome some of the challenges facing health and care services in NCL and improve the health and wellbeing of our local population. 

In ICSs, NHS organisations, in partnership with local councils, and others, take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve. 

We’re at a very early stage in our thinking but the potential benefits of ICSs are significant. However, no matter how strong our ambitions, designing ICSs that suits our needs and circumstances and those of local people remains a complex endeavour.  

With that in mind, we wanted to “bench test” or simulate how the arrangements might work as soon as possible, drawing on the experience and judgement of wide range of people with a range of expertise and interests who work across the STP. 

The ICS simulation event was the result. It provided us with insights about how integrated care might theoretically work and with some ideas about how we might be able to make it work in our “real world”. 

I’ll be continuing to work with the team to develop this work and will make sure we keep you up to date as things progress. We are at a very early stage of this work and will be talking widely to all stakeholders over the next few months.

Stop smoking in Stoptober

Stoptober, the national stop smoking campaign which encourages smokers to stop smoking for 28 days, launched on 20th September. The campaign presents the quitting process as a more manageable 28 days and rallies people around a specific date to get started. 

This year, the approach will help smokers to boost their chances of stopping smoking by getting prepared with the best support tools for them. 

Smokers will answer three questions to get a tailored recommendation on the stop smoking support that will work best for them. As talking to a trained advisor gives smokers the best chance of stopping smoking successfully, local stop smoking and pharmacy services will be prominently signposted in the results. 

Partners can download or order free resources from the Public Health England website.  

Embedding prevention within North Central London STP

We attended the NCL Joint Health Overview and Scrutiny Committee on 5th October to talk about how we are embedding prevention within the STP’s work. Our presentation explains why we need to focus on preventing ill health and what projects were are focusing on as part of the STP. 

Work in prevention remains ongoing at local level. As we seek to embed prevention even further, we’d like your views on how we do this and areas that are missing. This slide deck contains contact information at the end so do please read it, have a think and get in touch with your thoughts.

Adult social care prevention and early intervention in North Central London: using free text analytics and novel data to build predictive models

By Sarah Dougan, Chief Analytical Officer - London Borough of Islington

To make the shift to prevention, early intervention and to create a sustainable health and care system, we need the capability to better predict demand and escalation of needs. The evidence has identified a lack of good predictive models for adult social care. 

North central London local authorities, along with partners at LSE, UCL and NEL CSU, have been successful in their bid to secure funding from NHS Digital to look at the use of free text analytics and novel data in predicting adult social care demand across health and care. The proposal was ranked first out of all of the applications NHS Digital received in this category. 

Our hypothesis is that to robustly predict adult social care demand, we need other information in addition to linked, structured NHS and adult social care data. This includes: other data held by councils (e.g. housing); household-level data (e.g. main carer going into hospital); and most importantly, the large amount of ‘free-text’ data collected by social workers during their interactions with clients. This unstructured data is recorded within care records (e.g. assessment forms) and contains much of the contextual and rich descriptions of clients’ needs and their care use. 

Our objective is to work towards building a novel and comprehensive dataset that makes use of structured and unstructured data from across the local public sector system and includes the key predictors of adult social care needs and demands at individual and household levels. We will focus on older care recipients given that the rapid growth of the ageing population will drive future demand for support. This is an ambitious project, and at this stage we will seek to test whether we can identify the predictive variables from all of these sources in sample data from across north central London. This will be alongside robust information governance and with good understanding of resident acceptability and ethical considerations. We will also design it so we can sustainably scale this up at pace across north central London. 

Subsequently, we would use the north central London-wide dataset to build predictive models of adult social care demand which will support the cost-effective reconfiguration of local services, for instance in terms of the balance between community, institutional, and hospital care. This would all be done with proactive consideration of residents’ expectations of how their data may be used and the ethical considerations associated with prediction. 

For further information, please contact the SRO Dr Sarah Dougan ( or project lead, Mahnaz Shaukat (

Supporting Patients’ Choices to Avoid a Delayed Discharge

The ‘Supporting Patients’ Choices to Avoid a Delayed Discharge’ policy will be operational across north central London from Monday 15th October to help improve the way patients are supported to avoid delayed discharges from hospital.

This policy has been developed for staff to ensure that patients, families and carers are provided with accurate information and effective support throughout the discharge planning process. This policy will also support health and social care organisations to reduce the time people spend in hospital when they are ready to depart and no longer need acute care, but are delayed whilst making decisions about or making arrangements for their ongoing care. 

The primary driver behind this policy is the importance of preventing patients from spending longer than they need to in an acute bed. Too many people are unable to leave acute, rehabilitation or palliative beds when they no longer require that care. Evidence demonstrates that people’s physical, mental ability and independence can decline sharply when staying in hospital for non-acute care, and that risk of hospital-acquired infections also increases.  Research has shown that for people aged 80 years and over, 10 days spent in a hospital bed can result in significant muscle wasting. 

In addition, severely ill patients may be unable to access services if acute, rehabilitation or palliative beds are occupied with patients whose care can better be managed in another care setting. 

This policy has been developed by the Urgent and Emergency Care Simplified Discharge clinical leads for the North Central London Sustainability and Transformation Partnership (STP) with support from colleagues across health, social care and voluntary organisations. The policy has been formally endorsed by the North Central London Health and Care Cabinet, North Central London Directors of Adult Social Services and the North Central London Urgent and Emergency Care Programme Delivery Board. 

The policy will be operational from Monday 15th October 2018 across north central London.  To support implementation we will be holding training sessions for both health and social care operational leads. These sessions will help colleagues understand the key principles of the policy and how to put these into practice locally. Session details will be made available shortly and colleagues should contact Yewande Sangowawa to register interest. 

Please find a link to:

Clinical Advice and Guidance

It has been four months since we launched the Clinical Advice and Guidance (CAG) Service across NCL. The service is for GPs to use when they are considering making a hospital referral but are not sure that it is the correct course of action. 

At our latest CAG Project Group we reviewed our new dashboard. The headline information for July 2018 is:

  • There were 787 advice and guidance requests in NCL – that is an increase of 20% on June.
  • The Whittington is the best performing trust for providing responses within two working days – achieving 78% against a target of 80%.
  • The top three specialties receiving requests are Cardiology, Haematology, Gynaecology.
  • The target to attain advice and guidance across specialties covering 75% of GP referrals has been achieved by North Middlesex University Hospital (85%) and Royal Free London Hospital (100%). The Whittington Hospital and University College London Hospital are on track to meet the deadline by the end of November 2018. 

A few reminders to help us get the most out of the service:

  • As we pay for every response CAG should only be used for clinical advice and should not be used for general communication.
  • The e-Referral Service (e-RS) platform retains thread indefinitely in primary care (if actively saved) but it’s archived after six months in secondary care.
  • GPs are expected to complete their audits as part of the Locally Commissioned Service by the end of October 2018.
  • Acute trusts will be completing their audit of CAG by the end of October 2018.
  • If you are experiencing delays in receiving a response, we have produced guidance on how to resolve. 

The outputs of the audits will inform a clinician-to-clinician event in December to help further develop the service. We will bring you an update early next year on the results of the audit and the event.

For more information please contact:

Improving asthma services for children and young people across north central London

The Children and Young People’s Programme has four key priorities, all of which focus on improving health and care outcomes for children and young people across north central London (NCL). The programme will deliver the following important improvements: 

  1. Children and young people across NCL will be able to access surgery in a safe, consistent, timely and effective way, as close to home as possible
  2. Children, young people and families with asthma will receive the appropriate treatment, at the right time, in the right place and helped to stay as healthy as possible
  3. Children, young people and their families will be enabled to access appropriate community services as early as possible and reduce the need to attend A&E
  4. Children with complex medical needs, as well as those with complex and challenging behaviours, will be better supported across the system in a more consistent, effective and flexible way so that they stay as well as possible in their community 

As part of our second priority, the NCL Asthma Network has focused on developing a system-wide response to improving the way asthma is managed across our partnership. Significant work has already been undertaken, including the development of a single Asthma Pathway across NCL and participating in the #AskAboutAsthma campaign last month. 

More recently we built on that work as a partnership when we held an asthma logic model workshop which was attended by nearly 40 professionals from a range of agencies including secondary and primary care, public health, education, children’s social care, housing and environment services.

The workshop supported our partnership to understand the shared challenge that asthma presents and helped us to develop ways in which we can tackle the impact of asthma by both improving the way asthma services support children and young people, whilst also addressing the social and environmental issues that can trigger asthma. 

The outputs from the workshop will support the development of a system-wide plan, with key agencies taking responsibility for delivering interventions and improvements which will improve outcomes for children and young people with asthma. 

For more information, contact me at:

Diabetes Transformation Programme Bulletin

The North Central London Diabetes Transformation Programme was introduced in the August STP newsletter and briefly outlined the three work-streams:

  • Improving achievement of NICE-recommended treatment targets for diabetes
  • Expanding Diabetes Inpatient Specialist Nurse capacity
  • Establishing a single point of contact for people with acute diabetic foot conditions (as part of the Multi-Disciplinary Foot Team)A bi-annual bulletin has been prepared to hear from the leads working on each of the programme areas and report in more detail on the latest achievements. We hope you enjoy reading the first edition of the bulletin here.

For more information contact: 

Gateway-C is here!

GatewayC is an online cancer education platform for primary care professionals, accredited by the Royal College General Practitioners (RCGP) and endorsed by Cancer Research UK. The UCLH Cancer Collaborative is providing free access to all GP practices in north central and east London to GatewayC for up to a year. 

GatewayC has been developed by GPs and other specialists and aims to help increase the proportion of cancers diagnosed at stage one and two, reduce emergency presentations and support patients living with and beyond cancer. Modules are built around films based on real patient consultations, supported by interactive features. RCGP CPD credits can be claimed for all GatewayC modules. 

Register at to get your login details and begin your learning now!

For further information please contact 

Related news

BarnetCCG Annual General Meeting

Barnet Clinical Commissioning Group (CCG) held its Annual General Meeting (AGM) on 20 September. This was a major event for the CCG, attended by around 180 GPs representing the majority of member practices in Barnet and some members of the public. 

The CCG was proud to share its successes of the previous year which include:

  • being the top CCG in the country for improvement in one-year survival rates for cancer
  • the launch of the Barnet Dementia Hub
  • additional investment in mental health services for children, and
  • creating an additional 38,000 GP appointments through extended access. 

The audience also heard how the CCG commissions services in partnership with the local authority and within the context of the North Central London STP and the challenges in planning and buying services for Barnet residents over the previous year. 

Kay Matthews, the CCG’s Chief Operating Officer outlined the CCG’s focus for this year which includes continuing to set up more Care Closer to Home Integrated Networks and designing and implementing changes to planned and unplanned community services. 

It was Barnet CCG’s Chair, Dr Debbie Frost’s last AGM as she will be standing down in the New Year and taking up a new position within NHS England (London). We’d like to take this opportunity to thank Debbie for her many years of dedication and service to Barnet CCG and to the STP and wish her the very best of luck in her new role. 

Integrating care for every community

Our health and care needs are changing, with more people living longer often with multiple long term conditions. This new animation explains the challenges facing the health and care system and how partnerships are being formed between the NHS, local government and the third sector in every neighbourhood, town and area in England. These partnerships will make care more joined up, preventative and personal. By integrating services we can look after a person’s whole needs and can help people to start life well, live well and keep well. Watch and share the animation

HLP newsletter

The latest versions of the Healthy London Partners bi-monthly newsletters are available. The early September edition shines a spotlight on an independent report into the affordability of a healthy diet that meets the government’s nutrition guidelines: Affordability of the UK’s Eatwell Guide

The late September edition contains an interactive guide designed to support clinical commissioning groups, local authorities and integrated care systems across London to conduct a homeless health needs assessment

Safer Neighbourhoods survey

The office of the Mayor of London would like to know how you feel about local communities working together with the police to make neighbourhoods safer. Tell them what you think about crime, police and community activities in your area.

The survey will close at 5pm on Wednesday 31 October 2018.

North London Partners in Health and Care is now online. Visit our website at or follow us on twitter @nclstp