2019

Healthier Lives in North Central London

NORTH LONDON PARTNERS NOVEMBER 2019

DRAFT

Contents of this document

Overview and introduction to our collective plan:

1. Introduction and purpose of this document

2. The population in North Central London is diverse and vibrant

3. There are many partners delivering our health and care services in North Central

London

4. We want residents to start well, live well and age well

5. We have been listening to what residents have told us is important

6. What will working in new ways mean for residents?

7. We will work as partners to integrate care

8. To deliver this, we need to spend public money in the best possible way as well as fix

the basics

9. We need to shift our focus to prevent ill health the factors that cause it

10. Supporting individuals to have personalised care for their whole needs

11. We need to plan services on a population basis

12. We need to support the development of out of hospital care and have our hospitals work

together more often

13. What happens next?

14. How can I share my views and help shape the plan?

Detailed sections on the changes we want to make:

Working more effectively as a system: Section 1. Listening to residents and communities Section 2. Through working as partners to integrate care Section 3. Moving to population health planning Section 4. Embedding personalisation

Detailed service transformation plans:

Section 5. Integrated out of hospital and community care Section 6. A simplified urgent and emergency care system Section 7. Improved cancer services Section 8. Coordinated Mental Health services and improved outcomes for our population Section 9. Transformed outpatient care with shorter waits Section 10. Evidence based action to prevent ill health Section 11. A more coordinated approach to children’s care Section 12. Focused work on improvements to care for learning disabilities and autism Section 13. Coordinated and proactive care for people with long term conditions Section 14. Delivering better births through improved maternity services Section 15. Managing medicines effectively and Pharmacy working in new ways

Supporting the delivery of these changes:

Section 16. Tackling the workforce challenges across health and care

Section 17. Taking advantage of the opportunities of digital technology

Section 18. Managing our estates in a coordinated way

Introduction and purpose of this document:

Our aim is to help residents to live the fullest lives possible, stay well, and to recover from ill

health more quickly. We want to tackle the long-standing problems in North Central London

(NCL) that mean some residents experience inequalities in their health.

The organisations that provide health, care and voluntary services in Barnet, Camden,

Enfield, Haringey and Islington (North Central London) are working together to try and have

the greatest positive impact on the lives of our 1.5 million residents. This document sets out

what we are aiming to achieve together to deliver improvements over the next five years,

and what this will mean for residents.

This plan will be the basis for continued engagement and the development of more detailed

work with our staff, local residents and our partners.

The health and care system has never been busier, caring for an ageing population with

more complicated needs, supporting people with long term conditions, and providing access

to new treatments that are more expensive. We know that families work hard to pay their

taxes and that’s why we will make sure every penny is invested on the things that matter

most, by getting the basics right, providing high quality lifesaving treatment and care for

patients and their families, reducing pressure on our staff and investing in exciting new

technologies.

To do this, we will work with partners to integrate services where this improves care and

reduces waste, spend public money effectively and support our staff to work in new ways

and improve the lives of our residents and communities.

For residents, this means that it will be easier for you to get the support and care that you

need. More care will be closer to where you live, with less time spent in hospital, if you need

to go there, and you will be actively involved in shared decision-making about your health

and care.

In this document, you will find:

A summary of our population and the services we provide

What we want to achieve for our residents over the next five years

How we need to work differently as partners to help residents start well, live well and

age well

How we will change services to:

o Develop a wide range of out of hospital and community services to improve

health and wellbeing of residents and communities

o Ensure hospitals will work together more often to deliver excellent, efficient

services

We have also included further detailed sections outlining specific changes over the

next five years in detailed sections on:

o Integrated out of hospital and community care

o A simplified urgent and emergency care system

o Improved cancer services

o Coordinated Mental Health services and improved outcomes for our

population

o Transformed outpatient care with shorter waits

o Evidence based action to prevent ill health

o A more coordinated approach to children’s care

o Focused work on improvements to care for learning disabilities and autism

o Coordinated and proactive care for people with long term conditions

o Delivering better births through improved maternity services

o Managing medicines effectively and Pharmacy working in new ways

This is supported by information on how we will deliver these changes through work

to:

o Provide better support for our staff across health and care

o Take advantage of the opportunities of digital technology

o Manage our estates in a coordinated way

o Ensure finance supports the changes we need to make

This plan builds on work we have already started, (see our 2017 plan here) and sets out how

we will continue in our work to deliver the national priorities outlined in the NHS Long Term

Plan.

Across North Central London, there are lots of great examples of how we have already been

working closely together to improve the lives of residents:

We’ve already developed integrated networks based around GP practices: this will

make it easier to get appointments in primary care and the community and will help

to improve the quality of care, such as improving proactive community support for

residents of care homes to avoid hospital admissions.

We’ve worked to help make sure people are treated closer to home: for example, we

have invested in a unit to treat women who require intensive mental health care

closer to their family and communities, and residents are able to refer themselves to

a physiotherapist in their GP surgery.

We have worked with local authorities to support improved care in care homes by

supporting those working in care homes to access training that helps them support

residents.

We’ve worked in collaboration with partners to launch asthma friendly schools

training teachers to support children with asthma manage their health.

We’ve been working to simplify urgent and emergency care: ensuring more residents

and clinicians calling 111 speak to a clinician, as well as making discharge from

hospital quicker and safer.

We’ve been improving planned care and outpatient care: GPs can now access

specialist advice without referring a patient to hospital.

We’re using workforce and digital to drive and support change: we’re investing in

joining up health and care records to better organise care and launched a portal to

support recruitment of social care staff.

We want to keep what is working well, and make changes where we think we can do better

for residents by working differently and more collaboratively with partners.

We want to involve communities and staff in how we to continue to improve this plan. Please

see the section 1 for how to get involved.

The population in North Central London is diverse and vibrant…

North Central London is a great place to live and work and we want to ensure all local

people have an equal chance to live a healthy life here. It is a diverse area with vibrant

communities. North Central London is home to many of London’s historical and cultural

landmarks, and has excellent sporting facilities, green spaces and cuisine from around the

world.

The total estimated resident

population of NCL in 2019 is

approximately 1.5 million

people. Over 11% of our

population is aged over 65,

ranging from around 9% of

the population in Islington to

around 14% in Barnet. The

population is expected to

increase by 9% over the next

decade, with the fastest

growth expected amongst

those aged 65 and over, by

28%.

Poverty and deprivation are key

determinants of poor outcomes in health

and wellbeing, with higher levels of

deprivation linked to numerous health

and social vulnerability including chronic

illness and behaviours that pose a risk to

good health. 30% of NCL children are

growing up in poverty1. There continues

to be growing demand for housing and

increasing levels of homeless

households. Housing is often one of the

main causes of poor health and

wellbeing.

1 NCL Sustainability and Transformation Plan – Case for Change – September 2016

Levels of ethnic diversity vary across NCL,

ranging from 32% of people in Islington from

a Black and

Minority Ethnic (BME) group to 44% in

Enfield. The largest BME communities in

NCL are Turkish, Irish, Polish and Asian

(Indian and Bangladeshi) people. There are

also high numbers of people from Black

Caribbean and African communities,

particularly in Haringey and Enfield. The

number of people from BME communities is

much greater in younger age groups.

Health needs vary across BME communities. For example, there is a greater risk of

diabetes, stroke or renal disease for some BME people compared to White British people;

and people from some BME communities, including Black Caribbean, African and Irish

communities, use hospital services more frequently. The number of BME people across NCL

is expected to increase slightly from 37% in 2012 to 38% in 2020. The biggest increases in

BME communities are forecast in Barnet and Enfield.

Overall, around a quarter of people in NCL do not have English as their main language.

This diversity presents challenges, both in addressing potentially new and complex health

needs, and delivering accessible healthcare services.

All NCL residents have seen an increase in life expectancy over the past decade, with

current life expectancy for men and women higher than the England average, with the

exception of Haringey and Islington. There are stark differences in life expectancy between

those living in the most affluent areas compared to the most deprived. Across the NCL

boroughs, Camden has the highest life expectancy gap for men, with those living in the most

deprived areas living on average 10 years less than the least deprived.

Despite the higher life expectancy, overall, residents spend approximately 20 years of their

life living in poor health. Trends in healthy life expectancy show there has not been a

significant change in the number of years people are living healthy lives.

Significantly

better than

England

average

No significant

difference

compared to

England

average

National

Comparison:

It is estimated that there are 211,000 people living in NCL with a disability2. There is a total

of 17,550 people in receipt of carers allowance across NCL in 2018. This equates to 1.5% of

the total 18+ population. Of all the 5 NCL boroughs, Enfield has the highest percentage of

people receiving carer’s allowance (1.9%), and Barnet the lowest (1.1% of the total

population).

We recognise that to reduce health inequalities and improve the health and wellbeing

outcomes of our most vulnerable residents we need to work with communities themselves,

including through the voluntary and community sector. Engagement with local people and

understanding their needs is central to how we are developing our plan and services. Please

see section 1 on listening to our resident and communities for more detail.

There are many partners delivering our health and care services in

North Central London…

NCL is a diverse area covering five local authorities and Clinical Commissioning Groups, 12

NHS Trusts and 203 GP practices, as demonstrated by the diagram below.

In addition to this, we know there are 230 care homes, over 100 care home providers, and

countless voluntary sector organisations and community groups providing essential support

to communities and some of our frailest residents outside of hospital.

2 2017/18 Family Resource Survey (FRS) estimates that there are 14% of people aged 16-74, and over living with a disability in the inner London region. According to FRS, a person is considered to have a disability if they

have a long-standing illness, disability or impairment which causes substantial difficulty with day-to-day activities.

These partners work to meet the health and care needs of all local people, delivering a wide

range of services. Across NCL, each year there are:

523,000 GP appointments

22,600 babies born

1,454 A&E admissions due to childhood asthma

5,000 people in residential care or nursing care homes

16,000 people being supported with community care to stay in their own homes

122,410 people living with long-term conditions

12,000 orthopaedic operations

The health and care that we need to provide to local people is changing. People are living

longer, and many have long term conditions, such as diabetes, heart disease, dementia or

respiratory disease. We need to provide care that meets these changing needs and

understand what will help local people live healthier lives.

We recognise the important role that health and care services play within the local economy

as employers and part of local communities. Our staff are our greatest asset, and are as

diverse and varied as our communities, with a broad range of skills and experience. We

need to value and support them to work differently, for example in multi-disciplinary teams

where doctors, nurses, physiotherapists, health visitors and social care teams will work

closely together to support communities.

We want residents to start well, live well and age well…

Evidence shows that as little as 10% of a populations health and wellbeing is linked to

access to health care. We need to work with partners to look at the bigger picture, including:

fulfilling work

our surroundings

money and resources

housing

education and skills

the food we eat

transport

the support of family, friends and communities

As partners, there is a clear case for evolving the way we plan and provide health care and

other services to focus on the needs of populations, communities and individuals rather than

the institutions that deliver care.

To do this, we will need to work differently as partners to address the underlying challenges

we face in North Central London, and to make the best us of our people and other resources

to deliver the best possible outcomes for NCL residents.

We have been listening to what residents have told us is

important…

From a wide range of engagement with residents and communities across North Central

London we have heard what is important to local people.

We have listened to these priorities and concerns and thought about where these priorities

can be included in our plans to improve. Below are some examples of how we are taking

these forward:

Residents’ priorities Some examples of what we are doing…

Better access to services

Introducing care navigators to signpost

people to the right services

Embedding a ‘no wrong door’ approach to

mental health care and support

Patients involved in discussions and shared

decisions about their care

Children and young people with epilepsy

and their families being involved in the

development of local epilepsy services

Access to clear and accessible information,

including easy read versions and access to

interpreters

Healthy Futures providing clear, accessible

information for people with diabetes on how

to look after their condition

Empathy and understanding around cultural

or disability-related needs

Trialling a new pathway for women who do

not take up a smear test by offering them a

self-sampling kit

Patients given knowledge about how to

keep themselves well and support

wellbeing

Social prescribing in GP practices to

support people to stay active, eat well,

reduce isolation and contribute to their

communities

Patients given choice and care is planned

and delivered to meet each individual’s

needs

Residents supported to have personal

health budgets, including for mental health,

to best meet their individual needs for care

Use of technology both to increase access

to services and to health information

Residents to have access to online

consultations and video consultations

Better joint working between health and

social care

Working across NHS, public health and

social care to identify people at risk of

conditions, such as diabetes,

cardiovascular disease

A focus on prevention and proactive care

Increase community teams and ensure

physical health checks for adults with

serious mental illness and learning

disabilities are being carried out

Everyone gets the same care, regardless of

where they live

Whole system approach to tackle some

issues, such as childhood asthma, to

ensure everyone gets the same high-quality

care

You will find more detail on all of these in the each of the detailed sections on service

changes.

What will working in new ways mean for residents?

To bring these changes to life, we have worked with partners to develop a resident’s story

for each of the speech bubbles above. Below are Joan’s and Ali’s stories, for all the other

residents’ stories, please see our public facing leaflet here (link here).

We will work as partners to integrate care…

Where we can have a greater impact and there is a benefit for residents, we will work

together as partners rather than acting as individual organisations.

We have fantastic organisations with nationally recognised and world class services and we

need them to continue this amazing work and spread this best practice across North Central

London. For example, NCL has some of the most advanced radiotherapy services in the

country, with a number of large specialist centres, and one of only two proton beam units in

the country (at UCLH).

Our partnership will work to build on the strengths of organisations and their staff. We

recognise the important role that health and care services play within the local economy as

employers and part of local communities.

We will work together to simplify how the system works for residents and staff and plan and

deliver better services, that meet the needs of residents and their communities. Our

clinicians are part of wider networks across London, as well as within North Central London,

to share learning, spread best practice to improve the quality of services so that residents

will have access to the same care across the system.

Integrated care means teams and organisations that are responsible for health and care

working together, sharing resources and information to support the needs of individuals,

increasing our impact and reducing waste, and delivering our collective North Central

London vision locally. This integration of health and care services will happen in different

ways:

• Teams work together as partners at a neighbourhood level. This will mean

teams, with staff from across health and care, working to proactively support you and

your communities to stay well and live full lives. For example, GP practices will be

working with care workers and health visitors to make sure residents have access to

support around employment and community activities where this will support them to

live fuller lives, in addition to any clinical care they might need.

• Borough partnerships will work at a borough level to plan, coordinate and

develop services to best meet local community’s needs. For example, working

as partners to ensure that an area with a large proportion of older people has the

right level of health and care services and that these teams work closely together as

a single supportive service, rather than as separate organisations.

• There will be some pieces of work where partners work together across North

Central London – we are calling this ‘system working’. This will be where we

work together to tackle long term issues where no one organisation can solve it on

their own. For example, working together to tackle air pollution or reduce childhood

obesity. It will also mean working together to reduce unnecessary paperwork. For

example, having a single health and care record so residents don’t have multiple files

at different organisations.

This will require us to work with partners across health, the public sector and voluntary and

community groups, more information on how we are developing an integrated care system

can be found in the detailed section on this topic.

To deliver this, we need to spend public money in the best possible

way as well as fix the basics…

Across NCL we collectively spend over £4 billion per year on our health and care services.

We need to make sure we are making the best use of this money.

We also know that not everything in the health and care system is as well organised and

works as well as we would like.

We are committed to fixing the basics across the health and care system. We know that

these make a big difference to residents’ experience of care and tackling these will also

reduce the costs to the system. As part of our work on this plan, partners have agreed to

make sure they are working as efficiently and effectively as possible. We need to get the

basic things right first time to make our more ambitious plans successful. This includes

efficient administration and organisation, clear and accessible patient information, residents

able to access the services they need and health and care professionals having the right

equipment and information to do their jobs well.

To do this, we need to work together as partners to:

• Reduce waste in the system – for example, reducing the need for unnecessary

repeat tests by joining up information across the system, and reducing the number of

cancelled operations through better coordinated care across organisations.

• Support staff, our biggest asset, to work in new ways – for example sharing

nurses across organisations, placing pharmacists in GP surgeries, and developing

multi-disciplinary teams across health and social care.

• Invest in proactive care, support people to better look after their own health

and prevent ill health through closer working – for example, making sure people

with high blood pressure have the right medication early, and working across health

and social care to ensure older people can live in their community and stay active.

We need to shift our focus to prevent ill health the factors that

cause it…

This plan sets out both how we will treat people when they need it, and prevent them from

getting ill in the first place.

We want to support people to live longer, healthier lives by helping them to make healthier

lifestyle choices and treating avoidable illness proactively.

Much of the burden of ill health, poor quality of life, and health inequalities in North Central

London is preventable. Between 2012 and 2014, an estimated 20% (4,628) of deaths in our

community were from preventable causes.

By focusing on helping people to stay well, we will improve health and wellbeing outcomes

for our whole population, reduce health inequalities, and help manage demand for health

and care services in both the immediate and longer term. We know that better quality

housing and good quality employment helps improve the quality of life and our ambition is to

work with partners to improve these for communities in North Central London.

While an integrated service offer means patients can access help ranging from talking

therapies and medicines management, to assistance with day to day tasks and help with

social and housing needs and advice on benefits. For example, specialist mental health

support for older people provided by Camden and Islington brings together a team including

specialist inpatient and community health professionals and social workers to support

patients to manage their mental and physical health needs.

To tackle this we will…

Work as a system to tackle the wider determinants of health: Through partnership

working we can tackle issues that no one organisation can solve on their own, through

integrated planning such as air pollution and social isolation.

Embed evidence-based prevention and early interventions across the whole health

and care system to tackle risk factors such as smoking, alcohol and obesity. This will

include working with council services, social care and the voluntary and community sector to

maximise the impact we can have.

Work to become more proactive in the care we provide to residents. For example,

through earlier detection of disease and optimising treatment, such as atrial

fibrillation and hypertension, to prevent deterioration or episodes of ill-health, such

as heart attack or stroke. This proactive approach to prevention is embedded across our

service transformation programmes.

This includes maximising the opportunities that patient contact and hospital admissions bring

to help people to improve their health.

Below is a diagram showing our approach to prevention across the partnership. You can

read more about the specific interventions we will deliver in the detailed section on evidence

based action to prevent ill health.

Supporting individuals to have personalised care for their whole

needs…

Personalised care gives people the same choice and control over their mental and physical

health they have come to expect in every other aspect of their life.

Personalised care helps a range of people, from those with long term illness and complex

needs through to people managing mental health issues or struggling with social issues

which affect their health and wellbeing. It helps them make decisions about managing their

health so they can live the life they want to live based on what matters to them, working

alongside clinical information from the professionals who support them.

This is in response to a health and care system that in some circumstances simply cannot

meet the increasing complexity of people’s needs and expectations. Evidence shows that

people will have better experiences and improved health and wellbeing if they can actively

shape their care and support. For example, a specialist hospital admission was successfully

avoided through the deployment of intensive community support and creative use of a

personal budget to help a 13 year old patient with autism and an eating disorder.

To do this we will be embedding new ways of working such as shared decision making and

personal health budgets so they can control their own care, improve their life experiences

and achieve better value for money. By 2020/21 we will have recruited 30 social prescribing

link workers in Primary Care Networks to support patients across NCL, including to access

non-medical support and this is planned to grow to 148 in 2023/24.

We need to plan services on a population basis…

There is huge potential to use data, insight, and evidence more systematically and effectively

across our local public services in North Central London. This will help to improve the health

and wellbeing of our patients, residents, and communities, reduce health inequalities, and to

make more efficient use of our resources.

While there are some pockets of good work, our approach to using data and analytics has

historically been fragmented. This means that we are not routinely using data and analytics to

drive change in population health outcomes at scale, or to identify ‘gaps in care’ and

opportunities for quality improvement. There is great opportunity to use data to proactively

enable improvements in place-based systems, such as boroughs and neighbourhoods,

including on the wider determinants of health. .

We have already made some progress and we have big aspirations to change the way we

collaboratively work together, including with communities, patients and residents, to make

improvements. While appreciating the need to understand ethical risks and acceptability, we

also want to capitalise on the emergence of newer digital and analytical technologies, such as

machine learning. We also want to make best use of the capabilities of our partners outside

of North London Partners, including those at regional and national levels, and within local

academia and other organisations to make this a success.

We consider this a key and cross-cutting enabler to achieve our ambitions for better health

and wellbeing within our long term plan — that will also allow us to measure and evaluate

impact — which is why we are prioritising it. You can read more of the detail in the section on

population heath here xxx.

We need to support the development of out of hospital care and

have our hospitals work together more often…

We want to invest in and boost out of hospital care, centred on the needs of communities. We

now have integrated networks of care for the whole population in North Central London, based

around GP practices and these are the focus for bringing health and care professionals

together to provide proactive, well organised care close to home.

We are investing in those networks to develop capacity to treat people for their non-clinical

needs, for example, through the creation of new roles such as social prescribing link workers

and clinical pharmacists. This will support closer collaboration with community services,

enabling more proactive care as well as a more rapid response in a crisis.

We also want to support hospitals working together more often to deliver improvements to

care. In North Central London we have some world class hospitals and we know that through

sharing valuable staff and working in a more coordinated way, we could cancel fewer

operations and provide better quality care to more people.

Working as a partnership allows us to understand where we can change services to improve

care, involving residents in how we make these changes to the benefit of local communities.

An example of this is the work we have been doing to review orthopaedic services, where a

proposal for new ways of working would reduce the number of cancelled hip and knee

operations and provide higher quality care for patients.

What happens next?

Some of the changes outlined in the previous pages will take some time to deliver. Below are

a few examples of when you might expect to see improvements in your care.

As partners, we are going to be working to deliver the detailed plans set out in the appendices

of this document. As part of this, each year, we will share our plans for the year through

organisational boards and meetings. This will help us to know if we are on track to deliver what

we have set out in our plan.

We will also share progress, good news and stories on our public website.

How can I share my views and help shape the plan?

The plan will only be successful if it is based on the lived experience of residents and

communities and designed and supported by those who work in the health, care and

voluntary services in North Central London.

We want partners, staff and residents to review and help us develop our plan. We will also

be developing measures based on what residents tell us is important – this will make sure

we can monitor our success and determine if we are achieving our aims. We want your help

with this.

You can get involved:

• By joining our Residents’ Health Panel:

https://conversation.northlondonpartners.org.uk/

• In developing your local borough Integrated Care Partnership:

www.northlondonpartners.org.uk

• Review our more detailed plans: www.northlondonpartners.org.uk/draftresponseLTP

• Get updates on progress by signing up for our newsletter:

https://mailchi.mp/d5a0aa77bde9/signupnewsletter

Our detailed plans for services:

Please find our detailed plans below. These have been developed through working with

clinicians and staff across the partnership and represent our current plans. They will

continue to develop and improve as we engage with residents, partners and staff.

Working more effectively as a system: Section 1. Listening to residents and communities

Section 2. Through working as partners to integrate care

Section 3. Moving to population health planning

Section 4. Embedding personalisation

Detailed service transformation plans:

Section 5. Integrated out of hospital and community care

Section 6. A simplified urgent and emergency care system

Section 7. Improved cancer services

Section 8. Coordinated Mental Health services and improved outcomes for our population

Section 9. Transformed outpatient care with shorter waits

Section 10. Evidence based action to prevent ill health

Section 11. A more coordinated approach to children’s care

Section 12. Focused work on improvements to care for learning disabilities and autism

Section 13. Coordinated and proactive care for people with long term conditions

Section 14. Delivering better births through improved maternity services

Section 15. Managing medicines effectively and Pharmacy working in new ways

Supporting the delivery of these changes:

Section 16. Tackling the workforce challenges across health and care

Section 17. Taking advantage of the opportunities of digital technology

Section 18. Managing our estates in a coordinated way