Sue Jeffers
Managing Director
7th October 2014
Clinical Commissioning Groups
Clinical Commissioning Groups (CCGs) are the cornerstone of the new health system.
Each of the 8,000 GP practices in England is now part of a CCG.
Each CCG is a statutory NHS body with its own governance arrangements which vary
according to its Constitution.
Each CCG is responsible for meeting the health needs of its populations and their main
focus is on local issues.
They are accountable to their GP membership and NHS England.
In 2013/14 CCGs were responsible for a budget of £65 billion, around 60 per cent of the
total NHS budget.
Hounslow CCG came into being on 1st April 2013.
• 54 practices, registered population 288,000
• Council of Members
• Governing Body
There are 9 GPs on the Governing Body
• Dr Nicola Burbidge, GP Chair
• Dr Paul Shenton, GP Vice-Chair
• 5 localities
• CCG has a £285m commissioning budget for
Central London CCG
36 GP Practices
190,000 registered population
Budget approximately £258m
Ealing CCG
79 GP Practices
339,000 registered population
Budget approximately £408m
Hounslow CCG
54 GP Practices
288,000 registered population
Budget approximately £285m
West London CCG
55 GP Practices
230,000 registered population
Budget approximately £342m
Hammersmith and Fulham CCG
31 GP Practices
190,000 registered population
Budget approximately £256m
HOUNSLOW Clinical Commissioning Group
• Responsible for planning and buying (commissioning) local
health services for Hounslow with a budget in 14/15 of
• Joint Commissioning
• Services we do commission:
- Hospital Services (inpatient and outpatient clinics)
- Mental Health services (community and hospital)
- Community Services (diabetes, ophthalmology,
dermatology, physio, community nurses, GP out of hours)
• Services we do not commission: Childhood Immunisations;
Sexual Health; Health Screening; Specialist Cancer treatment;
Dentists and Opticians; Community Pharmacy; Core GP
services; very expensive treatments (heart attacks, renal
transplant, etc.)
Where the money is spent : Main suppliers
Contract Values 2014/15
West Middlesex University Hospital = £86.4m
Imperial College Hospital
= £29.2m
Ashford St Peters
= £12.1m
Mental Health
West London Mental Health Trust = £20.9m
Hounslow & Richmond Community Healthcare
= £19.6m
Hounslow & Richmond Community Healthcare
Urgent care centre @ WMUH
= £5.0m
= 75% of CCG acute spend
= 73% of CCG MH spend
= 75% of CCG community spend
The CCG has 150+ healthcare suppliers but the market is dominated by a handful of large NHS
Service reconfiguration
More health services available out of
hospital, in settings closer to
patients’ homes seven days a week.
Whole Systems
Integrated Care
Primary Care
Patients with complex needs receive
high quality multi-disciplinary care
close to home, with a named GP
acting as care co-ordinator.
Patients have access to General
Practice services at times, locations
and via channels that suit them seven
days a week.
GP as lead for
patient care
Supported to self
manage and held
together by resilience
Community hubs
Care delivery teams
and time for care
More local
Groups of
accountable care
Access via range of
Patient’s own
GP practice
Local Authority and
Social Care
Information systems
and record sharing
More specialised
hospital care
Less inappropriate
time in hospital
Capitated budgets
Hounslow Whole Systems Vision
Hounslow commissioners and providers have been developing an
integrated care model since 2012 and now has in place strategies and
programmes delivering integrated care to its residents.
Our vision for whole system integrated care is based on what patients and
carers tell us is most important to them – a seamless service to patients
and carers, delivering person-centred care.
To deliver Whose Systems integrated care will mean significant change
across the whole of our current health and care provider landscape, and
perhaps for voluntary and social organisations too.
Whole Systems is the catalyst and enabler for this change. We must take
this opportunity.
If we can get it right, we know it will transform the daily lives of many of
our residents.
Whole Systems Integrated Care vision of a Model of Care
Better Care Fund - £16.8 million
The Better Care Fund will be used to develop integrated working through:
1. Co-ordinating care around individuals using a proactive and joined up case
management approach
2. Improving outcomes for the individual, carer and local community
3. Improving the experience of care for patients, service users and their carers
4. Maximising independence, avoiding hospital admissions and use of
nursing/care homes
5. Developing preventative services to support people to stay well and healthy
for longer / Prevention Strategy
Areas for focus: THE BIG HEALTH ISSUES
Children and Young People
Long term conditions
Mental health
End of Life care
Children and Young People
Better communication and earlier intervention
Paediatric Hubs – specialist care closer to home
Access to Occupational Health & Mental health services
Improve access to leisure centres
Translation service
Children and Families Bill (Sept 2014)
Invested in perinatal mental health and promoting breast feeding
New Developments:
- Review of children continence service
- Re-commissioning children asthma nurse in the community in 15/16
- Roll out of children hubs
- New Children and Adolescent Mental Health Service out of hospital service
Integrated working with all children services (schools, LBH children service,
public health)
Long Term Conditions
• Care Navigators based in localities
• Better communication
• Self Help: directory of self help groups, support for those with disabilities
(inc benefit advice, help filling forms)
• Services need to be more community led (e.g. home base physiotherapy)
• Reduce fees for local facilities, especially for unemployed
• Psychological support and input
• Provide information for children moving into adulthood (transition)
• More Rehabilitation beds
• Increase preventive services
• New services to be provided through Whole Systems Integrated Care, Community
Recovery Service and Diabetes Intermediate Services
• Scoping use of Telehealth technology
New Developments: Whole Systems Integrated Care
Mental Health
• Mental Health Facilitator for Carers Groups
• Counselling Services (Improving Access to Psychological Services)
• Primary Mental Health Service ( Primary Care Plus)
• Developing urgent care (in-hours extended, home assessment)
New Development: Brentford and Isleworth Whole Systems for
Long Term Mental Health Needs
- Early Intervention
- Physical and Mental Health
Crisis Service from August 2014 : Duty clinical System (9am-5pm) , Speedier
diagnosis – MRI, Mapping Dementia Care Pathway
New Developments:
- Agreement for locality dementia nurses
- Dementia awareness: Dementia friendly Hounslow
- Whole Systems Integrated Care
• Patient Care Pathway – reduce waiting times
• Local facilities – care closer to home
• Better Training for GP’s
• Support to patients and Carers
New Developments:
- Discussing with Public Health ways to promote awareness
- Working closer with the Mulberry Centre
- Screening
End of Life Care
• Better training for GP’s
• Misdiagnosis in primary care
• 'Co-ordinate my care' - Extending the Care Plan
• Specialist Palliative Care Services, District Nursing, Marie Curie Planned
Nursing and Rapid Response, Integrated Community Response Service
New Developments:
Increasing Specialist Palliative Care provision between Secondary and
Primary Care.
How could the voluntary sector work together to respond to joint
• Through Helping people self-manage and provide care navigation working in
partnership with voluntary, community and long-term conditions charitable groups
• Supporting our work on reablement and rehabilitation and prevention through an
integrated Community Recovery model focused on short-term interventions and
facilitating hospital discharge and avoiding admissions and promotes independence
• Supporting patients and families living with Dementia
• Increased use of assistive technology, including Telecare and Telehealth
• Specific proven early interventions e.g. falls prevention, housing related support
Through promoting mobility and accessibility of community facilities (better
transport services)
• Supporting Healthy living advice and self-management, e.g. exercise classes,
dietary advice
You have already responded: Systems Resilience Winter Pressure bids
Hounslow Together emphasis on volunteering
• Dementia: Promote voluntary services to provide further help and training
• Prevention Strategy: Low level, practical services and support that enables people
to continue to live in their own homes, e.g. Handy Van services, floating support,
assisted shopping
• Reducing social isolation as loneliness and depression are recognised as major
factors in the quality of life for people, particularly older people, good
neighbourhood schemes
• Prevention Strategy: Situations where someone has a major life change and may
need support to help them regain their independence, e.g. illness, bereavement
• Working in localities, for instance GPs receptionist-type work
To advocate on behalf of vulnerable people
• Integrated Dementia Services - ensure that we support people and their carers
following diagnosis, improved pathways, early diagnosis, integrated working and
dementia friendly communities
• To advocate on behalf of Mental Health BME users – culture and language may
prevent use of services
• To support people with Dementia, Cancer and Mental illness, reducing the fear &
• To advocate for people with Dementia: Service users have told us they want more
say in care plans
• End of Life: To provide social support to patients and their families at end of life
4. Signposting
Using the Voluntary Sector reach
Universal Information, Advice and Signposting - includes support to people to access
low level support as well self funders, to help meet the statutory requirements of the
Care Act and support the prevention agenda
Dementia: Information pack & help recognising early signs
Hounslow - dementia friendly
Improve awareness and presentation
Prevention Strategy: Access to Information, advice and signposting to community
resources, so people are well informed, can help themselves and to support people
who do not meet social care eligibility criteria, or who fund themselves, in finding
services that can meet their needs.
Hounslow Community Network Newsletter
Through Website…
Through Contacting the CCG:
Fiona Thomas on 020 8630 1000

Sue-Jeffers-HCN-71014 - Hounslow Community Network